Pathophysiology of the Musculoskeletal SystemJoint Injury

SprainSubluxationDislocation

Bone InjuryOpen FractureClosed FractureHairline FractureImpacted Fracture

Pathophysiology — Mechanism of InjuryFive forces cause bone and joint injury

Direct force

Indirect force

Twisting force

Pathological

Fatigue

Classifications of Musculoskeletal InjuriesInjuries include:

FracturesSprainsStrains

Joint dislocations

Musculoskeletal InjuriesDirect trauma

Blunt force applied to an extremity

Indirect traumaVertical fall that produces spinal fracture

distant from site of impact

Pathological conditionsSome forms of arthritisMalignancy

Pathophysiology — FracturesUnstable — Proximal and distal ends move

freely in relationship to each other

Impacted — Jammed together so there is no movement between proximal and distal bones

Open — Skin is open, allowing introduction of bacteria, dirt, and other foreign bodies

Closed — Skin is intact

Fracture with dislocation — Fracture at joint with injury to supporting structures

FracturesBreak in continuity of bone or cartilage

Complete or incompleteLine of fracture through bone

Open or closedIntegrity of skin near fracture site

Classification of FracturesOpen

Closed

Comminuted

Greenstick

Spiral

Classification of FracturesOblique

Transverse

Stress

Pathological

Epiphyseal

Classification of Fractures

Pathophysiology — Fractures Impacted

Pathophysiology — Fractures

Joint DislocationsNormal articulating ends of two or more bones

are displacedLuxation: Complete dislocationSubluxation: Incomplete dislocation

Frequently dislocated joints

Suspect joint dislocation when joint is deformed or does not have normal range of motion

Dislocations can result in great damage and instability

Pathophysiology — Fractures Dislocation - Angulated

Pathophysiology — Fractures

SprainsPartial tearing of ligament

Caused by sudden twisting or stretching of joint beyond normal range of motion

Common in ankle and knee

Graded by severityFirst-degree sprainSecond-degree sprainThird-degree sprain

StrainsInjury to muscle or its tendon

Overexertion or overextension

Common in back and arms

May have significant loss of function

Severe strains may cause avulsion of bone from attachment site

Pathophysiology of the Musculoskeletal SystemInflammatory & Degenerative Conditions

BursitisTendinitisArthritis

OsteoarthritisDegenerative

Rheumatoid ArthritisChronic, systemic, progressive, debilitating

Gout Inflammation of joints produced by accumulation

of uric acid crystals

BursitisInflammation of bursa

Small, fluid-filled sac acts as cushion at a pressure point near joints

Most important bursae are around knee, elbow, and shoulder

BursitisBursitis is usually from:

Pressure FrictionInjury to membranes surrounding the joint

TreatmentRest, ice, and analgesics

TendonitisInflammation of tendon

Often caused by injury

Symptoms include:PainTendernessRestricted movement of muscle attached to affected

tendon

TreatmentNonsteroidal antiinflammatory drugs (NSAIDs)Corticosteroid medications

ArthritisJoint inflammation

Pain, swelling, stiffness, and redness

Joint disease Involving one or many joints Many causes

Varies in severity Mild ache and stiffness Severe pain and later joint deformity

ArthritisOsteoarthritis (degenerative arthritis) most

common

Pain usually managed with antiinflammatory agents

Extremity TraumaSigns and symptoms

Pain on palpation or movementSwelling, deformityCrepitusDecreased range of motionFalse movement (unnatural movement of

extremity)Decreased or absent sensory perception or

circulation distal to injury

Six "P"s of Compartment SyndromePain

On palpation (tenderness)On movement

Pallor—pale skin or poor capillary refill

Paresthesia—pins and needles sensation

Pulses—diminished or absentParalysis—inability to movePressure

Associated Complications Hemorrhage

Instability

Loss of tissue

Simple laceration and contamination

Interruption of blood supply

Nerve damage

Long-term disability

AssessmentDetermine if life-threatening conditions are

presentCare for those first

Never overlook musculoskeletal trauma

Don’t allow noncritical musculoskeletal injury to distract from priorities of care

Musculoskeletal AssessmentFour classes of patients

Life-/limb-threatening injuries or conditionsIncludes life-/limb-threatening musculoskeletal

traumaOther life-/limb-threatening injuries and

simple musculoskeletal traumaLife-/limb-threatening musculoskeletal

trauma No other life-/limb-threatening injuries

Isolated, non-life-/limb-threatening injuries

Musculoskeletal Injury AssessmentScene Size-upInitial Assessment

Categories of urgencyLife & Limb threatening injuryLife threatening injury and minor musculoskeletal

injuryNon-life threatening injuries but serious

musculoskeletal injuriesNon-life threatening injuries and only isolated minor

musculoskeletal injuriesRapid Trauma AssessmentFocused H&P

6 P’s: Pain, Pallor, Paralysis, Paresthesia, Pressure, Pulses

Detailed Physical ExamOngoing AssessmentSports Injury Consideration

Age-Associated Changes in BonesWater content of intervertebral disks

decreasesIncreased risk of disk herniationLoss of stature is common – ½ - 3/4 inch Bone tissue disorders shorten trunk

