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1 TheSkeleton Madeupof206bones Providesprotectionforvitalorgans+isframeworkforthebody Skeletonprovidessupport:
o Supportagainstgravityo Movemento Protectiono Productionsofbloodcellso Storageofcalcium+phosphorus
Musculoskeletal systemcomposedof:o Boneso Muscleso Cartilageso Tendonso Ligaments
1.1 AxialSkeleton(80bones)Forms
central
(longitudinal)
axis
of
body
Skull(28bones)o Cranium(8Bones)o Face(14Bones)o Earbones(6Bones)
Hyoidbone(1bone) Vertebralcolumn(26bones) Thoraciccage(25bones)1.2 Appendicularskeleton(126bones) Pectoralgirdle(4bones)
o Clavicle(2bones)o Scapula(2bones)
Upperlimbs(60bones) Pelvicgirdle(2bones) Lowerlimbs(60bones)
1.3 TheSkull Madeupof22bones
o 8of22bonesarecraniumboneso Craniumbonesisboxlikecavitycontainsandprotectsthebraino 14otherbonesfromfaceo Facialbonesgiveitsshapeandprovideprotectionforeyes
Amongbonesformingcraniumo Frontalo Occipitalo Parietal(2bones)o Temporal(2bones)
Amongbonesformingfaceo Maxillary(2bones)o Mandible(2bones)o Zygomatic(2bones)o Nasalbones(2bones)
InferiorNasalConchae(2bones)
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Other:LacrimalBones(2bones)PalatineBones(2bones)ZygomaticBones(2bones) AllbonesfusedorfixedtooneanotherEXCEPTmandible
o Mandibleattachedtoskulloneachsidebyhingejointtoallowformovement Infancy:craniumNOTfullyformed
o Donotfusetogetheruntilage+15montho Latefusionreasonwhyinfantshavetwosoftareasontheirheadso 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
withstrongligamentsatsacroiliacjointstoformpelviso Coccyx(4vertebraefused)
Lastfourvertebraefusedformcoccyx/tailbone1.5 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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1.6 Pelvis Bonyring Twoinnominatebones Eachbonemadeof3fusedbones
o Ilium(hip)o
Ischium
(bum
bone)
o Pubis1.7 Lowerextremities Threemainpartsoflowerextremities
o Thigho Lego Foot
Threejointsconnectmainpartsoflego Hip
Betweenhipandthigho Knee
Between
thigh
and
leg
o Ankle Betweenlegandfoot
Bonesofthelowerextremitieso Femur(Largestboneinthebody thigh)o Patella(kneecap)o Tibia(shinbone)o Fibulao Tarsalso Metacarpalso Phalanges
1.8 Upperextremities Extendsfromshouldergirdletofingertipscomposedof:
o Shouldergirdle Scapula(2) Clavicle(2)
o Humeruso Radiuso Ulnao Carpalso Metacarpalso 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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Classificationbasedonstructure:o Compactbone(hardanddense,outerbone)o Spongybone(marrow)
Classificationbasedonstructure:
Importantpartsofbonesbestillustratesbyfemur
Heado
Rounded
end
made
of
compact
bone
allows
for
rotation
Necko Belowthehead
Shafto Longcylindricalportionofbonewithcompactbone(outerlayer)+spongymarrow(innerlayer)
Condyleso Bumps/prominencesusuallyforarticulationwithanotherbone
Tuberositieso Prominencesonbone
Epiphysealplateo Plateofcartilageresponsibleforgrowthinlengthofbone(foundinchildren)
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1.10 Joints Jointformedwhentwobonescomeintocontact Jointconsistsofendsofbonesandsurroundingconnectingandsupportingtissue Mostjointsinbodynamedbycombiningnamesoftwobonesthatformjoint Jointclassifications
oBall
and
socket
o Condyloid+saddlejointso Gliding/Planeo Hingeo Pivot
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1.10.1 Ballandsocket Mostfreelymoveablejoint Possiblemovements:
o Flexiono Extensiono Adductiono Rotationo Circumduction
