Musculoskeletal Injury

© Jones & Bartlett Learning, LLC © Jones CHAPTER& Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Musculoskeletal Injury 13 © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Learning Objectives ✔ Distinguish between stable and unstable ✔ Apply the principles of splinting to unstable © Jones & Bartlettmusculoskeletal Learning, injuries. LLC © Jonesmusculoskeletal & Bartlett Learning,injuries. LLC NOT FOR✔ SALE Describe OR the DISTRIBUTION immediate and long-term NOT✔ FOR Describe SALE the OR treatment DISTRIBUTION of stable injuries. treatment of unstable injuries. ✔ Recognize high-risk musculoskeletal problems ✔ Describe the process of restoring alignment in and describe the field treatment. deformed injuries. ✔ Check for problems© withJones circulation, & Bartlett sensation, Learning, LLC © Jones & Bartlett Learning, LLC and movement. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

Introduction Bones meet at joints, and are held together by © Jones & Bartlett Learning, LLC ligaments. Some© Jones joints are& Bartletthighly mobile, Learning, and some LLC do If yourNOT scene FOR size-up SALE and primaryOR DISTRIBUTION assessment reveal not move muchNOT ( FIgUreFOR SALE 13- 1 ). Cartilage OR DISTRIBUTION provides the no existing or anticipated critical system problems, smooth surface and padding for bones to slide or pivot you have the luxury of time to perform a second- against each other. The synovial fluid contained inside ary assessment. You can develop a problem list and the ligamentous joint capsule lubricates the surfaces. Tendons are cord-like connective tissue that join © Jones &plan, Bartlett and safely Learning, evacuate your LLC patient to medical care © Jones & Bartlett Learning, LLC hours or days later. Like most backcountry medical muscle to bone, crossing joints in the cable and pulley NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION problems, musculoskeletal injuries are more often a logistical dilemma than any kind of emergency. Anatomy of a Joint Tendon: attaches muscle to bone. Ligament: attaches bone to bone or cartilage. Structure and© Jones Function & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC The structure of the musculoskeletalNOT FOR SALE system OR is com-DISTRIBUTION NOT FOR SALE OR DISTRIBUTION posed of bone, cartilage, tendon, ligament, muscle, TendonTendon FemurFemur and synovial fluid. Its function is support, protection, Ligament and mobility. The problems can be described generi- Joint space Cartilage cally ©as Jonesstable injury, & Bartlett unstable Learning, injury, and associatedLLC Cartilage © Jones & Bartlett Learning, LLC TibiaTibia neurovascularNOT FOR injury. SALE OR DISTRIBUTION LigamentLigament NOT FOR SALEFibulaFibul ORa DISTRIBUTION Bone provides structural support and protection for soft tissue, and leverage for mobility. It is living tissue with a rich blood supply and an overlying Anterior Posterior A B membrane called the periosteum, which is abun- © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC dantly supplied with sensory nerves. As with any FIgUre 13- 1 Anatomy of a joint. A . Anterior. B . Posterior. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION other tissue, bones bleed and hurt when injured.

Section IV: Trauma

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system that effects movement. The muscle tissue itself This explains our generic assessment for the wilder- © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC is encased in connective tissue compartments called ness context: stable or unstable. NOT FOR SALE fascia . OR This DISTRIBUTION structure in cross section resembles NOT a FOR When SALE the OR structure DISTRIBUTION and function of the system steak: the muscle is like the steak’s soft red tissue, and are compromised, surrounding soft tissue is also at the fascia is the tough white grizzle that you don’t eat. risk. Of primary concern in extremity injuries are the Because muscle contraction is active, and elonga- arteries, veins, and peripheral nerves that run adja- tion is strictly passive,© Jones muscle & groupsBartlett must Learning, work in LLCcent to bones and joints© (FIgUre Jones 13- & 2 ). Bartlett They tend Learning, to LLC balanced opposition.NOT One FOR group SALE is responsible OR DISTRIBUTION for be grouped in a neurovascularNOT FORbundle ,SALE much the OR way DISTRIBUTION pulling a bone one direction, and the opposite group electrical wires and plumbing are fixed together as is responsible for pulling the bone back. For example, they run through a ship. These unprotected struc- the contraction of your biceps flexes your elbow, and tures can be damaged during the initial injury, or the contraction of your triceps extends it. Balanced pinched by misalignment or swelling after the injury. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC opposition is an important concept to remember when NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION splinting an injured joint or reducing a dislocation. Unstable Injury There are many types of bones and joints, and many forms of injury. The mechanism can be direct Fractures, sprains, strains, and dislocations in extrem- or indirect force, overuse, infection, or even frost- ities can be caused by a variety of mechanisms © Jones & Bartlettbite. Chronic Learning, conditions LLC such as arthritis also affect© Jonesreflecting & Bartlett the different Learning, ways LLCforce can be applied to NOT FOR SALEstructure OR andDISTRIBUTION function. Knowing all types of injuryNOT FORbones SALE and joints. OR DISTRIBUTIONThe injury may be caused by lever- in detail is interesting, but not required for effective age, twisting, direct impact, or a piece of bone being field treatment. pulled away at the site of attachment of a tendon or The medical practitioner’s primary concern is ligament. whether an injured bone or joint can still safely per- High-velocity injuries, dissipating tremendous © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC form its function, or must be stabilized and protected. kinetic energy in a short period of time, tend to cause NOT FOR SALE OR DISTRIBUTIONligament and tendon ruptureNOT FOR and boneSALE fractures. OR DISTRIBUTION Low-velocity injuries are more prone to cause par- Neurovascular Bundle tial tears of ligament and tendon, and are less likely to fracture bones. For field purposes, defining the © Jones & Bartlett Learning, LLC mechanism© Jones of injury & canBartlett be generalized Learning, to a yes-or-LLC NOT FOR SALE OR DISTRIBUTION no question:NOT WasFOR there SALE sufficient OR DISTRIBUTION force to cause a fracture or to rupture a ligament or tendon?

