**4. Classification and management of musculoskeletal injuries**

#### **4.1. Soft tissue injuries1**

The soft tissue is a term that encompasses all body tissue except the bones. It includes skin, muscles, vessels, ligaments, tendons, and nerves. Their injuries can range from the trivial, such as a scraped knee, to the critical that includes internal bleeding; those which involve the skin and underlying musculature are commonly divided either as closed or open wounds.

#### *4.1.1. Closed wounds*

An injury where there is no open pathway from the outside to the injured site (**Figure 4**) and can be divided into:

<sup>1</sup> This will include soft tissue and connective tissue injuries for the sake of simplification.

*4.1.1.1. Managements of closed injuries*

for appropriate medical treatment.

Also, make sure to cover the following:

**5.** Splint and immobilize injured limb.

**7.** Arrange for transport to appropriate care center.

**3.** Check circulation, motor, and sensation before and after splinting.

*4.1.1.1.1. Strains and sprains*

followed [9, 10].

**1.** Reassure the patient.

**4.** Apply ice pack.

**Figure 6.** Open wound.

**6.** Elevate injured limb.

**2.** Gently support the site.

Closed injuries can be managed effectively by applying the **R.I.C.E.R.** regime [4]. This involves the application of (**R**) rest, (**I**) ice, (**C**) compression, (**E**) elevation, and obtaining a (**R**) referral

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A patient with strain and/or sprain usually has pain and edema, a point of tenderness or burning sensation with or without ecchymosis. There may be a mild deformity of the injured joint in addition to complete or near complete loss of movement of joint; treatment consists of pain control, supportive strapping or bandaging, and immobilization by splinting so that affected muscle is in relaxed position. If injury is severe, R.I.C.E.R must be

**Figure 4.** Closed wound.

**Figure 5.** Ankle ligament sprain.


#### *4.1.1.1. Managements of closed injuries*

Closed injuries can be managed effectively by applying the **R.I.C.E.R.** regime [4]. This involves the application of (**R**) rest, (**I**) ice, (**C**) compression, (**E**) elevation, and obtaining a (**R**) referral for appropriate medical treatment.

#### *4.1.1.1.1. Strains and sprains*

A patient with strain and/or sprain usually has pain and edema, a point of tenderness or burning sensation with or without ecchymosis. There may be a mild deformity of the injured joint in addition to complete or near complete loss of movement of joint; treatment consists of pain control, supportive strapping or bandaging, and immobilization by splinting so that affected muscle is in relaxed position. If injury is severe, R.I.C.E.R must be followed [9, 10].

Also, make sure to cover the following:


**Figure 6.** Open wound.

**1.** Contusion: a traumatic injury to the tissues beneath the skin without a break in the skin.

surrounding soft tissues causing the skin to turn different colors.

known as a pulled muscle or torn muscle [8].

Also known as a torn ligament [8].

**Figure 5.** Ankle ligament sprain.

**Figure 4.** Closed wound.

174 Essentials of Accident and Emergency Medicine

**3.** Edema: swelling as a result of inflammation or abnormal fluid under the skin.

**2.** Ecchymosis: discoloration under the skin that is caused when blood leaks out into the

**4.** Strain: stretching or tearing of a muscle resulting from overstretching or overexertion. Also

**5.** Sprain: a joint injury involving damage to supporting ligaments and partial or temporary dislocation of bone ends, partial tearing or stretching of supporting ligaments (**Figure 5**).

#### *4.1.2. Open wounds*

An injury in which the skin is interrupted or broken, exposing the tissues underneath (**Figure 6**) and can be divided into:


#### *4.1.2.1. Management of open injuries*

#### *4.1.2.1.1. Abrasions*

Also called "brush burns," "mat burns," and "road rash" in which some bleeding may result, but usually oozes from injured capillaries. Extremely painful because nerve endings are involved (**Figure 7**).

The management is usually so minimal requiring cleansing of the wound; small bandages may be applied but tactical situations will usually preclude applying field dressings that are needed for more serious injuries. A large amount of dirt may be ground into the wound; therefore, secondary treatment measures should focus on preventing or stopping infections.

*4.1.2.1.2. Lacerations and incisions*

**Figure 9.** More severe laceration of the forearm.

**Figure 8.** Simple laceration.

cut, immobilize the limb to prevent further damage.

