Emergency Care and Transportation of the Sick and Injured ...



Chapter 14

Injuries to Muscles and Bones

Unit Summary

After students complete this chapter and the related coursework, they will understand the general and specific types of, as well as patient assessment and treatment for, musculoskeletal injuries. General principles of splinting and the skills needed to splint specific injuries are covered. Standard precautions when treating musculoskeletal injuries are also discussed.

National EMS Education Standard Competencies

Trauma

Uses simple knowledge to recognize and manage life threats based on assessment findings for an acutely injured patient while awaiting additional emergency medical response.

Orthopaedic Trauma

Recognition and management of:

• Open fractures (pp 309–314)

• Closed fractures (pp 309–314)

• Dislocations (pp 309–315)

• Amputations (p 318)

Head, Facial, Neck, and Spine Trauma

Recognition and management of:

• Life threats (pp 328–333)

• Spine trauma (pp 330–333)

Knowledge Objectives

1. Discuss the anatomy and function of the musculoskeletal system. (pp 306–308)

2. Describe the mechanisms of injury for musculoskeletal injuries. (p 308)

3. Explain the characteristics of the following types of injuries:

- Fractures (p 309)

- Dislocations (p 309)

- Sprains and strains (p 309)

4. Explain the need for standard precautions when assessing or treating patients with musculoskeletal injuries. (pp 309–310)

5. Explain how to assess a patient with a musculoskeletal injury. (pp 305, 310–311)

6. Explain how to check circulation, sensation, and movement in an injured extremity. (p 311)

7. Describe how to splint the following injuries:

- Shoulder girdle injury (p 315)

- Shoulder dislocation (p 315)

- Elbow injury (p 316)

- Forearm injury (pp 316–317)

- Hand, wrist, or finger injury (pp 317–318)

- Pelvic fracture (pp 318–319)

- Hip injury (p 319)

- Thigh injury (pp 320–323)

- Knee injury (p 323)

- Leg injury (pp 323–324)

- Ankle or foot injury (pp 324–326)

8. List the signs and symptoms of open and closed head injuries. (p 328)

9. Describe the treatment of head injuries. (p 328)

10. Describe the treatment of facial injuries. (p 329)

11. Discuss the mechanism of spinal injuries. (p 330)

12. List the signs and symptoms of spinal injury. (p 331)

13. Describe the treatment of spinal injury. (p 331)

14. Explain how to remove the mask on a sports helmet. (pp 332–333)

15. Explain how to remove a helmet. (pp 332–335)

16. Describe the signs, symptoms, and treatment of the following injuries:

- Fractured ribs (pp 333–334)

- Flail chest (pp 335–336)

- Penetrating chest wound (pp 336–337)

Skills Objectives

1. Demonstrate use of standard precautions when assessing or treating patients with musculoskeletal injuries. (pp 309–310)

2. Demonstrate assessment of a patient with a musculoskeletal injury. (pp 310–311)

3. Demonstrate how to check circulation, sensation, and movement in an injured extremity. (p 311)

4. Demonstrate how to splint the following injuries:

- Shoulder girdle injury (p 315)

- Shoulder dislocation (p 315)

- Elbow injury (p 316)

- Forearm injury (pp 316–317)

- Hand, wrist, or finger injury (pp 317–318)

- Pelvic fracture (pp 318–319)

- Hip injury (p 319)

- Thigh injury (pp 320–323)

- Knee injury (p 323)

- Leg injury (pp 323–324)

- Ankle or foot injury (pp 324–326)

5. Demonstrate the treatment of head injuries. (p 328)

6. Demonstrate the treatment of facial injuries. (p 329)

7. Demonstrate the treatment of spinal injury. (p 331)

8. Demonstrate how to remove the mask on a sports helmet. (pp 332–333)

9. Demonstrate how to remove a helmet. (pp 332–335)

10. Demonstrate treatment of the following injuries:

- Fractured ribs (p 334)

- Flail chest (p 336)

- Penetrating chest wound (pp 336–337)

Readings and Preparation

Review all instructional materials, including Emergency Medical Responder, Fifth Edition, Chapter 14, and all related presentation support materials.

• Review the local protocol for splinting and realignment of injuries. Make sure splinting equipment is in working order.

Support Materials

• Lecture PowerPoint presentation

• Skill Drill PowerPoint presentations

• Skill Drill 14-1, Checking Circulation, Sensation, and Movement in an Injured Extremity PowerPoint presentation

• Skill Drill 14-2, Applying a SAM Splint PowerPoint presentation

• Skill Drill 14-3, Applying a Zippered Air Splint PowerPoint presentation

• Skill Drill 14-4, Applying a Traction Splint PowerPoint presentation

• Skill Drill 14-5, Applying an Air Splint to the Leg PowerPoint presentation

• Skill Drill 14-6, Applying a Pillow Splint for Ankle or Foot Injury PowerPoint presentation

• Skill Drill 14-7, Stabilizing the Cervical Spine and Maintaining an Open Airway PowerPoint presentation

• Skill Drill 14-8, Removing the Mask on a Sports Helmet PowerPoint presentation

• Skill Drill 14-9, Removing a Helmet PowerPoint presentation

• Medical exam gloves

• Blankets

• EMR life support kit

• Bandaging materials

• Human skeleton

• Triangular bandages for swathes and slings

• Rigid splints

• Soft splints

• Improvised splints

• Backboard

• Traction splint

• Football or motorcycle helmet

• Occlusive dressings

• Skill Evaluation Sheets

• Skill Drill 14-1, Checking Circulation, Sensation, and Movement in an Injured Extremity

• Skill Drill 14-2, Applying a SAM Splint

• Skill Drill 14-3, Applying a Zippered Air Splint

• Skill Drill 14-4, Applying a Traction Splint

• Skill Drill 14-5, Applying an Air Splint to the Leg

• Skill Drill 14-6, Applying a Pillow Splint for Ankle or Foot Injury

• Skill Drill 14-7, Stabilizing the Cervical Spine and Maintaining an Open Airway

• Skill Drill 14-8, Removing the Mask on a Sports Helmet

• Skill Drill 14-9, Removing a Helmet

Enhancements

• Direct students to visit the companion we bsite to the Fifth Edition at EMR. for online activities.