© Jones & Bartlett Learning, LLC Nerve © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION Vein NOT FOR SALE OR DISTRIBUTION Artery Unstable Injury • Instability by history or exam • Crepitus by history or exam © Jones & Bartlett Learning, LLC • Inability to use, move,© orJones bear weight & Bartlett Learning, LLC • Deformity or angulation NOT FOR SALE OR DISTRIBUTION• Impaired circulation,NOT sensation, FOR and SALE movement OR DISTRIBUTION

© Jones & Bartlett Learning, LLC The ©signs Jones and symptoms& Bartlett of Learning, an unstable muscu-LLC NOT FOR SALE OR DISTRIBUTION loskeletalNOT injury FOR are SALEsometimes OR very DISTRIBUTION obvious. Gross deformity, crepitus, and instability on exam make the assessment rather clear. Also, the patient may report gross instability by telling you that his knee gives out every time he tries to walk. These criteria are © Jones & Bartlett FIgUre Learning, 13- 2 Arteries, LLCveins, and peripheral nerves © Jones & Bartlett Learning, LLC tend to run together in a neurovascular bundle. very specific, and indicate an injury that is definitely NOT FOR SALE OR DISTRIBUTION NOT FOR unstable. SALE OR DISTRIBUTION

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Sometimes you will have to rely on nonspecific Extremity tissue can usually survive up to two © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC signs and symptoms. Rapid swelling, for example, hours of ischemia with minimal damage. Beyond NOT FOR SALE OR DISTRIBUTION NOT FORindicates SALE significantOR DISTRIBUTION bleeding at the injury site. The this, the risk of tissue death and permanent damage inability to use a joint or extremity after trauma indi- increases quickly with time. Ischemia also increases cates a more serious injury. Impairment of circulation, the risk of frostbite in freezing weather and makes sensation, and movement (CSM) distal to the injury infection more likely in open wounds. If your treat- implies damage to the© Jones neurovascular & Bartlett bundle. Learning, The LLCment efforts do not succeed in ©restoring Jones CSM, & Bartlett you have Learning, LLC patient may report a snapNOT or FORpop at SALEthe time OR of injury. DISTRIBUTION a limb-threatening emergency.NOT Immediate FOR evacuation SALE OR is DISTRIBUTION Although these nonspecific criteria are less definitive, indicated if conditions permit. you might choose to treat the injury as unstable pend- ing more information or response to treatment. Treatment of Unstable Injury It is© worth Jones noting & Bartlett that the amountLearning, of pain LLC is not a © Jones & Bartlett Learning, LLC reliable sign. For example, a minor grade I ligament The process of stabilization has three distinct phases: NOT FOR SALE OR DISTRIBUTION 1. NOT FOR SALE OR DISTRIBUTION sprain will hurt much more than an unstable grade Traction into position III ligament rupture. The primary pain receptors in 2. Hands-on stable ligaments are stretch receptors. Because the ruptured 3. Splint stable ligament is no longer being stretched, pain is mini- Before you begin, check and document the status of © Jones &mal. Bartlett The primary Learning, complaint LLC is often instability rather © Jones & Bartlett Learning, LLC the neurovascular bundle (check CSM). You will want than discomfort. NOT FOR SALE OR DISTRIBUTION NOTto FOR know SALE that your OR treatment DISTRIBUTION has improved the situa- It is important to protect any injury in which an tion, or at least not made it worse. Most of the time, unstable fracture or ligament rupture may exist. Manip- CSM will remain normal throughout the process. ulation or use of extremities with fractured bones and Sometimes, an extremity feels numb or cold imme- loose or dislocated joints can cause further damage to © Jones & Bartlett Learning, LLCdiately following trauma, especially© Jones if a& fracture Bartlett or Learning, LLC surrounding soft tissue like the organs, muscles, and NOT FOR SALE OR DISTRIBUTIONdislocation results in deformity,NOT pain, FOR and acuteSALE stress OR DISTRIBUTION neurovascular bundle. This potential for damage is reaction. Your treatment should result in a signifi- especially important to evaluate whenever the associ- cant improvement in CSM status as circulation is ated soft tissue is part of a critical system, such as the restored. Beware, however, that distal CSM may spinal cord running through damaged vertebrae, or the become impaired later as swelling develops under a femoral© Jonesartery lying & Bartlettadjacent to Learning, a fractured femur. LLC © Jones & Bartlett Learning, LLC splint or