Musculoskeletal Trauma

Question 1

what do injuries result from? what are common causes? is upper extremity or lower extremity injury more life threatening?

Answer 1

Injuries result from application of significant direct or transmitted force

Common causes:

Penetrating trauma

Sports injuries

Falls

MVCs

Assaults

Multi-system trauma often results in significant musculoskeletal trauma, as well as underlying organ injury and
internal/external hemorrhage

Injury to upper extremities may be painful and debilitating, but are not usually life-threatening

Injury to lower extremities result from a greater force of impact – more often leading to the possibility of
internal hemorrhage and life/limb threat

Question 2

what does the musculoskeletal system include?

Answer 2

Musculoskeletal system includes:

Bones

Cartilage

Ligaments

Muscles

Tendons

Question 3

how has injury prevention improved over the years?

Answer 3

Prevention of injury has improved over the years

Seatbelts and airbags

Sports equipment

Safety equipment – boots, vests, harnesses, and WSIB regulations

Canes, walkers, and wheelchairs

Question 4

how are bones, blood vessels, joints, and muscles connected? what are injuries to each of them called?

Answer 4

Bone lies deep within muscle tissue

Blood vessels and major nerves run parallel with the bone proximally to distally

Joints (points of articulation) have a complex arrangement of ligaments, cartilage, and synovial fluid

Keeps the joint together and allows range of motion

Muscle is connected to bone by tendons

Direct skeletal movement through fibres and fasciculi, along with the muscle bodies

Complex arrangement of connective, skeletal, vascular, nervous, and muscular tissue

Can be classified as muscular, joint, and bone injuries

Muscular – contusion, compartment syndrome, penetrating injury, muscle fatigue/cramp/spasm/strain

Joint – sprain, subluxation, dislocation

Bone – fractures (closed, open, hairline, impacted, transverse, oblique, comminuted, spiral, fatigue, greenstick, and
epiphyseal)

Question 5

what may muscular injuries result from?

Answer 5

May result from:
Blunt/penetrating trauma
Overexertion
Oxygen depletion
Usually do not contribute significantly to hypovolemia and/or shock
-Except in cases associated with large hematomas or penetrating trauma that causes vessel damage
Bone is living tissue – requires constant supply of oxygenated circulation

Question 6

what are contusions?

Answer 6

Damage the muscle cells and the blood vessels that supply them
Small vessels leak blood into interstitial space – causing pain, erythema, and ecchymosis
Tissue edema due to the body’s inflammatory response and engorged capillary beds
Swelling may make one limb larger than the other, but most damage is hidden
Blood may pool beneath tissue layers = HEMATOMA
Large enough hematoma or significant muscular edema may contribute to hypovolemia
Can affect any part of the body

Question 7

what is compartment syndrome?

Answer 7

Internal hemorrhage and swelling (from other injuries)
Increased pooling of blood causes pressure build up within fascial compartment where injury is
Obstructs blood flow, nerve impulse, and venous return
May lead to stop in arterial circulation
Often patient seems to be in more discomfort than external signs indicate
Initially may be increased pain with movement, the feeling of muscle tension, and loss of distal sensation
Decreased distal circulation is a late sign

Question 8

what is a penetrating injury?

Answer 8

Injury to deep, underlying muscle masses and tendons
May affect muscle function
Damaged muscle/tendon can no longer fight opposing muscles to keep neutral alignment
Require surgical intervention to reattach tendon/muscle
May lead to infection (from open wound) and/or ischemia (from decreased blood flow)
Penetrating object should only be removed if it interferes with ABCs – including CPR efforts

Question 9

what are different types of burns and major concerns?

Answer 9

1st degree – superficial
2nd degree – partial thickness; blistering
3rd degree – full thickness; partially or fully charred
4th degree – complete thickness; likely into muscle and bone
Major concerns:
Infection
Hypovolemia
Hypothermia
Pain

Question 10

what is the rule of 9s and the rule of palms?

