I
Detailed Lesson Plan
Chapter 30
Musculoskeletal Trauma
120–130 minutes
|Chapter 30 objectives can be found in an accompanying folder. |
|These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines. |
|Minutes |Content Outline |Master Teaching Notes |
| |Introduction |Case Study Discussion |
|5 |During this lesson, students will learn to assess and treat a painful, swollen, or deformed extremity. |What are the patient management priorities in such a |
| |Case Study |situation? |
| |Present Dispatch and Upon Arrival information from the chapter. |Describe how you will proceed with this patient. |
| |Discuss with students how they would proceed. | |
| |Musculoskeletal System Review—The Muscles |Teaching Tip |
|10 |Voluntary (skeletal) muscles are under control of a person’s will. |Since this section is review material, rely more heavily on |
| |Voluntary muscles make possible all deliberate acts such as walking, chewing, and frowning. |questioning students rather than providing information. |
| |Most voluntary muscles are attached to the skeleton at one or both ends. | |
| |Voluntary muscles form the major muscle mass of the body. |Knowledge Application |
| |Muscle tissue contracts when stimulated by a nerve impulse. |Students should be able to use the information in this section|
| |Muscles give our bodies their distinctive shapes. |to assess and describe musculoskeletal injuries. |
| |Muscles can be injured in many ways. | |
| |Broken fibers from overextension |Discussion Question |
| |Bruises |What happens to the shape of the muscles when they contract? |
| |Crushing | |
| |Cuts | |
| |Tears | |
| |Painful swelling and weakness | |
| | | |
| | | |
| |Musculoskeletal System Review—Tendons and Ligaments | |
|5 |The “glue” that holds the body together | |
| |Composed of specialized connective tissue | |
| |Tendons connect muscle to bone. | |
| |Ligaments connect bone to bone. | |
| |Can be bruised, crushed, cut, or torn | |
| |Musculoskeletal System Review—Cartilage |Discussion Question |
|5 |Extension of the bone |What is the function of cartilage? |
| |Comprised of connective tissue | |
| |Strong, smooth, flexible, compressible, slippery substance | |
| |Found at the point of articulation of two bones | |
| |Protects bones in motion from friction | |
| |Acts as shock absorber between bone surfaces | |
| |Leads to joint pain when injured | |
| |Musculoskeletal System Review—The Skeletal System |Discussion Questions |
|10 |Upper extremity (shoulder girdle, arm, forearm, hand) |What are the components of the appendicular skeleton? |
| |Clavicle (collar bone) |Where is the greater trochanter of the femur? |
| |Scapula (shoulder blade) | |
| |Humerus (upper arm bone) |Class Activity |
| |Radius (lower arm bone) |Assign groups of students to prepare presentations to review |
| |Ulna (including the olecranon) (lower arm bone and elbow) |the musculoskeletal system. Divide the following topics among |
| |Carpal bones (wrist bones) |the groups: Skeletal Muscle, Axial Skeleton, Shoulder Girdle |
| |Metacarpals (hand bones) |and Upper Extremities, Pelvis and Lower Extremities, and Types|
| |Phalanges (finger bones) |of Joint Movements. Give students 20 minutes to prepare before|
| |Lower extremity (pelvis, thigh, leg, foot) |reporting back to the class. |
| |Pelvis (including the ilium, ischium, and pubis) | |
| |Femur (thigh bone) | |
| |Patella (kneecap) | |
| |Tibia (lower leg bone) | |
| |Fibula (lower leg bone) | |
| |Calcaneus (heel bone) | |
| |Tarsals (ankle bones) | |
| |Metatarsals (foot bones) | |
| |Phalanges (toe bones) | |
| |Injuries to Bones and Joints—Types of Injuries |Teaching Tip |
|15 |Fracture |Obtain and show a variety of radiographs of orthopedic |
| |A break in the continuity of a bone |injuries. |
| |Caused by direct force, indirect force, or twisting force | |
| |Open fracture—Associated with an open wound |Discussion Questions |
| |Closed fracture—Skin is not broken. |Which joints are most commonly dislocated? |
| |Type can only be distinguished by X-ray. |Why should you consider dislocations significant injuries? |
| |Hairline fracture—Small crack in bone, does not create instability | |
| |Pathologic fracture—Result of degenerative disease such as osteoperosis |Knowledge Application |
| |Can result in various complications |Students should be able to recognize a painful, swollen, |
| |Hemorrhage from the bone |deformed extremity as well as other indications of |
| |Instability of the extremity |musculoskeletal injury. |
| |Surrounding tissue damage | |
| |Infection (open fracture) |Weblinks |
| |Interruption of distal blood supply |Go to and click on the mykit link for |
| |Strain |Prehospital Emergency Care, 9th edition to access web |
| |Injury to a muscle or tendon |resources on osteoperosis, fractures (including images), |
