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MusculoskeletalSystem
TheSkeleton
Madeupof206bones Providesprotectionforvitalorgans+isframeworkforthebody Skeletonprovidessupport: o Supportagainstgravity o Movement o Protection o Productionsofbloodcells o Storageofcalcium+phosphorus Musculoskeletalsystemcomposedof: o Bones o Muscles o Cartilages o Tendons o Ligaments
1.1
AxialSkeleton(80bones)
1.2
Appendicularskeleton(126bones)
Pectoralgirdle(4bones) o Clavicle(2bones) o Scapula(2bones) Upperlimbs(60bones) Pelvicgirdle(2bones) Lowerlimbs(60bones)
1.3
TheSkull
Madeupof22bones o 8of22bonesarecraniumbones o Craniumbonesisboxlikecavitycontainsandprotectsthebrain o 14otherbonesfromface o Facialbonesgiveitsshapeandprovideprotectionforeyes Amongbonesformingcranium o Frontal o Occipital o Parietal(2bones) o Temporal(2bones) Amongbonesformingface o Maxillary(2bones) o Mandible(2bones) o Zygomatic(2bones) o Nasalbones(2bones) InferiorNasalConchae(2bones)
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Module9
MusculoskeletalSystem
Other: LacrimalBones(2bones) PalatineBones(2bones) ZygomaticBones(2bones) AllbonesfusedorfixedtooneanotherEXCEPTmandible o Mandibleattachedtoskulloneachsidebyhingejointtoallowformovement Infancy:craniumNOTfullyformed o Donotfusetogetheruntilage+15month o Latefusionreasonwhyinfantshavetwosoftareasontheirheads o Softspotscalledanteriorandposteriorfontanelle
1.4
Spinalcolumn
Spinalcolumncentralsupportingstructureofbody Composedof33bones o Cervical(7vertebrae) Cervicalspinal:C1C7 SkullrestonC1 o Thoracic(12vertebrae) Thoracicspine:T1T12 Onepairofribsattachedtoeachvertebrae o Lumbar(5vertebrae) Lumbarspine:L1L5 Akadorsalspine o Sacrum(5vertebraefused) Sacralspinal:S1S5 Fusedtogetherformonebonecalledsacrum Sacrumjoinedtoiliacbonesofpelvis withstrongligamentsatsacroiliacjointstoformpelvis o Coccyx(4vertebraefused) Lastfourvertebraefusedformcoccyx/tailbone
1.5
TheThorax
Thorax/ribcagemadeupof12pairsofribsandsternum(breastbone) Contains+protectslungs,heart,greatvessels,trachea(windpipe),oesophagus(gullet/foodpipe) Thorax/chestcavitytwomainparts o 12pairsofribs Trueribs,falseribs,floatingribs o Sternum
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Module9 1.6
MusculoskeletalSystem
Pelvis
Bonyring Twoinnominatebones Eachbonemadeof3fusedbones o Ilium(hip) o Ischium(bumbone) o Pubis
1.7
Lowerextremities
Threemainpartsoflowerextremities o Thigh o Leg o Foot Threejointsconnectmainpartsofleg o Hip Betweenhipandthigh o Knee Betweenthighandleg o Ankle Betweenlegandfoot Bonesofthelowerextremities o Femur(Largestboneinthebodythigh) o Patella(kneecap) o Tibia(shinbone) o Fibula o Tarsals o Metacarpals o Phalanges
1.8
Upperextremities
Extendsfromshouldergirdletofingertipscomposedof: o Shouldergirdle Scapula(2) Clavicle(2) o Humerus o Radius o Ulna o Carpals o Metacarpals o Phalanges
1.9
TypesofBones
Theyarehardandstrongstructures Bonesclassifiedaccordingtoshape o Longbone Longbonesofthearmsandlegs o Shortbone Smallbonesofwristandankle o Flatbone Shoulderbladeandscalp,sternum o Irregularbone Vertebrae o Sesamoidbone Patella
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Module9
MusculoskeletalSystem
Importantpartsofbonesbestillustratesbyfemur Head o Roundedendmadeofcompactboneallowsforrotation Neck o Belowthehead Shaft o Longcylindricalportionofbonewithcompactbone(outerlayer)+spongymarrow(innerlayer) Condyles o Bumps/prominencesusuallyforarticulationwithanotherbone Tuberosities o Prominencesonbone Epiphysealplate o Plateofcartilageresponsibleforgrowthinlengthofbone(foundinchildren)