bandage. Detecting and correcting ischemia AssessmentNOT FOR for SALE neurovascular OR DISTRIBUTION bundle injury NOT FOR SALE OR DISTRIBUTION is an important function of continued care through- involves checking distal CSM. Problems with circu- out your treatment and evacuation. lation are found by observing for signs of ischemia— such as cool and pale skin or a weak or absent Traction into Position pulse—in the distal extremity. Problems with sen- © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC sation are reported by the patient as numbness and Injured bones and joints, and the soft tissues around NOT FORtingling. SALE BecauseOR DISTRIBUTION nervous system tissue is exquisitely NOTthem, FOR are SALE much OR more DISTRIBUTION comfortable and much less sensitive to oxygen deprivation, these are usually the likely to be damaged further if splinted in normal first symptoms. The examiner can further evaluate anatomic position. Although many injured extremi- the problem by checking the patient’s ability to distin- ties remain in good position or return there sponta- guish sharp from dull© touch Jones on the & Bartlettdistal extremity. Learning, neously,LLC some will require manual© Jones realignment. & Bartlett Learning, LLC Often sharp and dull sensationNOT FOR is fully SALE intact evenOR withDISTRIBUTION To restore anatomic position,NOT the FOR first SALE step is OR to DISTRIBUTION the complaint of numbness and tingling. Ultimately, apply traction. This separates bone ends and reduces ischemic injuries can become very painful, with loss pain. Then, while traction is maintained, position is of motor control developing later in the process. restored (Figure 13-3). Shaft fractures of long bones Impaired CSM can be caused by various mecha- are returned to the “in-line” position so that the effect © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC nisms, including the following: of opposing muscles is most balanced and the neuro- • NOTDeformity FOR SALE OR DISTRIBUTION vascular bundleNOT is FORleast likely SALE to be OR compressed. DISTRIBUTION • Swelling The amount of force necessary depends on the • Tight splints, boots, jewelry structure being realigned. Forearm and lower leg • Vasoconstriction from cold exposure fractures usually require only gentle traction. Femur © Jones & •Bartlett Tight litter Learning, straps, pressure LLC points © Jonesfractures, & Bartlett with the Learning, large surrounding LLC muscle mass, NOT FOR SALE• Artery OR laceration DISTRIBUTION NOTmay FOR require SALE significant OR DISTRIBUTION traction to restore length and

Section IV: Trauma

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© JonesA & Bartlett Learning, LLC B © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION FIGURE 13-3 Traction into normal anatomic position reduces pain and improves perfusion.

alignment. Deformed wrist fractures may also require Spine injuries are also realigned by considering © Jones & Bartlettsigni icant Learning, traction because LLC the bone ends tend to© Jonesthe & stacked Bartlett vertebrae Learning, o the spineLLC to be a single long NOT FOR SALElock against OR DISTRIBUTION each other (FIGURE 13-4). NOT FORbone SALE with a jointOR atDISTRIBUTION the pelvis and the skull. However, Injured joints without dislocation usually do not traction should not be used. Spine alignment and need to be repositioned. I the patient is conscious protection are discussed in more detail in the spine and mobile, he or she will have already found the injury chapter. most comfortable© position Jones for& Bartlett the injured Learning, joint. I LLC © Jones & Bartlett Learning, LLC not, stabilize it in NOTplace unlessFOR thereSALE is impaired OR DISTRIBUTION CSM NOT FOR SALE OR DISTRIBUTION or the position prevents safe packaging. In joint dislocations, there is likely to be some loss o CSM distal to the injury (FIGURE 13-5). Under these conditions, traction and repositioning are used until circulation© Jones is & reestablished. Bartlett Learning, In speci ic cases,LLC covered © Jones & Bartlett Learning, LLC inNOT the Simple FOR Dislocations SALE OR chapter, DISTRIBUTION repositioning can be NOT FOR SALE OR DISTRIBUTION used to completely reduce dislocations o the shoul- der, digits, and patella with a signi icant improvement in comfort and circulation. The use o traction © Jones & Bartletton more Learning, complex dislocations, LLC such as the elbow,© Jones & Bartlett Learning, LLC wrist, or ankle, is indicated only for restoration and NOT FOR SALEpreservation OR DISTRIBUTION o perfusion. NOT FOR SALE OR DISTRIBUTION

