Musculoskeletal Trauma
Musculoskeletal trauma is connected to broader emergency care topics, specifically secondary assessment and the management of bleeding and shock.
Secondary assessment involves a thorough evaluation of injuries, including musculoskeletal trauma, to identify all potential problems after initial life threats are addressed.
Bleeding and shock are critical complications that can arise from musculoskeletal injuries, requiring prompt recognition and intervention to prevent further harm.
Standard
Orthopedic trauma involves injuries to the musculoskeletal system, including bones, joints, ligaments, tendons, and muscles.
Basic emergency care for acutely injured patients requires rapid assessment to identify life-threatening conditions and prioritize treatment.
Key steps include immobilizing fractures and dislocations, controlling bleeding, and preventing further injury during transportation.
Assessment findings guide emergency interventions, such as splinting, applying dressings, and monitoring for signs of shock.
Core Concepts
Understanding the musculoskeletal system involves knowing the structure and function of bones, muscles, and related components.
Emergency care for musculoskeletal injuries follows general guidelines, including assessing the injury, preventing further harm, and providing appropriate first aid.
Splinting serves to immobilize injured areas, reduce pain, and prevent further injury; general procedures include selecting the right type of splint and applying it properly to support the affected limb.
Assessment and care of upper and lower extremity injuries require evaluating the specific injury, monitoring for signs of circulation or nerve impairment, and applying targeted first aid measures to stabilize and protect the injured area.
Learning Objectives
The musculoskeletal system provides support, movement, and protection for the body, and consists of bones, joints, muscles, cartilage, ligaments, and tendons.
Bones are living tissues that can heal after injury, but their structure and function mean that skeletal injuries can have significant consequences, including potential damage to underlying organs.
Joints connect bones and allow for movement; understanding their function helps anticipate injury patterns.
Muscles, cartilage, ligaments, and tendons each have distinct roles: muscles produce movement, cartilage cushions joints, ligaments connect bones, and tendons attach muscles to bones.
Certain fractures, such as those involving the pelvis or femur, have a high risk of emergency complications like severe bleeding or organ injury.
Assessment of musculoskeletal injuries includes checking for deformity, swelling, pain, and loss of function, as well as performing serial checks of distal circulation, sensation, and motor function (CSM) to monitor for complications like compartment syndrome.
Management priorities include ensuring patient safety, immobilizing injuries, and using splints appropriately to prevent further damage; traction may be used in specific cases.
Transport decisions should consider the severity of the musculoskeletal injury in the context of the patient’s overall condition, prioritizing life-threatening issues first.
Key Terms
Musculoskeletal injuries involve damage to muscles, bones, joints, ligaments, tendons, and cartilage, and can range from minor to life-threatening.
Fractures are breaks in bones and can be classified as angulated, comminuted (bone broken into multiple pieces), greenstick (incomplete fracture, common in children), open (bone protrudes through skin), or closed (skin intact).
Dislocations occur when bones are forced out of their normal position in a joint, often accompanied by ligament injury.
Sprains involve stretching or tearing of ligaments, while strains affect muscles or tendons.
Compartment syndrome is a serious complication where increased pressure within a muscle compartment impairs blood flow and can lead to tissue damage.
Crepitus is a grating sensation or sound felt over fractured bone ends.
Manual traction and traction splints are techniques used to align and stabilize fractures, especially in extremities.
Evaluation of musculoskeletal injuries should not distract you from identifying and treating life-threatening conditions first.
Musculoskeletal System
The musculoskeletal system includes bones, joints, muscles, cartilage, tendons, and ligaments, forming the structural framework and enabling movement.
The skeleton is divided into two main parts: the axial skeleton and the appendicular skeleton.
The axial skeleton consists of the skull (cranium and face), sternum, ribs, and spine (cervical, thoracic, lumbar vertebrae, sacrum, and coccyx).
The appendicular skeleton includes the bones of the extremities: upper extremities (clavicles, scapulae, humerus, radius, ulna, carpals, metacarpals, phalanges) and lower extremities (pelvis—ilium, pubis, ischium—femur, patella, tibia, fibula, tarsals, metatarsals, phalanges).
The axial skeleton provides central support and protection for vital organs, while the appendicular skeleton enables limb movement and interaction with the environment.
