Treat a Casualty with a Musculoskeletal Injury
Musculoskeletal injuries are frequently encountered in the field. Appropriate management can prevent further painful injury and even prevent permanent disability or death.
(1) Skull
(a) Cranium
(b) Facial
(c) Mandible
(2) Spine
(a) Cervical spine
(b) Thoracic spine
(c) Lumbar spine
(d) Sacral spine
(e) Coccyx
(1) Shoulder
(a) Clavicle
(i) Collarbone
(ii) Located anteriorly
(b) Scapula
(i) Shoulder blade
(ii) Located posteriorly
(c) Acromion process of the scapula is the highest portion of the shoulder. Forms acromioclavicular joint with clavicle and is frequent area of shoulder injury.
(2) Upper arm and forearm
(a) Humerus - bone between shoulder and elbow
(b) Radius
(i) Lateral bone of the forearm - articulates with carpals
(ii) Aligned with the thumb - articulates with the humerus
(c) Ulna - medial forearm bone
(3) Wrists - consists of eight bones called carpals
(a) Metacarpals - bones of the hand
(b) Phalanges - finger bones
(1) Commonly referred to as the hip
(2) Contains bones that are fused together
(a) Ilium
(i) Superior bone that contains iliac crest
(ii) Wide bony wing that can be felt near the waist
(b) Ischium - inferior, posterior portion of the pelvis
(c) Pubis - formed by the joining of the bones of the anterior pubis
(3) Pelvis is joined posteriorly to sacral spine
(4) Hip joint consist of:
(a) Acetabulum (socket of the hip joint)
(b) Ball at proximal end of femur
(1) Femur - thigh bone
(2) Patella
(a) Kneecap
(b) Sits anterior to the knee joint
(3) Knee - connects the thigh with the lower leg
(4) Tibia
(a) Medial
(b) Larger bone of the lower leg
(c) Also referred to the shin bone
(5) Fibula
(a) Lateral
(b) Smaller bone of the lower leg
(6) Ankle - joint of the tibia and fibula of the leg with the talus of the foot
(a) Two distinct landmarks (protrusions that you see on lateral and medial aspects of ankles):
(i) Lateral malleolus - lower end of the fibula
(ii) Medial malleolus - lower end of tibia
(b) Consists of bones called tarsals
(7) Metatarsals - foot bones
(8) Calcaneus - heel bone
(9) Phalanges - toe bones
(1) Where bones connect to other bones
(2) Types of joints
(a) Ball-and-socket - ball rotates in a round socket
(b) Hinge - bends and straightens
(c) Pivot - rotation
(d) Condyloid - motion in two planes at right angles, but no radial rotation
(e) Saddle - motion in two planes at right angles, but no axial rotation
(f) Gliding - limited motion for glididing
(1) Assess airway
(2) Assess breathing
(3) Assess circulation - especially pulses distal to site of injury
(4) Assess for signs and symptoms of shock - fracture to larges bones such as the femur and pelvis may cause massive hemorrhage leading the hypovolemic shock.
(1) Consider mechanism of injury
(a) Direct force
(b) Indirect force
(c) Twisting force (torsion)
(2) If casualty is conscious, ask:
(a) Location of injury?
(b) Pain?
(c) Tenderness?
(d) Can he/she move the extremity?