Hipandshoulderjoints1.10.2 Condyloid+saddlejoints Movementtakesplacearoundtwoaxis Permittingmovements:
o Flexiono Extensiono Adductiono Abductiono Circumductiono Circumduction(Combinationofabovemovements)
Wrist
1.10.3 Gliding/Plane Articularsurfacesglideovereachother Possiblemovements:
o Glidemovement Sternoclavicularjoint,jointsbetweencarpalsbonesandbetweentarsalbones,jointbetweenvertebrae
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1.10.4 Hinge Permitsmovementinoneplaneonly Possiblemovements:
o Flexiono Extension
Knee,
Elbow,
ankle
1.10.5 Pivot Rotarymovement(allowsmovementaroundoneaxisonly) Possiblemovements:
o Rotarymovement Classicexample:superior+inferiorradioulnajoints1.11 Tendons Tendonsareconnectivetissue Attachesmuscletobone Composedofwhitefibroustissuearrangedinverydensemanner+ofgreatstrength1.12 Ligaments Similarstructuretotendons Butattachbonetobone Ligamentsstrongbandsoffibroustissueservetobindtogetherbonesenteringinjoints
o TheyareeitherCordlikeorflattenedbandso Thoughmostjointssurroundedbyfibrouscapsule/capsularligament
1.13 Cartilage Cartilagealsotypeofconnectivetissue Formsthesmoothsurfaceovertheendsofthebones Cartilageprovidescushioningatjoints1.14 Muscles Muscleiscontractiletissue
o Hasabilitytoactivelyshortenandlengthen Mostmusclesattachedtobonebymeansoftendons 3typesofmuscles(maintainpostureandallowformovement)
o Skeletalmuscles(Striated)o Smooth(Involuntary)o Cardiac
1.14.1 SkeletalMuscle Skeletalmuscleattachestotheboneoftheskeleton Formmajormusclemassofthebody CalledVoluntarymuscle
o Underdirectvoluntarycontrolofbraino Canbestimulatedtocontractandrelaxatwill
AlsocalledStriatedmuscle Whenviewedundermicroscopehascharacteristicsofstripes(striations) Specificnervespassdirectlyfrombraintospinalcord
o Theyconnectwithothernervesandpasstoeachskeletalmuscleo Facia Coversallskeletalmuscles
Faciaencasesthemuscletissue AteitherendofmuscleFaciaextendsbeyondmuscletoattachtobone
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1.14.2 SmoothMuscle Involuntarymuscle
o Carriesoutmuchofautonomicworkofbody Foundinwallsofmosttubularstructures
o Gastrointestinal tracto Urinarysystemo Bloodvesselso Bronchioflungs
1.14.3 CardiacMuscle Speciallyadaptedinvoluntarymuscle
o Veryrichsupplybloodsupplyandownelectricalsystem Heartislargemusclecomposedoftwopumps
o Unequalforce Onelowerpressure Onehigherpressure
Heartfunctionscontinuouslyfrombirthtodeath
Cardiac
muscle
can
tolerate
interruption
of
blood
supply
ONLY
FOR
A
FEW
SECONDS
o Requirescontinuoussupplyofoxygen+glucosefornormalfunction Cardiacmuscleplacedinseparatecategory
o Becauseofspecialstructureandfunction
2 MusculoskeletalInjuries2.1 ClassificationInjuriesresultedfromtraumaticforceinclude:
Strains Sprains Fractures Jointdislocations2.2 Complications Haemorrhage Instability Lossoftissue Simplelaceration Contamination(speciallyopenfractures) Interruptionofbloodsupply Nervedamage
Long
term
disability
Canresultfromo Directtrauma
Bluntforceappliedtoanextremityo Indirecttrauma
Verticalfallthatcausesfracturedistantfromsiteofimpacto Pathologicconditions
Tumours FormsofArthritis Malignancy
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2.2.1 Strains Injurytomuscleoritstendon Causedbyoverexertionoroverextension Commonlyoccurinbackandarms Maybeaccompaniedbysignificantlossinfunction
Severe
strains
may
cause
avulsion
of
bone
from
attachment
site
2.2.2 Sprains Moreeventsandsportsinjuries Partialtearingofligament Causedbysuddentwistingorstretchingofjointbeyondnormalrangeofmotion Twocommonareasforsprains