The number of bones in each region is specific: for example, the skull has 22 bones (8 cranium, 14 face), the vertebral column includes 7 cervical, 12 thoracic, 5 lumbar vertebrae, 5 fused sacral, and 4 fused coccygeal vertebrae.
The upper extremities contain 60 bones (including humerus, radius, ulna, carpals, metacarpals, and phalanges), and the lower extremities also contain 60 bones (including femur, patella, tibia, fibula, tarsals, metatarsals, and phalanges).
Anatomy of Bone
Bones are dense connective tissue that form the body's framework, providing support, protection, and flexibility to withstand stress.
Bones are highly vascular, meaning they have a rich blood supply and can bleed significantly when fractured, potentially leading to shock from blood loss.
Bones store salts and metabolic materials and are the site for red blood cell production within the bone marrow.
Bones are classified by shape: long (arms, thighs), short (hands, feet), flat (sternum, ribs, shoulder blades), and irregular (vertebrae).
Bone strength comes from a combination of hardness (due to calcium) and flexibility (due to protein fibers); with age, bones lose protein and calcium, becoming brittle and more prone to fractures.
Bones are covered by the periosteum, a strong, white, fibrous membrane through which blood vessels and nerves pass; objects embedded in the periosteum should not be removed due to risk of further injury.
Joints are where bones meet (articulate), enabling movement; ball-and-socket joints have rounded bone ends (heads) connected to shafts by necks, allowing rotational movement.
Self-Healing Nature of Bone
A bone fracture is the most common bone injury, leading to swelling and blood clot formation due to damaged blood vessels in the periosteum and bone.
Interruption of blood supply at the fracture site causes cell death, while nearby cells survive and rapidly divide, forming a callus that surrounds the fracture.
The callus serves as the foundation for new bone generation, eventually healing the fracture over weeks or months, depending on factors like bone type, fracture type, patient health, and age.
Immediate and sustained immobilization of the broken bone is crucial for proper healing; mishandling can increase soft tissue damage, delay healing, and risk permanent disability.
In children, fractures near the growth plate can disrupt normal bone growth, potentially resulting in one limb being shorter if not properly managed.
Muscles, Cartilage, Ligaments, and Tendons
The musculoskeletal system includes muscles, cartilage, ligaments, and tendons in addition to bones.
Muscles are responsible for movement and are classified into three types: voluntary (skeletal), cardiac (myocardial), and involuntary (smooth). Skeletal muscles control conscious movements and are attached to bones, as well as present in the tongue, pharynx, and upper esophagus. Cardiac muscle is found in the heart, and smooth muscle is found in the walls of organs and digestive structures.
Cartilage is a flexible connective tissue that covers bone ends (epiphyses) at joints, enabling smooth articulation and forming flexible structures like the nose septum, external ear, trachea, and rib-sternum connections.
Tendons are connective tissues that attach muscles to bones, transmitting the force needed for movement across joints.
Ligaments are connective tissues that connect bone to bone, stabilizing joints and allowing a controlled range of motion.
Mnemonics to distinguish connective functions: (tendons connect muscle to bone) and (ligaments connect bone to bone).
General Guidelines for Emergency Care
Musculoskeletal injuries are caused by three main mechanisms: direct force, twisting force, and indirect force.
Direct force involves an external impact directly to the body, such as being struck by a vehicle, leading to crushed tissues and fractures.
Twisting force results from rotational movement, causing stretching or tearing of muscles and ligaments, and can also break bones; for example, when a skier’s body rotates while the ski remains fixed.
Indirect force occurs when the impact is transmitted through the body to another area, such as breaking a clavicle after falling on an outstretched arm.
Sporting activities and motor vehicle collisions are common sources of these injuries, with both direct and indirect forces capable of causing significant harm.
Indirect forces can cause injuries distant from the point of impact, such as injuries to the knees, femurs, pelvis, and spine when landing on feet after a fall from height, while direct forces affect the area of initial contact (feet and ankles in this example).
Injury to Bones and Connective Tissue
A fracture is a break in a bone, which may present with pain, swelling, and sometimes deformity, but not all fractures are obvious without imaging.
Field treatment should assume the worst—any painful, swollen, or deformed extremity should be treated as a fracture and immobilized, since distinguishing between fracture, dislocation, sprain, or bruise without imaging is not possible or necessary.
Bones are living tissue and can bleed significantly when fractured; blood loss varies by location: tibia–fibula fractures can cause about 500 mL loss, femur fractures about 1,000 mL, and pelvic fractures 1,500–2,000 mL.