FIGURE 13-4 Complex joint injuries, like this fracture dislocation of the wrist, are manipulated in the eld FIGURE 13-5 This ankle fracture shows obvious only when necessary to restore perfusion or enable a deformity, but not enough to require TIP for © Jones & Bartlettsafe evacuation. Learning, LLC © Jones perfusion& Bartlett or splinting. Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

Chapter 13: Musculoskeletal Injury

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splinting. If you are alone, you can use snow, rocks, or © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC pieces of equipment to hold the limb in place. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Splint Stabilization Unstable Injury: Long Bones Whether a commercially manufactured product, or • Traction into position something improvised from your equipment, a splint • Hand stable • Splint stable © Jones & Bartlett Learning, LLCshould be complete, comfortable,© Jones and compact. & Bartlett Learning, LLC • Check CSM beforeNOT and aFOR er SALE OR DISTRIBUTION• Complete . Long bones shouldNOT FORbe splinted SALE in theOR DISTRIBUTION in-line position, and the ideal splint should immobilize the injured bone as well as the joint above and below the injury. To splint a lower leg Traction and repositioning is a safe procedure if fracture effectively, the ankle and knee should © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC done properly. To be successful at reducing pain and be immobilized. Joint injuries are splinted in restoringNOT position, FOR SALE it is critical OR DISTRIBUTIONto have the coopera- the mid-rangeNOT FOR position, SALE including OR DISTRIBUTION the bones tion and confidence of the injured person. Muscle above and below the injury. To splint the elbow, groups in spasm, or a patient fighting your efforts, for example, the forearm and upper arm are will vastly complicate the procedure. Your patient will included in the splint. © Jones &be Bartlettreassured toLearning, hear that repositioning LLC is intended to © Jones & Bartlett Learning, LLC For splinting purposes, the stacked vertebrae of the be a slow and gentle process. It will also help to let the NOT FOR SALE OR DISTRIBUTION NOTspine FOR may SALE be viewed OR asDISTRIBUTION a long bone with joints at the patient know that he or she is in control, and that you pelvis and base of the skull. Splinting an unstable spine will stop the process if asked. injury would require stabilizing the pelvis, shoulders, The therapeutic effect of a calm voice and reassur- and head. Unstable pelvis injuries require stabilization ing manner is truly amazing. What this treats is the © Jones & Bartlett Learning, LLCof the spine and femur. Femur© fracturesJones require& Bartlett stabi- Learning, LLC patient’s acute stress reaction, as well as yours. Pain lization of the pelvis and knee. For these spine, pelvis, medication is valuable,NOT but it FOR can be SALE dangerous OR to DISTRIBUTION use NOT FOR SALE OR DISTRIBUTION and femur injuries, the ideal treatment is whole-body in the backcountry setting at the dosage necessary to stabilization in a litter or vacuum mattress. completely relax a scared and uncomfortable patient. • Comfortable . Splints should be well-padded, strong, Field treatment, combining reassurance with the and snug. There should be no movement of the lowest© effectiveJones dose& Bartlett of medication, Learning, can offer LLC less risk © Jones & Bartlett Learning, LLC injured bones or any pressure points or loose with equal benefit. NOT FOR SALE OR DISTRIBUTION spots. ANOT splint FOR should SALE allow you OR to DISTRIBUTION monitor distal Open shaft fractures with bone ends protruding CSM, and should be easily adjustable if ischemia through the skin are still managed with traction and or pain develops. A good splint decreases pain repositioning following thorough cleaning of the and preserves CSM; attention to this principle exposed bone ends and surrounding skin (see the chap- is critical to prevent pressure sores and infection © Jones &ter Bartlett on soft-tissue Learning, injury). To LLC keep skin from becoming © Jones & Bartlett Learning, LLC during long-term care and transport. NOT FORtrapped SALE under OR theDISTRIBUTION bone as you realign the fracture, you NOT FOR SALE OR DISTRIBUTION • Compact . For wilderness use, a splint should may have to pull it free with forceps or a gloved finger be no larger or more complex than absolutely as the bone is manipulated back into the wound. necessary (FIgUre 13-6). It should not inhibit the Occasionally it will be impossible to restore position comfortably and ©safely. Jones You &should Bartlett discontinue Learning, LLC © Jones & Bartlett Learning, LLC traction and stabilize theNOT injury FOR in the SALE position OR found DISTRIBUTION NOT FOR SALE OR DISTRIBUTION if traction causes a significant increase in pain or resistance. These rare situations represent a limb- threatening emergency if deformity is significant or ischemia is detected. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC HandNOT Stabilization FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Once you have repositioned an extremity injury, sta- bility must be maintained until the splint can take FIgUre 13-6 Wrist splint--complete, comfortable, over. This may mean having someone hold gentle and compact--in the position of comfort. © Jones &traction Bartlett on Learning, the extremity LLC while you prepare for © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