• Contact a local/regional orthopaedic care center for current information, handouts, audiovisual support materials, or guest lecturers on the subject of musculoskeletal injuries and care.

• Contact a local physical therapy center for guest lecturers on the subject of long-term care of musculoskeletal injuries.

• Have the students spend a clinical shift at a residential rehabilitation center in your area.

• Students can be asked to prepare a demonstration of specific types of splinting. This will make them more active participants in the learning process.

Teaching Tips

• Stress the importance of examining an injured extremity for circulation and sensation. The absence of good sensation or circulation creates a more urgent need for treatment.

• Use the simple splinting equipment that EMRs will be carrying in their life support kits. This practice will help the students to begin operating in the environment they will encounter in the field.

• Have students perform some simulations using only improvised objects such as magazines, towels, and boards. This kind of exercise increases their awareness of the availability of simple splinting materials.

• Create simulations that require students to integrate the skills from earlier chapters with the material presented in this chapter. For example, the student will need to decide, “Should I control bleeding or splint first?”

• Review spinal immobilization; it is a skill that is needed every day in EMS.

• Ask the students to describe any experiences they have had or their family has had with musculoskeletal injuries.

Unit Activities

Writing activities: Assign students research projects on pertinent orthopaedic topics, such as “How to prevent infections in open fractures” or “Long-term effects of the poor stabilization of fractures in the field.”

Group activities: Facilitate a group discussion on the differences between pediatric and geriatric care of musculoskeletal injuries.

Medical terminology review: Create a crossword puzzle that includes important medical terms, injuries, and treatment.

Visual thinking: Provide students with handouts of images or project images on-screen. Images could include open or closed fractures. Ask the students to explain these injuries to the class.

Pre-Lecture

You are the Provider

“You are the Provider” is a progressive case study that encourages critical thinking skills.

Instructor Directions

1. Direct students to read the “You are the Provider” scenario found throughout Chapter 14.

2. You may wish to assign students to a partner or a group. Direct them to review the discussion questions at the end of the scenario and prepare a response to each question. Facilitate a class dialogue centered on the discussion questions.

3. You may also use this exercise as an individual activity and ask students to turn in their comments on a separate piece of paper.

Lecture

I. Introduction

A. As an EMR, you will encounter many types of musculoskeletal injuries:

1. Fractures

2. Dislocations

3. Sprains

4. Strains

5. Head injuries

6. Spinal cord injuries

7. Chest injuries

B. Understanding the basic anatomy and functioning of the musculoskeletal system will help you treat these injuries.

C. You must be able to recognize signs and symptoms of various musculoskeletal injuries.

D. Providing proper care at the scene can prevent additional injury or disability.

II. Patient Assessment of Injuries to Muscles and Bones

A. When assessing a patient who has sustained an injury to the muscles and bones, you need to complete all five of the parts of the patient assessment sequence.

1. Perform a thorough size-up of the scene.

a. Do not get tunnel vision because the patient has an obvious injury.

b. You need to complete all parts of the scene size-up to render the scene safe and to gain as much information as you can about the mechanism of injury.

c. Be especially careful about following standard precautions to protect you and the patient from infectious diseases.

2. Perform a complete primary assessment to determine whether the patient has any life-threatening problems related to the airway, breathing, or circulation.

3. It is often more efficient and helpful to perform the primary assessment, and then immediately follow with the secondary assessment, holding off on obtaining the patient’s medical history.

a. Be thorough and systematic in examining all parts of the patient.

4. Perform a thorough SAMPLE medical history to determine whether the patient has any medical conditions that require attention.

5. Continue to reassess the patient.

a. Every 15 minutes for stable patients

b. Every 5 minutes for unstable patients

III. The Anatomy and Function of the Musculoskeletal System

A. The skeletal system

1. The skeletal system consists of 206 bones and is the supporting framework for the body.

2. The four functions of the skeletal system are:

a. To support the body

b. To protect vital structures

c. To assist in body movement

d. To manufacture red blood cells

3. The skeletal system is divided into seven areas:

a. Head, skull, and face

b. Spinal column

c. Shoulder girdle

d. Upper extremities

e. Rib cage (thorax)

f. Pelvis

g. Lower extremities

4. The bones of the head include the skull and the lower jawbone.

a. The skull is actually many bones fused together to form a hollow sphere that contains and protects the brain.

b. The jawbone is a movable bone attached to the skull that completes the structure of the face.

5. The spine consists of a series of separate bones called vertebrae.

a. The spinal cord—a group of nerves that carry messages to and from the brain—passes through a hole in the center of each vertebra.

b. The spine is the primary support structure for the entire body.

c. The spine has five sections:

i. Cervical spine (neck)

ii. Thoracic spine (upper back)

iii. Lumbar spine (lower back)

iv. Sacrum

v. Coccyx (tailbone)

6. Each shoulder girdle supports an arm and consists of the collarbone (clavicle) and the shoulder blade (scapula).

7. The upper extremities consist of three major bones plus the wrist and hand.

a. The arm has one bone (the humerus).

b. The forearm has two bones (the radius and the ulna).

i. The radius is located on the thumb side of the arm.

ii. The ulna is located on the side of the little finger.

c. The wrist and hand consist of several bones.