Answer 10

(memorize diagram**
The rule of nines assigns a percentage that’s either nine or a multiple of nine to determine how much body surface area is damaged. For adults, the rule of nines is:

Body part Percentage
Arm (including the hand) 9 percent each
Anterior trunk (front of the body) 18 percent
Genitalia 1 percent
Head and neck 9 percent
Legs (including the feet) 18 percent each
Posterior trunk (back of the body) 18 percent

CHILDREN
Body part Percent
Arm (including the hand) 9 percent each
Anterior trunk (front of the body) 18 percent
Head and neck 18 percent
Legs (including the feet) 14 percent each
Posterior trunk (back of the body) 18 percent

A medical provider can use calculations from the rule of nines in several ways. This includes the amount of fluid replacement and degree of care a person needs.

Question 11

other muscular injuries - fatigue

Answer 11

FATIGUE
Condition in which a muscle’s ability to respond to stimulation is lost or reduced through overactivity
Muscle reaches the limits of performance/ability
Decreasing ability of muscle fibres to contract
Oxygen is depleted, lactic acid is produced
Decreased strength to muscle
Painful when used
Requires restored oxygenation and proper rest

Question 12

other muscular injuries - muscle cramp

Answer 12

Muscle pain resulting from overactivity, lack of oxygen, and accumulation of waste product
Circulatory system fails to remove waste product
Caused by muscle fatigue from strenuous exercise or if the muscle was in an unusual position
Obstructed circulatory flow needs to be restored to relieve discomfort
Change limb’s position and/or massage muscle
Pain typically subsides after rest and return of regular circulation
Often associated with muscle spasm

Question 13

other muscular injuries - muscle spasm

Answer 13

Intermittent or continuous contraction of a muscle
CLONIC – intermittent
TONIC – continual
Spasm can cause enough muscle tension to seem like skeletal deformity
Typically subsides with rest, hydration, and restoration of circulation
Rigor mortis – entire body in muscle spasm following death
Typically sets in 1-3hrs after death and subsides 6-8hrs after death (depending on ambient temperatures)
Caused by a loss of ATP from body muscles after death

Question 14

other muscular injuries: strain

Answer 14

Injury resulting from overstretching of muscle fibres from excessive forces, leading to tears in the fibres
Pain with any use of muscle involved
Caused during extreme muscle stress (heavy lifting, sprinting) or from muscle fatigue due to reduced number of muscle fibres working, leading to increased likelihood of muscle overload
Pain on palpation of injured area, however typically no external signs of bleeding, edema, contusion, or discoloration
Cause limited use of affected area
Not interchangeable with ‘sprain’

Question 15

joint injury: strain

Answer 15

Tearing of a joint capsule’s connective tissue – typically a ligament
Acute pain and inflammation/swelling
Ecchymotic discoloration sets in gradually
Ligament tears affect joint function – can lead to complete joint failure
Grade I – Minor, incomplete tear. Ligament is painful, and swelling is minimal. Joint is stable.
Grade II – Significant, incomplete tear. Swelling and pain are moderate-severe. Joint is intact but unstable.
Grade III – Complete tear of ligament. May appear the same as a fracture due to pain severity and spasms. Joint is unstable.

Question 16

joint injury: subluxation

Answer 16

DIAGRAM

Partial displacement of a bone end from its position in a joint capsule
Caused by joint stress and stretching of ligaments
Hyperextension, hyperflexion, lateral rotation beyond normal ranges, or extreme axial force
More significantly reduces the joints integrity than a sprain
Increasing pain and swelling rapidly
Limited range of motion and unstable joint

Question 17

joint injury - dislocation

Answer 17

Complete displacement of a bone end from its position in a joint capsule
Joint gets “stuck” in an abnormal position once it is out of the socket – noticeable deformity
Painful, swollen, and immobile
May damage or compression blood vessels and nerves
Occurs when the joint moves forcefully beyond its normal range of motion
May lead to ligament damage, socket damage, or associated cartilage damage

Question 18

bone injury: fracture

Answer 18

Disruption in the continuity of the bone structure
May be from direct force (baseball bat to femur) or transmitted for (fall from a ladder, landing on feet – impact is transmitted from foot to ankle to tibia/fibula to femur
Always pay attention to mechanism of injury to anticipate any internal damage that is not yet evident
During bone fracture, multiple structures within bone are disrupted
Collagen, osteocytes, salt crystals, blood vessels, nerves, and medullary canal
Bone ends may cause additional damage to surrounding structures, nerves, and vessels
VASCULAR DAMAGE – increased cap refill, diminished distal pulses, cool limb temperature, discolouration/pallor, and paresthesia
NERVE DAMAGE – distal paresthesia, anesthesia (complete), paresis (weakness), or paralysis
MUSCLE/TENDON DAMAGE – inability to move or decreased ROM; could result in compartment syndrome
Multiple different types of fractures

Question 19

what are the different types of fractures?

