Pathophysiology of the Musculoskeletal
System
Joint Injury
Sprain
Subluxation
Dislocation
Bone Injury
Open Fracture
Closed Fracture
Hairline Fracture
Impacted Fracture
Pathophysiology — Mechanism of Injury
Five forces cause bone and joint injury
Direct force
Indirect force
Twisting force
Pathological
Fatigue
Classifications of Musculoskeletal
Injuries
Injuries include:
Fractures
Sprains
Strains
Joint dislocations
Musculoskeletal Injuries
Direct trauma
Blunt force applied to an extremity
Indirect trauma
Vertical fall that produces spinal fracture distant from site of
impact
Pathological conditions
Some forms of arthritis
Malignancy
Pathophysiology — Fractures
Unstable — Proximal and distal ends move freely
in relationship to each other
Impacted — Jammed together so there is no movement
between proximal and distal bones
Open — Skin is open, allowing introduction of
bacteria, dirt, and other foreign bodies
Closed — Skin is intact
Fracture with dislocation — Fracture at joint with
injury to supporting structures
Fractures
Break in continuity of bone or cartilage
Complete or incomplete
Line of fracture through bone
Open or closed
Integrity of skin near fracture site
Classification of Fractures
Open
Closed
Comminuted
Greenstick
Spiral
Classification of Fractures
Oblique
Transverse
Stress
Pathological
Epiphyseal
Classification of Fractures
Pathophysiology — Fractures
Impacted
Pathophysiology — Fractures
Joint Dislocations
Normal articulating ends of two or more bones are displaced
Luxation: Complete dislocation
Subluxation: Incomplete dislocation
Frequently dislocated joints
Suspect joint dislocation when joint is deformed or does not have
normal range of motion
Dislocations can result in great damage and instability
Pathophysiology — Fractures
Dislocation - Angulated
Pathophysiology — Fractures
Sprains
Partial tearing of ligament
Caused by sudden twisting or stretching of joint beyond
normal range of motion
Common in ankle and knee
Graded by severity
First-degree sprain
Second-degree sprain
Third-degree sprain
Strains
Injury to muscle or its tendon
Overexertion or overextension
Common in back and arms
May have significant loss of function
Severe strains may cause avulsion of bone from
attachment site
Pathophysiology of the Musculoskeletal
System
Inflammatory & Degenerative Conditions
Bursitis
Tendinitis
Arthritis
Osteoarthritis
Degenerative
Rheumatoid Arthritis
Chronic, systemic, progressive, debilitating
Gout
Inflammation of joints produced by accumulation of uric acid crystals
Bursitis
Inflammation of bursa
Small, fluid-filled sac acts as cushion at a pressure point near
joints
Most important bursae are around knee, elbow, and shoulder
Bursitis
Bursitis is usually from:
Pressure
Friction
Injury to membranes surrounding the joint
Treatment
Rest, ice, and analgesics
Tendonitis
Inflammation of tendon
Often caused by injury
Symptoms include:
Pain
Tenderness
Restricted movement of muscle attached to affected tendon
Treatment
Nonsteroidal antiinflammatory drugs (NSAIDs)
Corticosteroid medications
Arthritis
Joint inflammation
Pain, swelling, stiffness, and redness
Joint disease
Involving one or many joints
Many causes
Varies in severity
Mild ache and stiffness
Severe pain and later joint deformity
Arthritis
Osteoarthritis (degenerative arthritis) most common
Pain usually managed with antiinflammatory agents
Extremity Trauma
Signs and symptoms
Pain on palpation or movement
Swelling, deformity
Crepitus
Decreased range of motion
False movement (unnatural movement of extremity)
Decreased or absent sensory perception or circulation distal to
injury
Six "P"s of Compartment Syndrome
Pain
On palpation (tenderness)
On movement
Pallor—pale skin or poor
capillary refill
Paresthesia—pins and needles
sensation
Pulses—diminished or absent
Paralysis—inability to move
Pressure
Associated Complications
Hemorrhage
Instability
Loss of tissue
Simple laceration and contamination
Interruption of blood supply
Nerve damage
Long-term disability
Assessment
Determine if life-threatening conditions are present
Care for those first
Never overlook musculoskeletal trauma
Don’t allow noncritical musculoskeletal injury to distract
from priorities of care
Musculoskeletal Assessment
Four classes of patients
Life-/limb-threatening injuries or conditions
Includes life-/limb-threatening musculoskeletal trauma
Other life-/limb-threatening injuries and simple
musculoskeletal trauma
Life-/limb-threatening musculoskeletal trauma
No other life-/limb-threatening injuries
Isolated, non-life-/limb-threatening injuries
Musculoskeletal Injury Assessment
Scene Size-up
Initial Assessment
Categories of urgency
Life & Limb threatening injury