8. The rib cage or chest (thorax)

a. The 12 sets of ribs protect the heart, lungs, liver, and spleen.

b. All of the ribs are attached to the spine.

i. The upper five rib sets connect directly to the sternum (breastbone).

ii. A bridge of cartilage connects the ends of the 6th through 10th rib sets to each other and to the sternum.

iii. The 11th and 12th rib sets are called floating ribs because they are not attached to the sternum.

c. The sternum is located in the front of the chest.

d. The pointed structure at the bottom of the sternum is called the xiphoid process.

9. The pelvis links the body and the lower extremities.

a. The pelvis protects the reproductive organs and the other organs located in the lower abdominal cavity.

10. The lower extremities consist of the thigh and the leg.

a. The thighbone (femur) is the longest and strongest bone in the entire body.

b. The leg consists of two major bones, the tibia and fibula, plus the ankle and foot.

c. The kneecap (patella) is a small, relatively flat bone that protects the front of the knee joint.

11. A protective bony structure surrounds each of the body’s essential organs.

12. Red blood cells are manufactured primarily within the spaces inside the bone called the marrow.

B. The muscular system

1. The muscles of the body provide both support and movement.

2. Muscles are attached to bones by tendons and cause movement by alternately contracting (shortening) and relaxing (lengthening).

3. The musculoskeletal system gets its name from the coordination between the muscular system and the skeletal system that produces movement.

a. Movement occurs at joints, where two bones come together.

b. The bones are held together by ligaments—thick bands that arise from one bone, span the joint, and insert into the adjacent bone.

4. The body has three types of muscles.

a. Voluntary (skeletal) muscles are attached to bones and can be contracted and relaxed by a person at will.

i. They are responsible for the movement of the body.

b. Involuntary (smooth) muscles are found on the inside of the digestive tract and other internal organs of the body.

i. They are not under conscious control and perform their functions automatically.

c. Cardiac muscle is found only in the heart.

IV. Mechanism of Injury

A. You must understand the various mechanisms of injury (MOI)—that is, how injuries occur.

B. Musculoskeletal injuries are caused by three types of mechanisms of injury:

1. Direct force

2. Indirect force

3. Twisting force

C. Use the information provided by the dispatcher and gathered from your size-up of the scene to identify the possible mechanism of injury.

D. A word about terminology

1. There are many different ways to describe a patient’s injuries.

a. Use your senses of sight and touch to determine the type of injury.

b. Listen to the information that the patient gives you.

c. You do not have the training or tools to diagnose an injury as a physician can.

2. Although you are not expected to diagnose these injuries, the patient’s signs and symptoms will lead you to suspect that a certain injury is most probable.

3. The most important part of your job is to provide the best assessment and treatment for the patient.

V. Types of Injuries

A. All three types of musculoskeletal extremity injuries are serious, and all must be identified so that appropriate medical treatment can be provided.

B. Fractures

1. A fracture is a broken bone.

2. A variety of mechanisms can cause a fracture, but a fracture most often occurs as a result of a significant force.

3. Fractures are classified as either closed or open.

a. In the more common closed fracture, the bone is broken but there is no break in the skin.

b. In an open fracture, the bone is broken and the overlying skin is lacerated.

i. The open wound can be caused by a penetrating object or by the fractured bone end itself protruding through the skin.

ii. Contamination by dirt and bacteria may lead to infection.

4. Both open and closed fractures injure adjacent soft tissues, resulting in bleeding at the fracture site.

5. Fractures can injure nearby nerves and blood vessels.

C. Dislocations

1. A dislocation is a disruption that tears the supporting ligaments of the joint.

2. The bone ends that make up the joint separate completely from each other and can lock in one position.

3. Any attempt to move a dislocated joint is very painful.

4. A dislocation can damage nearby nerves and blood vessels.

D. Sprains and strains

1. A sprain is a joint injury caused by excessive stretching of the supporting ligaments.

a. It can be thought of as a partial dislocation.

2. Strains are caused by stretching or tearing of a muscle.

E. Signs and symptoms of extremity injuries include:

1. Pain at the injury site

2. An open wound

3. Swelling and discoloration (bruising)

4. The patient’s inability or unwillingness to move the extremity

5. Deformity or angulation

6. Tenderness at the injury site

VI. Standard Precautions and Musculoskeletal Injuries

A. Patients with musculoskeletal injuries may have open wounds.

1. Assume that trauma patients have open wounds that pose a threat of infection.

2. Always wear approved gloves.

B. When you are responding to motor vehicle crashes or to other situations that may present a hazard from broken glass or other sharp objects, wear heavy rescue gloves.

1. Some EMRs wear latex or nitrile gloves under the heavy rescue gloves for added protection from infectious body fluids.

C. If the patient has active bleeding that may splatter, you should have protection for your eyes, nose, and mouth.

VII. Examination of Musculoskeletal Injuries

A. General patient assessment

1. All the steps in the patient assessment process must be carried out before focusing your attention on any injured limb.

2. Limb injuries are not life threatening unless there is excessive bleeding from an open wound.

a. Stabilize the patient’s airway, breathing, and circulation first.

3. Treat the patient with the same care and consideration that you would give to a close member of your own family.

B. Examination of the injured limb

1. Inspect the injured limb and compare it to the opposite, uninjured limb.

a. Gently and carefully cut away any clothing covering the wound, if necessary.

2. When you examine the limb, you may find any one of the following:

a. Open wound

b. Deformity

c. Swelling

d. Bruising

3. Gently feel the injured limb for points of tenderness.

a. Tenderness is the best indicator of an underlying fracture, dislocation, or sprain.

4. To detect limb injury, start at the top of each limb and using both hands, squeeze the entire limb in a systematic, firm manner, moving down the limb and away from the body.

5. As you conduct the hands-on examination, ask the patient where it hurts most.

a. The location of greatest pain is probably the injury site.

b. Ask if the patient feels tingling or numbness in the extremity; this finding may indicate nerve damage or lack of circulation.

