Introduction

Musculoskeletal (MSK) injuries sustained after trauma are a very common occurrence across the United States and throughout the world. Nearly 15% of all routine emergency department (ED) visits are for MSK injuries according to the American College of Surgeons Committee on Trauma. They also state that 85% of all patients suffering blunt force trauma experience some form of MSK injury. MSK injuries are one of the most common injuries that emergency medical services (EMS) providers manage. In addition, MSK injuries affect 1 in 4 Americans annually, and their symptoms are the second most common reason for physician visits.[1][2][3][4]

EMS providers encounter MSK injuries in a wide variety of incidents including motor vehicle collisions, falls, sporting accidents, and physical assaults. MSK injuries are a substantial source of pain and disability. Proper management with appropriate splinting technique not only diminishes this pain but also reduces additional injury to the surrounding tissues and prevents long-term damage. Isolated MSK injuries, along with those occurring as a result of multi-system trauma, all merit the same proper management and treatment to provide the patient with optimal care. It is imperative that EMS providers know how to appropriately stabilize and manage these injuries as many can result in limb-threatening or life-threatening conditions.

Not all bones are created alike or have equal strength. Generally, small bones such as the bones of the wrist and hand, require a smaller amount of force to sustain injury as compared to larger bones like the femur or pelvis. An injury to the MSK system proximal to the ankle or wrist is an indication that a significant force impacted the body. The larger the injured bone and the greater the force, the more suspicion EMS providers need to have for other injuries.

Issues of Concern

Types of Fractures

According to Mosby’s medical dictionary, a fracture is, "A traumatic injury to the long bone in which the continuity of the bone tissue is broken." A fracture can be further described as closed or open. Fractures that have no break in the skin are called closed fractures.[5][6][7]

An open or compound fracture occurs when the traumatic force that caused the bone to fracture also results in an external wound. This wound is often caused by the sharp edges of the bone puncturing the skin from the inside out, or by the external compressing force or shearing the skin, leading to an open wound.

Open fractures have a high risk of developing osteomyelitis, an infection of the bone itself. This type of infection typically requires intravenous antibiotics and surgical debridement. When left untreated, can be limb or life-threatening.

Fractures can also be categorized as displaced or non-displaced. In a displaced fracture, angulation and deformity of the bone are often seen. A non-displaced fracture is difficult to diagnose without x-ray films and is not as pertinent for EMS providers to identify.

Types of Splints

Air splints are essentially large air bladders that are initially deflated and wrapped around the affected extremity. After application, they are inflated to provide rigidity through air pressure.

Vacuum splints are applied longitudinally along the length of the extremity, and straps are applied around it to secure it in place. A hand pump is then attached to a valve stem on the splint and is used to withdraw air from the splint. As air is removed, the splint forms to the shape of the injured extremity and becomes rigid.

Slings are used to immobilize suspected clavicle fractures or shoulder injuries. They can also be used to hold and support upper extremity injuries in a position of comfort.

Rigid splints are made out of plastic, malleable metals, wood, or other materials. They tend to be less flexible and more supportive than soft splints and are usually padded. They are typically secured to the patient via circumferentially applied adhesive, bandages, or straps. The joint above and below the injury should be immobilized as well.

Traction splints are used to immobilize femur fractures. They are comprised of straps that attach over the pelvis as an anchor, metal rods to mimic bone stability, and a mechanical device to apply traction. This is done in an attempt to reduce pain, realign the limb, and decrease vascular and neurologic complications to the affected lower extremity.

Pelvic circumferential compression devices (pelvic binder) work to provide circumferential stabilization of the entire pelvic cavity. This is performed to reduce pelvic fractures and decrease pelvic volume, in turn leading to decreased hemorrhage. The compression force is applied at the level of the femoral trochanters. This can also be achieved by wrapping a sheet around the pelvis and tying it tightly to secure it in place.

Clinical Significance

Approach to MSK Injury

Prior to the evaluation of specific MSK injuries, EMS providers should follow advanced trauma life support (ATLS) guidelines. The primary survey in ATLS consists of the airway, breathing, and circulation (ABCs). Any life-threatening hemorrhage found should be managed as part of the circulation exam. Severe hemorrhage from an MSK injury is best controlled with direct pressure and takes precedence over injury stabilization.[8][9][10]

EMS providers should begin the evaluation of the MSK injury by visually assessing the injury and removing any overlying clothing or jewelry so they can fully examine the affected body part. One should look for any debris such as broken glass and dirt that can be easily brushed away and not become embedded into the skin of the patient. Also, one should assess whether there is disruption of the skin secondary to a fracture. Next, palpate the injured area for any deformity, bony tenderness, swelling, or crepitus. Evaluate the distal portion of the affected extremity to assess for proper circulation, sensation, and muscle strength. Do this by checking capillary refill, distal pulses, muscle strength testing, and skin sensation.

When an MSK injury is identified, the treatment goal of the EMS providers is to restore and maintain bone and joint alignment. By doing this, EMS providers control pain, reduce motion, prevent further soft tissue injury, and promote the tamponade effect of muscles on any injured blood vessels. This is best attained by realigning the extremity into anatomical position as soon as possible, then applying a splint to maintain its position.

There is some controversy over whether or not EMS providers should attempt reduction to realign bone fractures. The current teaching is that the MSK injury should be splinted in the position the patient is found unless there is apparent poor distal circulation. In this case, EMS providers should employ one attempt to try to reposition and realign the extremity, and then splint it in place. If their attempt is unsuccessful, they should return to splinting in the initial position found.

Approach to Reduction

To perform a reduction of a fracture, EMS providers start by checking for distal circulation, sensation, and motor function. Next, stabilize above and below the injury, followed by applying gentle traction to the distal extremity in the direction it is facing. While maintaining traction, move the distal extremity back toward its anatomical position. Stop immediately if there is resistance, a significant increase in pain, or when the correct anatomical position is obtained. Recheck distal circulation, sensation, and motor function. Apply an effective splint to maintain anatomical position and to protect the extremity from further damage. 

Aggressive pain management is indicated if possible to help relax the patient during an attempt to reduce and realign a displaced fracture. Realignment is uncomfortable for the patient. However, it is frequently associated with a considerable reduction in pain. For this reason, realignment should not be delayed if the administration of pain medication is not readily available.