(3) Assess skin
(a) Color
(b) Sensation
(c) Temperature
(d) Capillary refill
(4) Obtain vital signs
(5) Assess fracture
(a) Closed fracture
(i) Bone injury is entirely internal
(ii) No break in skin
(iii) Loss of up to a liter of blood can be caused by a closed fractures of one femur - Two fractured femurs can cause hemorrhaging of a life-threatening nature
(b) Open fracture - open wound of skin
(i) Occur when sharp end of broken bone pushes out through the skin
(ii) Made by an object such as a bullet that penetrates from the outside
(iii) Usually involve extensive damage to tissues and likely to become infected
(iv) Look for open wounds and the possibility of an open fracture
(c) Fractured bone ends are extremely sharp and pose a serious threat to surrounding tissue
(i) Nerves, arteries, and which frequently are located near the bone or near the skin are often injured
(ii) Neurological injuries may be due to lacerations from bone fragments or from pressure due to hematomas or swelling
(d) Fractures of the clavicle
(i) Injured shoulder is lower than uninjured
(ii) Casualty is usually unable to raise arm above level of the shoulder
(iii) May attempt to support injured shoulder by holding elbow with other hand
(iv) Deformity
(v) Localized pain
(vi) Tenderness
(e) Fractures of the humerus
(i) Pain
(ii) Tenderness
(iii) Swelling
(iv) Wobbly motion at point of fracture
(v) If fracture is near the elbow, arm is likely to be straight with no bend at elbow
(f) Fractures of the radius and/or ulna
(i) When both are broken, the arm usually appears deformed
(ii) When only one bone is broken, the other acts as a splint and the arm retains a more natural appearance
(iii) Pain
(iv) Tenderness
(v) Inability to use forearm
(vi) Unstable fracture segment
(g) Simple rib fractures
(i) Pain localized at site of fracture
(ii) Possible rib deformity
(iii) Coughing or movement is usually painful
(iv) Casualty remains still and often leans toward injured side
(h) Fractures of the pelvis
(i) Can cause extensive bleeding in retroperitoneal space or abdomen
(ii) Usually fractures in several places
(iii) Bone fragments from a fractured pelvis may perforate/lacerate the bladder- an indication may be blood present in the urine
(iv) Bone fragments may lacerate large blood vessels in the pelvis that may cause fatal hemorrhage into the abdomen
(v) Severe pain
(vi) Loss of ability to use lower part of body
(vii) Unable to sit or stand
(i) Fractures of the femur
(i) Muscle spasm
(ii) Excruciating pain
(iii) Unnatural position, external rotation
(iv) Fractured leg is typically shorter than uninjured because of contraction of thigh muscle
(v) Swelling at site of fracture
(vi) Damage to blood vessels and nerves often result
(j) Fractures of the patella
(i) Pain
(ii) Deformity of patella
(k) Fractures of the tibia and fibula
(i) Tenderness
(ii) Swelling
(iii) Pain at point of fracture
(6) Assess joints
(a) Injuries to joints and muscles often occur together
(b) Distinguishing between joint or muscle injury and fracture is difficult
(c) Possible joint and muscle injuries:
(i) Dislocations
* Bone is forcibly displaced from its joint
* Likely to bruise or tear the muscles, ligaments, blood vessels, tendons, and nerves near a joint
* Rapid swelling and discoloration
* Loss of ability to use joint
* Severe pain
* Muscle spasms
* Possible numbness and loss of pulse below the joint
* Stiff and immobile
(ii) Sprains
* Injury to ligaments and soft tissues that support a joint
* Pain or pressure at joint
* Pain upon movement
* Swelling and tenderness
* Possible loss of movement
* Discoloration
(iii) Strains
* Forcible overstretching or tearing of a muscle or tendon
* Pain
* Lameness or stiffness - sometimes involving knotting of muscles
* Moderate swelling at place of injury
* Discoloration
* Possible loss of strength in affected area
* Distinct gap felt at site
(iv) Contusions
* Caused by blunt trauma that may damage bones, muscles, tendons, blood vessels, nerves, and other body tissues
* Immediate pain
* Swelling occurs - blood from broken vessels oozes into soft tissues under the skin
* Initial skin reddening due to irritation
* Later, characteristic black and blue marks appear
* Skin eventually turns yellowish or greenish
* Bruised area is usually very tender
(7) Assess Amputations
(a) Potentially life-threatening injuries due to severe tissue damage with subsequent hemorrhage and shock
(b) Massive hemorrhage can occur but most often the bleeding will control itself with a spontaneous retraction of major vessels and ordinary pressure applied to the stump
(c) If possible, locate the amputated part and transport with the patient
Expose the area
Control bleeding
(1) Direct pressure
(2) Pressure dressing
(3) Pressure points
NOTE: Splinting i.e. immobilization is the most effective method to control bleeding of fractures. Splint the fracture(s) in the position found. DO NOT attempt to reposition or straighten the injury.