6. After you have made a careful visual and hands-on examination, and if the patient shows no sign of injury, ask the patient to move the limb carefully.

a. If there is an injury, the patient will report pain and refuse to move the limb.

C. Evaluation of circulation, sensation, and movement

1. Once you suspect limb injury, you must evaluate the circulation and sensation in that limb.

2. Any injury may have associated blood vessel or nerve damage.

3. It is essential to check circulation and sensation after any movement of the limb.

4. Follow the steps in Skill Drill 14-1 to check circulation, sensation, and movement in an injured extremity.

VIII. Treatment of Musculoskeletal Injuries

A. All limb injuries are treated in the same way in the field.

1. Cover open wounds with dry, sterile dressings.

2. Apply firm but gentle pressure to control bleeding, if necessary.

3. Apply a cold pack to painful, swollen, or deformed extremities.

4. Splint the injured limb.

B. General principles of splinting

1. All limb injuries should be splinted before the patient is moved, unless the environment prevents effective splinting or threatens the patient’s life.

2. Splinting prevents the movement of broken bone ends, a dislocated joint, or damaged soft tissues, thereby reducing pain.

3. Splinting helps to control bleeding and decreases the risk of additional damage.

4. Splinting prevents closed fractures from becoming open fractures during movement or transport.

5. Adhere to the general principles of splinting:

a. Remove clothing from the injured limb to inspect for open wounds, deformity, swelling, bruising, and capillary refill.

b. Note and record the pulse, capillary refill, sensation, and movement distal to the point of injury, both before and after splinting.

c. Cover all open wounds with a dry, sterile dressing before applying the splint.

d. Do not move the patient before splinting, unless there is an immediate danger to the patient or the EMR.

e. Immobilize the joint above and the joint below the injury site.

f. Pad all rigid splints.

g. When applying the splint, support the injury site and minimize movement of the limb until splinting is completed.

h. Splint the limb without moving it unnecessarily.

i. When in doubt, splint.

C. Materials used for splinting

1. Rigid splints

a. Rigid splints are made from firm material and are applied to the sides, front, or back of an injured extremity.

b. Common types of rigid splints include:

i. Padded board splints

ii. Molded plastic or aluminum splints

iii. Padded wire ladder splints

iv. SAM splints

v. Folded cardboard splints

2. Soft splints

a. The most commonly used soft splint is the inflatable, clear plastic air splint.

i. This splint is available in a variety of sizes and shapes, with and without zippers.

ii. After it is applied, the splint is inflated by mouth.

iii. The air splint is comfortable for the patient and provides uniform pressure to a bleeding wound.

b. The air splint has some disadvantages.

i. If it must be used in cold, dirty areas, the zipper can stick, clog with dirt, or freeze.

ii. After it is inflated, the splint can be punctured by sharp fragments of glass or other objects.

iii. Temperature and altitude changes can increase or decrease the pressure in the air splint.

3. Traction splints

a. A traction splint holds a lower extremity fracture in alignment by applying a constant, steady pull on the extremity.

b. Properly applying a traction splint requires two trained EMTs working together.

D. Splinting specific injury sites

1. Most splinting techniques require two people.

a. One person stabilizes and supports the injured limb while the other person applies the splint.

2. Shoulder girdle injuries

a. The easiest way to splint most shoulder injuries is to apply a sling made of a triangular bandage and to secure the sling to the patient’s body with swathes.

b. Apply the sling by tying a knot in the point of the triangular bandage, placing the elbow into the cup formed by the knot, and passing the two ends of the bandage up and around the patient’s neck.

3. Shoulder dislocation

a. Place a pillow or a rolled blanket in the space between the upper arm and the chest wall.

b. Apply the sling and swathe as for other shoulder injuries.

4. Elbow injuries

a. Do not move an injured elbow from the position in which you find it.

i. The elbow must be splinted as it lies because any movement can cause nerve or blood vessel damage.

b. An effective splint for an injured elbow is a pillow splint.

i. Wrap the elbow in a pillow, add padding to keep the elbow in the position found, and secure the pillow.

c. The patient is usually transported in a sitting position with the splinted elbow resting on his or her lap.

5. Forearm injuries

a. Several splints can be used to stabilize the forearm:

i. Air splint

ii. Cardboard splint

iii. SAM splint

iv. Rolled newspapers and magazines

b. Follow the steps in Skill Drill 14-2 to apply a SAM splint.

c. Be sure to pad all rigid splints adequately.

d. An air splint can be applied quickly, and it immobilizes the forearm quite well.

i. The air splint with a full length-zipper is easiest to use.

ii. Follow the steps in Skill Drill 14-3 to apply a zippered air splint.

e. To apply an air splint without a zipper:

i. Place the air splint over your hand and lower arm and grasp the patient’s hand.

ii. Have a second person support the patient’s elbow and upper arm to prevent movement.

iii. Apply slight pull in the long axis of the forearm.

iv. Slip the air splint off your arm and onto the patient’s injured forearm.

6. Hand, wrist, and finger injuries

a. The functions of the fingers and hand are so complex that any injury, if poorly or inadequately treated, may result in permanent deformity and disability.

b. You can use a bulky hand dressing and a short splint to immobilize all injuries of the wrist, hand, and fingers.

c. Send any amputated parts to the hospital with the patient by placing them in a sealed plastic bag.

d. To treat injuries of the hand, wrist, or fingers:

i. Cover all wounds with a dry, sterile dressing.

ii. Place the injured hand and wrist into the position of function.

iii. Place one or two soft roller dressings into the palm of the patient’s hand.

iv. Apply a splint and secure it with a soft roller bandage.

