Musculoskeletal Injuries

Musculoskeletal injuries include fractures, dislocations, sprains, and strains. While they are rarely the immediate cause of death, they can cause significant blood loss (a closed femur fracture can lose 1-2 liters of blood), permanent disability, and severe pain. Proper splinting and neurovascular monitoring are essential EMT skills.

Fractures: Open vs. Closed

Closed Fracture:

• The bone is broken but the skin is intact
• Signs: pain, swelling, deformity, crepitus (grating sound/feeling), false motion, guarding, inability to bear weight
• May have significant internal bleeding at the fracture site

Open Fracture:

• The bone has broken through the skin, or an external wound communicates with the fracture
• High risk of infection and contamination
• Management: Cover the exposed bone and wound with a moist sterile dressing, then splint
• Do NOT push protruding bone back under the skin
• Do NOT intentionally pull bone ends back into the wound

Dislocations

A dislocation occurs when a bone is displaced from its normal position at a joint:

• Presents with deformity, locked joint position, and inability to move the joint through its normal range of motion
• Commonly affects the shoulder, elbow, finger, hip, knee, and ankle
• Do NOT attempt to reduce (relocate) a dislocation in the field at the EMT level
• Splint in the position found and transport
• Monitor and document distal PMS

Sprains vs. Strains

Splinting Principles

General Rules:

1. Assess PMS (Pulse, Motor function, Sensation) before splinting
2. Remove or cut away clothing and jewelry from the injured extremity
3. Cover open wounds with a sterile dressing before splinting
4. Immobilize the joint above and the joint below the fracture site
5. Pad all voids and bony prominences within the splint
6. Splint in the position found unless there is no distal pulse (then gentle realignment per protocol)
7. Reassess PMS after splinting - if PMS is lost, loosen and reposition the splint
8. Apply cold packs to reduce swelling (place a barrier between the cold pack and skin)
9. Elevate the injured extremity when possible

Types of Splints

Rigid Splints:

• Board splints, cardboard, metal (SAM splint)
• Must be padded and secured with cravats or roller bandage
• Best for long bone fractures

Soft Splints:

• Pillow splints, sling and swathe, blanket rolls
• Conform to the body and are comfortable
• Good for ankle, foot, wrist, and shoulder injuries

Traction Splints:

• Apply mechanical traction to realign the bone and reduce pain and internal bleeding
• Indicated ONLY for isolated midshaft femur fractures

Traction Splint: Indications and Contraindications

Indications:

• Isolated midshaft femur fracture with pain, swelling, and deformity
• Shortened, externally rotated leg

Contraindications:

• Fracture near or involving the knee or hip joint
• Pelvic fracture
• Partial amputation or avulsion with bone separation
• Lower leg or ankle injury on the same extremity

Application Steps:

1. Assess distal PMS
2. Stabilize the leg manually and apply manual traction
3. Apply the ankle hitch
4. Position the splint alongside the leg
5. Apply mechanical traction until the leg length is equal to the uninjured leg or pain is relieved
6. Secure the leg to the splint with straps
7. Reassess distal PMS

Compartment Syndrome

Compartment syndrome is a limb-threatening emergency caused by increased pressure within a closed fascial compartment:

• Cause: Swelling from fractures, crush injuries, or tight casts/splints
• Hallmark symptom: Pain out of proportion to the injury that worsens with passive stretch of the muscles in the affected compartment
• The 6 P's: Pain, Pressure, Paresthesia (numbness/tingling), Paralysis, Pallor, Pulselessness
• Note: Loss of pulse is a very late finding; do not wait for absent pulses to suspect compartment syndrome
• EMT Management: Remove any constricting bandages/splints, elevate the extremity, transport promptly