(1) Fractures of the clavicle
(a) If fracture is open, control bleeding - immobilize
(i) Pressure dressing
(ii) Pressure points
(b) Apply sling and swathe if possible
(i) Bend casualty's arm on injured side and place forearm across the chest
(ii) Raise hand about 4 inches above the level of the elbow
(iii) Support forearm in position by means of a wide sling. A wide roller bandage may be used to secure the casualty's arm to the chest
(iv) A figure-of-eight bandage may also be used for a fracture clavicle
(c) Assess for signs and symptoms of shock
(d) Evacuate to nearest treatment facility
NOTE: Splint in the position you find it and evaluate circulation.
(2) Fractures of the humerus
(a) If fracture is open, control bleeding
(i) Pressure dressing
(ii) Pressure points
(iii) Immobilize
(b) If fracture is in upper part of arm near shoulder:
(i) Place a pad or folded towel in armpit
(ii) Bandage arm securely to body
(iii) Support forearm in narrow sling
(iv) Splint should extend from shoulder to elbow
(v) Fasten splinted arm firmly to body and support forearm in narrow sling
(c) If fracture is in middle of humerus:
(i) Fasten two wide splints or four narrow splints around the arm
(ii) Support the forearm in a narrow sling
(iii) Be sure sling does not extend too far up the armpit - this may cause compression of blood vessels and nerves
(d) If fracture is at or near elbow
(i) Do not attempt to straighten or move
(ii) Splint arm in position to prevent further nerve and blood vessel damage
(iii) Exception: if no pulse distal to fracture, gentle traction may be applied and arm splinted
(e) In all cases, assess for signs and symptoms of shock
(f) Transport to nearest treatment facility
(3) Fractures of the radius and/or ulna
(a) If fracture is open, control bleeding
(i) Pressure dressing
(ii) Pressure points
(iii) Immobilize
(b) Straighten forearm is possible
(c) Apply two well-padded splint to forearm, one on top and one on bottom
(i) Splints should be long enough to extend from elbow to wrist
(ii) Use bandages to hold splints in place
(iii) Place forearm across the chest
(iv) Support forearm in position by means of wide sling and cravat bandage
(v) Raise hand about 4 inches above level of elbow
(i) Assess for signs and symptoms of shock
(j) Transport to nearest treatment facility
(4) Simple rib fractures
(a) Ordinarily, rib fractures are not bound, strapped, or taped if the casualty is reasonably comfortable
(b) Provide anagelsia available in combat vest
(c) Place casualty in position of comfort
(d) Transport to nearest treatment facility
(5) Fractures of the pelvis
(a) Initiate large bore IV 0.9% Normal Saline
(b) Provide anagelsia available in combat vest
(c) Minimize movement - only move unless necessary
(d) Assess for signs and symptoms of shock
(e) Keep casualty supine. Legs may be straight or bend, depending on comfort
(f) Immobilize
(i) Fractures of the hip are best treated with traction splints
(ii) Adequate immobilization can also be obtained by placing folded poncho's, poncho liners or blankets between legs
(iii) Use cravats, roller bandages, or straps to hold the legs together
(iv) Fasten casualty securely to stretcher or improvised support
(g) Transport to nearest treatment facility
(6) Fractures of the femur
(a) If fracture is open, control bleeding - immobilize
(i) Pressure dressing
(ii) Pressure points
(b) Carefully straighten the leg. Apply two splints:
(i) One on the outside of the injured leg - should reach from armpit to foot
(ii) One inside - from groin to foot
(c) Fasten splints
(i) Around ankle
(ii) Over knee
(iii) Just below hip
(iv) Around pelvis
(v) Just below armpit
(d) The legs can be tied together to support injured leg
(e) Assess for signs and symptoms of shock
(f) Transport to nearest treatment facility
(7) Fractures of the patella
(a) Straighten the injured limb
(b) Immobilize fracture by placing padded board under injured limb. The board should be at least 4 inches wide and reach from buttock to heel
(c) Place extra padding under knee and just above heel
(d) Use strips of bandage to fasten the leg to the board
(i) Just below the knee
(ii) Just above the knee
(iii) At the ankle
(iv) At the thigh
(e) Be sure not to cover the knee. Any bandage of tie fastened over the knee could created a problem should swelling occur.