| |Often due to overextension (overstretching) |growth plate injuries, and additional fracture information |
| |Can be caused by extreme muscle stress or fatigue associated with overuse |from the Journal of the American Medical Association. |
| |No edema or discoloration | |
| |Pain or weakness with use of the muscle | |
| |Sprain |Video Clip |
| |Injury to a joint capsule |Go to and click on the mykit link for |
| |Damage to or tearing of the connective tissue |Prehospital Emergency Care, 9th edition to access a video on |
| |Usually involves ligaments |joint injuries. |
| |Usually occurs in shoulder, knee, or ankle | |
| |Immediate pain and tenderness, followed by inflammation and swelling | |
| |Dislocation | |
| |Displacement of bone from normal position in joint | |
| |Caused by joint being forced beyond normal range of motion | |
| |Obvious deformity and swelling; pain and tenderness | |
| |May occur at shoulder, elbow, wrist, hand, hip, knee, ankle, or foot | |
| |General injury considerations | |
| |Similar signs and symptoms: swelling, pain, or deformity | |
| |Usually associated with external forces (falls, vehicle collisions) | |
| |May occur through degenerative disease, particularly in elderly patients | |
| |Force may cause injuries to surrounding soft tissues and other body areas | |
| |Injuries to Bones and Joints—Mechanism of Injury |Discussion Questions |
|3 |Direct force—Injury occurs at the point of impact. |What is an example of direct force applied to a bone? |
| |Indirect force—Force impacts on one end of a limb, causing injury some distance away from point of impact. |What is an example of indirect force applied to a bone? |
| |Twisting force—One part of extremity remains stationary while the rest twists. | |
| | |Weblink |
| | |Go to and click on the mykit link for |
| | |Prehospital Emergency Care, 9th edition to access a web |
| | |resource on tennis elbow. |
| | | |
| | Injuries to Bones and Joints—Critical Fractures: The Femur and the Pelvis | |
|5 |Femur | |
| |Symptoms | |
| |Bone itself bleeds heavily—Up to 1.5 liters of blood | |
| |Tension on thigh muscles is lost so thigh diameter increases, allowing more blood to be housed within thigh. | |
| |Goals of treatment | |
| |Immobilize bone ends. | |
| |Reduce bleeding. | |
| |Effect of traction splint | |
| |Bone ends are realigned, preventing further injury and reducing pain. | |
| |Diameter of thigh is decreased, allowing less blood to accumulate. | |
| |Pelvis | |
| |Bone itself bleeds heavily—Up to two liters of blood | |
| |Application of Pneumatic Antishock Garment (PASG) will stabilize fracture and may help tamponade bleeding pelvis. | |
| |IX. Injuries to Bones and joints—Assessment-Based Approach: Bone or Joint Injuries |Class Activity |
|20 |Scene size-up and primary assessment |Divide the class into small groups to practice assessment of |
| |Take appropriate Standard Precautions. |musculoskeletal injuries. |
| |Consider the mechanism of injury. | |
| |Ask bystanders what caused the injury. | |
| |Try to imagine the forces to which the patient’s body was subjected. | |
| |Check for obvious signs of severe hemorrhage. |Critical Thinking Discussion |
| |Look for signs of shock and treat. |How can you balance the need for immediate transport of a |
| |If the injury has caused a life-threatening condition, immobilize injured extremity and transport immediately |patient in shock with the need to immobilize major fractures |
| |following secondary assessment. |to prevent further bleeding, tissue damage, and pain? |
| |Secondary assessment | |
| |If the patient has a life-threatening condition not directly related to the injury, initiate transport and | |
| |immobilize injury en route if time and patient’s condition permits. | |
| |If the patient is responsive and oriented, inspect and gently palpate bone or joint. | |
| |Be gentle and reassuring. | |
| |Check injury site for signs and symptoms of injury (deformity, contusions, tenderness, and so on). | |
| |Assess baseline vitals and obtain a history from the patient. | |
| |Evaluate the six “Ps.” | |
| |Pain | |
| |Pallor | |
| |Paralysis—May indicate nerve, muscle, tendon, or ligament damage | |
| |Paresthesia (numbness, prickly feeling, or tingling)—May indicate nerve damage | |
| |Pressure—May indicate damaged tissue or internal blood loss | |
| |Pulse—Decrease to or absence of distal pulse may indicate arterial damage. | |
| |Emergency medical care | |
| |If injury threatens patient’s life, immobilize injured extremity during primary assessment or secondary assessment | |
| |if the appropriate resources are available and it does not cause a delay in transport. | |
| |If the patient has other life-threatening conditions, initiate transport and immobilize injured extremity en route | |
| |if time and patient’s condition permits. | |
| |Immobilize the suspected fracture. | |