Life threatening injury and minor musculoskeletal injury
Non-life threatening injuries but serious musculoskeletal injuries
Non-life threatening injuries and only isolated minor musculoskeletal
injuries
Rapid Trauma Assessment
Focused H&P
6 P’s: Pain, Pallor, Paralysis, Paresthesia, Pressure, Pulses
Detailed Physical Exam
Ongoing Assessment
Sports Injury Consideration
Age-Associated Changes in Bones
Water content of intervertebral disks decreases
Increased risk of disk herniation
Loss of stature is common – ½ - 3/4 inch
Bone tissue disorders shorten trunk
Age-Associated Changes in Bones
Vertebral column assumes arch shape
Costal cartilages ossify, making thorax more rigid
Shallow breathing due to rigid thoracic cage
Facial contours change
Fractures
Limb-Threatening Injuries
Knee dislocation
Fracture or dislocation of ankle
Subcondylar fractures of elbow
Require rapid transport
Musculoskeletal Injury Management
Other Injury Consideration
Pediatric Musculoskeletal Injury
Athletic Musculoskeletal Injury
Patient Refusals & Referral
Psychological Support
Musculoskeletal Injury Management
General Principles
Protecting Open Wounds
Positioning the limb
Immobilizing the injury
Checking Neurovascular Function
Musculoskeletal Injury Management
Splinting Devices
Rigid splints
Formable Splints
Soft Splints
Traction Splints
Other Splinting Aids
Vacuum Splints
Air Sprints
Cravats or Velcro Splints
Fracture Care
Joint Care
Muscular & Connective Tissue Care
Musculoskeletal Injury Management
Care for Specific Fractures
Pelvis
Scoop Stretcher
PASG
Fluid Resuscitation
Femur
Traction Splints
PASG
Fracture versus hip doslocation
Musculoskeletal Injury Management
Care Specific Fractures
Tibia/Fibula
Clavicle
Most frequently fractured bond in the body
Transmitted to 1st and 2nd rib
Alert for lung injury
Humerus
Radius/Ulna
Musculoskeletal Injury Management
Care for Specific Joint Injuries
Hip
Knee
Ankle
Foot
Joint Injuries
Shoulder
Elbow Alert for PMS
Wrist/Hand
Finger Compromise
Musculoskeletal Injury Management
Soft & Connective Tissue Injuries
Tendon
Ligament
Muscle
Musculoskeletal Injury Management
Medications
Not A Biotel Option
Nitrous Oxide Diazepam
50% O2:50% N Benzodiazepine
Non-explosive Antianxiety
Effects dissipate in 2-5 Analgesic
minutes Dose
Easily diffused into air filled 5-15 mg titrated
spaces in body. Onset
Dose 10-15 minutes
Inhaled & self administered Duration
Onset 15-60 minutes
1-2 minutes Counter Agent
Flumazenil
Dislocation of Acromioclavicular
Joint
Humerus Injury
Older adults and children
Difficult to stabilize
Complications
Radial nerve damage if fracture
in middle or distal portion of
humeral shaft
Humeral neck fracture may
cause axillary nerve damage
Internal hemorrhage into joint
Musculoskeletal Injury Management
Medications
Oxygen
n Nitrous Oxide
n Morphine Sulfate
Fluids
Nitrous Oxide
Class: Gaseous Analgesic/Anesthetic
Route: Inhalation Adult Dose: Instruct patient to inhale
deeply through patient-held mask or
mouthpiece Pediatric
Dose: Instruct patient to inhale deeply through patient-
held mask or mouthpiece Drug
Action: Depresses the central nervous system Increases
oxygen tension in the blood thereby reducing
hypoxia Onset:2 minutes - 5 minutes Duration:2
minutes - 5 minutes
Nitrous Oxide
Indications: Adjunct analgesic for ischemic chest pain Severe
pain or discomfort in all patients without contraindications.
Precautions: Must be self administered Check machine gauges
daily for proper concentrations Monitor blood pressure and pulse
oximetry values during administration
Side Effects: Hypotension Dizziness Nausea and vomiting
Contraindications: Any altered level of consciousness or head
injury Chronic obstructive pulmonary disease Chest trauma or
actual/suspected pneumothorax Abdominal trauma Major facial
trauma Acutely psychotic patients Pregnancy, other than active
labor Any patient (adult or pediatric) unable to self-administer
Decompression sickness
Morphine Sulfate
Indications Pain and anxiety secondary to AMI
Chest pain unrelieved by Nitroglycerin
Pulmonary edema
Pain secondary to amputations or fractures
Precautions: Monitor respiratory status and blood pressure
closely.
Notify Biotel prior to administration if patient is >65yrs of age,
debilitated, has altered mental status, or systolic BP<110mmHg
CHF: be prepared to intubate
Antidote: Naloxone (Narcan®)
Morphine Sulfate
Class: Narcotic Analgesic
Route: Slow IV push
Dose: Adult: Administer in titrated doses of 2 - 4mg, up to a
maximum of 10mg
Pediatric: 0.1mg/kg
Drug Action: Alleviates pain
Decreases peripheral vascular resistance - vasodilator
Decreases cardiac workload and oxygen demand on the heart