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Musculoskeletal Trauma. Silvia De La Guardia RN, BSN, CEN Tenet Health Systems Emergency Department. Learning Objectives. List three signs or symptoms of joint dislocations. Identify how much blood can accumulate in the femur compartment.

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Musculoskeletal trauma


Silvia De La Guardia RN, BSN, CEN

Tenet Health Systems

Emergency Department

Learning objectives
Learning Objectives

  • List three signs or symptoms of joint dislocations.

  • Identify how much blood can accumulate in the femur compartment.

  • Explain why prompt reduction of joint injuries is important.

  • Identify signs of a femur and pelvic fracture.

  • Identify injuries or complications associated with pelvic fractures.

  • Discuss emergent management of compartment syndrome.

Musculoskeletal trauma1
Musculoskeletal Trauma

  • Musculoskeletal injuries often appear dramatic, rarely cause immediate threat to life or limb

  • Major injuries, especially to long bones, indicate significant forces applied to body

  • Imperative to recognize and control hemorrhage from musculoskeletal injures in primary survey

  • Suspect neurovascular injury with any injury to the bones of an extremity.

  • Splinting significantly decreases bleeding

    • Reducing motion

    • Tamponade effect

Mechanism of injury
Mechanism of Injury

  • Motor Vehicle Crash

    • Patella injury

    • Fractured femur

    • Hip fracture/dislocation

  • Assault

  • Fall

    • Calcaneus fracture

    • Compressed vertebral bodies

  • Sports

  • Recreational and home activities



  • Appearance of Extremity

    • Normal vs. abnormal

    • Difference between injured and non-injured

  • Integrity of injured area

    • Deformity - Burns

    • Contusions - Tenderness

    • Abrasions - Lacerations

    • Punctures - Swelling

    • Bleeding - Protrusion of bone



  • Six P’s

    • Pulse

    • Pain

    • Pallor

    • Paresthesias

    • Paralysis

    • Pressure

  • Palpate for stability and crepitus



Cap refill








Pathophysiologic changes
Pathophysiologic Changes


  • Large blood loss is due to damage to arteries or veins close to bones

  • Edema can cause compression of structures.

  • Physiological changes activated to minimize damage:

    • Clotting system activation to decrease bleeding

    • Cell membrane restoration to enhance fluid reabsorption

    • Increased collateral blood flow to promote healing

Pathophysiologic changes1
Pathophysiologic Changes

  • Bone/joint displacement can compress surrounding vessels and nerves

  • As arterial blood is obstructed, tissue oxygenation ceases. Ischemia/tissue death.

  • In this process:

    • Pain increases - Pale limb

    • Weak pulses - Skin cyanotic

    • Cool skin - Increased capillary refill

Pathophysiologic changes2
Pathophysiologic Changes


  • Nerves can be compressed or lacerated

  • Nerve injury results in

    • Diminished pain

    • Partial or complete loss of motor

    • Partial or complete loss of sensation

Pathophysiologic changes3
Pathophysiologic Changes


  • Open - Closed

  • Complete - Incomplete

  • Comminuted - Greenstick

  • Impacted - Displaced

  • Fissure - Spiral

Types of injuries1

Blunt injures

  • Acceleration/deceleration mechanism

    • Falls, MVC, work/home injuries

    • Assaults, sport injuries

  • Include

    • Fractures, dislocations,

    • Strains: Injury to muscle or tendon

    • Sprains: Injury to ligament

    • Ligamentous tears

      Penetrating Injuries

  • Penetrating objects

  • Open fractures

Joint injuries
Joint Injuries

  • Considered limb-threatening injuries

  • Joint dislocations

    • Normal range of motion is exceeded

    • Complicated by neurovascular compromise

    • Associated fractures

  • Avascular necrosis

    • Complication of joint injuries

    • Caused by delay reduction

    • Knee dislocations require immediate reduction to prevent complications

      • Peroneal nerve injury

      • Popliteal artery disruption

Joint injuries1
Joint Injuries

Signs and Symptoms

  • Inability to move the affected area

  • Neurovascular compromise

  • Abnormal range of motion

  • Pain

  • Deformity of joint

  • Edema

Femur fractures
Femur Fractures

  • Result from major trauma

  • Common mechanism of injury

    • Falls

    • MVC

    • penetrating wounds (GSW)

