FMST Student Manual - 2008 Web Edition*

Manage Musculoskeletal Injuries

ENABLING LEARNING OBJECTIVES

1.    Without the aid of references, given a description or list, identify the anatomy of the musculoskeletal system, per the student handout.  (FMST-HSS-1407a)

2.    Without the aid of references, given a description or list, identify standard medical terminology related to the musculoskeletal system, per the student handout.  (FMST-HSS-1407b)

3.    Without the aid of references, given a description or list, identify the type of musculoskeletal injuries, per the student handout. (FMST-HSS-1407c)

4.    Without the aid of references, given a description or list, identify the treatment for musculoskeletal injuries, per the student handout. (FMST-HSS-1407d)

5.    Without the aid of references, given a description or list, identify the general rules for splinting, per the student handout.  (FMST-HSS-1407e)

6.    Without the aid of references, given a description or list, identify the three types of splints, per the student handout.  (FMST-HSS-1407f)

7.    Without the aid of references, given a simulated casualty with musculoskeletal injuries and standard field medical equipment and supplies, manage the casualty, per the student handout.  (FMST-HSS-1407g)

1.      ANATOMY

The Skeletal System - composed of all the bones, joints and muscles of the body, as well as cartilage, tendons and ligaments.  Bones are formed of dense connective tissue.  As components of the skeleton, they provide the body’s framework.  They are strong in order to provide support and protection for the internal organs, but they are also flexible to withstand stress.

Axial Skeleton - consists of the skull, spinal column, and rib cage.

Appendicular Skeleton - consists of  the upper extremities to include the scapula and bones of the lower extremities to include the pelvic girdle.

Appendages:

Upper extremities - made up of the humerus, ulna, radius and bones of the wrist and hand

Lower extremities - made up of the femur, tibia, fibula and bones of the ankles and feet

Types of Bones - there are four types of bones that are classified by shape

Long bones - such as the femur and humerus

Short bones - such as the wrist and ankle bones

Irregular bones - such as vertebrae, mandible and pelvic bone

Flat bones - such as the sternum and skull

Muscular System

Muscles - tissue fibers that cause movement of body parts or organs.  There are three kinds of muscles. 

Skeletal (voluntary)

Smooth (involuntary)

Cardiac (myocardium)

 Cartilage - connective tissue covering the outside of bone ends and act as a surface for articulation.

Tendons - bands of connective tissue that bind the muscle to bones.

Ligaments - connective tissues that support joints by attaching the bone ends and allowing for stable range of motion (see figure 3).

2.      TYPES OF MUSCULOSKELETAL INJURIES

Soft Tissue Injuries - involve the skin and underlying musculature, commonly referred to as either a closed or open wound.

Closed - an injury where there is no open pathway from the outside to the injured site.

Open - an injury in which the skin is interrupted, or broken, exposing the tissues underneath.  Open wounds include abrasions, lacerations, avulsions, and amputations.

Abrasions

Definition - superficial scratches of the skin’s surface.  Also called "brush burns," "mat burns," and  "road rash."  Some bleeding may result, but usually oozes from injured capillaries.  Extremely painful because nerve endings are involved.

Treatment:

- Hemorrhage is usually so minimal that primary treatment may only require cleansing of the wound.

- Small bandages may be applied but tactical situations will usually preclude applying field dressings that are needed for more serious injuries.

- A large amount of dirt may be ground into the wound, therefore secondary treatment measures should focus on preventing or stopping infections.  

Lacerations

Definition - a laceration is a cut.  It may be smooth or jagged and can be caused by an object with a sharp edge or may result from a severe blow or impact with a blunt object (see figure 7).

­Treatment - treatment is generally the same as for abrasions:

- Control hemorrhage

- If major tendons and muscles are completely severed, immobilize limb to prevent further damage.

- Treat for shock

- Consider CASEVAC    

Avulsion

Definition - an injury in which flaps of skin are torn loose or completely pulled off (see figure 8).

Treatment

- Control bleeding

- Apply field dressing to avulsed area.  (For extremely large or deep avulsions, several pressure dressings may be necessary or an air splint and dressing).

- Transport the avulsed part to the BAS with the patient but keep it well-protected from further damage and out of view of the patient.

- Immobilize extremity or body part as indicated by the severity of the avulsion. 

Amputations     

Definition - removal of a limb or other appendage of the body.  May be removed surgically or traumatically.  Because blood vessels are elastic, they tend to spasm and retract into surrounding tissue.  With complete amputations there is less bleeding then with partial or degloving cases. 

Treatment

- Hemorrhage Control - Apply a tourniquet.  If a tourniquet is applied, mark the patient's forehead with a "T" (indicating the time it was applied).

- Place the patient in shock position.  (Head down, feet elevated)

- Make every effort to preserve the amputated part and evacuate the patient as soon as possible.

- Wrap amputated part in sterile dressing, place in ice and send with patient.  When possible, prevent direct contact between tissue and ice.

Strains, Sprains and Dislocations

Strain - injury to a muscle or tendon resulting from over stretching or overexertion.

Sprain - a joint injury resulting in partial tearing or stretching of supporting ligaments (see figure 10).

Dislocation - the displacement of bone ends at the joints resulting in an abnormal stretching of the ligaments around the joints.  Sometimes causes tearing or complete ligament separation (see figure 11).