May be smooth or jagged and can be caused by an object with a sharp edge (**Figures 8** and **9**) or may result from a severe blow or impact with a blunt object. Treatment is generally the same as for abrasions. It is very important to remember protecting yourself from disease by using medical gloves, wash or irrigate the injury with warm saline, remove all foreign bodies, control bleeding by applying local compression and dressing, start intravenous fluids when necessary (e.g., in cases of severe bleeding and possible hemodynamic compromise). Insure to keep the patient warm, elevate the injured part of the body. If major tendons and muscles are completely

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**Figure 7.** Abrasion post road accident.

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**Figure 8.** Simple laceration.

*4.1.2. Open wounds*

(**Figure 6**) and can be divided into:

176 Essentials of Accident and Emergency Medicine

may be iatrogenic or due to trauma.

*4.1.2.1. Management of open injuries*

*4.1.2.1.1. Abrasions*

involved (**Figure 7**).

**Figure 7.** Abrasion post road accident.

infections.

**1.** Abrasions: where the top layer of the skin is removed.

**2.** Lacerations: these are cuts of the skin with jagged edges.

An injury in which the skin is interrupted or broken, exposing the tissues underneath

**3.** Incisions: which are characterized by smooth edges and resemble a paper cut.

**5.** Avulsions: where a flap of skin is forcefully torn from its attachment.

**4.** Punctures: usually deep, narrow wounds such as a stab wound from a nail or knife.

**6.** Amputations: partial or full detachment of a limb or other appendage of the body which

Also called "brush burns," "mat burns," and "road rash" in which some bleeding may result, but usually oozes from injured capillaries. Extremely painful because nerve endings are

The management is usually so minimal requiring cleansing of the wound; small bandages may be applied but tactical situations will usually preclude applying field dressings that are needed for more serious injuries. A large amount of dirt may be ground into the wound; therefore, secondary treatment measures should focus on preventing or stopping

**Figure 9.** More severe laceration of the forearm.

#### *4.1.2.1.2. Lacerations and incisions*

May be smooth or jagged and can be caused by an object with a sharp edge (**Figures 8** and **9**) or may result from a severe blow or impact with a blunt object. Treatment is generally the same as for abrasions. It is very important to remember protecting yourself from disease by using medical gloves, wash or irrigate the injury with warm saline, remove all foreign bodies, control bleeding by applying local compression and dressing, start intravenous fluids when necessary (e.g., in cases of severe bleeding and possible hemodynamic compromise). Insure to keep the patient warm, elevate the injured part of the body. If major tendons and muscles are completely cut, immobilize the limb to prevent further damage.

**Figure 10.** Avulsion.

#### *4.1.2.1.3. Avulsions*

These should be assessed carefully to rule out vascular and/or neurological injury (**Figure 10**). Bleeding should be controlled by direct pressure on the bleeding site; the avulsed part should be managed by applying several pressure dressings or an air splint and followed by regular dressing. Contamination should be avoided; ensure avulsed flap is lying flat and that it is aligned in its normal position. If the avulsed part is completely pulled off, make every effort to preserve it. Wrap that part in a saline or water-soaked field dressing, pack wrapped part in ice, and whenever possible be careful to avoid direct contact between the tissue and ice. Transport the avulsed part with the patient but keep it well-protected from further damage and out of view of the patient [4].

*4.1.2.1.4. Amputations*

**Figure 12.** Pneumatic tourniquet in place.

Amputation is a very traumatic event for the patient both physically and psychologically (**Figure 11**). With complete amputations, there is less bleeding than with partial or degloving cases. This is due to elastic nature of blood vessels as they are tended to spaz and retract into the surrounding tissue. It is very important to notice that replantation is performed only with an injury of isolated finger or extremity and should be performed by a skilled surgical team. Treatment should always be started by ABCDE, which is the management of airway, breathing, circulation, disabilities, and environment in addition to warmth of the patient and control of hemorrhage by direct pressure or application of a tourniquet (**Figure 12**). If a tourniquet is applied, it must occlude arterial inflow, as occluding only venous system can increase bleeding. In severe cases where the patient's life might be at compromise, a tourniquet may remain in place for a prolonged period in order to save the patient's life. The physician must be able

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It is helpful to mark the patient's forehead with a "T" (indicating the time it was applied) using a marker to be able to track time of which the tourniquet was applied. Place the patient in shock position (head down, feet elevated). Continue the management by treatment of shock via IV fluids and/or blood transfusion, vasopressors if necessary, pain control, and continuous monitoring of the patient's vitals. Make every effort to preserve the amputated part and transfer the patient to the theater as soon as possible after stabilization of the ABCDE. Wrap the amputated part in a sterile dressing, place in ice and send with patient, and prevent direct

A break in the continuity of bone which may result in partial or complete disruption of the

to make such decision and be aware that this choice is for life and against limb.

contact between tissue and ice as possible [7].

bone. Fractures are further classified as open or closed.