7. Pelvic fractures

a. Fractures of the pelvis often involve severe blood loss because the broken bones can easily lacerate large blood vessels.

b. Pelvic fractures commonly cause shock.

c. Treat the patient for shock, but do not raise the patient’s legs until he or she is secured on a backboard.

d. The most definitive sign of a pelvic fracture is tenderness when you use both your hands to firmly compress the patient’s pelvis.

e. Immobilize pelvic fractures with a long backboard.

f. EMTs may apply a pneumatic antishock garment to stabilize the fracture and treat shock.

8. Hip injuries

a. Two types of hip injuries are commonly seen: dislocations and fractures.

i. Both injuries may result from high-energy trauma.

b. Hip fractures occur at the upper end of the femur, rather than in the hip joint itself.

i. These fractures often occur in elderly patients because bone weakens and becomes more fragile with age (osteoporosis).

ii. Fractures of the hip region usually cause the injured limb to become shortened and externally rotated.

c. A dislocated hip is extremely painful.

i. The joint is usually locked with the thigh flexed and rotated inward.

ii. The knee joint is often flexed as well.

d. Treat all hip injuries by immobilizing the hip in the position found.

i. Use several pillows and/or rolled blankets.

ii. Place the patient on a long backboard for transportation.

e. Any elderly person who has fallen and reports pain in the hip, thigh, or knee should be splinted and transported to the hospital.

9. Thigh injuries

a. A fractured femur is very unstable and usually produces significant thigh deformity, with much bleeding and swelling.

b. Place the patient in as comfortable a position as possible, treat him or her for shock, and call for additional personnel and equipment.

c. After a motor vehicle crash:

i. You may have to move patients quickly.

ii. Secure both of the patient’s legs together with swathes, cravats, or bandages so that the two lower extremities are immobilized as one unit.

e. Traction splints are the most effective way to splint a unilateral fractured femur.

i. They were designed specifically for this purpose.

ii. You should know how to use traction splints so you can assist other EMS personnel in their application.

iii. Before applying a traction splint, trained EMTs align deformed fractures by applying manual longitudinal traction.

iv. Skill Drill 14-4 illustrates the steps for applying a Hare traction splint.

10. Knee injuries

a. Immobilize an injured knee in the same position that you find it.

b. If the knee is straight, use long, padded board splints or a long-leg air splint.

c. If there is significant deformity:

i. Place pillows, blankets, or clothing beneath the knee.

ii. Secure the splint materials to the leg with bandages, swathes, or cravats.

iii. Secure the injured leg to the uninjured leg.

iv. Place the patient on a backboard.

11. Leg injuries

a. Fractures of the leg can be splinted using air splints, cardboard splints, and magazines and newspapers.

b. Skill Drill 14-5 shows how to apply an air splint to the leg.

i. It takes two trained people to perform this skill—one person supports the leg with both hands, while the other person applies the splint.

12. Ankle and foot injuries

a. Fractures of the ankle and foot can be splinted with either a pillow or an air splint.

b. Place the pillow splint around the injured ankle and foot, and tie or pin it in place.

c. Skill Drill 14-6 shows how to apply a pillow splint to the ankle or foot.

E. Additional considerations

1. Extremity injuries are not, by themselves, life threatening unless excessive bleeding is present.

2. Sometimes you may be the only trained person at the scene of an accident.

3. Practice splinting until you can quickly and competently apply the principles in any situation.

a. Practice splinting both a sitting person and a prone volunteer.

4. It takes two people to splint most limb injuries adequately: one person to stabilize and support the extremity and one person to apply the splint.

5. Learn how the team functions as a unit during stressful situations and be prepared to work with any member of the EMS team who arrives to assist you.

IX. Injuries of the Head (Skull and Brain)

A. Severe head and spinal cord injuries can result from many different kinds of trauma.

1. These injuries are common causes of death.

2. If not fatal, they may lead to irreversible paralysis and permanent brain damage.

3. The human skull has two primary parts:

a. The cranium, a tough four-bone shell that protects the brain

b. The facial bones, which give form to the face and furnish frontal protection for the brain

B. Mechanisms of injury

1. Head injuries are common with certain types of trauma.

2. Between the skull and the brain, the cerebrospinal fluid (CSF) cushions the brain from direct blows.

a. A direct force can injure the skull and the brain inside.

b. An indirect force can also cause injury.

3. Spinal injury is often associated with head injury.

a. The force of direct blows to the head is often transmitted to the spine, producing a fracture or dislocation.

4. All patients with head injuries must have the cervical spine immobilized to protect the spinal cord.

C. Types of head injuries

1. In a closed head injury, bleeding and swelling within the skull may increase pressure on the brain, leading to irreversible brain damage and death.

2. An open head injury usually bleeds profusely.

a. Severe open head injuries are serious but not always fatal.

3. Examine the nose, eyes, and the wound itself to see if any blood or CSF is seeping out.

4. In severe cases of open head injury, brain tissue or bone may be visible.

D. Signs and symptoms of head injuries

1. A patient who sustained a head injury may exhibit some or all of the following signs and symptoms:

a. Confusion

b. Unusual behavior

c. Unconsciousness

d. Nausea or vomiting

e. Blood from an ear

f. Decreasing consciousness

g. Unequal pupils

h. Paralysis

i. Seizures

j. External head trauma: bleeding, bumps, and contusions

2. A serious head injury may produce raccoon eyes and Battle’s sign.

a. Raccoon eyes look like the black eyes that develop after a fistfight.

b. Battle’s sign appears as a bruise behind one or both ears.

E. Treatment of head injuries

1. Immobilize the head in a neutral position.

2. Maintain an open airway.

a. Use the jaw-thrust maneuver.

b. Be prepared to suction if the patient vomits.

3. Support the patient’s breathing.

a. As soon as oxygen becomes available, it should be administered to the patient.

4. Monitor circulation.

a. Be prepared to perform full CPR if the patient’s heart stops.