Answer 19

CLOSED FRACTURE – a broken bone in which the bone ends or the forces that caused the break do not penetrate the skin
OPEN FRACTURE – a broken bone in which the bone ends or the forces that caused the break penetrate the surrounding skin
Risk of associated infection
If bone is close to the surface of the skin (like the shin), open fracture can occur with limited force
HAIRLINE FRACTURE – small crack in a bone that does not disrupt its total structure; is painful but maintains its position and remains stable
IMPACTED FRACTURE – break in a bone in which the bone is compressed on itself; typical of compression/crush injuries; maintains its position
Both hairline and impacted fractures may become worse with additional stress
TRANSVERSE FRACTURE – a break that runs across a bone perpendicular to the bone’s orientation
OBLIQUE FRACTURE – a break in a bone running across it at an angle other than 90 degrees
COMMINUTED FRACTURE – fracture in which a bone is broken into several pieces
SPIRAL FRACTURE – a curving break in a bone as may be caused by rotational forces
A limb caught in machinery, or a child’s arm being grabbed and twisted by an adult
FATIGUE FRACTURE – break in a bone associated with prolonged or repeated stress
Often in metatarsals from extensive walking with inappropriate shoes or running a marathon
Fractures may lead to fat embolism
Injury releases fat into the damaged vessels of the circulatory system – enters venous system and travels to heart
Emboli moves to lungs
Typically caused by crush injuries and manipulation of a fracture

Question 20

pediatric considerations for fractures

Answer 20

PEDIATRIC CONSIDERATIONS
Pediatric bones contain a larger percentage of cartilage, do not fracture in the same way as adult bones
Still growing from the epiphyseal plate
GREENSTICK FRACTURE – partial fracture of a child’s bone
Disrupts only one side of the long bone, causes angulation, and resists alignment; as it heals, the injured side grows more quickly, causing more angulation
Often best healed if surgically broken completely to heal evenly
EPIPHYSEAL FRACTURE – disruption in the epiphyseal plate of a child’s bone
If growth plate is disrupted, the disruption may lead to a reduction or stop in bone growth – most often at proximal tibia

Question 21

geriatric considerations for fractures

Answer 21

GERIATRIC CONSIDERATIONS
Bone mass and collagen structure begins to decrease progressively >40 y/o
Bones are less flexible, more brittle, and more easily fractured
Healing slows down, loss of muscle and coordination increases likelihood of skeletal injury
Fractures occur more easily and without as much overt force
OSTEOPOROSIS – weakening of bone tissue due to loss of essential minerals, especially calcium
Accelerated degeneration of bone tissue
Typically affects women more than men – especially after menopause
Increased occurrence of fractures, spinal curvature, structure degeneration

Question 22

pathological fractures

Answer 22

PATHOLOGICAL FRACTURES
Result from disease pathologies that affect bone development 
May be caused by tumours of the bone, periosteum, or articular cartilage; diseases that increase osteoclast activity and osteoporosis
Radiation treatment
Kills bone cells
Localized bone degeneration
Weakened bones and fractures
Do not heal well, if at all

Question 23

other important considerations to know (review)

Answer 23

Bones are smallest through the diaphysis and largest at the epiphyseal area (joint)
Largest diameter around midshaft due to placement of skeletal muscle
Understanding injury is best when both muscular and skeletal systems are considered together
Helpful for looking at possible nervous or vascular injuries
Limited tissue surrounding joints increases risk of dislocation, subluxation, sprain, and fracture – swelling/deformity compromise the nerve and vasculature
Nerve and vascular injury less likely in long bone fracture, unless manipulated
Blood vessels enter bone at epiphysis – if displacement occurs, distal compromise may occur causing tissue death
In long bone fracture, pain causes surrounding muscle to contract and spasm
Causes bone ends to cross fracture site, interferes with muscles and causes crepitus

Question 24

what is the bone repair cycle?