**4.2. Fracture and dislocation injuries**

*4.2.1. Fractures*

**Figure 11.** Severe bilateral amputation of the lower limbs.

**Figure 12.** Pneumatic tourniquet in place.

#### *4.1.2.1.4. Amputations*

*4.1.2.1.3. Avulsions*

**Figure 10.** Avulsion.

178 Essentials of Accident and Emergency Medicine

and out of view of the patient [4].

**Figure 11.** Severe bilateral amputation of the lower limbs.

These should be assessed carefully to rule out vascular and/or neurological injury (**Figure 10**). Bleeding should be controlled by direct pressure on the bleeding site; the avulsed part should be managed by applying several pressure dressings or an air splint and followed by regular dressing. Contamination should be avoided; ensure avulsed flap is lying flat and that it is aligned in its normal position. If the avulsed part is completely pulled off, make every effort to preserve it. Wrap that part in a saline or water-soaked field dressing, pack wrapped part in ice, and whenever possible be careful to avoid direct contact between the tissue and ice. Transport the avulsed part with the patient but keep it well-protected from further damage Amputation is a very traumatic event for the patient both physically and psychologically (**Figure 11**). With complete amputations, there is less bleeding than with partial or degloving cases. This is due to elastic nature of blood vessels as they are tended to spaz and retract into the surrounding tissue. It is very important to notice that replantation is performed only with an injury of isolated finger or extremity and should be performed by a skilled surgical team.

Treatment should always be started by ABCDE, which is the management of airway, breathing, circulation, disabilities, and environment in addition to warmth of the patient and control of hemorrhage by direct pressure or application of a tourniquet (**Figure 12**). If a tourniquet is applied, it must occlude arterial inflow, as occluding only venous system can increase bleeding. In severe cases where the patient's life might be at compromise, a tourniquet may remain in place for a prolonged period in order to save the patient's life. The physician must be able to make such decision and be aware that this choice is for life and against limb.

It is helpful to mark the patient's forehead with a "T" (indicating the time it was applied) using a marker to be able to track time of which the tourniquet was applied. Place the patient in shock position (head down, feet elevated). Continue the management by treatment of shock via IV fluids and/or blood transfusion, vasopressors if necessary, pain control, and continuous monitoring of the patient's vitals. Make every effort to preserve the amputated part and transfer the patient to the theater as soon as possible after stabilization of the ABCDE. Wrap the amputated part in a sterile dressing, place in ice and send with patient, and prevent direct contact between tissue and ice as possible [7].

#### **4.2. Fracture and dislocation injuries**

#### *4.2.1. Fractures*

A break in the continuity of bone which may result in partial or complete disruption of the bone. Fractures are further classified as open or closed.

Alternative classification to fractures can be applied in relation to the size of the wound and

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Type II: Moderate wound (>1 cm), minimal soft tissue damage or loss; low energy.

Type III: Severe skin wound, with extensive soft tissue damage; high velocity impact.

The following guidelines can be applied to any type of fracture, regardless of location:

• Treat any associated injuries and cover the injured area with sterile dressing.

• Treat as any case of trauma by starting management of airway, breathing, circulation, dis-

• Initiate IV antibiotics (usually broad-spectrum type to cover both Gram-positive and Gram-

• DO NOT re-place protruding bone or explore the wound nor clamp any vessel at the emer-

In general, during clinical examination for suspected fractures, look for the following signs:

Type I: Small wound (<1 cm), usually clean; low energy.

abilities, and patients' environment (ABCDE).

• Check distal pulses before and after splinting.

negative bacteria), in addition to tetanus prophylaxis.

gency setting and wait for the orthopedic physician.

causative force:

*4.2.1.1. Management of fractures*

• Control hemorrhage. • Treatment for shock.

• Discoloration.

• Point tenderness.

• Limited range of motion.

• Exposed bone fragments (open fractures).

• Direct or indirect pain.

• Deformity.

• Edema. • Crepitus.

• Relieve pain (can include opioids).

• Immobilize the fracture using splints.

• Check pulse, motor, and sensation (PMS).

**Figure 13.** Open versus closed fracture.

**Figure 14.** Inside-out open fracture.

**Open fractures**: in which there is a break through the overlying skin and connective tissue with exposure of the broken bone (**Figure 13**).

It can be **inside-out** (**Figure 14**) where the broken end of the bone breaks through or pierces the skin, or **outside-in** where the external force causes laceration and breaks the layers till the bone. The latter has a higher likelihood of contamination.