5. Determine whether blood or CSF is seeping from a wound or from the nose or ears.

6. Control bleeding from all head wounds with dry, sterile dressings.

7. Examine and treat other serious injuries.

8. Arrange for prompt transport.

X. Injuries of the Face

A. Facial injuries commonly result from the following types of incidents:

1. Motor vehicle crashes in which the patient’s face hits the steering wheel or windshield

2. Assaults

3. Falls

B. Airway obstruction is the primary danger in severe facial injuries.

1. Severe damage to the face and facial bones can cause bleeding and the collapse of the facial bones, leading to airway problems.

2. If the patient has facial injuries, you should also suspect a spinal injury.

3. Facial injuries are rarely life threatening unless the airway is obstructed.

C. Treatment of facial injuries

1. Immobilize the head in a neutral position.

2. Maintain an open airway.

a. Use the jaw-thrust maneuver.

b. Clear any blood or vomitus from the patient’s mouth with your gloved fingers.

3. Support breathing.

4. Monitor circulation.

5. Control bleeding by covering any wound with a dry, sterile dressing and applying direct pressure.

6. Look for and stabilize other serious injuries.

7. Arrange for prompt transport.

8. If these measures do not keep the airway clear or if you are unable to control severe facial bleeding, log roll the patient onto his or her side, keeping the head and spine stable and rolling the whole body as a unit.

XI. Injuries of the Spine

A. Spinal injuries can cause irreversible paralysis.

B. Mechanisms of injury

1. A displaced vertebra, swelling, or bleeding may put pressure on the spinal cord and damage it.

2. In severe cases of spinal injury, the spinal cord may be severed.

a. If all or part of the spinal cord is cut, nerve impulses cannot travel to and from the brain.

b. Without the conduction of these nerve impulses, the patient is paralyzed below the point of injury.

3. Injury to the spinal cord high in the neck paralyzes the diaphragm and results in death.

4. Gunshot wounds to the chest or abdomen may produce spinal cord injury at that level.

5. Falls, motor vehicle crashes, and stabbings are other common causes of spinal injuries.

6. Suspect a spinal injury if the patient has sustained high-energy trauma.

7. Common causes of spinal cord injuries include:

a. Athletic collisions

b. Diving injuries

c. Gunshot wounds and stabbings to the chest or neck

d. Falls of greater than three times the patient’s height

e. Hangings

f. Motorcycle crashes at speeds exceeding 20 mph

g. Motor vehicle crashes with the following conditions:

i. Patient is ejected from vehicle

ii. Patient is unrestrained

iii. Speed is more than 40 mph

iv. There is at least 12" of intrusion into the passenger compartment

C. Signs and symptoms of spinal cord injury

1. To determine whether a patient has sustained an injury to the spinal cord, talk to the patient and perform a careful examination.

a. Ask the patient to describe any points of tenderness or pain.

b. Do not move the patient during your examination.

c. Be extremely careful and take your time.

2. Signs and symptoms of spinal injuries include:

a. Laceration, bruise, or other sign of injury to the head, neck, or spine

b. Tenderness over any point on the spine or neck

c. Pain in the neck or spine or pain radiating to an extremity

d. Extremity weakness, numbness, paralysis, or loss of movement

e. Loss of sensation or movement, or tingling/burning sensation in any part of the body below the neck

f. Loss of bowel or bladder control

D. Treatment of spinal injuries

1. Place the head and neck in a neutral position.

2. Stabilize the head and prevent movement of the neck.

3. Maintain an open airway.

a. Use the jaw-thrust maneuver.

b. Clear any blood or vomitus from the mouth with your gloved fingers.

4. Support the patient’s breathing by administering oxygen (if available) and by keeping the airway open.

a. A spinal cord injury may paralyze some or all of the respiratory muscles, resulting in abnormal breathing patterns.

b. Breathing using the diaphragm only is called abdominal breathing.

5. Monitor circulation.

6. Assess the pulse, movement, and sensation in all extremities.

7. Examine and treat other serious injuries.

8. Do not move the patient unless it is necessary to perform CPR or to remove him or her from a dangerous environment.

9. Assist in immobilizing the patient using a long or short backboard.

10. Arrange for prompt transport.

E. Stabilizing the cervical spine

1. Stabilization of the cervical spine is initially accomplished manually, as shown in Skill Drill 14-7.

F. Motorcycle and football helmets

1. In most cases, helmets do not need to be removed.

a. Helmets are frequently fitted to be snug and cradle the head.

b. They can be secured directly to the spinal immobilization device.

2. You should remove part or all of a helmet only under two circumstances:

a. When the face mask or visor interferes with adequate ventilation or with your ability to restore an adequate airway

i. When part of a motorcycle helmet interferes with ventilation, the visor should be lifted away from the face.

ii. In the case of a football helmet, the face guard should be removed.

iii. In most instances, exposing the face and jaw allows you access to the airway to secure adequate ventilation.

iv. Follow the steps in Skill Drill 14-8 to remove the mask on a sports helmet.

b. When the helmet is so loose that securing it to the spinal immobilization device will not provide adequate immobilization of the head

i. A loose helmet can be removed easily while the head and neck are being stabilized manually.

ii. The procedure for helmet removal in this circumstance is shown in Skill Drill 14-9.

XII. Injuries of the Chest

A. The chest cavity contains the lungs, the heart, and several major blood vessels.

B. The cavity is surrounded and protected by the chest wall, which is made up of the ribs, cartilage, and associated chest muscles.

C. Fractures of the ribs

1. Even a simple fracture of one rib produces pain at the site and difficulty breathing.

2. Multiple rib fractures result in significant breathing difficulty.

3. The patient may not be able to breathe deeply enough to take in adequate amounts of oxygen.

4. Rib fractures may be associated with injury to the underlying organs.

5. To determine whether a rib is bruised or broken, apply some pressure to another part of the rib.

a. Pain in the injured area indicates a bruise, crack, or fracture.