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MusculoskeletalSystem
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Module9
MusculoskeletalSystem
1.10.1 Ballandsocket
Mostfreelymoveablejoint Possiblemovements: o Flexion o Extension o Adduction o Rotation o Circumduction Hipandshoulderjoints
1.10.2 Condyloid+saddlejoints
Movementtakesplacearoundtwoaxis Permittingmovements: o Flexion o Extension o Adduction o Abduction o Circumduction o Circumduction(Combinationofabovemovements) Wrist
1.10.3 Gliding/Plane
Articularsurfacesglideovereachother Possiblemovements: o Glidemovement Sternoclavicularjoint,jointsbetweencarpalsbonesandbetweentarsalbones,jointbetweenvertebrae
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MusculoskeletalSystem
1.10.5 Pivot
Rotarymovement(allowsmovementaroundoneaxisonly) Possiblemovements: o Rotarymovement Classicexample:superior+inferiorradioulnajoints
1.11 Tendons
Tendonsareconnectivetissue Attachesmuscletobone Composedofwhitefibroustissuearrangedinverydensemanner+ofgreatstrength
1.12 Ligaments
Similarstructuretotendons Butattachbonetobone Ligamentsstrongbandsoffibroustissueservetobindtogetherbonesenteringinjoints o TheyareeitherCordlikeorflattenedbands o Thoughmostjointssurroundedbyfibrouscapsule/capsularligament
1.13 Cartilage
Cartilagealsotypeofconnectivetissue Formsthesmoothsurfaceovertheendsofthebones Cartilageprovidescushioningatjoints
1.14 Muscles
Muscleiscontractiletissue o Hasabilitytoactivelyshortenandlengthen Mostmusclesattachedtobonebymeansoftendons 3typesofmuscles(maintainpostureandallowformovement) o Skeletalmuscles(Striated) o Smooth(Involuntary) o Cardiac
1.14.1 SkeletalMuscle
Skeletalmuscleattachestotheboneoftheskeleton Formmajormusclemassofthebody CalledVoluntarymuscle o Underdirectvoluntarycontrolofbrain o Canbestimulatedtocontractandrelaxatwill AlsocalledStriatedmuscle Whenviewedundermicroscopehascharacteristicsofstripes(striations) Specificnervespassdirectlyfrombraintospinalcord o Theyconnectwithothernervesandpasstoeachskeletalmuscle o FaciaCoversallskeletalmuscles Faciaencasesthemuscletissue AteitherendofmuscleFaciaextendsbeyondmuscletoattachtobone
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MusculoskeletalSystem
1.14.3 CardiacMuscle
Speciallyadaptedinvoluntarymuscle o Veryrichsupplybloodsupplyandownelectricalsystem Heartislargemusclecomposedoftwopumps o Unequalforce Onelowerpressure Onehigherpressure Heartfunctionscontinuouslyfrombirthtodeath CardiacmusclecantolerateinterruptionofbloodsupplyONLYFORAFEWSECONDS o Requirescontinuoussupplyofoxygen+glucosefornormalfunction Cardiacmuscleplacedinseparatecategory o Becauseofspecialstructureandfunction
2
2.1
MusculoskeletalInjuries
Classification
2.2
Complications
Haemorrhage Instability Lossoftissue Simplelaceration Contamination(speciallyopenfractures) Interruptionofbloodsupply Nervedamage Longtermdisability Canresultfrom o Directtrauma Bluntforceappliedtoanextremity o Indirecttrauma Verticalfallthatcausesfracturedistantfromsiteofimpact o Pathologicconditions Tumours FormsofArthritis Malignancy
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Module9 2.2.1
MusculoskeletalSystem
Strains
Injurytomuscleoritstendon Causedbyoverexertionoroverextension Commonlyoccurinbackandarms Maybeaccompaniedbysignificantlossinfunction Severestrainsmaycauseavulsionofbonefromattachmentsite
2.2.2
Sprains