Femur fractures historically had high mortality due to blood loss and muscle spasms, but the invention and early application of the traction splint greatly reduced death rates by stabilizing the bone and reducing spasms.
Splinting a suspected fracture prevents further blood loss, pain, and complications such as nerve and blood vessel injury.
Four main types of musculoskeletal injuries:
Fracture: break in a bone, classified as open (bone breaks through skin) or closed (skin intact), and by pattern (comminuted—broken in several places, greenstick—incomplete break common in children, angulated—bone bent at an angle).
Dislocation: disruption of a joint where ligaments and joint capsule are stretched and torn.
Sprain: stretching and tearing of ligaments, usually at joints.
Strain: muscle injury from overstretching or overexertion.
Open extremity injuries involve broken skin and higher risk of infection, often requiring surgery, while closed injuries do not break the skin and are less likely to become infected.
Proper splinting and care can prevent closed injuries from becoming open injuries and reduce the risk of further complications.
Assessment of Musculoskeletal Injuries
Examination of patients relies on inspection (looking), palpation (feeling), and auscultation (listening), but clothing may need to be removed or cut away based on the situation, environment, and patient needs.
During trauma assessment, always prioritize identifying and treating life-threatening conditions (airway, breathing, circulation, head, spine, chest, abdomen) before focusing on musculoskeletal injuries to the extremities.
Do not let severe-looking but non-life-threatening extremity injuries distract you from more serious, less obvious injuries; ensure a full assessment and ask appropriate questions to avoid missing other injuries.
Compartment syndrome occurs when bleeding and swelling from a fracture or crush injury increase pressure within a muscle compartment, compressing arteries, veins, and nerves, and potentially leading to loss of blood flow and tissue death if not relieved.
Progression of compartment syndrome:
Trauma causes bleeding and swelling in the muscle compartment.
Pressure builds, preventing arterial blood flow and tissue perfusion.
Cellular damage and further swelling occur.
Blood flow is lost, risking loss of the limb.
Signs and symptoms of compartment syndrome include pain, swelling, a sensation of pressure, hardness of the extremity on palpation, and reduced or absent distal circulation, sensation, and motor function (CSM); loss of distal pulse is a late sign.
Treatment for compartment syndrome includes cold application, elevation of the extremity (if safe after splinting), and prompt transport to an appropriate medical facility.
Patient Assessment
Pain and tenderness are key indicators of musculoskeletal injury; patients often guard the injured area and experience pain when it is touched or moved.
Deformity or angulation occurs when trauma causes bones to fracture and shift out of their normal position; comparing the injured side to the uninjured side can help identify subtle deformities.
Grating (crepitus) is the sound or sensation of bone ends rubbing together, which should not be intentionally elicited due to the pain it causes.
Swelling results from bleeding into soft tissues after a fracture, which can worsen deformity and may require removal of jewelry to prevent constriction.
Bruising (ecchymosis) indicates underlying injury and may be present hours or days after trauma; visible bruises suggest the need for splinting.
Exposed bone ends signal an open fracture that requires splinting, but life-threatening injuries should always be prioritized over extremity injuries.
Joints locked into position may occur with dislocations; these should be splinted in the position found.
Nerve and blood vessel compromise must be assessed by checking pulses, sensation, and movement distal to the injury, both before and after splinting; gloves and footwear must be removed for accurate assessment.
The six Ps for assessing extremity compromise are: Pain or tenderness, Pallor, Paresthesia (pins and needles), Pulses diminished or absent, Paralysis, and Pressure.
Important decision points include determining if the injuries constitute serious multiple trauma and whether circulation, sensation, and motor function (CSM) are present distal to the injury.
Patient Care
Always use Standard Precautions to protect yourself and the patient when managing musculoskeletal injuries.
Prioritize the primary assessment to identify and address life-threatening conditions before focusing on visible or painful extremity injuries.
Multiple fractures, especially of the femur, can cause severe bleeding (external or internal) and may be life-threatening.
Apply a cervical collar during the secondary assessment if a spinal injury is suspected.
After addressing life threats, splint any suspected extremity fractures; for stable (low-priority) patients, splint individual injuries before transport.
For unstable (high-priority) patients, immobilize the entire body on a long spine board and transport immediately; do not delay by splinting each injury separately.