Section IV: Trauma

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evacuation you have in mind. A simple sling and amount of traction is applied to the femur, the pres- © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC swathe, for example, splints everything from sure at the anchor points will inevitably cause skin NOT FOR SALE OR DISTRIBUTION NOT FOR SALEthe OR clavicle DISTRIBUTION to the elbow. This simple structure and soft tissue ischemia. For these reasons, the use of can be created with a safety pin and the patient’s a traction splint may not be appropriate or safe for shirt. No additional material is necessary. backcountry rescue or long-term care. In this setting, femur fractures are best stabilized in a litter, vacuum Once an injury© is Jones stabilized, & Bartlett the most Learning, important LLCmattress, or well-padded© backboard. Jones & Bartlett Learning, LLC anticipated problemNOT for long-termFOR SALE care becomesOR DISTRIBUTION distal NOT FOR SALE OR DISTRIBUTION ischemia caused by compression of the neurovascular Pelvic Fracture bundle as swelling develops inside splints or bandages Shock and distal ischemia are anticipated problems (FIgUre 13-7). Treatment should include medication, due to the proximity of the iliac arteries and veins. rest, and elevation to reduce swelling and pressure. © Jones & Bartlett Learning, LLC Pelvic binding© Jones with & a paddedBartlett strap Learning, or wide compres- LLC This is essentially the same as the generic treatment sion bandage may be useful to help stabilize a pelvic forNOT stable FOR injuries. SALE As long OR as DISTRIBUTION distal CSM remains nor- NOT FOR SALE OR DISTRIBUTION fracture and reduce the space available for internal mal or continues to improve, you can take your time blood loss. This can be accomplished by wrapping a planning a safe and comfortable evacuation. tarp or backpack hip belt around the pelvis and tight- © Jones & Bartlett Special Learning, Wilderness LLC Considerations© Jonesening & Bartlett gently to Learning,restore anatomy. LLC The patient is then NOT FOR SALE OR DISTRIBUTION NOT FORfurther SALE stabilized OR byDISTRIBUTION a litter, vacuum mattress, or well- Femur Fracture padded backboard. Urgent evacuation is indicated. Shock and distal ischemia are anticipated problems due to the proximity of the neurovascular bundle to Compartment Syndrome the femoral shaft.© The Jones usual treatment& Bartlett for Learning, a femoral LLC Swelling due to bleeding© orJones edema & inside Bartlett a muscle Learning, LLC shaft fracture in the EMS setting is the application compartment can increase intra-compartment pres- NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION of a traction splint and urgent evacuation to a hos- sure to the point that perfusion is impaired. The pital. This may be appropriate for short-term care, mechanism is usually blunt trauma or collateral dam- but the risks outweigh the benefits in long or difficult age from a fracture. It is also possible to see com- evacuations. partment syndrome develop from repetitive motion © InJones many backcountry& Bartlett situations,Learning, it canLLC be impos- injury. © Ischemia Jones develops, & Bartlett with Learning, necrosis of LLC muscle sibleNOT to FOR distinguish SALE a OR femoral DISTRIBUTION shaft fracture from a and nerveNOT tissue FOR as theSALE anticipated OR DISTRIBUTION problem. Symp- femoral neck or pelvis fracture that might be further toms include pain out of proportion to the apparent deformed by the application of traction. Even when injury, distal numbness, and pain on passive stretching properly applied, traction splints are notoriously of the affected muscle group. Compartment syn- © Jones & Bartlettdifficult toLearning, monitor and LLC package. When the proper© Jonesdrome & Bartlett can develop Learning, hours toLLC days after the initial NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

A B

FIgUre 13-7 A quick splinting job may help with extrication from a dangerous spot, but it needs to be carefully tted and padded later for long-term use. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