Moreeventsandsportsinjuries Partialtearingofligament Causedbysuddentwistingorstretchingofjointbeyondnormalrangeofmotion Twocommonareasforsprains o Ankles+knees Sprainsaregradedbyseverity o Firstdegreesprain o Seconddegreesprain o Thirddegreesprain
2.2.3
Jointdislocations
Occurwhennormalarticulatingendsoftwoormorebonesaredisplace o Luxationcompletedislocation o Subluxationincompletedislocation Suspectjointdislocationwhenjointisdeformed/doesnotmovewithnormalrangeofmotion Alldislocationscanresultingreatdamageandinstability
2.2.4
Arthritis
Inflammationofthejoint Characterizedbypain,swelling,stiffnessandredness Ajointdisease(involvingone/manyjoint)canoccurfrommanycauses Variesinseverityfrommildachetostiffnesstoseverepainandlaterjointdeformity Osteoarthritis(degenerativearthritis)mostcommon Painassociatedwiththisconditionusuallymanagedwithantiinflammatoryagents
2.2.5
Fractures
Breakinthecontinuityofbone/cartilage Maybecomplete/incompletedependingonlineoffracturethroughbone Maybeclassifiedasopen/closeddependingonintegrityofskinnearfracture
2.2.5.1 Classificationoffractures
o o o o o o o o o o Open Closed Comminuted(crushinginjury) Greenstick(bonesbend) Spiral Oblique(angle/slantlinefracture) Transverse(straightlinefracture) Stress(manyhairlinefractures) Pathological Epiphyseal(atthegrowthplate)
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Module9
MusculoskeletalSystem
2.2.6
Extremitytrauma
2.2.7
Assessment
Conductinitialassessmentdetermineifanylifethreateningconditions o Emergencycareforlifethreateningconditionsfirst(severebleeding) Neveroverlookmusculoskeletaltrauma Neverallowanoncriticalmusculoskeletalinjurytodistractfromprioritiesofcare
2.2.8
SIXPsofmusculoskeletalinjuries
Pain Painonpalpation(tenderness) Painonmovement Pale,coldandclammyskin+poorcapillaryrefill Pinsandneedlessensation Diminished/absent Inabilitytomove Compartmentsyndrome(pressurebuildupunderneaththeskin)
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Module9
MusculoskeletalSystem
Principlesofsplinting
Thegoalofsplintingisimmobilizationoftheinjuredbodypart Immobilizationbysplinting: o Helpsalleviatepain(decreaselevelofpain) o Decreasedtissueinjury Bleedingandcontaminationinopenwound o Simplifiesandfacilitatespt.transport Splintjointsabove+belowandboneends o Immobilizeopenandclosefracturesinsamemanner o Coverfracturestoreducecontamination o Assessandreassess(aftersplinting) distalpulse capillaryrefill neurologicalsensation motorfunctionbeforeandaftersplinting o Stabilizeextremitygently Inlinetractiontonormalpositionofalignment GeneralrulealignONLYONCE o Immobilizelongboneextremityinstraightpositionthatcanbeeasilysplinted Immobilizeddislocationinpositionofcomfort o Ensuregoodvascularsupply Immobilizejointsfound o JointinjuriesonlyalignedifNOdistalpulse Applyicetoreduceswellingandpain Applycompressiontoreduceswelling Elevateextremity(ifpossible)
3.1
Splints
Threemaintypes o Rigidsplints o Softorformablesplints o Tractionsplints
3.1.1
Rigidsplints
Padbeforeuse Canonlychangeitsshapeminimally(andonlywithsomesplints) Bodyneedstobepositionedtofitthesplint o Boardsplints o Cardboardsplints o Samsplint
3.1.2
Softorformablesplints
Canbemouldedintovariousshapestoaccommodatetheinjuredbodypart o Pillows o Blankets o Slingsandswathes
3.1.3
Tractionsplints
Speciallydesignedformidshaftfemurfracture DONOTapplyormaintainsufficienttractiontoreduceafemoralfracture DOESprovideenoughtractiontostabilizeandalignit
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Module9 3.2