6. If the injury is to the side of the chest, place one hand on the front of the chest and the other on the back and squeeze gently.

7. To check an injury to the front or back of the rib cage, put your hands on either side of the chest and squeeze gently.

8. In patients with rib fractures, be alert for signs and symptoms of internal injury, particularly shock.

9. Treatment of rib fractures

a. Place a pillow against the injured ribs to splint them.

b. Prevent excessive movement of the patient as you prepare for transport.

c. Administer oxygen if it is available and you are trained to use it.

D. Flail chest

1. If three or more ribs are broken in at least two places, the injured portion of the chest wall does not move with the rest of the chest.

2. The injured part bulges outward when the patient exhales and moves inward when the patient inhales.

3. A flail chest decreases the amount of oxygen and carbon dioxide exchanged in the lungs, and it causes breathing problems that will progressively become worse.

4. Treatment of flail chest

a. Firmly place a pillow on the flail section of the chest to stabilize it.

b. In severe cases, it may be necessary to support the patient’s breathing.

c. Monitor and support the patient’s ABCs.

d. Arrange for prompt transport.

E. Penetrating chest wounds

1. If an object (a knife or bullet) penetrates the chest wall, air and blood escape into the space between the lungs and the chest wall.

2. The air and blood may cause the lung to collapse.

a. Lung collapse greatly reduces the amount of oxygen and carbon dioxide that is exchanged and can result in shock and death.

b. Blood loss into the chest cavity can produce shock.

3. Treatment of penetrating chest wounds

a. Quickly seal an open chest wound with a material that will prevent more air from entering the chest cavity.

i. If it is more difficult for a patient to breathe after you seal the wound, uncover one corner of the occlusive dressing to see if the breathing improves.

b. Administer oxygen if it is available and you are trained to use it.

c. If a knife or other object is impaled in the chest, do not remove it.

i. Seal the wound around the object with a dressing to prevent air from entering the chest.

ii. Stabilize the impaled object with bulky dressings.

d. Any chest injury that results in air leakage and bleeding requires prompt transport.

e. Patients with severe chest injuries require rapid transport.

f. A conscious patient with chest trauma should be placed in a sitting position to ease breathing.

i. Unless you must immobilize the spine or treat the patient for shock, help the patient assume whatever position eases his or her breathing.

g. If the patient’s heart stops, begin chest compressions, regardless of whether chest injuries are present.

XIII. Summary

A. Musculoskeletal injuries are caused by three types of mechanism of injury: direct force, indirect force, and twisting force.

B. A fracture is a broken bone. Fractures can be closed (the bone is broken but there is no break in the skin) or open (the bone is broken and the overlying skin is lacerated).

C. A dislocation is a disruption that tears the supporting ligaments of the joint.

D. A sprain is a joint injury caused by excessive stretching of the supporting ligaments.

E. Follow three steps in examining a patient with a limb injury:

1. Perform a general assessment of the patient.

2. Examine the injured part.

3. Evaluate the circulation, sensation, and movement in the injured limb.

F. Regardless of the extent or severity, all limb injuries are treated the same way in the field. For all open extremity wounds, first cover the entire wound with a dry, sterile dressing and then apply firm but gentle pressure to control bleeding, if necessary. The injured limb should then be splinted.

G. The three basic types of splints are rigid, soft, and traction.

H. It takes two people to splint most limb injuries adequately: one to stabilize and support the extremity and one to apply the splint.

I. Severe head and spinal cord injuries can result from many different kinds of trauma. These injuries are common causes of death; if not fatal, they may lead to irreversible paralysis and permanent brain damage.

J. Injuries of the head are classified as open or closed. In a closed head injury, bleeding and swelling within the skull may increase pressure on the brain, leading to irreversible brain damage. An open injury of the head usually bleeds profusely.

K. When a sign or symptom of a head injury is present, immobilize the head and stabilize the patient’s neck; maintain an open airway; support breathing; monitor circulation; determine whether cerebrospinal fluid or blood is seeping; control bleeding with dry, sterile dressings; treat other serious injuries; and arrange for prompt transport.

L. Airway obstruction is the primary danger in severe facial injuries.

M. When facial injuries are present, immobilize the head and stabilize the patient’s neck; maintain an open airway; support breathing; monitor circulation; control bleeding with a dry, sterile dressing and apply direct pressure; treat other serious injuries; and arrange for prompt transport.

N. When you suspect a spinal injury, do not move the patient during the examination, and do not allow the patient to move.

O. When a sign or symptom of spinal injury is present, place the patient’s head and neck in a neutral position; stabilize the head and prevent movement of the neck; maintain an open airway; support breathing; monitor circulation; assess pulse, movement, and sensation; examine and treat other serious injuries; assist in immobilizing the patient using a long or short backboard; and arrange for prompt transport.

P. The most common chest injuries are rib fractures, flail chest, and penetrating wounds.

Post-Lecture

This section contains various student-centered end-of-chapter activities designed as enhancements to the instructor’s presentation. As time permits, these activities may be presented in class. They are also designed to be used as homework activities.

Assessment in Action

This activity allows the student an opportunity to analyze an emergency care scenario and develop responses to critical-thinking questions. This scenario is designed to help students gain a further understanding of issues surrounding musculoskeletal care.

Instructor Directions

1. Direct students to read the “Assessment in Action” scenario located in the Prep Kit at the end of Chapter 14.

2. Direct students to read and individually answer the quiz questions at the end of the scenario. Facilitate a class review and discussion of the answers, allowing students to correct their responses as needed. Use the quiz question answers noted here to assist in building this review.

3. You may wish to ask students to complete the activity on their own and turn in their answers on a separate piece of paper.