(f) Transport to the nearest treatment facility
(8) Fractures of the tibia and fibula
(a) If fracture is open, control bleeding
(i) Pressure dressing
(ii) Pressure points
(b) Carefully straighten the leg
(c) Consider PASG or apply three splints
(i) Pad each splint well, particularly under the knee and at the bones on each side of the ankle.
(ii) Place splints on both sides and leg and one underneath
(iii) A folded poncho liner and two side splints may be used
(d) When available, use traction splints
(e) Assess for signs and symptoms of shock
(f) Transport to nearest treatment facility
(1) Dislocations
(a) Loosen clothing around injured part
(b) Place casualty in position of comfort
(c) Support injured part by means of a sling, pillows, bandages, splints
(d) Treat all dislocations as fractures
(e) Evacuate to the nearest treatment facility
(2) Sprains
(a) Treat all sprains as fractures in the field
(b) Apply cold packs for the first 24 to 48 hours to reduce swelling and to control internal hemorrhage
(c) Elevation and rest of affected area
(d) Apply snug, smooth, figure-of-eight bandage to control swelling
(e) Provide immobilization
(f) Transport to nearest treatment facility
(3) Strains
(a) Keep affected area elevated and at rest
(b) Apply cold packs for the first 24 to 48 hours to control hemorrhage and swelling
(c) Apply mild heat to increase circulation and aid healing 24 hours after the last cold pack
(d) Muscle relaxants, adhesive straps, and complete immobilization of the area may be indicated
(4) Contusions
(a) Slight bruises do not require treatment
(b) Apply an elastic bandage to contused area as needed for comfort
(c) Elevate injured part
(d) A sling may be used for a bruised arm or hand. Folded ponchos, poncho liners, clothing, or blankets may be used to elevate a bruised leg
(e) Ice may be applied to contused area for 24 to 48 hours
(1) Apply pressure to stump to control bleeding
(2) Cover stump with damp sterile dressing and elastic wrap. Apply tight enough to apply uniform, reasonable pressure across entire stump
(3) If direct pressure does not control bleeding, a tourniquet may be used
(4) Care for the amputated part
(a) Place amputated parts in plastic bag, if available
(b) Place bag in larger bag or container containing ice and water - cooling slows the chemical processes and will increase viability in excess of four hours
(c) Do NOT place amputated part directly on ice
(1) Continue to monitor casualty's airway and breathing
(2) Monitor circulation
(a) Reassessing skin for
(i) Color
(ii) Sensation
(iii) Temperature
(iv) Capillary refill
(b) Reassess distal pulses
(3) Monitor vital signs
(4) Continue non-pharmacological and pharmacological interventions
(a) IV fluids
(b) Antibiotics
(c) Analgesics
(1) To prevent the sharp edges of the bone from moving and cutting tissue, muscle, blood vessels, and nerves
(2) To reduce pain and help prevent or control shock
(3) To prevent bone fragments from converting closed fracture to open fracture
(4) To control bleeding - one of the best ways to control bleeding
(1) Splints may be improvised from such items as
(a) Boards
(b) Poles
(c) Sticks
(d) Tree limbs
(e) Rolled magazines, newspapers, or cardboard
(2) Narrow materials such as wire or cord should not be used to secure a splint in place
(3) If raw materials are not available, anatomical splints may be utilized. For example: the chest wall can be used to immobilize a fractured arm and the uninjured leg can be used to immobilize (to some extent) the fractured leg
(4) Splints should be padded in order to prevent pressure points on bony prominences if standard padding materials are unavailable, padding may be improvised from such items as:
(a) Clothing
(b) Blankets
(c) Ponchos
(d) Shelter halfs
(e) Leafy vegetation
(1) Slings may be improvised by using
(a) The tail of a coat or shirt
(b) Pieces torn from such items as clothing and blankets
(c) The triangular bandage is ideal for this purpose
(2) Remember when applying a sling that the casualty's hand should be higher than his elbow, and the sling should be applied so that the supporting pressure is on the uninjured side
(1) Triangular and cravat bandages are often used as or referred to as swathe bandages
(2) The purpose of the swathe is to immobilize, therefore, the swathe bandage is placed above and/or below the fracture - not over it
(1) Reassure the casualty
(2) Loosen any tight or binding clothing
(3) Remove all the jewelry from the casualty distal to the fracture site. If the jewelry is not removed at this time and swelling occurs later, further bodily injury can occur
(1) Gather splints or material for an improvised splint
(2) Ensure that splints are long enough to immobilize the joint above and below the suspected fracture
(3) If possible, use at least four ties (two above and two below the fracture) to secure the splints. The ties should be nonslip knots and should be tied away from the body on the splint.