MusculoskeletalSystem
Shoulderinjuries
Commoninolderadultsbecauseofweakerbonestructure o Frequentlyresultfromfallonoutstretchedarm
3.2.1
Anteriorfractureanddislocation
Pt.oftenpositionedwithaffectedarmorshoulderclosetochest Lateralaspectofshoulderappearsflatinsteadofround Deepdepressionbetweenheadofhumerusandtheacromionlaterally(hollowshoulder)
3.2.2
Posteriorfractureanddislocation
Pt.maybepositionedwitharmabovehead
3.2.3
Managementofshoulderinjuries(fractureanddislocation)
Assessandreassess(aftersplinting) o Neurovascularstatus o Neurologicalsensation o Distalpulse o Capillaryrefill Applicationofice Applicationofslingandswathe Splintmayneedtobeimprovisedtoholdinjury
3.3
Humerusinjuries
Commoninolderadultsandchildren o Oftendifficulttostabilize
3.3.1
Associatedcomplication
Radialnervedamage o Maybepresentifmiddleordistalportionofhumeralshaftfractured Axillarynervedamage o Maybepresentifhumeralneckfracture Internalhaemorrhaging o IntothejointCompartmentsyndrome(pressurebuildupunderneaththeskin)
3.3.2
ManagementofHumerusinjuries
Assessandreassess(aftersplinting) o Neurovascularstatus o Neurologicalsensation o Distalpulse o Capillaryrefill Applyice Alignifthereisvascularcompromise Applicationofrigidsplitandslingandswathe ORsplinttheextremitywitharmextended
3.4
Radius,Ulna/Wristinjuries
Commoninadultandinchildren Usuallyresultfromfallonoutstretchedarm Wristinjuriesmayinvolve: o Distalradius o Ulna o Oranyoftheeightcarpalbones Commoninjury:CollesFracture(wristfracture)
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Module9 3.4.1
MusculoskeletalSystem
ManagementofHumerusinjuries
Assessandreassess(aftersplinting) o Neurovascularstatus o Neurologicalsensation o Distalpulse o Capillaryrefill Applyice Splintinpositionfountwithrigidorformablesplints/slingandswathe Elevation
3.5
Hand(metacarpal)injuries
Frequentlyresultsfrom: o Contactsports o Violence(fighting) o Crushinginindustrialcontext Commoninjury o Boxersfracture o Resultfromdirecttraumatoclosedfistfracturingfifthmetacarpalbone Injuriesmaybeassociatedwithhaematomasandopenwounds
3.5.1
ManagementofHumerusinjuries
Assessandreassess(aftersplinting) o Neurovascularstatus o Neurologicalsensation o Distalpulse o Capillaryrefill Applyice Splintinpositioninnormalpositionofalignment/normalpositionoffunction Elevation
3.6
Lowerextremityinjuries
Comparetoupperextremityinjurieslowerextremityinjuriesare: o Associatedwithgreaterwoundingforce o Moresignificantbloodloss o Moredifficulttomanageinpt.withmultipleinjuries o Maybelifethreatening: Femurfracture Pelvicfracture Cancausehypovolemicshock
3.6.1
Femurfracture
Usuallyresultfrommajortrauma(MVA/pedestrianaccidents) Fairlycommoninchildabuse Fracturesusuallyevidentfrompowerfulthighmusclesproducingoverridingofbonefragments Pt.generallyhasshortenedleg+externallyrotatedandmidthighswellingfromhaemorrhaging Bleedingmaybelifethreatening
3.6.1.1 ManagementofFemurfracture
Highconcentrationoxygenadministration Treatmentforshock Assessandreassess(aftersplinting) o Neurovascularstatus o Neurologicalsensation o Distalpulse o Capillaryrefill
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Module9
MusculoskeletalSystem
3.6.2
Pelvicfracture
Bluntforcetraumaorpenetratinginjurytopelvismayresultin: o Fracture o Severehaemorrhaging o Associatedinjurytourinarybladderandurethra Deformitymaybedifficulttosee Suspectinjurytopelvisbasedon: o MOI(Mechanismofinjury) o Presenceoftendernessonpalpationoftheiliaccrest(hipbone)
3.6.2.1 ManagementofPelvicfracture