Answers to Assessment in Action Questions

1. Answer: C Perform a full-body assessment.

2. Answer: D Any part of the body

3. Answer: B A rigid splint

4. Answer: A Yes

5. Answer: D Stop the bleeding with direct pressure, cover the wound with a sterile dressing, and splint the leg.

6. Answer: D Immobilize the fracture site and the joints above and below it.

7. Answer: D Immobilize the joint and the bones above and below it.

8. Answer: Circulation, sensation, and movement should be evaluated in the injured limb after the primary assessment has been completed and again after any motion or splinting.

9. Answer: There is a possibility of spinal injury because of indirect force being transferred from the feet, through the legs to the pelvis and to the spine. This patient should be evaluated for injuries to all the bones and joints from the feet to the head. Spinal injury may occur because of the compressive forces of landing on the feet.

10. Answer: The lower leg should be splinted using a rigid splint that immobilizes the ankle and knee. The splint should be well padded and secured with an elastic bandage. Circulation, sensation, and motion of the injured limb should be assessed before and after splinting. The patient should also be placed in spinal immobilization and transported to a medical facility on a long backboard with a cervical collar in place. Once the patient is immobilized and secured on the backboard, circulation, sensation, and motion should be reevaluated in all four limbs.

Lesson Review

A. What is a mechanism of injury? Give some examples. (Lecture IV)

B. Describe the difference between the following conditions: (Lecture V)

1. Fracture

2. Sprain

3. Dislocation

C. Should the initial patient assessment portion of the patient assessment sequence be done before an injured extremity is treated? (Lecture VII-A)

D. True or false: You should ask a patient whether he or she can move the injured extremity after you have completed your hands-on examination. (Lecture VII-C)

E. What are the four things you should assess when examining a patient with a musculoskeletal injury? (Lecture VII-C)

F. Name some signs and symptoms of a head injury. (Lecture IX-D)

G. Name some signs and symptoms of a spine injury. (Lecture XI-C)

H. When should you remove a football helmet? (Lecture XI-F)

Assignments

A. Complete all the Student Workbook activities for Chapter 14.

B. Review all materials from this lesson and be prepared for a lesson quiz to be administered (date to be determined by the instructor).

C. Read Chapter 15: Childbirth for the next class session.

Unit Assessment Keyed for Instructors

1. List the seven areas of the skeletal system.

Answer: Head, skull, and face; spinal column; shoulder girdle; upper extremities; rib cage (thorax); pelvis; lower extremities

p 306

2. Musculoskeletal injuries are caused by the following types of mechanisms of injury, except:

A. direct force.

B. indirect force.

C. low-energy force.

D. twisting force.

Answer: C

p 308

3. A ____________ is a disruption that tears the supporting ligaments of the joint.

A. fracture

B. dislocation

C. sprain

D. strain

Answer: B

p 309

4. Name four signs of injury you should look for during an examination of a limb.

Answer: An open wound, deformity, swelling, and bruising

p 310

5. Which procedure is done at least twice whenever a splint is applied?

A. elevation of the injured extremity

B. manual stabilization of the injured extremity

C. assessment for circulation, sensation, and movement distal to the injury

D. application of gentle manual traction

Answer: C

p 311

6. List three examples of rigid splints.

Answer: Padded board splints, molded plastic or aluminum splints, padded wire ladder splints, SAM splints, folded cardboard splints

p 314

7. Emergency care of a patient who has a painful, deformed femur includes:

A. moving the patient as soon as possible.

B. treating the patient for shock.

C. having the patient attempt to walk.

D. asking the patient to move the limb.

Answer: B

p 320

8. Facial injuries commonly result from which of the following types of incidents?

A. motor vehicle crashes in which the patient’s face hits the steering wheel or windshield

B. assaults

C. falls

D. all of the above

Answer: D

p 329

9. The unconscious trauma patient should be:

A. treated as if he or she has a potential spine injury.

B. rolled immediately to check for back injuries.

C. placed in the recovery position.

D. placed in a prone position for fluid to drain.

Answer: A

p 330

10. When treating a patient with a potential spine injury, one EMR should always:

A. strap the patient’s head, and then his or her torso, to the long spine board.

B. maintain constant manual in-line immobilization until the patient is secured to the backboard.

C. assess for range of cervical spine motion.

D. pad the neck before stabilizing the patient.

Answer: B

p 331

Unit Assessment

1. List the seven areas of the skeletal system.

2. Musculoskeletal injuries are caused by the following types of mechanisms of injury, except:

A. direct force.

B. indirect force.

C. low-energy force.

D. twisting force.

3. A ____________ is a disruption that tears the supporting ligaments of the joint.

A. fracture

B. dislocation

C. sprain

D. strain

4. Name four signs of injury you should look for during an examination of a limb.

5. Which procedure is done at least twice whenever a splint is applied?

A. elevation of the injured extremity

B. manual stabilization of the injured extremity

C. assessment for circulation, sensation, and movement distal to the injury

D. application of gentle manual traction

6. List three examples of a rigid splint.

7. Emergency care of a patient who has a painful, deformed femur includes:

A. moving the patient as soon as possible.

B. treating the patient for shock.

C. having the patient attempt to walk.

D. asking the patient to move the limb.

8. Facial injuries commonly result from which of the following types of incidents?

A. motor vehicle crashes in which the patient’s face hits the steering wheel or windshield

B. assaults

C. falls

D. all of the above

9. The unconscious trauma patient should be:

A. treated as if he or she has a potential spine injury.

B. rolled immediately to check for back injuries.

C. placed in the recovery position.

D. placed in a prone position for fluid to drain.

10. When treating a patient with a potential spine injury, one EMR should always:

A. strap the patient’s head, and then his or her torso, to the long spine board.

B. maintain constant manual in-line immobilization until the patient is secured to the backboard.

C. assess for range of cervical spine motion.

D. pad the neck before stabilizing the patient.

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