| |Use proper Standard Precautions. | |
| |Administer oxygen if needed. | |
| |Maintain in-line spine stabilization if spine injury is suspected. | |
| |Splint bone and joint injuries. | |
| |Apply cold packs to painful, swollen, or deformed extremity. | |
| |Elevate the extremity (if spine injury is not suspected). | |
| |Transport. | |
| |Reassessment | |
| |Recheck patient’s vital signs and interventions. | |
| |Make certain injured extremity is properly immobilized. | |
| |Make sure immobilization has not adversely affected patient’s distal pulses, motor function, or sensation. | |
| | Injuries to Bones and Joints—Summary: Assessment and Care | |
|2 |Review possible assessment findings and emergency care for musculoskeletal injuries. | |
| |Review Figures 30-15 and 30-16. | |
| | | |
| |Basics of Splinting—General Rules of Splinting |Discussion Question |
|5 |Before and after applying the splint, assess pulse, motor function, and sensation distal to the injury. |What are the general rules of splinting? |
| |Immobilize joints above and below a long bone injury. | |
| |Remove or cut away clothing and jewelry around the injury site. |Knowledge Application |
| |Cover all wounds with sterile dressings and gently bandage before splinting. |Given a series of scenarios, students should be able to assess|
| |If there is severe deformity or the distal extremity is cyanotic (bluish) or lacks pulses, align injured limb with |musculoskeletal injuries, assign injuries proper priority in |
| |gentle manual traction before splinting. |the overall management of the patient, and demonstrate proper |
| |Never intentionally replace protruding bones or push them back below the skin. |splinting techniques. |
| |Pad each splint to prevent pressure and discomfort. | |
| |Apply the splint before trying to move the patient. |Video Clip |
| |When in doubt, splint the injury. |Go to and click on the mykit link for |
| |If the patient shows signs of shock, do not apply a splint first; align him in the normal anatomical position, |Prehospital Emergency Care, 9th edition to access a video |
| |treat for shock, and transport immediately. |about long bone injuries and splints. |
| | | |
| |Basics of Splinting—Splinting Equipment |Teaching Tips |
|10 |Rigid splints |Show examples of each type of splint as you talk about it. |
| |Commercially manufactured |Provide students with adequate time to practice splinting |
| |Made of wood, wood fiber, plastic, or cardboard |under supervision. |
| |Designed to fit specific limbs, or can be molded to fit any appendage | |
| |May come with washable pads |Discussion Question |
| |Pressure (air or pneumatic) splints |What are some advantages and disadvantages of rigid splints? |
| |Soft and pliable before inflation; rigid once applied and inflated | |
| |Cannot be sized | |
| |May impair circulation | |
| |May interfere with ability to assess pulses |Video Clip |
| |May lose or gain pressure with changes in temperature/altitude |Go to and click on the mykit link for |
| |Seek medical direction regarding use |Prehospital Emergency Care, 9th edition to access a video on |
| |Traction splints |the application of a Sager splint. |
| |Provide a counterpull that alleviates pain, reduces blood loss, and minimizes further injury | |
| |Purpose is to immobilize bone ends, reduce diameter of thigh, and prevent further injury. | |
| |Many types available | |
| |Formable splints | |
| |Rigid but made to be shaped to fit deformed extremity | |
| |Can be fixed in place with cravats or Velcro | |
| |Typically comprised of wire, aluminum, or other flexible metal | |
| |Vacuum splints | |
| |Soft and pliable | |
| |Easily formed to deformed extremities | |
| |When air is sucked out, splint becomes extremely rigid. | |
| |Sling and swathe | |
| |Provides stability to injured shoulder, elbow, or upper humerus | |
| |Sling supports arm; swathe holds arm against chest. | |
| |Minimizes pain and further injury | |
| |Spine board | |
| |Considered a full body splint | |
| |Use in cases of critical injury to provide stability where extremity fractures cannot be splinted at scene. | |
| |Improvised splints |Class Activity |
| |Light in weight but firm and rigid |Have a contest to see which group of students can come up with|
| |As wide as thickest part of fractured limb |the best improvised splint. |
| |Long enough to extend past joints and prevent movement | |
| |Padded well so inner surfaces are not in contact with skin | |
| |Possible materials include cane, cardboard, umbrella, pillow, and so on. | |
| |Basics of Splinting—Hazards of Improper Splinting | |
|5 |Compression of nerves, tissues, and blood vessels | |
| |Delay in patient’s transport | |
| |Reduction of distal circulation | |
| |Aggravation of bone or joint injury | |
| |Aggravation or cause of damage to tissue, nerves, blood vessels, or muscles | |