  • Femoral neck fractures common

  • Femur fractures may not be obvious

  • Result in significant blood loss

Femur fractures1
Femur Fractures

Signs and Symptoms

  • Pain

  • Inability to bear weight

  • Shortened extremity

  • Internal or external rotation

  • Edema or deformity

  • Hypovolemic shock

Pelvic fractures
Pelvic Fractures


  • Stable:

    • Pelvic ring fracture in one place

    • Stable to palpation

    • Can withstand normal physiologic forces

    • Without abnormal deformation

  • Unstable

    • Pelvic ring fractured in more than one place

    • Bony instability with palpation

Pelvic fractures1
Pelvic Fractures

  • Can be classified by type of force

    • External rotation (anteroposterior)

    • Lateral compression

    • External rotation (abduction)

    • Shear

  • These can be life-threatening and often have large blood loss and genitourinary injuries.

  • Bleeding significant enough to cause hypovolemic shock

Pelvic fractures2
Pelvic Fractures

  • Injuries to pelvis can be:

    • Open: associated with injuries to perineum, rectum, genitourinary system. Have higher mortality rate.

    • Closed.

Pelvic fractures3
Pelvic Fractures

Signs and Symptoms

  • Intra-abdominal or genitourinary injury

    • Look for blood in meatus

    • Higher mortality rate

  • Shortening and abnormal rotation of the affected leg

  • Pain to pelvic area, back, thighs

  • Hypovolemic shock


  • Stabilize pelvic fractures

    • PASG

    • Wrap pelvis in sheet

    • External fixator

  • Assist with additional diagnostic studies

    • Radiographs

    • CT scan

    • Cystogram

    • Angiogram

    • Embolization

Open fractures
Open Fractures

  • Considered Limb-threatening injuries

  • Consider contaminated avoid retracting bone back into tissue

  • Higher risk of infection

    • Poor wound healing

    • Osteomyelitis

    • Sepsis

Open fractures1
Open Fractures

Signs and Symptoms

  • Skin disruption

  • Protrusion of bone

  • Pain

  • Bleeding can be minimal or severe

  • Neurovascular compromise

    • Do not move fracture: minimize more damage

    • Call orthopedic consult early

      • Realign to restore blood flow and nerve integrity

      • Operative debridement

Emergent interventions
Emergent Interventions

  • Obtain wound culture

  • Irrigate the wound with sterile saline

  • Cover open wounds with dry sterile dressing

  • Administer medications

    • Tetanus

    • Antibiotics

  • Inspect dressings frequently

Avascular injury
Avascular Injury

  • Acutely avascular extremity must be recognized promptly and treated emergently

    • Assess temperature, color, capillary refill, pulses

  • Early operative revascularization is critical

    • Muscles and nerves do not tolerate lack or arterial blood flow for longer than 6 hours

  • Use of tourniquets is controversial

    • Indicated for ongoing hemorrhage uncontrolled by direct pressure

    • Use of tourniquets is a “Life over limb” decision

    • Risk of tourniquet increase with time


  • Traumatic event for patient:

    • Physically and emotionally

  • Amputations may benefit from a tourniquet

  • Replantation

    • Injury of an isolated extremity

    • Clean sharp amputations

      • Fingers

      • Distal extremity, below the knee or elbow

      • Wrist, forearm

      • Pediatric patient


Signs and Symptoms

  • Obvious tissue loss

  • Pain

  • Evidence of hypovolemic shock

  • Bleeding (minimal to severe)

    • Complete: less bleedingthan partial because of retraction of arteries.

    • Avulsive type complete amputation can result in severe bleeding.

Emergent interventions1
Emergent Interventions

  • Control active bleeding

  • Remove gross debris

  • Elevate and splint the stump

  • Place amputated part on ice bath: do not freeze

    • Wrap in saline soaked gauze

    • Place in plastic bag then

    • Place bag on ice or ice water mixture

  • Prepare patient for admission or transfer

  • Administer medications: pain meds, antibiotics.