**Closed fracture**: the bone is broken with no skin penetration or connection with the exterior surface (**Figure 13**).

Alternative classification to fractures can be applied in relation to the size of the wound and causative force:

Type I: Small wound (<1 cm), usually clean; low energy.

Type II: Moderate wound (>1 cm), minimal soft tissue damage or loss; low energy.

Type III: Severe skin wound, with extensive soft tissue damage; high velocity impact.

#### *4.2.1.1. Management of fractures*

The following guidelines can be applied to any type of fracture, regardless of location:


In general, during clinical examination for suspected fractures, look for the following signs:


**Open fractures**: in which there is a break through the overlying skin and connective tissue

It can be **inside-out** (**Figure 14**) where the broken end of the bone breaks through or pierces the skin, or **outside-in** where the external force causes laceration and breaks the layers till the

**Closed fracture**: the bone is broken with no skin penetration or connection with the exterior

with exposure of the broken bone (**Figure 13**).

surface (**Figure 13**).

**Figure 14.** Inside-out open fracture.

**Figure 13.** Open versus closed fracture.

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bone. The latter has a higher likelihood of contamination.


• Any open wounds over or near a joint should be assumed to extend to the joint till proven otherwise.

• DO NOT retract the exposed bone of an open fracture back into the body.

**Common complications** that can be seen with splinting include abrasions, sores, neurovascular compromise due to tight fitting splints, contact dermatitis, pressure ulcers, and thermal burns. Splints should be applied by skilled and trained professional, applied splint correctly

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**1.** Volar short splint which is used for wrist fractures, fractures of the second to fifth metacar-

pal bones, carpal tunnel syndrome, and soft tissue injuries (**Figure 15**).

**2.** Finger splints which are used for phalangeal fractures (**Figure 16**).

• Pad splint at bony prominence points (elbow, wrist, and ankle).

• Reassess circulation and neurological status after splinting.

• Splint the joints above and below the fracture site.

followed by neurovascular status checkup.

*4.2.1.1.1.2. Common types of splints*

**Figure 15.**

#### **Serious complications** of open fractures are:


#### *4.2.1.1.1. Splints and splinting*

An appliance made of wood, metal, or plaster used for the fixation and protection of an injured part of the body aiming to:


#### *4.2.1.1.1.1. General rules for splinting*


**Common complications** that can be seen with splinting include abrasions, sores, neurovascular compromise due to tight fitting splints, contact dermatitis, pressure ulcers, and thermal burns. Splints should be applied by skilled and trained professional, applied splint correctly followed by neurovascular status checkup.

#### *4.2.1.1.1.2. Common types of splints*

• Any open wounds over or near a joint should be assumed to extend to the joint till proven

An appliance made of wood, metal, or plaster used for the fixation and protection of an

• prevent further damage to muscles, nerves, or blood vessels caused by broken ends of

• Control hemorrhage. Direct pressure and/or pressure dressings will control virtually all

• An attempt should be made to straighten a severely deformed limb with gentle traction

only if there are no distal pulses, if resistance is felt, stop and splint as it lies.

• Move the fractured part as little as possible while applying the splint.

• prevent a closed fracture from converting into an open fracture.

otherwise.

**1.** Soft tissue infection.

182 Essentials of Accident and Emergency Medicine

**2.** Osteomyelitis. **3.** Gas gangrene.

**5.** Crush syndrome.

**7.** Malunion or Nonunion.

*4.2.1.1.1. Splints and splinting*

• decrease and control pain.

external hemorrhage.

*4.2.1.1.1.1. General rules for splinting*

• Expose fracture site. Remove jewelry and watches.

• Splint in the position found unless limb is pulse-less.

• Before splinting, check for distal pulses.

injured part of the body aiming to:

• immobilize the injured body part.

**4.** Tetanus.

**6.** Skin loss.

bones.

**Serious complications** of open fractures are:


**Figure 15.**

**Figure 16.**

**3.** Gutter splint which can be used for phalangeal fractures and metacarpal fractures; these are two types: radial and ulnar (**Figure 17**).