If possible, cover open wounds with sterile dressings, elevate the injured extremity, and apply a cold pack to reduce swelling.
In unstable patients, managing airway, breathing, and circulation (A-B-Cs) takes precedence over treating extremity injuries; rapid transport is essential.
Splinting
Splinting is the first step in emergency care for suspected extremity fractures, and an effective splint must immobilize both the injury site and adjacent joints to minimize movement, reduce pain, and prevent further injury to soft tissues, nerves, and blood vessels.
Realignment (straightening) of a deformed extremity is performed to restore circulation and facilitate splinting, but is generally limited to angulated long bone shafts (humerus, ulna, radius, femur, tibia, fibula). Realignment should be done with gentle traction, stopping if resistance is felt or if bone ends threaten to break through the skin.
Splinting devices are categorized as rigid, formable, and traction splints: rigid splints (e.g., cardboard, wood, vacuum splints) provide strong support and require the limb to be in anatomic position; formable splints (e.g., pillows, blankets) mold to the limb and are used for joint injuries; traction splints are specifically for femur fractures.
Improvised splints can be used when standard devices are unavailable, such as using pillows, rolled blankets, lumber, cardboard, or even everyday objects like umbrellas or canes.
General rules for splinting include: address life-threatening conditions first, expose and control bleeding at the injury site, assess and record distal circulation, sensation, and motor function (CSM) before and after splinting, align long-bone injuries if necessary, never push protruding bones back in, and immobilize both the injury and adjacent joints.
The method of splinting is dictated by patient condition and transport priority: individual splinting is best but slowest, securing the limb to the torso or uninjured leg is faster, and full-body immobilization on a spine board is used for multiple fractures or unstable patients.
Padding voids between the splint and body is essential to ensure immobilization and patient comfort, especially with rigid splints that do not conform to body curves.
Major hazards of splinting include delaying care for life-threatening conditions and improper splint application—splints that are too tight can cause tissue and nerve damage, while those too loose can allow harmful movement.
For long-bone and joint injuries, the splinting process involves: taking standard precautions, exposing and stabilizing the injury, assessing CSM, realigning if necessary, measuring and positioning the splint, securing it to immobilize the injury and adjacent joints, and reassessing CSM after splinting.
Joints are usually splinted in the position found unless the distal extremity is cyanotic or pulseless, in which case gentle realignment toward the anatomic position is attempted.
SCAN 32-1
Always begin by taking standard precautions to protect yourself and the patient before immobilizing a long bone or joint.
Vacuum splints are flexible devices filled with small polystyrene pieces that become rigid when air is removed.
To use a vacuum splint, first assess and prepare the injured extremity, then position the splint around it, ensuring that the distal end (fingers or toes) remains exposed for circulation checks.
Remove air from the splint using a pump until the splint is firm, then secure it with Velcro straps.
Continuously monitor the patient after immobilization to ensure proper circulation and comfort.
SCAN 32-3
Femur fractures require traction splints to counteract muscle spasms and prevent bone ends from overriding, reducing pain and further injury.
Traction splints are categorized as bipolar (two rods cradling the leg, e.g., Hare, Fernotrac) and unipolar (one rod alongside the leg, e.g., Sager, Kendrick). Bipolar splints are anchored against the pelvis, while unipolar splints are anchored against the pubis or lateral side of the extremity.
Traction should be applied to align the limb and relieve pain, but relief may take several minutes as muscle spasms subside. For Sager unipolar splints, traction is measured as approximately 10% of the patient’s body weight, not exceeding 15 pounds ().
Traction splints exert countertraction, not true traction, by pulling on the ankle hitch and anchoring against the pelvis or pubis. Movement of the pelvis can cause loss of traction with bipolar splints, while unipolar splints are less likely to shift.
Indications for traction splint use include painful, swollen, deformed mid-thigh injuries without joint or lower leg involvement. Contraindications include pelvis, hip, or knee injuries, avulsions or partial amputations, and lower third leg injuries interfering with the ankle hitch. Open femur fractures are not contraindicated.
Application steps include: taking standard precautions, exposing and stabilizing the leg, assessing circulation/sensation/movement (CSM) distal to injury, adjusting and positioning the splint, securing proximal and distal devices, applying mechanical traction, securing support straps, reassessing CSM, and immobilizing the hip and splint to a spine board.
Emergency Care of Specific Injuries
Fractures and dislocations are common types of extremity injuries, typically presenting with pain, swelling, or deformity.