(4) If splinting material is not available and suspected fracture CANNOT be splinted, then swathes, or a combination of swathes and slings can be used to immobilize an extremity
(5) Pad the splints where they touch any bony prominences. Padding prevents excessive pressure to the area
(6) Check the circulation distal to the injury
(a) Note any pale, white, or bluish-gray color of the skin which may indicate impaired circulation
(b) Assess capillary refill
(7) Check the temperature of the injured extremity
(a) Use your hand to compare the temperature of the injured side with the uninjured side of the body
(b) The body area below the injury may be cooler to the touch indicating poor circulation
(8) Question the casualty about the presence of numbness, tightness, cold, or tingling sensations
(9) Casualties with fractures to the extremities may show impaired circulation, such as numbness, tingling, cold and/or pale to blue skin distal to injured site. These casualties should be treated and evacuated as soon as possible. Prompt medical treatment may prevent possible loss of the limb
(1) Splint the fracture(s) in the position found. DO NOT attempt to reposition or straighten the injury.
(2) If it is an open fracture, stop the bleeding and protect the wound
(3) Cover the wound before applying a splint
(4) If bones are protruding (sticking out), DO NOT attempt to push them back under the skin
(5) Apply padding to protect the area
(6) Place one splint on each side of the arm or leg. Make sure that the splints reach, if possible, beyond the joints above and below the fracture.
(7) Tie the splints. Secure each splint in place above and below the fracture site with improvised (or actual) cravats. Improvised cravats, such as strips of cloth, belts, or whatever else you have, may be used
(8) With minimal motion to the injured areas, place and tie the splints with the bandages
(9) Push cravats through and under the natural body curvatures (spaces), and then gently position improvised cravats and tie in place
(10) Use nonslip knots. Tie all knots on the splint away from the casualty. DO NOT tie cravats directly over suspected fracture/dislocation site.
(11) Check the Splint for Tightness
(a) Check to be sure that bandages are tight enough to securely hold splinting materials in place, but not so tight that circulation is impaired
(b) Recheck the circulation after application of the splint
(i) Check the skin color and temperature. This is to ensure that the bandages holding the splint in place have not been tied too tightly.
(ii) A finger tip check can be made by inserting the tip of the finger between the wrapped tails and the skin
(d) Make any adjustment without allowing the splint to become ineffective
(1) An improvised sling may be made from any available nonstretching piece of cloth such as
(a) A fatigue shirt or trouser
(b) Poncho or shelter half
(c) The tail of a coat, belt, or a piece of cloth from a blanket or some clothing
(d) A pistol belt or trouser belt also may be used for support
(e) A sling should place the supporting pressure on the casualty's uninjured side
(f) The supported arm should have the hand positioned slightly higher than the elbow
(2) Insert the splinted arm in the center of the sling
(3) Bring the ends of the sling up and tie them at the side (or hollow) of the neck on the uninjured side
(3) Twist and tuck the corner of the sling at the elbow
(1) You may use any large piece of cloth, such as a soldier's belt or pistol belt, to improvise a swathe
(2) The swathe should not be placed directly on top of the injury, but positioned either above and/or below the fracture site
(3) Apply swathes to the injured arm by wrapping the swathe over the injured arm, around the casualty's back and under the arm on the uninjured side. Tie the ends on the uninjured side
(4) A swathe is applied to an injured leg by wrapping the swathe(s) around both legs and securing it on the uninjured side
Injuries to bones and joints should be splinted prior to the movement of the casualty. If life-threatening injuries exist, address them first and, if the casualty is a high priority for evacuation, immobilize the whole casualty on a long spine board.