Crush injuries
Crush Injuries

  • Life-threatening and difficult to treat

    • Cellular destruction

    • Damage to vessels

  • Result from

    • prolonged entrapment

    • Crushing blow

  • Sequelae

    • Hemorrhage and fluid loss

    • Destruction of muscle

    • Infection

    • Compartment syndrome

    • Rhabdomyolysis

Crush injuries1
Crush Injuries

Sign and Symptoms

  • Massively crushed pelvis or extremities

  • Soft tissue swelling

  • Pain

  • Hypovolemic shock

  • Compartment syndrome

  • Loss of neurovascular function distal to injury

Emergent interventions2
Emergent Interventions

  • Administer intravenous fluids to increase urinary output and excrete myoglobin

  • Elevate the injured extremity

  • Cleanse open wounds

  • Reassess urinary output

  • Motor and sensory function

  • Prepare for surgical debridement

Compartment syndrome
Compartment Syndrome

  • Pressure increases inside fascial compartment Decreased perfusion and cellular ischemia.

  • Nerves, vessels, muscles can be compressed.

  • Prolonged ischemia results in

    • Pain

    • Necrosis

    • Loss of function

    • Amputation

  • Degree of damage

    • Amount of pressure

    • Time

Compartment syndrome1
Compartment Syndrome

  • Internal sources:

    • Bleeding

    • Tissue edema

    • Crush injuries

  • External sources

    • Tight dressings

    • Cast, excessive traction

  • More frequently seen

    • Lower leg

    • Forearm

Compartment syndrome2
Compartment Syndrome

Signs and Symptoms

  • Pulses

    • Loss of pulse uncommon

    • Late unreliable sign

  • Pain

    • Disproportionate to injury

    • With passive movement

  • Pallor: Poor color, cool temperature

  • Paresthesia: Numbness, tingling,

  • Paralysis: motor dysfunction, injury to nerves, weak.

  • Pressure: compartment will feel tense, swollen

Emergent interventions3
Emergent Interventions

  • Remove dressings, cast and splints

  • Elevate limb to level of the heart

  • Assist with measurement of compartment pressures

  • Reassess neurovascular status

  • Surgical consultation: Fasciotomy (may prevent muscle/neurovascular damage and loss of limb)


  • X-Rays

    • Different views (anterior, posterior, lateral)

    • Film should include joints above/below.

  • Angiography

    • Indicated to identify tears or compressions in arteries/veins of extremity.


  • Control bleeding

  • Splint and immobilize affected extremity

  • Apply ice

  • Elevate extremity: compartment syndrome keep at level of heart

  • Administer medication: antibiotics, tetanus, pain

  • Prepare for definitive stabilization

  • Provide psychosocial support

  • Prepare for operation, admission, or transfer, discharge


  • Monitor breathing effectiveness and rate of respiration.

    • Tachypnea, rales, and wheezes may be indicators of fat embolus syndrome.

  • Reassess and document 5 P’s.

Learning objectives1
Learning Objectives

  • List three signs or symptoms of joint dislocations.

  • Identify how much blood can accumulate in the femur compartment.

  • Explain why prompt reduction of joint injuries is important.

  • Identify signs of a femur and pelvic fracture.

  • Identify injuries or complications associated with pelvic fractures.

  • Discuss emergent management of compartment syndrome.


  • ATLS, advanced trauma life support for doctors (8th ed.). (2008). Chicago, IL: American College of Surgeons.

  • Beers, M. H. (2006). The Merck manual of diagnosis and therapy (18th ed.). Whitehouse Station, N.J.: Merck Research Laboratories.

  • Coven, D. L., & Yang, E. H. (n.d.). Retrieved September 1, 2010, from

  • Howard, P. K., Steinmann, R. A., & Sheehy, S. B. (2010). Sheehy's emergency nursing: principles and practice. (6th ed.). St. Louis, Mo.: Mosby Elsevier.

  • Tintinalli, J. E., & Stapczynski, J. S. (2011). Tintinalli's emergency medicine: a comprehensive study guide (7th ed.). New York: McGraw-Hill.

  • TNCC: trauma nursing core course (5th ed.). (2000). Park Ridge, Ill.: Emergency Nurses Association.