Age-Associated Changes in BonesVertebral column assumes arch shape

Costal cartilages ossify, making thorax more rigid

Shallow breathing due to rigid thoracic cage

Facial contours change

Fractures

Limb-Threatening InjuriesKnee dislocationFracture or dislocation of ankleSubcondylar fractures of elbowRequire rapid transport

Musculoskeletal Injury ManagementOther Injury Consideration

Pediatric Musculoskeletal InjuryAthletic Musculoskeletal InjuryPatient Refusals & ReferralPsychological Support

Musculoskeletal Injury ManagementGeneral Principles

Protecting Open WoundsPositioning the limbImmobilizing the injuryChecking Neurovascular Function

Musculoskeletal Injury ManagementSplinting Devices

Rigid splintsFormable SplintsSoft SplintsTraction SplintsOther Splinting Aids

Vacuum SplintsAir SprintsCravats or Velcro Splints

Fracture CareJoint CareMuscular & Connective Tissue Care

Musculoskeletal Injury ManagementCare for Specific Fractures

PelvisScoop StretcherPASGFluid Resuscitation

FemurTraction SplintsPASGFracture versus hip doslocation

Musculoskeletal Injury ManagementCare Specific Fractures

Tibia/FibulaClavicle

Most frequently fractured bond in the bodyTransmitted to 1st and 2nd ribAlert for lung injury

HumerusRadius/Ulna

Musculoskeletal Injury ManagementCare for Specific Joint Injuries

HipKneeAnkleFootShoulderElbowWrist/HandFinger

Joint Injuries

Alert for PMS Compromise

Musculoskeletal Injury ManagementSoft & Connective Tissue Injuries

TendonLigamentMuscle

Musculoskeletal Injury ManagementMedications

Nitrous Oxide50% O2:50% NNon-explosiveEffects dissipate in

2-5 minutesEasily diffused into

air filled spaces in body.

DoseInhaled & self

administeredOnset

1-2 minutes

Not A Biotel OptionDiazepam

BenzodiazepineAntianxietyAnalgesicDose

5-15 mg titratedOnset

10-15 minutesDuration

15-60 minutesCounter Agent

Flumazenil

Dislocation of Acromioclavicular Joint

Humerus InjuryOlder adults and

children

Difficult to stabilize

ComplicationsRadial nerve damage if

fracture in middle or distal portion of humeral shaft

Humeral neck fracture may cause axillary nerve damage

Internal hemorrhage into joint

Musculoskeletal Injury ManagementMedications

Oxygen n Nitrous Oxide n Morphine SulfateFluids

Oxygen n Nitrous Oxide n Morphine SulfateFluids

Nitrous Oxide Nitrous Oxide Class: Gaseous Analgesic/Anesthetic Route: Inhalation Adult Dose: Instruct

patient to inhale deeply through patient-held mask or mouthpiece Pediatric

Dose: Instruct patient to inhale deeply through patient-held mask or mouthpiece Drug

Action: Depresses the central nervous system Increases oxygen tension in the blood thereby reducing hypoxia Onset:2 minutes - 5 minutes Duration:2 minutes - 5 minutes 

Nitrous Oxide Nitrous Oxide Indications: Adjunct analgesic for ischemic chest

pain  Severe pain or discomfort in all patients without contraindications.  

Precautions: Must be self administered  Check machine gauges daily for proper concentrations  Monitor blood pressure and pulse oximetry values during administration  

Side Effects: Hypotension Dizziness Nausea and vomiting 

Contraindications: Any altered level of consciousness or head injury  Chronic obstructive pulmonary disease   Chest trauma or actual/suspected pneumothorax  Abdominal trauma  Major facial trauma  Acutely psychotic patients  Pregnancy, other than active labor  Any patient (adult or pediatric) unable to self-administer Decompression sickness

Morphine Sulfate Indications Pain and anxiety secondary to AMI

Chest pain unrelieved by NitroglycerinPulmonary edemaPain secondary to amputations or fractures

Precautions: Monitor respiratory status and blood pressure closely.

Notify Biotel prior to administration if patient is >65yrs of age, debilitated, has altered mental status, or systolic BP<110mmHg

CHF: be prepared to intubate

Antidote: Naloxone (Narcan®)

Morphine SulfateMorphine SulfateClass: Narcotic Analgesic Route: Slow IV push

Dose: Adult: Administer in titrated doses of 2 - 4mg, up to a maximum of 10mg

Pediatric:0.1mg/kg

Drug Action: Alleviates pain Decreases peripheral vascular resistance -

vasodilatorDecreases cardiac workload and oxygen

demand on the heart