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injury ( FIgUre 13- 8 ). Field treatment includes anti- Distal ischemia and infection are anticipated prob- © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC inflammatory medication, rest, elevation, and cooling lems. Aggressive debridement (removal of foreign NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION of the extremity. Urgent evacuation is indicated if material and dead tissue) and irrigation with clean immediate improvement is not noted. water are necessary before bone ends are pulled under the skin. Early use of prophylactic antibiotics Open Fracture should be considered as part of the ideal field treat- © Jones & Bartlett Learning, LLCment. In cases such as crush© Jones injuries where& Bartlett bones Learning, LLC Fractures may be open (compound) or closed (sim- NOT FOR SALE OR DISTRIBUTIONremain exposed, moist dressingsNOT over FOR the woundSALE willOR DISTRIBUTION ple). In an open fracture, the site is exposed to the help preserve tissue. Urgent evacuation is indicated. outside environment through a wound in the skin. This opening can be produced from inside by sharp Joint Infection bone ends, or from outside by the same object that The symptoms of joint infection (also called sep- caused© theJones fracture & Bartlett (such as Learning, a bullet). Fortunately, LLC © Jones & Bartlett Learning, LLC tic arthritis ) include swelling, redness, pain, and open NOTfractures FOR are SALEuncommon OR ( FIgUreDISTRIBUTION 13-9). NOT FOR SALE OR DISTRIBUTION warmth. The patient may develop a fever. Joint infection usually develops shortly after a laceration or puncture wound that penetrates the joint space, Superficial Calf but it may develop after a minor abrasion or without © Jones & Bartlettposterior Learning, LLC Deep posterior © Jones & Bartlett Learning, LLC compartment compartment any skin defect being visible. These infections have NOT FOR SALE OR DISTRIBUTION NOTthe FOR potential SALE to ORbecome DISTRIBUTION systemic, and result in life- threatening vascular shock.

Impending Surgery Fibula © Jones & Bartlett Learning, LLC Serious fractures, infections,© and Jones compartment & Bartlett syn- Learning, LLC NOT FOR SALE OR DISTRIBUTIONdromes will be likely candidatesNOT for immediateFOR SALE surgery OR DISTRIBUTION Tibia upon arrival at the hospital. The anesthesiologist pre- Lateral compartment Anterior paring the patient for surgery will anticipate patient compartment vomiting because it is a problem associated with general Shin © Jones & Bartlett Learning, LLC anesthesia and© Jonesintubation. & BartlettFor that reason, Learning, EMS per- LLC sonnel in the ambulance context do not give any fluids, FIgUreNOT 13- FOR 8 Compartment SALE OR syndrome DISTRIBUTION occurs NOT FOR SALE OR DISTRIBUTION when swelling of injured muscle tissue increases food, or medications by mouth to such patients. This is compartment pressure to the point that perfusion referred to as keeping the patient NPO , an abbreviation becomes impaired. It is most common in the lower for the Latin nil per os . Intravenous (IV) fluids and IV or leg and forearm. intramuscular (IM) medications are used instead. © Jones & Bartlett Learning, LLC © Jones During & Bartlett a long evacuation, Learning, priority LLC must be given NOT FOR SALE OR DISTRIBUTION NOTto FOR maintaining SALE hydration,OR DISTRIBUTION perfusion, and body core temperature. Fluid replacement by IV line is ideal, but oral intake of fluids will be necessary if the IV route is not available or is impractical. Food is important in maintaining calories for heat produc- © Jones & Bartlett Learning, tion.LLC You can help the anesthesiologist© Jones & byBartlett giving Learning, LLC NOT FOR SALE OR DISTRIBUTIONyour patient easily digestedNOT and FOR absorbed SALE simple OR DISTRIBUTION sugars and carbohydrates and avoiding protein and fat when possible. NPO is not an option in most prolonged evacuations. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION StableNOT Injury FOR SALE OR DISTRIBUTION Stable musculoskeletal injuries have none of the specific signs and symptoms associated with instability. FIgUre 13-9 An open fracture is a high-risk problem that can be hidden by layers of clothing. Often, the patient will be able to move, use, or bear © Jones & Bartlett Learning, LLC © Jonesweight & with Bartlett the extremity Learning, within LLC a short time after NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

