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Musculoskeletal Injury © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION © 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 LLigamentigament 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 © 2013 by Jones & Bartlett Learning, LLC, an Ascend Learning Company and Wilderness Medical Associates International 89206_CH13_Printer.indd 78 2/8/12 7:03 PM 79 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 . ORThis DISTRIBUTION structure in cross section resembles NOTa 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 LLCyes-or- 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 Chapter 13: Musculoskeletal Injury © 2013 by Jones & Bartlett Learning, LLC, an Ascend Learning Company and Wilderness Medical Associates International 89206_CH13_Printer.indd 79 2/8/12 7:03 PM 80 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© Jonesneurovascular & 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
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