o Ankles+knees Sprainsaregradedbyseverity
o Firstdegreespraino Seconddegreespraino Thirddegreesprain
2.2.3 Jointdislocations Occurwhennormalarticulatingendsoftwoormorebonesaredisplace
o Luxationcompletedislocationo Subluxationincompletedislocation
Suspectjointdislocationwhenjointisdeformed/doesnotmovewithnormalrangeofmotion Alldislocationscanresultingreatdamageandinstability2.2.4 Arthritis Inflammationofthejoint Characterizedbypain,swelling,stiffnessandredness Ajointdisease(involvingone/manyjoint)canoccurfrommanycauses Variesinseverityfrommildachetostiffnesstoseverepainandlaterjointdeformity Osteoarthritis(degenerativearthritis)mostcommon Painassociatedwiththisconditionusuallymanagedwithantiinflammatoryagents2.2.5 Fractures Breakinthecontinuityofbone/cartilage Maybecomplete/incomplete dependingonlineoffracturethroughbone Maybeclassifiedasopen/closeddependingonintegrityofskinnearfracture2.2.5.1 Classificationoffractures
o Openo Closedo Comminuted(crushinginjury)o Greenstick(bonesbend)o Spiralo Oblique(angle/slantlinefracture)o Transverse(straightlinefracture)o Stress(manyhairlinefractures)o Pathologicalo Epiphyseal(atthegrowthplate)
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2.2.6 ExtremitytraumaCommonsignsandsymptoms
Painonpalpitationormovement Swelling,deformity
Crepitus
Decreasedrangeofmotion Falsemovement(unnaturalmovementofextremity) Decreased/absentsensoryperception Decreased/absentcirculationdistaltoinjury2.2.7 Assessment Conductinitialassessmentdetermineifanylifethreateningconditions
o Emergencycareforlifethreateningconditionsfirst(severebleeding) Neveroverlookmusculoskeletaltrauma Neverallowanoncriticalmusculoskeletalinjurytodistractfromprioritiesofcare2.2.8 SIXPsofmusculoskeletalinjuries Pain Painonpalpation(tenderness)
Painonmovement
Pallor Pale,coldandclammyskin+poorcapillaryrefill Paraesthesia Pinsandneedlessensation Pulse Diminished/absent Paralysis Inabilitytomove Pressure Compartmentsyndrome(pressurebuildupunderneaththeskin) Evaluatinganextremitiesneurovascularstatusby:
o Assessingdistalpulseo Functiono Sensation(beforeandaftermovement/splinting)
Compareinjuredextremitywithoppositeuninjuredextremity Ifextremitytraumasuspectedimmobilizedinjurybysplinting
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3 Principlesofsplinting Thegoalofsplintingisimmobilizationoftheinjuredbodypart Immobilization bysplinting:
o Helpsalleviatepain(decreaselevelofpain)o Decreasedtissueinjury
Bleedingandcontaminationinopenwoundo Simplifiesandfacilitatespt.transport
Splintjointsabove+belowandboneendso Immobilizeopenandclosefracturesinsamemannero Coverfracturestoreducecontaminationo 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 Rigidsplintso Softorformablesplintso Tractionsplints
3.1.1 Rigidsplints Padbeforeuse Canonlychangeitsshapeminimally(andonlywithsomesplints) Bodyneedstobepositionedtofitthesplint
o Boardsplintso Cardboardsplintso Samsplint
3.1.2 Softorformablesplints Canbemouldedintovariousshapestoaccommodatetheinjuredbodypart
o Pillowso Blanketso Slingsandswathes
3.1.3 Tractionsplints Speciallydesignedformidshaftfemurfracture DONOTapplyormaintainsufficienttractiontoreduceafemoralfracture DOESprovideenoughtractiontostabilizeandalignit
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3.2 Shoulderinjuries Commoninolderadultsbecauseofweakerbonestructure
o Frequentlyresultfromfallonoutstretchedarm3.2.1 Anteriorfractureanddislocation
Pt.