Answer 24

Trauma fractures a bone – tear to periosteum, blood vessels, soft tissue, and endosteum
Blood fills injury and forms RBC and collagen clot – initiates repair process
Osteocytes from bone ends multiply and produce osteoblasts, which put salt crystals in collagen clot – begins to connect bone ends
CALLUS – thickened area that forms at the site of a fracture as part of the repair process
Salt crystals and collagen continue to strengthen the callus
Osteoclasts dissolve salt crystals and collagen in areas of low stress; osteoblasts lay down new collagen and salts in areas of high stress
If bone is well aligned at fracture, may not result in permanent damage
If bone is displaced, injury site may never heal properly; may cause disability, deformity, or persistent issues

Question 25

what are imflammatory/degenerative conditions?

Answer 25

May present with join pain, tenderness, and fatigue

May cause difficulty walking, moving, and performing normal daily functions without assistance

Question 26

what is bursitis?

Answer 26

BURSITIS – acute or chronic inflammation of the small synovial sacs that reduce friction and cushion the ligaments/tendons/joints
Results from repeated trauma, gout, and infection
Localized pain, swelling, and tenderness at joint – typically olecranon (elbow), above patella (knee), and shoulder

Question 27

what is tendinitis?

Answer 27

TENDINITIS – inflammation of a tendon and/or its protective sheath
Presents similarly to bursitis
Caused by repeated trauma to a muscle group
Usually affects major tendons of the upper and/or lower extremities

Question 28

what is arthritis?

Answer 28

inflammation of a joint

Question 29

what are different types of arthritis?

Answer 29

OSTEOARTHRITIS – inflammation of a joint resulting from wearing down of the articular cartilage
Most common type of connective tissue disorder; general wear and tear of articular cartilage
Results in bony overgrowths – causing pain, stiffness, decreased movement, and joint enlargement (especially in the fingers)
Predisposing factors include trauma, obesity, and aging
RHEUMATOID ARTHRITIS – chronic disease that causes deterioration of peripheral joint connective tissue
Inflammation of the synovial joints – causing immobility, pain (especially with movement), and fatigue
2-3x more common in women
GOUT – inflammation of joints and connective tissue due to buildup of uric acid crystals
Most frequently in males who have high concentrations of uric acid in the blood (metabolism end-product that is not easily dissolved)
Peripheral joint pain, swelling, and possible deformity

Question 30

important info to know for musculoskeletal assessment

Answer 30

Musculoskeletal injury on its own is rarely life threatening
Typically well assessed and well managed at the scene, however cannot be conclusively diagnosed without x-ray/ultrasound
Serious injury occurs when the energy is transmitted down the bone to the internal organs
Always consider mechanism of injury to evaluate potential for internal injuries
Assessment will follow the same pattern as any patient – scene assessment, primary assessment, focused history and focused secondary assessment
Should also include a rapid trauma assessment and detailed secondary assessment for traumatic patients, especially if presenting with altered LOC
Ensure that if the mechanism is on a roadway, you are protected from oncoming traffic
If the injury was from an assault, ensure the assailant is not on scene
Contact appropriate resources, whenever necessary

Question 31

important things to consider for musculoskeletal primary assessment - what are 4 classifications for musk/skel injuries?

Answer 31

AVPU and ABCs, as with all other patients
Identify the risk of C-spine/spinal injuries – take appropriate precautions
Musculoskeletal injuries can look very gruesome, but should not be a cause for tunnel vision
As mentioned, they are often not life threatening on their own, but may look “bad”
Classified in 4 different ways:
Life and limb threatening injuries
Life threatening injuries with minor musculoskeletal injuries
Non-life threatening injuries but serious limb-threatening musculoskeletal injuries
Non-life threatening injuries and only isolated minor musculoskeletal injuries
If the patient falls into the 4th category, only an focused secondary assessment is needed
For more severe injuries, do a detailed secondary, as the patient may have one distracting injury that does not allow them to give an accurate account of their injuries

