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					                            UNITED STATES MARINE CORPS
                           Field Medical Training Battalion – East
                                       Camp Lejeune
                                          FMST 1407
                               Manage Musculoskeletal Injuries

1. Given a casualty with musculoskeletal injuies in a combat environment and standard field
   medical equipment and supplies, manage musculoskeletal injuries, to prevent further injury
   or death. (FMST-HSS-1407)
1. Without the aid of references, given a description or list, identify the anatomy of the
   musculoskeletal system, within 80% accuracy, per Pre-Hospital Trauma Life Support,
   Military Edition, 6th Ed, Chapter 12. (FMST-HSS-1407a)
2. Without the aid of references, given a description or list, identify types of musculoskeletal
   injuries, within 80% accuracy, per Pre-Hospital Trauma Life Support, Military Edition, 6th
   Ed, Chapter 12. (FMST-HSS-1407b)
3. Without the aid of references, given a description or list, identify treatments for
   musculoskeletal injuries, within 80% accuracy, per Pre-Hospital Trauma Life Support,
   Military Edition, 6th Ed, Chapter 12. (FMST-HSS-1407c)
4. Without the aid of references, given a description or list, identify the general rules for
   Ed, Chapter 12. (FMST-HSS-1407d)
5. Without the aid of references, given a description or list, identify types of splints, within
   80% accuracy, per Pre-Hospital Trauma Life Support, Military Edition, 6th Ed, Chapter 12 .
6. Without the aid of references, given a simulated casualty with musculoskeletal injuries and
   standard field medical equipment and supplies, manage the casualty, per Pre-Hospital
   Trauma Life Support, Military Edition, 6th Ed, Chapter 12. (FMST-HSS-1407f)

  The Skeletal System - composed of all the bones, joints and muscles of the body, as well as
  cartilage, tendons and ligaments. Bones are formed of dense connective tissue. As
  components of the skeleton, they provide the body’s framework. They are strong in order to
  provide support and protection for the internal organs, but they are also flexible to withstand
     Axial Skeleton - consists of the skull, spinal column, and rib cage.
     Appendicular Skeleton - consists of the upper extremities to include the scapula and
     bones of the lower extremities to include the pelvic girdle
        Upper extremities - made up of the humerus, ulna, radius and bones of the wrist and
        Lower extremities - made up of the femur, tibia, fibula and bones of the ankles and
     Types of Bones - there are four types of bones that are classified by shape (see figure 1):
        Long bones - such as the femur and humerus
        Short bones - such as the wrist and ankle bones
        Irregular bones - such as vertebrae, mandible and pelvic bone
        Flat bones - such as the sternum and skull

                                    Figure 1. Bones Classified By Shape

Muscular System
   Muscles - tissue fibers that
   cause movement of body parts
   or organs. There are three kinds
   of muscles (see figure 2).

      Skeletal (voluntary)
      Smooth (involuntary)
      Cardiac (myocardium)

                                                      Figure 2. Three Types Of Muscle

   Cartilage - connective tissue covering the outside of bone ends and act as a surface for
   Tendons - bands of connective tissue that bind the muscle to bones
   Ligaments - connective tissues that support joints by attaching the bone ends and
   allowing for stable range of motion (see figure 3)

                              Figure 3. Tendons and Ligaments

  Soft Tissue Injuries - involve the skin and underlying musculature, commonly referred to as
  either a closed or open wound.
     Closed - an injury where there is no open pathway from the outside to the injured site (see
     figure 4)
     Open - an injury in which the skin is interrupted or broken, exposing the tissues
     underneath (see figure 5). Open wounds include abrasions, lacerations, avulsions and

           Figure 4. Closed Wound                       Figure 5. Open Wound

  Abrasions                                                        Figure 6. Abrasion
     Definition - superficial scratches of the skin’s
     surface. Also called "brush burns," "mat burns,"
     and “road rash." Some bleeding may result, but
     usually oozes from injured capillaries.
     Extremely painful because nerve endings are
     involved (see figure 6).
        - Hemorrhage is usually so minimal that
          primary treatment may only require
          cleansing of the wound.

         - Small bandages may be applied but                          Figure 6. Abrasion
           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.