You are not required to diagnose the exact injury; instead, focus on immobilizing any extremity that is painful, swollen, or deformed.
Immobilization is the primary immediate care for suspected fractures or dislocations in both upper and lower extremities.
Upper-Extremity Injuries
Pain in the shoulder is a key indicator of injury, but specific signs help identify the type of injury.
A dropped shoulder with the patient holding the injured arm against the chest often signals a clavicle fracture.
A severe blow to the back over the scapula may result in a scapular fracture, which is rare but should be considered if trauma is present; only the spine of the scapula is easily palpable.
Assessment involves checking the entire shoulder girdle for deformity and tenderness, especially at the clavicle-acromion junction and along the clavicle from the sternum to the shoulder.
If the head of the humerus is felt or moves in front of the shoulder, this suggests an anterior dislocation or fracture.
Patient Care
Assess distal circulation, sensation, and movement (CSM) in any shoulder girdle injury; if impaired, immobilize and transport the patient promptly, notifying the receiving facility.
Rigid splints are not practical for clavicle, scapula, or proximal humerus injuries; instead, use a sling and swathe for immobilization.
Avoid tying a sling around the neck if a cervical spine injury is suspected to prevent further harm.
For anterior dislocation of the humerus, place a thin pillow between the arm and chest before applying the sling and swathe, and never attempt to straighten or reduce the dislocation yourself.
Reassess distal CSM after immobilization to ensure no further compromise has occurred.
If a shoulder dislocation reduces itself, check distal CSM, apply a sling and swathe, and transport the patient, as the joint remains at high risk for re-dislocation and requires physician evaluation.
Lower-Extremity Injuries
Pelvic fractures can result from direct or indirect trauma, such as falls, motor vehicle collisions, or crushing injuries.
Key signs and symptoms include pain in the pelvis, hips, groin, or back, which may be the only indication of injury, especially if the mechanism suggests a possible fracture.
Obvious deformity and pain upon pressure to the iliac crests or pubic bones are common findings.
Inability to lift the legs while lying supine may be present, but sensation should be checked rather than actively testing movement.
Lateral rotation of the foot on the injured side can indicate a pelvic or hip fracture.
Unexplained pressure on the urinary bladder and a frequent urge to urinate may occur.
Bleeding from the urethra, rectum, or vaginal opening is a significant sign, especially after high-impact trauma.
Blood at the meatus of the penis is a unique indicator of pelvic fracture.
Pelvic wraps or commercial binding devices are used to stabilize open or severe pelvic fractures.
Patient Care
Minimize patient movement; if movement is necessary, move the body as a unit and never lift with the pelvis unsupported to prevent further injury.
Assess circulation, sensation, and movement (CSM) distal to the injury before and after any intervention to monitor for neurovascular compromise.
Stabilize the pelvis and lower limbs by applying a pelvic wrap or placing a folded blanket between the legs and binding them together with wide cravats at multiple points (upper thigh, above and below the knee, above the ankle).
Assume possible spinal injuries; immobilize the patient accordingly and avoid placing straps or ties over the pelvic area.
Monitor for and treat shock, providing high-concentration oxygen as needed, since pelvic fractures can cause significant internal bleeding.
Transport the patient promptly and continue to monitor vital signs; in the ambulance, legs may be gently flexed and a pillow placed under the knees for comfort if allowed and spinal injury precautions are maintained.
When in doubt between pelvic and upper femur fracture, treat as pelvic fracture to protect blood vessels and nerves, and always consider the possibility of spinal injury.
Pelvic wrap application is indicated for pelvic deformity, instability, or mechanism of injury suggestive of pelvic fracture, regardless of shock presence.
Pelvic wrap can be commercial or improvised with a sheet; the sheet should be about 10 inches (25 cm) wide, centered at the greater trochanter (not the iliac wings), and tied firmly but not overly tight to stabilize the pelvis.
Some EMS protocols recommend applying the pelvic wrap before moving the patient to the backboard to minimize pain and further injury.
Always follow local protocols for pelvic injury management and device use.
Patient Assessment
Hip dislocation occurs when the femoral head is displaced from its pelvic socket, often causing intense pain similar to a proximal femur fracture.
Patients with hip replacements are at higher risk for dislocation, especially middle-aged and older adults, due to prosthesis malfunction.