often
positioned
with
affected
arm
or
shoulder
close
to
chest
Lateralaspectofshoulderappearsflatinsteadofround Deepdepressionbetweenheadofhumerusandtheacromionlaterally(hollowshoulder)3.2.2 Posteriorfractureanddislocation Pt.maybepositionedwitharmabovehead3.2.3 Managementofshoulderinjuries(fractureanddislocation) Assessandreassess(aftersplinting)
o Neurovascularstatuso Neurologicalsensationo Distalpulseo Capillaryrefill
Applicationofice Applicationofslingandswathe Splintmayneedtobeimprovisedtoholdinjury3.3 Humerusinjuries Commoninolderadultsandchildren
o Oftendifficulttostabilize3.3.1 Associatedcomplication Radialnervedamage
o Maybepresentifmiddleordistalportionofhumeralshaftfractured Axillarynervedamage
o Maybepresentifhumeralneckfracture Internalhaemorrhaging
o Intothejoint Compartmentsyndrome(pressurebuildupunderneaththeskin)3.3.2 ManagementofHumerusinjuries Assessandreassess(aftersplinting)
o Neurovascularstatuso Neurologicalsensationo Distalpulseo Capillaryrefill
Applyice Alignifthereisvascularcompromise Applicationofrigidsplitandslingandswathe ORsplinttheextremitywitharmextended3.4 Radius,Ulna/Wristinjuries Commoninadultandinchildren Usuallyresultfromfallonoutstretchedarm Wristinjuriesmayinvolve:
o Distalradiuso Ulnao Oranyoftheeightcarpalbones
Commoninjury:CollesFracture(wristfracture)
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3.4.1 ManagementofHumerusinjuries Assessandreassess(aftersplinting)
o Neurovascularstatuso Neurologicalsensationo Distalpulseo Capillaryrefill
Applyice Splintinpositionfountwithrigidorformablesplints/slingandswathe Elevation3.5 Hand(metacarpal)injuries Frequentlyresultsfrom:
o Contactsportso Violence(fighting)o Crushinginindustrialcontext
Commoninjuryo Boxersfractureo
Result
from
direct
trauma
to
closed
fist
fracturing
fifth
metacarpal
bone
Injuriesmaybeassociatedwithhaematomasandopenwounds3.5.1 ManagementofHumerusinjuries Assessandreassess(aftersplinting)
o Neurovascularstatuso Neurologicalsensationo Distalpulseo Capillaryrefill
Applyice Splintinpositioninnormalpositionofalignment/normalpositionoffunction Elevation3.6 Lowerextremityinjuries Comparetoupperextremityinjurieslowerextremityinjuriesare:
o Associatedwithgreaterwoundingforceo Moresignificantbloodlosso Moredifficulttomanageinpt.withmultipleinjurieso Maybelifethreatening:
Femurfracture Pelvicfracture
Cancausehypovolemicshock3.6.1 Femurfracture Usuallyresultfrommajortrauma(MVA/pedestrianaccidents) Fairlycommoninchildabuse Fracturesusuallyevidentfrompowerfulthighmusclesproducingoverridingofbonefragments Pt.generallyhasshortenedleg+externallyrotatedandmidthighswellingfromhaemorrhaging Bleedingmaybelifethreatening3.6.1.1ManagementofFemurfracture Highconcentrationoxygenadministration Treatmentforshock Assessandreassess(aftersplinting)
o Neurovascularstatuso Neurologicalsensationo Distalpulseo Capillaryrefill
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Applicationoftractionsplintmidshaftfemurfracture Regularmonitoringofvitalsigns Rapidtransportisessential3.6.2 Pelvicfracture Bluntforcetraumaorpenetratinginjurytopelvismayresultin:
o Fractureo Severehaemorrhagingo Associatedinjurytourinarybladderandurethra
Deformitymaybedifficulttosee Suspectinjurytopelvisbasedon:
o MOI(Mechanismofinjury)o Presenceoftendernessonpalpationoftheiliaccrest(hipbone)
3.6.2.1ManagementofPelvicfracture Highconcentrationoxygenadministration Treatmentforshock