   Definition - a laceration is a cut. It may be smooth or jagged and
   can be caused by an object with a sharp edge or may result from
   a severe blow or impact with a blunt object (see figure 7).
   Treatment - treatment is generally the same as for abrasions:
       - Control hemorrhage
       - If major tendons and muscles are completely severed,
          immobilize limb to prevent further damage.
                                                                            Figure 7. Laceration of the Lower
       - Treat for shock                                                                  Arm
       - Consider CASEVAC
   Definition - an injury in which flaps of skin are torn loose or completely pulled off (see
   figure 8).
      - Control bleeding
      - Apply field dressing to avulsed area
         (For extremely large or deep
         avulsions, several pressure
         dressings may be necessary or an air
         splint and dressing).
      - Prevent further contamination
      - Ensure avulsed flap is lying flat and
         that it is aligned in its normal
         position                                          Figure 8. Avulsion of the palm
      - If the avulsed part is completely pulled off, make every effort to preserve it. Wrap
         the 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 to the BAS with the patient but keep it well-protected
         from further damage and out of view of the patient
      - Immobilize extremity or body part as indicated by the severity of the avulsion

   Definition - removal of a limb or other
   appendage of the body. May be removed
   surgically or traumatically. Because blood
   vessels are elastic, they tend to spasm and retract
   into surrounding tissue. With complete
   amputations there is less bleeding then with
   partial or degloving cases (see figure 9).

                                                         Figure 9. Traumatic amputation of the lower legs.

       - Hemorrhage Control - Apply a tourniquet. If a tourniquet is applied, mark the
         patient's forehead with a "T" (indicating the time it was applied)
       - Place the patient in shock position (Head down, feet elevated)
       - Make every effort to preserve the amputated part and evacuate the patient as soon as
       - Wrap amputated part in sterile dressing, place in ice and send with patient. When
         possible, prevent direct contact between tissue and ice.
Strains, Sprains and Dislocations
   Strain - injury to a muscle or tendon
   resulting from over stretching or overexertion
   Sprain - a joint injury resulting in partial
   tearing or stretching of supporting ligaments
   (see figure 10)
   Dislocation - the displacement of bone ends at
   the joints resulting in an abnormal stretching
   of the ligaments around the joints.
   Sometimes causes tearing or complete
   ligament separation (see figure 11)
       Signs and Symptoms
          - Point tenderness or burning
          - Marked deformity of joint
          - Pain and edema                              Figure 10. Ankle Ligament Sprain
          - Complete or near complete loss of movement of joint
       Strains Sprains:
           - Supportive strapping or
           - Immobilize by splinting so
              that affected muscle is in
              relaxed position, if injury is
           -R.I.C.E. (Rest, Ice,
              Compression, Elevation)
       Dislocations:                                             Figure 11. Ankle Dislocation
          - Attempt to reduce only if no
            pulse is present in the extremity. If patient can be CASEVAC’ed quickly, the
            better decision may be to transport rather than attempt manipulation.
          - Splint, as found, to immobilize injured part.
          - Pain management
          - CASEVAC

           Hemorrhage - caused by separated bone ends tearing muscle tissue and laceration
           of blood vessels
           Nerve Damage - due to the cutting or pinching of nerves by seperated bone ends or
           muscle injury
     Definition - a break in the continuity of the bone. This may result in partial or complete
     disruption of the bone. May be classified as either open or closed (see figure 12):
         Open fracture - initial injury or bone end has produced an open wound at or near the
         fracture site.
         Closed fracture - the bone is broken with no skin
     Signs and Symptoms                                      Open                               Closed
        - Discoloration
        - Deformity
        - Edema
        - Crepitus/grating
        - Point tenderness
        - Limited range of motion
        - Direct or indirect pain
        - Exposed bone fragments (open fractures)                    Figure 12. Open/Closed Fracture

     General Principles of Treatment for Fractures - the following
     guidelines can be applied to any type of fracture, regardless of location:
        - Treat associated injuries
        - Control hemorrhage
        - Treat for shock
        - Check distal pulses before and after splinting
        - Immobilize the fracture using splints
        - Recheck PMS (pulse, motor, and sensation)
        - Relieve pain (see medication appendix at the back of Block 2 for more information)
        - DO NOT reduce fractures in field unless distal pulses are not present
        - Monitor and CASEVAC

  Definition - an appliance made of wood, metal or plaster used for the fixation, union or
  protection of an injured part of the body.
     - To immobilize the injured body part
     - To prevent further damage to muscles, nerves, or blood vessels caused by broken ends
       of bone
     - To prevent a closed fracture from converting to an open fracture
     - To decrease pain