Section IV: Trauma

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injury, and there will be no history of instability. Any © Jones & Bartlett Learning, LLC © Jones & BartlettWilderness Learning, PerspectiveLLC swelling will develop slowly over several hours. You NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION will find no deformity, crepitis on movement, or Musculoskeletal Injury instability on exam. High-risk problem: Treatment is designed to reduce and control swell- • Pain out of proportion to apparent injury ing and pain and includes using anti-inflammatory • Critical system injury medication as well© asJones rest, ice & ifBartlett available, Learning, compres- LLC • Unstable fracture of© pelvis Jones or femur & Bartlett Learning, LLC sion, and elevationNOT (RICE). FOR Because SALE a stableOR DISTRIBUTION injury is • Persistent impaired NOTCSM FOR SALE OR DISTRIBUTION • Compartment syndrome safe to use within the limits of discomfort, the patient • Open fracture is allowed pain-free activity. • Joint infection Elevation and rest are the most effective elements of RICE and most useful early on when the swelling © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC is likely to be the worst. Ice can also be helpful if it is NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION available, but not so much that it is worth carrying bandages may also be employed to provide some sup- chemical cold packs in a backcountry medical kit. port to a sore joint. Frequent monitoring of the distal Compression of an injured extremity with an elas- CSM is important when using a compression ban- tic bandage is intended to limit the space available dage. © Jones & Bartlettfor swelling Learning, or to force LLC accumulated fluid out of the© Jones & Medication Bartlett suchLearning, as aspirin, LLC ibuprofen, or acet- NOT FOR SALEextracellular OR DISTRIBUTION space. Sometimes this is helpful, but NOTit FORaminophen SALE OR can helpDISTRIBUTION reduce discomfort. A regular can also contribute to compartment syndrome and dose over several days will raise an appreciable level increase swelling of the distal extremity. Compression of the drug in the body and may work better than just taking it occasionally in response to pain. Because © Jones & Bartlett Learning, LLCaspirin and ibuprofen © inhibit Jones blood & Bartlett clotting Learning, and LLC NOT FOR SALE OR DISTRIBUTIONincrease swelling from bleeding,NOT FOR acetaminophen SALE OR may DISTRIBUTION be preferred in the immediate post-injury period. Pain-free activity is allowed after the first 24 hours, or when most of the pain and swelling has resolved. Stable Injuries The patient may perform whatever activity is possible © Jones• No deformity & Bartlett or instability Learning, on exam LLC as long ©as painJones is not & increased. Bartlett This Learning, may include LLC ski- NOT• NoFOR sense SALE of instability OR reportedDISTRIBUTION by patient ing, or NOTit may FORrequire SALE very limited OR DISTRIBUTION use around camp • Able to move and bear weight a er accident for several days. • Distal CSM intact • Slow onset of swelling Following these treatment guidelines, all stable • Pain proportional to apparent injury injuries should show steady improvement. If not, © Jones & Bartlett Learning, LLC © Jonesyour & Bartlettpatient is beingLearning, too active, LLC or your assessment may be wrong. It is possible to have a stable injury NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION with a small fracture causing prolonged discomfort. Medical follow-up is indicated if rapid improvement is not noted or if symptoms persist at the end of the trip. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Stable Injuries Overuse Syndromes • Rest, ice, compression, elevation (RICE) • Pain-free activity Bursitis, tendonitis, and joint inflammation can be • Splint or sling for comfort symptoms of overuse. These injuries develop over © Jones• NSAIDs & for Bartlett pain and Learning,swelling LLC time without© Jones an & obvious Bartlett precipitating Learning, traumatic LLC NOT• MonitorFOR SALE CSM OR DISTRIBUTION event otherNOT than FOR repetitive SALE motion.OR DISTRIBUTION A long hike or • Medical follow-up when possible bike ride can bring on pain and near-complete disability. You should be able to rule out unstable injury