Question 32

important info for musk/skel rapid trauma assessment

Answer 32

Performed for any patient with signs/symptoms/mechanism of serious injury
Perform assessment from head to toe – hands on assessment for any patient who is altered LOC or who may have a distracting injury
Remember to only palpate the pelvis once if crepitus, instability, or pain exists – do not want to manipulate the pelvis if it could be fractured to avoid causing life-threatening hemorrhage
Evidence of blood loss/swelling may be difficult to see in the femurs due to muscle mass
Check upper and lower extremities for stability, sensation, colouration, temperature, and circulation
If the patient is conscious, have them show grip strength, joint movement, and range of motion bilaterally; check plantar flexion (pushing down on a gas pedal) and dorsiflexion (pulling toes towards nose)
Accompany physical assessment with detailed history

Question 33

important info to consider for histroy and secondary assessment for musc/skel

Answer 33

Primary assessment will provide initial findings, while detailed history and secondary assessment will provide further information about initial findings
Secondary assessment should be performed:
ON SCENE – stable patients only
ENROUTE – unstable patients (where time permits)
Remove or cut any restrictive clothing, jewellery, or shoes – remove before more inflammation sets in and it is harder to remove
Have partner/bystander stabilize injured extremity to avoid movement/manipulation
Make sure to expose to all injury sites and compare to uninjured side
Complete OPQRST
Full 5 Ps before and after any manipulation/splinting of injury
Pain, Pallor, Pulse, Paralysis, and Paresthesia (can also include ‘Pressure’ as a 6th P, if applicable)
Question about whether the patient heard a “snap”, “pop”, or “crack” and whether the sound came before or after fall

Question 34

management for musk/skel trauma

Answer 34

Manage all ABC issues and spinal precautions prior to worrying about extremity splinting
With the exception of the pelvis
Goal is to prevent further injury
Protect against infection by covering open injuries and avoid overt manipulation to avoid nerve and vessel damage
Splint injuries in position found unless circulation is compromised – manipulate into neutral alignment (one attempt only)
Explain all actions to the patient, as initial manipulation will probably cause increased pain until splinted
Do not reduce a dislocation
Stop all realignment attempts when you meet resistance or patient complains of intense increase in pain
Do not attempt alignment of injuries within 7cm of a joint (considered joint injury if within 7cm)
If unable to secure to joint above and below, secure limb directly against body for stability
Place limb in position of function or neutral whenever possible

Question 35

what is the aim of immobilization? what is RICE?

Answer 35

Immobilization is aimed to prevent:
Movement of broken bone ends
Dislodging of bone from a joint
Reduce further stress on muscles, ligaments, or tendons
Secure splinting device above and below the injury – holds joints in place to prevent the transmission of movement through long bone
Wrap splint from distal to proximal
Ensures the pressure of the dressing causes the blood to be moved into systemic circulation instead of into distal limb
Assists venous dressing
Wrap dressing tightly enough to ensure its secured, but not so tight that you can’t get a finger under it
Be sure to check 5 Ps before, during, and after splinting
REMEMBER – R. I. C. E. (Rest, Immobilize, Cold, Elevate); do not apply cold directly onto skin
For muscular and joint injuries, alternate heat and ice after 48hrs

Question 36

what are different splinting devices?

Answer 36

RIGID SPLINTS
Firm and durable supports – cardboard, plastic, metal, synthetic, or wood
Require added padding to reduce discomfort when applied
Speed splint is typically used in prehospital setting in Ontario
Other pre-formed splints are also available, just not typically purchased by EMS

FORMABLE SPLINTS
Malleable – able to be shaped to fit extremity
SAM splint is typically used in EMS
Can be used to splint a hand/wrist, most commonly
Is also used to support a flail segment in chest trauma
Are made of foam and mesh, or can be “ladder” splints made of soft metal wires
Form splint around your own arm loosely before applying to patient
Wrap circumferentially from distal to proximal

SOFT SPLINTS
Typically considered air splints or pillow splints – built in padding or inflate with air to support injury
Positions the limb in an aligned position without extreme manipulation and provides pressure to injury – reduce internal/external hemorrhage
Not to be used above knee or elbow
Change in temperatures can change the pressure within an air splint
Pillow/blanket splint allows for the ankle/foot to be wrapped comfortable in position found, with triangular bandages to secure it