Hip dislocations are classified as anterior or posterior, with posterior dislocations being more common.
Anterior dislocation signs: the entire lower limb is rotated outward and the hip is flexed.
Posterior dislocation signs: the leg is rotated inward, the hip is flexed, and the knee is bent; often accompanied by a lack of sensation in the limb, indicating possible sciatic nerve damage.
Posterior hip dislocations frequently result from high-energy trauma, such as knees striking the dashboard in a car crash, and are often associated with multi-system injuries.
Patient Care
Assess distal circulation, sensation, and movement (CSM) before and after immobilization to ensure there is no nerve or blood vessel impairment.
Move the patient onto a long spine board or scoop-style stretcher for safe transport, ensuring the injured limb is immobilized using pillows or rolled blankets.
Secure the patient with straps or cravats to prevent further injury during movement and transport.
Monitor for signs of shock and provide high-concentration oxygen as needed, while continuously checking vital signs and reassessing for nerve or circulation problems.
If there is any loss of pulse, sensation, or movement, notify medical direction and transport immediately.
A painful, swollen, or deformed thigh with a flexed leg that will not straighten may indicate a femur fracture in addition to hip dislocation.
Patient Assessment
A hip fracture refers specifically to a break in the proximal femur (femoral head, neck, or just below the neck), not the pelvis.
Older adults, especially women, are at higher risk due to brittle or diseased bones, and the fracture may occur either from a fall or may cause a fall if the bone breaks first.
Key signs and symptoms include: localized pain (sometimes radiating to the knee), sensitivity to pressure over the greater trochanter, possible delayed discoloration and swelling, inability to move the limb or stand, and the injured foot typically turning outward (occasionally inward).
The injured limb may appear shorter compared to the uninjured side.
Patient Care
Always assess distal circulation, sensation, and movement (CSM) before and after splinting, and during transport to monitor for neurovascular compromise.
Stabilize a hip fracture by immobilizing the patient on a long spine board or orthopedic stretcher after splinting to prevent further injury during movement and transport.
Leg binding method: Place a folded blanket between the legs, bind them together with wide straps, Velcro straps, or cravats, and use pillows to support the lower limbs before securing the patient to the board.
Padded board splinting: Use two long padded boards—one from armpit to beyond the foot, the other from crotch to beyond the foot—cushioning the armpit and crotch, and padding all voids at the ankle and knee. Secure the boards with cravats or straps placed across the chest, abdomen, below the crotch, above and below the knee, and at the ankle.
An orthopedic stretcher can substitute for a long spine board for immobilization and transport.
Patient Assessment
Femoral shaft fractures require significant force due to the strength and size of the femur.
Muscle contractions can cause the fractured bone ends to override each other, leading to limb shortening and deformity.
Open fractures may present with bone ends protruding through a wound, but even without visible bone, a wound on the thigh could indicate an open fracture.
Common signs and symptoms include intense pain, deformity (with or without bone protrusion), severe angulation in closed fractures, and apparent shortening of the injured limb.
Patient Care
Control external bleeding by applying direct pressure away from the fracture site; use a tourniquet if bleeding cannot be controlled.
Treat for shock (hypoperfusion) by providing high-concentration oxygen and monitoring for signs of shock.
Assess distal circulation, sensation, and motor function (CSM) before and after splinting.
Apply a traction splint if the patient is stable and one is available; the goal is to overcome muscle spasm, not to equalize leg length.
If a traction splint is unavailable or the patient is unstable, bind the legs together in the anatomic position.
Use appropriately sized traction splints for children with thigh injuries.
Reassess distal CSM after splinting to ensure no compromise in blood flow or nerve function.
Isolated femur fractures are rare; significant force often causes additional injuries that may contraindicate traction splint use or make it a lower priority.
Point of View: Patient
Accidents can happen unexpectedly, even during routine or recreational activities, such as building a home project.
Injuries like broken bones are often immediately recognizable by both sensation and sound, as described by the feeling and hearing of a twist and break.
Immediate response and communication are crucial after an accident, including calling for help and relying on neighbors or emergency services.
Emergency medical technicians (EMTs) play a vital role in providing care and honest communication, preparing you for pain during treatment and safely transporting you, even in challenging circumstances.
Recovery from injuries such as a broken leg typically involves a significant healing period, in this case, about eight weeks before resuming normal activities.