Chapter 13: Musculoskeletal Injury

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by history, but that may not make the patient any water and food. The stomach may allow a couple of © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC more functional. days of this, which can suppress the inflammation NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION You will note pain, swelling, and sometimes red- enough to prevent complete disability. Reduce the ness over an inflamed muscle, tendon, or joint struc- dose as soon as improvement is noted. ture. Moving it will hurt, and you may be able to feel Using tape and padding, you can create a soft splint crepitus as a damaged tendon slides roughly through that will help reduce the stress on the irritated struc- an irritated tendon sheath.© Jones Resting & it Bartlett will bring Learning, relief. LLC © Jones & Bartlett Learning, LLC ture. Joint taping is another technique for providing These symptoms are typicalNOT FORof all kindsSALE of ORrepetitive DISTRIBUTION NOT FOR SALE OR DISTRIBUTION support and limited mobility ( FIgUre 13- 10 ). Encourage motion injury. Bikers get it in the knee, hikers in the the patient to rest frequently, letting pain be the signal foot, and rowers in the wrists. To treat an overuse syndrome effectively, you to stop. Continue only after the pain is under control. have to break the cycle of injury and inflammation. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Treatment includes RICE and anti-inflammatory risk Versus Beneﬁ t medication.NOT FOR If travel SALE is required, OR DISTRIBUTION functional splint- NOT FOR SALE OR DISTRIBUTION ing for support and mobility will be necessary. As Traction into position to restore alignment in signifi- pain subsides, remove the splint two or three times a cantly deformed fractures and dislocations can be pain- day and do gentle exercises, taking the part through ful for the patient and intimidating for a practitioner © Jones &its Bartlett normal range Learning, of motion LLC as pain allows. Apply © Jonesinexperienced & Bartlett in the Learning, procedure. ItLLC is worth remem- NOT FORheat SALE after ORthe initialDISTRIBUTION inflammation has settled down. NOTbering FOR that SALE significant OR DISTRIBUTION deformity represents a high risk Use warm soaks four times a day for 15 minutes at a of ischemia to infarction and increased bleeding and time. This is good to do just before range of motion tissue damage. It is also more painful and difficult to exercises. stabilize and evacuate safely. Gentle repositioning is a Change the way your patient performs the repeti- © Jones & Bartlett Learning, LLClow-risk procedure for a high-risk© Jones problem. & Bartlett Learning, LLC tive motion. This will put the stress on different Procedures that seem to cause intolerable pain or muscle/tendon groups.NOT For FOR example, SALE using OR a shortDISTRIBUTION NOT FOR SALE OR DISTRIBUTION require a lot of force are more dangerous. When you loop of webbing as a handle on a kayak paddle can allow the paddler to pull with the wrist held vertically meet significant resistance, you should stop and reas- instead of horizontally. This may not be ideal, but it sess. Wait a few minutes or modify the technique may allow© Jones the group & Bartlett to continue Learning, its travel. LLC and try again.© Jones If you are& Bartlett still unsuccessful, Learning, consider LLC TheNOT patient FOR should SALE take ORthe full DISTRIBUTION therapeutic dose of the persistentNOT deformity FOR andSALE severe OR pain DISTRIBUTION to indicate a anti-inflammatory medication. For ibuprofen, this is high-risk problem and the need for urgent evacuation. 2400 mg a day. Gastrointestinal and kidney problems Even stable injuries, with continued use, run can be minimized by taking these drugs with ample the risk of becoming worse. This must be balanced against the benefit of continued mobility and self- © Jones & Bartlett Learning, LLC © Jonessufficiency. & Bartlett Moderating Learning, activity LLC with splinting NOT FOR SALE OR DISTRIBUTION NOTor FOR wrapping SALE to ORminimize DISTRIBUTION the increase in pain and swelling is a reasonable goal for early treatment in a difficult situation. Splints and wraps are applied where necessary to © Jones & Bartlett Learning, reduceLLC the risk of further soft-tissue© Jones trauma & Bartlett in unsta- Learning, LLC NOT FOR SALE OR DISTRIBUTIONble musculoskeletal injury. AtNOT the same FOR time, SALE they canOR DISTRIBUTION create an increased threat to the patient’s safety and survival. A sling and swathe, for example, can inhibit a skier’s ability to negotiate a cliff band safely. Back- © Jones & Bartlett Learning, LLC board or litter© Jones stabilization & Bartlett can drown Learning, a patient LLCon NOT FOR SALE OR DISTRIBUTION an overturnedNOT boat. FOR Sometimes SALE theOR benefit DISTRIBUTION of a sta- FIgUre 13- 10 Joint taping can provide support and limited mobility. bilized injury does not match the overall risk to the patient and the plan must be modified.

Section IV: Trauma

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© Jones & BartlettChapter Learning, Review LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION ✔✔ Musculoskeletal injuries alone are not ✔✔ Unstable joint injuries should be splinted as emergencies, but they can affect critical system found unless circulation is impaired or the function, causing ischemia, respiratory distress, position will inhibit safe evacuation. ✔ and shock. © Jones & Bartlett Learning, LLC ✔ Splints, if needed, should© Jones be complete, & Bartlett Learning, LLC ✔✔ Unstable injuries present risk of injury comfortable, and compact. to surroundingNOT soft FORtissue, SALEincluding OR the DISTRIBUTION ✔✔ Stable injuries are safeNOT to use FOR and SALEmove within OR DISTRIBUTION neurovascular bundle, and should be protected the limits of pain-free activity. and stabilized. ✔✔ High-risk musculoskeletal injury should be ✔✔ Deformed long bone fractures should be restored evacuated urgently to definitive medical care. © Jonesto normal & alignmentBartlett usingLearning, traction LLCinto position. © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

Chapter 13: Musculoskeletal Injury

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