Signs and Symptoms

- Complete or near complete loss of movement of joint

Treatment

Strains Sprains:

- Supportive strapping or bandaging

- Immobilize by splinting so that affected muscle is in relaxed position, if injury is severe

-R.I.C.E. (Rest, Ice, Compression, Elevation)

- Attempt to reduce only if no pulse is present in the extremity.  If patient can be CASEVAC’ed quickly, the better decision may be to transport rather than attempt manipulation.

- Splint, as found, to immobilize injured part.

- Pain management

- CASEVAC

Complications

Hemorrhage - caused by separated bone ends tearing muscle tissue and laceration of blood vessels

Nerve Damage - due to the cutting or pinching of nerves by seperated bone ends or muscle injury 

Fractures

Definition - a break in the continuity of the bone.  This may result in partial or complete disruption of the bone.  May be classified as either open or closed:

Open fracture - initial injury or bone end has produced an open wound at or near the fracture site.

Closed fracture - the bone is broken with no skin penetration

- Discoloration

- Deformity

- Edema

- Crepitus/grating

- Point tenderness

- Limited range of motion

- Direct or indirect pain

- Exposed bone fragments (open fractures)

General Principles of Treatment for Fractures - the following guidelines can be applied to any type of fracture, regardless of location: 

- Control hemorrhage

- Treat for shock

- Check distal pulses before and after splinting

- Immobilize the fracture using splints

- Recheck PMS (Pulse, motor, and sensation)

- Relieve pain (see medication appendix at the back of Block 2 for more information)

- DO NOT reduce fractures in field unless distal pulses are not present

- Monitor and CASEVAC 

3.      SPLINTS AND SPLINTING

Definition - an appliance made of wood, metal or plaster used for the fixation, union or protection of an injured part of the body.

Purpose

- To immobilize the injured body part

- To prevent further damage to muscles, nerves, or blood vessels caused by broken ends of bone

- To prevent a closed fracture from converting to an open fracture

- To decrease pain

General Rules for Splinting

- Control hemorrhage.  Direct pressure and/or pressure dressings will control vitually all external hemorrhage encountered in the field.

- Expose fracture site.  Remove jewelry and watches.

- Before splinting, establish distal pulse.

- Splint in the position found unless limb is pulse-less.

- An attempt should be made to straighten a SEVERELY deformed limb with gentle traction only if there are no distal pulses, if resistance is felt, stop and splint as it lies.

- Move the fractured part as little as possible while applying the splint.

- DO NOT retract the exposed bone of an open fracture back into the body.

- Pad splint at bony prominence points (elbow, wrist and ankle).

- Splint the joints above and below the fracture site.

- Reassess circulation and neurological status after splinting.

- When in doubt treat as a fracture. 

Anatomical Splints - use of the patient's body as a splint

- Strap legs together

- Secure arm to chest

Improvised Splints - made from any available material that can be used to stabilize a fracture.  The only limitation to improvised splinting is your imagination and creativity.

Manufactured Splints - manufactured splints are generally designed for specific injuries, thus they are applied in specific ways.

Soft Splint - the soft splint can be used to splint various fractures throughout the body.

Purpose - used to immobilize fractures and suspected fractures of the neck, back, arms, and legs.

Description - a wrap around, non-rigid splint that limits motion in the area applied

commonly made from items such as pillows, ponchos, and blankets.

Rigid Splint/ SAM Splint

Purpose - used to immobilize suspected fractures.

Description - a rigid splint that prohibits motion in the area applied.

Air Splints

Purpose - used to immobilize arms and legs (see figure 15).

Description - a pre-formed, one piece, clear plastic, balloon-like envelope with a  zipper, string, velcro, or combination of these for closure.

- If splint is used in aircraft, some air may have to be released as plane gains altitude.

- This splint is inflatable (be careful not to over inflate the splint).        

Splinting for Specific Types of Fractures

Fractured Clavicle - immobilize using a figure eight bandage.

Fractured Humerus - splint to body using full arm wrap leaving elbow exposed.

Fractured Radius/Ulna

- Splint from wrist to elbow.

- Place patient's hand in top of jacket for elevation and support.

- Sling arm using a cravat to cradle elbow and tie around neck for immobilization.

Fractured Wrist/Hand

- Splint in position of function, leaving fingers exposed to check circulation.

- Place patient's hand in top of jacket for elevation and support.

Fractured Ribs

- Single closed rib fractures - do not bind or strap around chest.

- Multiple fractures - immoblize flailed segments, do not hinder breathing.  Sling and swathe arm to injured side of chest to reduce motion and pain.  Do not hinder breathing!

Fractured Pelvis - consider wrapping bed sheet tightly around lower aspect of pelvis and tying it as a sling.

- Strap knees and ankles together.

- Place pad around bony prominences and soft pad under knees.

Fractured Femur - immobilize fractured leg by splinting one leg to the other with five ties.

- One above wound

- One below wound

- One above the knees

- One below the knees

- One around feet to secure ankles/boots

Fractured Patella - splint to other leg using four ties:

- One around the thighs

- One above the knee

- One below the knee

- One around the ankles

Fractured Tibia/Fibula - splint one leg to the other with four cravats or improvised ties:

- One above wound.

- One below wound.

- One around the thighs

- One around feet to secure ankles/boots

Fractures of Ankle/Foot - immobilize using soft splint or uninjured extremity and four cravats:

- One above the ankle

- Figure eight bandage around the ankles

- One below the knee

- One above the knee

REFERENCE

Pre-Hospital Trauma Life Support, Military Edition, 6th Ed, Chapter 12

REV: July 2008

Musculoskeletal Injuries Review