General Rules for Splinting
   - Control hemorrhage. Direct pressure and/or pressure dressings will control virtually all
     external hemorrhage encountered in the field.
   - Expose fracture site. Remove jewelry and watches.
   - Before splinting, establish distal pulse.
   - Splint in the position found unless limb is pulse-less.
   - 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.
   - DO NOT retract the exposed bone of an open fracture back into the body.
   - Pad splint at bony prominence points (elbow, wrist and ankle).
   - Splint the joints above and below the fracture site.
   - Reassess circulation and neurological status after splinting.
   - When in doubt treat as a fracture.
    Anatomical Splints - use of the patient's
    body as a splint (see figure 13).
       - Strap legs together
       - Secure arm to chest
       - Secure arm to the body (for
         fractured arm/ribs)
       - Tape fingers together                              Figure 13. Anatomical Splint
    Improvised Splints - made from any available material that
    can be used to stabilize a fracture. The only limitation to
    improvised splinting is your imagination and creativity (i.e.
    sticks/branches, blankets, tent poles, see figure 14)
    Manufactured Splints - manufactured splints are generally
    designed for specific injuries, thus they are applied in specific
    Soft Splint - the soft splint can be used to splint various
    fractures throughout the body (see figure 14)
        Purpose - used to immobilize fractures and suspected          Figure 14. Improvised/ Soft Splint
        fractures of the neck, back, arms, and legs
        Description - a wrap around, non-rigid splint that limits motion in the area applied
        commonly made from items such as pillows, ponchos, and blankets
    Rigid Splint/ SAM Splint
       Purpose - used to immobilize suspected fractures
       Description - a rigid splint that prohibits motion in the area applied

   Air Splints
       Purpose - used to immobilize arms and legs (see
       figure 15)
       Description - a pre-formed, one piece, clear plastic,
       balloon-like envelope with a zipper, string, velcro or
       combination of these for closure
           - If splint is used in aircraft, some air may have
              to be released as plane gains altitude
           - This splint is inflatable (be careful not to over
              inflate the splint)                                     Figure 15. Air Splint
Splinting for Specific Types of Fractures
   Fractured Clavicle - immobilize using a figure eight bandage
   Fractured Humerus - splint to body using full arm wrap leaving elbow exposed
   Fractured Radius/Ulna
       - Splint from wrist to elbow
       - Place patient's hand in top of jacket for elevation and support
       - Sling arm using a cravat to cradle elbow and tie around neck for immobilization
   Fractured Wrist/Hand
       - Splint in position of function, leaving fingers exposed to check circulation
       - Place patient's hand in top of jacket for elevation and support
   Fractured Ribs
       - Single closed rib fractures - do not bind or strap around chest
       - Multiple fractures - immoblize flailed segments, do not hinder breathing. Sling and
         swathe arm to injured side of chest to reduce motion and pain. Do not hinder
   Fractured Pelvis - consider wrapping bed sheet tightly around lower aspect of pelvis and
   tying it as a sling
       - Strap knees and ankles together
       - Place pad around bony prominences and soft pad under knees
   Fractured Femur - immobilize fractured leg by splinting one leg to the other with five ties
       - One above wound
       - One below wound
       - One above the knees
       - One below the knees
       - One around feet to secure ankles/boots
   Fractured Patella - splint to other leg using four ties:
       - One around the thighs
       - One above the knee
       - One below the knee
       - One around the ankles

       Fractured Tibia/Fibula - splint one leg to the other with four cravats or improvised ties:
           - One above wound.
           - One below wound.
           - One around the thighs
           - One around feet to secure ankles/boots
       Fractures of Ankle/Foot - immobilize using soft splint or uninjured extremity and four
           - One above the ankle
           - Figure eight bandage around the ankles
           - One below the knee
           - One above the knee

Care Under Fire Phase: If the casualty has a life-threatening hemorrhage, use a tourniquet for
extremity injury or direct pressure for non extremity injuries.

Tactical Field Care Phase: During this phase, you will be required to inspect the injury using
DCAP-BTLS for any signs of injury. Don BSI. Note and treat all musculoskeletal injuries.
Complete a head to toe assessment using DCAP-BTLS noting and treating additional injuries.
Determine if vascular access is required (see Tactical Fluid Resuscitation lesson) and give fluids
if necessary. If the casualty is able to drink fluids, they should be encouraged to do so. Consider
pain medications and give antibiotics if warranted. Reassess all care provided. Document care
given, prevent hypothermia, and CASEVAC.


                                  Musculoskeletal Injuries Review
1. Define an open injury and list four examples.

2. Describe the differences between a complete amputation and a partial amputation.

3. List the first four general rules of splinting.

4. Identify the appropriate treatment for a fractured pelvis.


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