**Figure 17.**

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**Figure 18.**


#### *4.2.2. Dislocations*

A displacement of bone ends at the joints (**Figures 22**–**24**) resulting in an abnormal stretching of the ligaments around the joints. Also called luxation, occurs when there is an abnormal separation in the joint where two or more bones meet [9, 10]. Sometimes causes tearing or complete ligament separation; a partial dislocation is referred to as subluxation. They are easily recognized and diagnosed; the impact area may be swollen or look bruised with associated redness Musculoskeletal Injuries: Types and Management Protocols for Emergency Care http://dx.doi.org/10.5772/intechopen.81939 185

**Figure 17.**

**3.** Gutter splint which can be used for phalangeal fractures and metacarpal fractures; these

**4.** Buddy taping of toes used to secure the fractured toe to the adjacent one with adhesive strips; it is necessary to apply a small pad or sheet between toes to prevent maceration

**5.** Thumb spica splint used for scaphoid fractures, extraarticular fractures of the thumb and

**6.** Stirrup splint is a below knee splint wrapping around the ankle to immobilize ankle frac-

**7.** Posterior leg splint is used for distal leg fractures, ankle fractures, tarsal fractures, and

A displacement of bone ends at the joints (**Figures 22**–**24**) resulting in an abnormal stretching of the ligaments around the joints. Also called luxation, occurs when there is an abnormal separation in the joint where two or more bones meet [9, 10]. Sometimes causes tearing or complete ligament separation; a partial dislocation is referred to as subluxation. They are easily recognized and diagnosed; the impact area may be swollen or look bruised with associated redness

are two types: radial and ulnar (**Figure 17**).

184 Essentials of Accident and Emergency Medicine

ulnar collateral ligament injuries (**Figure 19**).

(**Figure 18**).

**Figure 16.**

tures (**Figure 20**).

*4.2.2. Dislocations*

metatarsal fractures (**Figure 21**).

**Figure 18.**

**Figure 19.**

or discoloration. It may also have a strange shape or be deformed as a result of the unexpected or unbalanced trauma. Some of the other symptoms associated with dislocated joints include:

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**1.** Limited or lost motion. **2.** Pain during movement.

**Figure 21.**

**3.** Numbness around the area.

**Figure 22.** Posterior shoulder dislocation on X-ray.

**Figure 20.**

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**Figure 21.**

**Figure 19.**

186 Essentials of Accident and Emergency Medicine

**Figure 20.**

**Figure 22.** Posterior shoulder dislocation on X-ray.

or discoloration. It may also have a strange shape or be deformed as a result of the unexpected or unbalanced trauma. Some of the other symptoms associated with dislocated joints include:


#### **4.** Paresthesia and tingling feeling in the limb.

X-ray is usually the preferred method of imaging in the emergency department, on occasion, special imaging such as an MRI may be required for diagnosis to roll out associated fractures or tear in muscles and ligaments.

If the joint does not return to normal naturally, treatment options should be one or more of

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**1.** Manipulation or repositioning (sedatives or anesthetics are necessary to keep the patient comfortable and also to allow muscles near to the injured joint to relax, which eases the procedure).

**5.** Surgery is usually indicated only if there are damaged nerves or blood vessels, or if the doctor is unable to return bones to their anatomical position. Surgery may also be necessary for those who often dislocate the same joints, such as recurrent shoulder

**2.** Immobilization (a sling, splint, or cast for several weeks to prevent recurrence).

**4.** Rehabilitation (to increase the joint's strength and restore its range of motion).

**3.** Medication (a pain reliever or a muscle relaxant).

**Figure 25.** Acute compartment syndrome of the left foot.

the following:

dislocations.

**Figure 26.** Fasciotomy.

**Figure 23.** Shoulder dislocation.

**Figure 24.** Ankle dislocation.

#### *4.2.2.1. Management of dislocation*

Treatment of dislocations and/or subluxations will depend on the site of joint; it may also depend on the severity of injury. According to Johns Hopkins University, initial treatment for any dislocation involves R.I.C.E: rest, ice, compression, and elevation. In some cases, the dislocated/subluxated joint might go back into place naturally after this treatment [11–13].

**Figure 25.** Acute compartment syndrome of the left foot.

**4.** Paresthesia and tingling feeling in the limb.

or tear in muscles and ligaments.

188 Essentials of Accident and Emergency Medicine

**Figure 23.** Shoulder dislocation.

*4.2.2.1. Management of dislocation*

**Figure 24.** Ankle dislocation.

X-ray is usually the preferred method of imaging in the emergency department, on occasion, special imaging such as an MRI may be required for diagnosis to roll out associated fractures

Treatment of dislocations and/or subluxations will depend on the site of joint; it may also depend on the severity of injury. According to Johns Hopkins University, initial treatment for any dislocation involves R.I.C.E: rest, ice, compression, and elevation. In some cases, the dislocated/subluxated joint might go back into place naturally after this treatment [11–13].

If the joint does not return to normal naturally, treatment options should be one or more of the following:


**Figure 26.** Fasciotomy.