TRACTION SPLINTS
Used primarily for closed femur fractures, but can also be used for tibia/fibula fractures
Is occasionally taught for use in hip fractures
Uses the force against the truck and the tension against the ankle to pull bone ends apart from rubbing
Use cravats after traction is applied to hold extremities together
Can be used for bilateral femur fractures as well
One femur = 10% of body weight (max. 15lbs)
Bilat femurs = 20% of body weight (max. 30lbs)
Tib/Fib = 5-7lbs
Contraindicated for use in femur fractures in patients with knee, tibia, or foot injuries

Question 37

care for specific injuries - Pelvis

Answer 37

Involve either iliac crest or pelvic ring
Iliac crest fractures are often isolated and stable – cared for by simple immobilization
Pelvic ring fractures often serious, unstable, and life-threatening – due to “ring” structure = 2 fracture sites
Pelvis is active in blood cell production; adjacent to major blood vessels feeding lower extremities, interfering with lower extremity circulation
High risk of circulatory compromise – vessels can empty into pelvic and retroperitoneal cavities
May also result in hip dislocation
Care involves stabilizing pelvis
Cravats or pillow/blanket padding
Securing patient to scoop stretcher or spinal board
Managing hemodynamic compromise
Rapid transport
Remember – pelvis fracture is “load and go” no matter if the patient is deemed stable or not

Question 38

care for specific injuries - Femur

Answer 38

Could be of traumatic or non-traumatic (degenerative) cause
Degenerative disease is typical for older age, history of degenerative issues, may have limited pain, and no significant traumatic mechanism
Traumatic mechanism usually leads to extreme discomfort
Proximal fractures (neck and intertrochanteric) – may appear to be hip fractures or associated with hip/pelvic trauma (more common in elderly)
Femur = foot externally rotated and shortened
Mid-shaft fractures – causes by higher levels of force and result in greater blood loss
Distal fractures (condylar and epicondylar) – extensive injury and usually involved blood vessels before they enter the knee/lower leg
Manage obvious femur fractures with traction splint (if fracture is not compound)
One femur – “stay and play”, if otherwise stable; Bilat femur – “load and go”, even if patient is stable
Ensure 5 Ps before, during, and after splinting

Question 39

care for specific injuries - tibia/fibula

Answer 39

Can occur separately or together
Tibia is the most commonly fractured leg bone – often causing compound fracture
If only tibia is fractured, leg may remain inline but is not strong enough to bear weight
Fibula fracture may accompany tibia fracture, or may be related to knee or ankle injuries
If only fibula is fractured, leg may remain inline and may be stable with symptoms being discomfort when bearing weight
If distal circulation is present, use speed splint to immobilize the patient’s leg
If distal circulation is absent, consider use of sager splint
Ensure 5 Ps before, during, and after care
R.I.C.E

Question 40

care for specific injuries - - clavicle

Answer 40

Most frequently fractured bone in the human body
Typically caused by transmitted forces – falling only outstretched arm and force travelling up arm and ending with clavicle
Main concern is the fact that the clavicles are very close to upper lungs and the vasculature of the upper body – risk of pneumothorax or hemorrhage if left unsecured
Typical presentation involved pain to clavicle and shoulder, with shoulder rotated forward
Can either use a sling and swathe with cold pack to immobilize clavicle
May also use a tension splint – figure 8 around shoulders, with traction being “twisted” and pulled from back
Use a pen or a tongue depressor to turn traction
5 Ps before, during, and after

Question 41

care for specific injuries - humerus

Answer 41

Due to position of humerus into shoulder, and proximity to axillary artery, traction to humerus is difficult to accomplish without compromising circulation
Best treated if the body is used as a “splint”
Sling and swathe with cold pack
Can wrap a triangular around the patient’s wrist and use as a countertraction to anchor arm to body
If the patient is conscious, have them hold arm in position of comfort
May also use a speed splint – best for mid-shaft or distal humerus injuries
5 Ps before, during, and after

Question 42

care for specific injuries - radius / ulna

Answer 42

May involve the bones individually or together
Most common fracture is the distal end of the radius, as it meets the wrist
Referred to as Colle’s fracture (silver fork fracture) – wrist angulates upwards and circulation may be compromised, causing hand to become ashen in colour
Typically not a life or limb threatening injury
If only one of the bones are fractured, the angulation may be minor
Use speed splint or SAM splint to immobilize forearm – secure above and below fracture, just like all other long bone fractures
Additionally, the patient may be more comfortable with a sling and swathe applied after splint
Leave at least the fingernail beds exposed to be able to check distal circulation, but when possible leave a small gab for radial pulse check
5 Ps before, during, and after