Highconcentrationoxygenadministration Treatmentforshock Fullbodyimmobilization(longspinboardandspiderstraps) o Adequatelypaddedforcomfort Regularmonitoringofvitalsigns Rapidtransportisessential
3.6.3
Hipinjury
Commoninolderadultsbecauseofafall o Alsoinyoungeradultfromtrauma Ifhipfracturedatfemoralheadandneck o Affectedlegusuallyshorterandexternallyrotated(rotatesoutwards) Dislocationofhipusuallyevidencedbyshortenedandrotatedleg
3.6.3.1 ManagementofHipinjury
Assessandreassess(aftersplinting) o Neurovascularstatus o Neurologicalsensation o Distalpulse o Capillaryrefill Fullbodyimmobilization(longspinboardandspiderstraps) o Adequatelypaddedforcomfort Slightflexofthekneeorpaddingbeneaththekneemayimprovecomfort Regularmonitoringofvitalsigns Rapidtransportisessential
3.7
Kneeandpatellainjuries
Fracturestokneeanddislocationsofpatellacommonlyresultfrom: o MVA o Pedestrianaccidents o Contactsports o Fallsonflexedknee Relationshipofpoplitealarterytokneejointmayleadtovascularinjury o Particularlywithposteriordislocation
3.8
TibiaandFibiainjuries
Mayresultfromdirectorindirecttraumaortwistinginjury Isassociatedwithknee,poplitealvascularinjuryshouldbesuspected
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Module9 3.8.1
MusculoskeletalSystem
Managementoftibiaandfibiainjuries
Assessandreassess(aftersplinting) o Neurovascularstatus o Neurologicalsensation o Distalpulse o Capillaryrefill Applicationofice Splintwithrigidorformablesplint Elevate
3.9
Footandankleinjuries
Fracturesanddislocationoffootandanklemayresultfrom: o Crushinjury o Fallfromheight o Violentrotaryforce Pt.usuallycomplainsofpointtendernessandishesitanttobearweightonextremity
3.9.1
Managementoffootandankleinjuries
Assessandreassess(aftersplinting) o Neurovascularstatus o Neurologicalsensation o Distalpulse o Capillaryrefill Applicationofice Splintwithrigidorformablesplint(e.g.pillow,blanket/airsplint) Elevate
3.10 OpenFractures
Consideranysofttissuewoundaroundsuspectedfracturetobeevidenceofopenfracture Fracturesmaybeopenintwoways: o Fromwithin(bonefragmentspiercethroughskin) o Fromwithout(gunshot) Openfracturesmayhavemadecontactwithskinsomedistanceawayfromfracture Openfracturesconsideredatruesurgicalemergencybecauseofthepotentialforinfection
3.11 Limbthreateninginjuries
Kneedislocation Fractureordislocationofpoplitealandankle Subcondylarfractureofelbow o Theseinjuryrequirerapidtransportforphysicianevaluation
3.12 Managementoffracturesanddislocations
Elbowshowneverbemanipulatedinprehospitalsetting Asarule,fractureanddislocationshouldbeimmobilizedinpositionofinjury o Andpt.transportedtoemergencydepartmentdoerealignment(reduction) Iftransportdelayed/prolongedandcirculationisimpaired ONEattempttorepositionagrosslydeformedfractured/dislocatedjointshouldbemade
3.12.1 Method
Handleinjurycarefully Applygentle,firmtractionindirectionoflongaxisofextremity Ifnotobviousresistancesplintextremitywithoutrepositioning
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MusculoskeletalSystem
ONLYONEattemptatrealignmentshouldbemadeinprehospitalsetting ONLYifseverneurovascularcompromise(extremelyweak/absentdistalpulse) Manipulationshouldbeperformedassoonaspossible(ONLYifindicated) Shouldbeavoidedinpresenceofotherseverinjuries IfNOcontractindicationsconsideruseofEntonoxforrealignmentprocedure Assess+documentandreassess+document(aftersplinting) o Neurovascularstatus o Neurologicalsensation o Distalpulse o Capillaryrefill
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