Full
body
immobilization
(long
spin
board
and
spider
straps)
o Adequatelypaddedforcomfort Regularmonitoringofvitalsigns Rapidtransportisessential3.6.3 Hipinjury Commoninolderadultsbecauseofafall
o Alsoinyoungeradultfromtrauma Ifhipfracturedatfemoralheadandneck
o Affectedlegusuallyshorterandexternallyrotated(rotatesoutwards) Dislocationofhipusuallyevidencedbyshortenedandrotatedleg3.6.3.1ManagementofHipinjury Assessandreassess(aftersplinting)
o Neurovascularstatuso Neurologicalsensationo Distalpulseo Capillaryrefill
Fullbodyimmobilization (longspinboardandspiderstraps)o Adequatelypaddedforcomfort
Slightflexofthekneeorpaddingbeneaththekneemayimprovecomfort Regularmonitoringofvitalsigns Rapidtransportisessential3.7 Kneeandpatellainjuries Fracturestokneeanddislocationsofpatellacommonlyresultfrom:
o MVAo Pedestrianaccidentso Contactsportso Fallsonflexedknee
Relationshipofpoplitealarterytokneejointmayleadtovascularinjuryo Particularlywithposteriordislocation
3.8 TibiaandFibiainjuries Mayresultfromdirectorindirecttraumaortwistinginjury Isassociatedwithknee,poplitealvascularinjuryshouldbesuspected
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3.8.1 Managementoftibiaandfibiainjuries Assessandreassess(aftersplinting)
o Neurovascularstatuso Neurologicalsensationo Distalpulseo Capillaryrefill
Applicationofice Splintwithrigidorformablesplint Elevate3.9 Footandankleinjuries Fracturesanddislocationoffootandanklemayresultfrom:
o Crushinjuryo Fallfromheighto Violentrotaryforce
Pt.usuallycomplainsofpointtendernessandishesitanttobearweightonextremity3.9.1 Managementoffootandankleinjuries Assessandreassess(aftersplinting)
o Neurovascularstatuso Neurologicalsensationo Distalpulseo Capillaryrefill
Applicationofice Splintwithrigidorformablesplint(e.g.pillow, blanket/airsplint) Elevate3.10 OpenFractures Consideranysofttissuewoundaroundsuspectedfracturetobeevidenceofopenfracture Fracturesmaybeopenintwoways:
o Fromwithin(bonefragmentspiercethroughskin)o Fromwithout(gunshot)
Openfracturesmayhavemadecontactwithskinsomedistanceawayfromfracture Openfracturesconsideredatruesurgicalemergencybecauseofthepotentialforinfection3.11 Limbthreateninginjuries Kneedislocation Fractureordislocationofpoplitealandankle Subcondylarfractureofelbow
o Theseinjuryrequirerapidtransportforphysicianevaluation3.12 Managementoffracturesanddislocations Elbowshowneverbemanipulatedinprehospitalsetting Asarule,fractureanddislocationshouldbeimmobilizedinpositionofinjury
o Andpt.transportedtoemergencydepartmentdoerealignment(reduction) Iftransportdelayed/prolongedandcirculationisimpaired ONEattempttorepositionagrosslydeformedfractured/dislocatedjointshouldbemade3.12.1 Method Handleinjurycarefully Applygentle,firmtractionindirectionoflongaxisofextremity Ifnotobviousresistancesplintextremitywithoutrepositioning
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3.12.2 Realignment ONLYONEattemptatrealignmentshouldbemadeinprehospitalsetting ONLYifseverneurovascularcompromise(extremelyweak/absentdistalpulse) Manipulationshouldbeperformedassoonaspossible(ONLYifindicated) Shouldbeavoidedinpresenceofotherseverinjuries IfNOcontractindicationsconsideruseofEntonoxforrealignmentprocedure Assess+documentandreassess+document(aftersplinting)
o Neurovascularstatuso Neurologicalsensationo Distalpulseo Capillaryrefill