Question 43

care for specific injuries - hip dislocation

Answer 43

May dislocate anteriorly or posteriorly
Anterior = foot turned outward and head of femur palpable in inguinal area
Posterior = flexed knee and internally rotated limb; head of femur buried in muscle mass of buttock (not often palpable)
Treat the same way as a pelvic fracture – padding and careful movement/transport
Not considered a “load and go” unless circulation is compromised or other serious injuries present
5 Ps are still required with any manipulation
Compare the length and positioning of the injured leg against the non-injured leg for evidence of changes/deformity
Compare circulation of both legs
Remember that hip dislocations are more common in elderly patients, and the new spinal restriction standard requires a collar to be applied for any patient over 65 y/o who has had a fall

Question 44

care for specific injuries - knee

Answer 44

May include fractures of the femur, tibia, patellar dislocation, or frank dislocation of the knee
Dislocation of the patella most common
Anterior dislocation – angled up; posterior dislocation – angled down
Any knee injury could be considered serious to the patient’s quality of life and limit the patient’s mobility in the future
Knee is a large joint responsible for significant weight bearing and ambulation
Damage to the knee could result in popliteal artery damage – compromising distal circulation
Whenever possible, immobilize knee injuries in the position found
Use the “A” frame technique – one ridged splint on medial side and one on lateral side – to support injured knee
Do not attempt to reduce a knee dislocation
Multiple ligaments, vessels, nerves, and synovial fluid sacs that may become injured
Still require 5 Ps before, during, and after

Question 45

care for specific injuries - ankle/foot

Answer 45

Fracture often causes obvious deformity due to smaller diameter of ankle
Foot fractures are typically painful but do not present gross deformity since bones are very small and cannot angulate (other than toes)
Sprains are common ankle injuries, however present with isolated swelling more than overt deformity
Dislocation can occur in any direction
Anterior = dorsiflexion (upward pointing)
Posterior = lengthen plantar reflex (downward pointing)
Lateral = foot turned outward most common
Use a pillow splint for gross deformity/foot angulation
Use a speed splint for injuries that do not result in significant angulation
5 Ps before, during, and after
Cold pack should be applied to reduce swelling

Question 46

care for specific injuries - shoulder

Answer 46

Fractures often involve proximal humerus, lateral scapula, and distal clavicle
Dislocation can be in multiple directions
Anterior = displaces forward – patient often holding arm against body and pulling across midline
Posterior = elbow and forearm held away from body due to internal rotation of shoulder
Inferior = humoral head is down, patients arm may be locked above head or hanging down immobile
Sling and swathe whenever possible
Secure arm against the patient’s body with a bulky dressing between arm and body
5 Ps before, during, and after
Cold pack on shoulder
Do not try and reduce a dislocation
If the patient has had prior dislocations to shoulder, recurrence is common

Question 47

care for specific injuries - elbow

Answer 47

High occurrence of nerve/vascular involvement – especially with children
Brachial artery
Medial, ulnar, and radial nerves
Often occurs from falling on outstretched hand
In children, common with someone grabbing and pulling arm forcefully
Use speed splint or sling/swathe to immobilize injury against body
Ensure 5 Ps before, during, and after
Do not try and reduce a dislocation

Question 48

care for specific injuries - wrist/hand/fingers

Answer 48

Commonly associated with direct trauma
Noticeable deformity is common
Often associated with emotional distress since the patient uses their hands for daily function
Use SAM splint to immobilize wrist/hand
Ensure distal circulation
Monitor capillary refill
If fingers are fractures, splint injured finger against stable finger next to it, or use a tongue depressor as a rigid splint
Do not attempt to manipulate finger dislocations/fractures

Question 49

pain management - non pharmaceutical

Answer 49

Splinting/Immobilization
Hot packs – to improve circulation
Cold packs – to reduce inflammation
Patient positioning
Patient coaching/breathing
Oxygen therapy (if needed)

Question 50

analgesia medical directive ??

Answer 50

what is??