Patient Assessment
The knee is a joint composed of multiple bones, including the distal femur, proximal tibia and fibula, and the patella (kneecap), all of which can be fractured.
Common signs and symptoms of a knee injury include pain, tenderness, swelling, and deformity with obvious swelling.
Patient Care
Two main methods are used to immobilize a knee injury: If the knee is bent, immobilize it in the position found using two padded board splints (secured to the thigh and above the ankle) and support with a pillow; if the knee is straight, immobilize with two padded board splints (placed medially and laterally) or a single padded splint, ensuring to pad any voids at the knee and ankle.
Always assess and reassess distal CSM (circulation, sensation, movement) before and after splinting to monitor for changes in neurovascular status.
Differentiate between patella dislocation and knee dislocation: Patella dislocation presents with the knee stuck in flexion and the kneecap displaced laterally; knee dislocation involves the tibia being forced anteriorly or posteriorly relative to the femur and can compromise the popliteal artery.
A knee dislocation with absent distal pulse is a true emergency: Contact medical direction for permission to gently move the lower leg to restore pulse and transport immediately.
Splint and transport all suspected fractures, dislocations, sprains, or strains: Even if the patella appears to have repositioned, hidden injuries may exist.
Monitor for loss of distal CSM or changes in foot color and temperature: If the foot becomes white, mottled, blue, or cold, transport without delay and notify medical direction while en route.
Patient Assessment
Pain and tenderness are typical indicators of a tibia or fibula injury.
Swelling commonly occurs in the affected area.
Possible deformity of the lower leg may be present with a fracture, but deformity is often not visible even when a fracture exists.
Patient Care
Immobilizing the leg is essential to relieve pain and control bleeding in tibia or fibula injuries.
Assess distal circulation, sensation, and movement (CSM) before and after splint application to ensure proper limb function and detect complications.
Vacuum splint method: Maintain manual traction while sliding the splint under the injured limb, ensure the splint is wrinkle-free and extends to adjacent joints or bones, deflate the splint to secure it, and periodically check that it remains firm and supportive.
Two-splint method: Immobilize the fracture using two rigid board splints for added stability.
Single splint method: Apply a single splint, with or without an ankle hitch, as an alternative immobilization technique.
Patient Assessment
Sprains (torn ligaments) and fractures are the most common injuries to the ankle and foot.
It can be difficult to tell the difference between a sprain and a fracture, so you should always treat the injury as a fracture.
Common signs and symptoms include pain, swelling, and possible deformity.
Patient Care
Soft splinting is a rapid and effective method for most ankle and foot injuries, often using a pillow as the splinting material.
Key steps in soft splinting include: assessing distal circulation, sensation, and movement (CSM); stabilizing the limb; carefully removing the shoe if possible; and avoiding manual traction.
The splint is applied by placing cravats under the ankle, positioning a pillow lengthwise under the limb (extending 6 inches beyond the foot), and gently lowering the limb onto the pillow without changing its position.
Cravats are tied at the top, middle, and heel of the pillow, with a fourth cravat loosely tied at the arch of the foot, and the limb is elevated with a second pillow or blanket.
Reassess distal CSM after splinting, and provide care for shock if necessary, though this is uncommon with isolated injuries.
Apply a cold pack to reduce swelling and bleeding, but never place it directly on the skin.
Commercial lower extremity splints that extend above the knee may provide better immobilization by also stabilizing the knee joint.
SCAN 32-4
A sling is a triangular bandage used to support the shoulder and arm, while a swathe holds the arm against the chest for additional immobilization.
Commercial slings and swathes are available, but you can use any safe material that will not injure the patient.
Always assess distal circulation, sensation, and motor function (CSM) before and after applying a sling and swathe to ensure proper blood flow and nerve function.
SCAN 32-5
Injuries to the humerus can occur at the shoulder (proximal), shaft, or elbow (distal) regions, with deformity being the most obvious sign, but always assess for pain and swelling as well.
Always check distal circulation, sensation, and motor function (CSM) before and after immobilizing or splinting the extremity.
If there is no distal pulse in a closed fracture and no signs of shoulder or elbow fracture/dislocation, attempt to gently straighten the angulation following local protocol.
If straightening restores pulse or function, proceed with immobilization; if not, splint with the forearm extended and reassess CSM.
If circulation, sensation, or motor function remains absent after splinting, attempt a second splinting; if still unsuccessful, transport the patient immediately.