| |Basics of Splinting—Splinting Long Bone Injuries | |
|5 |Look for exposed bone ends, joints locked in position, paresthesia (tingling), paralysis, and pallor. | |
| |Assess the pulse and motor and sensory function below the injury site. | |
| |If limb is severely deformed, cyanotic (bluish), or lacks distal pulses, align with gentle traction. | |
| |Basics of Splinting—Splinting Joint Injuries | |
|5 |Look for paresthesia (tingling) or paralysis. | |
| |Assess the pulse and motor and sensory function below the injury site. | |
| |If distal extremity is cyanotic (bluish) or lacks distal pulses, align with gentle traction; stop if pain or | |
| |crepitus increases. | |
| |Basics of Splinting—Traction Splinting |Discussion Question |
|3 |Use for fractured femur. |What is the mechanism by which traction splinting works? |
| |Reduces diameter of thigh | |
| |Decreases space in which bleeding can occur | |
| |Do not use in the following instances. | |
| |Injury is within one to two inches of the knee or ankle. | |
| |Knee itself is injured. | |
| |Hip is injured. | |
| |Pelvis is injured. | |
| |There is partial amputation or avulsion with bone separation. | |
| |Basics of Splinting—Splinting Specific Injuries | |
|2 |Special techniques may be applied to the splinting of suspected bone and joint injuries to specific sites. | |
| |Review splinting techniques for the shoulder, upper arm, elbow, forearm, wrist, hand, fingers, pelvis, hip, thigh, | |
| |knee, lower leg, ankle, and foot in EMS Skills 30-07 and 30-08. | |
| |Basics of Splinting—Pelvic Fracture | |
|5 |Pneumatic Antishock Garment (PASG) can splint pelvis and decrease compartment size to reduce bleeding. | |
| |Commercial pelvic splint is another method. | |
| |Improvised pelvic wrap may be applied if necessary. | |
| |Fold a sheet lengthwise to eight-inch width. | |
| |Slide it under the small of the back, then down under the pelvis until centered. Ends of the sheet must be of equal| |
| |length on both sides of patient. | |
| |Cross tail ends over patient and twist until sheet is tightly secured around pelvis. | |
| |Tuck sheet ends under patient or tie into square knot. | |
| |Place patient on backboard or rigid device. | |
| |Basics of Splinting—Compartment Syndrome |Discussion Question |
|5 |May occur when fracture or injury to an extremity has occurred |What is compartment syndrome? |
| |May occur in buttocks or abdomen | |
| |Occurs when pressure in space around capillaries exceeds pressure needed to perfuse tissues; blood flow is cut off |Critical Thinking Discussion |
| |and cells become hypoxic. |What causes the pain and paresthesia associated with |
| |Usually develops over time as edema around injured area increases |compartment syndrome? |
| |Commonly associated with fractures, bleeding from trauma, crush injuries, and high-energy trauma | |
| |Signs and symptoms | |
| |Severe pain or burning sensation | |
| |Decreased strength in extremity | |
| |Paralysis of extremity | |
| |Pain with movement | |
| |Extremity feeling hard to palpitation | |
| |Distal pulses, motor, and sensory function possibly normal | |
| |Treatment | |
| |Immobilize and splint affected extremity. | |
| |Elevate extremity and apply cold pack or ice. | |
| |Transport the patient as soon as possible. | |
| |XX. Follow-Up |Case Study Follow-Up Discussion |
|10 |Answer student questions. |Do you agree with the choice of splints? Why or why not? |
| |Case Study Follow-Up | |
| |Review the case study from the beginning of the chapter. |Class Activity |
| |Remind students of some of the answers that were given to the discussion questions. |Alternatively, assign each question to a group of students and|
| |Ask students if they would respond the same way after discussing the chapter material. Follow up with questions to |give them several minutes to generate answers to present to |
| |determine why students would or would not change their answers. |the rest of the class for discussion. |
| |Follow-Up Assignments | |
| |Review Chapter 30 Summary. |Teaching Tips |
| |Complete Chapter 30 In Review questions. |Answers to In Review and Critical Thinking questions are in |
| |Complete Chapter 30 Critical Thinking. |the appendix to the Instructor’s Wraparound Edition. Advise |
| |Assessments |students to review the questions again as they study the |
| |Handouts |chapter. |
| |Chapter 30 quiz |The Instructor’s Resource Package contains handouts that |
| | |assess student learning and reinforce important information in|
| | |each chapter. This can be found under mykit at |
| | |. |
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MASTER TEACHING NOTES
• Case Study Discussion
• Teaching Tips
• Discussion Questions
• Class Activities
• Media Links
• Knowledge Application
• Critical Thinking Discussion
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