Never attempt to straighten angulation if there are signs of fracture or dislocation at the shoulder or elbow.
SCAN 32-6
The elbow is a hinge joint formed by the distal humerus and the proximal ulna and radius, not a single bone.
Identifying the injury site relies on locating deformity and tenderness to determine if the injury involves the elbow or another area.
If a distal pulse is present, immobilize a dislocated elbow in the position found to avoid damaging nerves and blood vessels.
If there is no distal pulse, attempt gentle repositioning only after consulting medical direction, and never force the limb into its normal position.
Always assess circulation, sensation, and movement (CSM) distal to the injury both before and after immobilization or splinting.
SCAN 32-7
Forearm injuries are indicated by deformity and tenderness; if only one bone is broken, deformity may be minimal or not present.
Wrist injuries typically present with deformity and tenderness.
Hand injuries are characterized by deformity and pain, with dislocated fingers being easily noticeable.
Always assess distal circulation, sensation, and motor function before and after immobilizing or splinting the affected extremity.
SCAN 32-8
Always assess distal circulation, sensation, and motor function (CSM) both before and after immobilizing or splinting an extremity to ensure there is no compromise to neurovascular status.
A bipolar traction splint is used to immobilize certain extremity injuries, particularly femur fractures, by applying longitudinal traction to align the bone and reduce pain and further injury.
Proper application of the splint involves careful handling to avoid additional injury, and continuous monitoring of the affected limb’s CSM status throughout the procedure.
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Always assess distal circulation, sensation, and motor function (CSM) both before and after immobilizing or splinting an extremity.
The Sager traction splint is used for immobilizing certain extremity injuries, particularly femur fractures, to prevent further injury and reduce pain.
Proper application of the splint helps maintain limb alignment and minimizes the risk of complications such as neurovascular compromise.
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If there is a distal pulse and nerve function present, or if straightening the limb causes resistance or severe pain, you should splint knee injuries with the knee in the position found.
Maintaining the knee in its current position helps prevent further injury when using the two-splint method for bent knee injuries.
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The one-splint method is used to immobilize an extremity with a straight knee.
It is essential to assess distal circulation, sensation, and movement (CSM) both before and after applying the splint to ensure proper blood flow and nerve function.
Proper assessment of CSM helps prevent complications such as nerve damage or impaired circulation during immobilization.
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The two-splint method is used to immobilize a straight knee injury.
It is essential to assess distal circulation, sensation, and movement (CSM) both before and after applying a splint to ensure there is no compromise to blood flow or nerve function.
Proper assessment and documentation of CSM help detect any changes or complications resulting from the splinting process.
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The two-splint method is used for immobilizing leg injuries to prevent further damage and reduce pain during transport.
Distal CSM (Circulation, Sensation, Movement) must be assessed both before and after immobilization or splinting to ensure that blood flow, nerve function, and movement are not compromised by the splinting process.
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Always assess distal circulation, sensation, and movement (CSM) both before and after immobilizing or splinting a leg injury.
Monitoring CSM ensures that blood flow, nerve function, and mobility are not compromised by the injury or the splinting process.
Think Like an EMT
Care for musculoskeletal injuries depends on the patient's overall condition and the presence of isolated versus multiple injuries. Patients with isolated fractures and stable vital signs can often be splinted and transported routinely, while those with multiple fractures or signs of shock require more urgent transport and should be treated as multiple-trauma patients.
Assessment of vital signs and injury mechanism is crucial in determining treatment priority. For example, a patient with an isolated wrist fracture, normal vital signs (pulse = 88, respirations = 16, BP= 140/84, SpO2 = 97% ), and no other concerning findings can be splinted on scene before transport.
Patients with multiple fractures or signs of shock (e.g., tachycardia, hypotension, agitation, cool/clammy skin) require rapid transport to a trauma center, using a backboard as the main splinting device. For instance, a patient pinned by a heavy object with deformities in both thighs and a lower leg, elevated pulse (112), increased respirations (24), and low blood pressure (108/64) is at risk for shock and should be transported urgently.
Mechanism of injury and abnormal vital signs can indicate hidden or more severe trauma, even if the patient complains of only a single injury. A patient ejected from a vehicle with a weak, rapid pulse (130), hypotension (88/56), and cool, moist skin should be prioritized for immediate transport due to the high risk of internal injuries and shock, regardless of the apparent isolated arm fracture.