Managing Unstable Musculoskeletal Injuries

Musculoskeletal injuries are a significant source of pain; appropriate management is key to patient comfort and long-term recovery.

This CE activity is approved by EMS World Magazine, an organization accredited by the Continuing Education Coordinating Board for Emergency Medical Services (CECBEMS) for 1 CEU. To take the CE test that accompanies this article, go to to take the test and immediately receive your CE credit. Questions? E-mail


  • Review the anatomy of the musculoskeletal system
  • Describe the physics of fractures
  • Review consequences of improper splinting
  • Discuss management of musculoskeletal injuries

Musculoskeletal injuries are one of the most common injuries EMS providers manage. Nearly 85% of all patients suffering blunt force trauma experience some sort of musculoskeletal injury.1 In addition, musculoskeletal injuries affect one in four Americans annually, and their symptoms are the number two reason for physician visits.2 EMS providers encounter musculoskeletal injuries in a wide variety of incidents including motor vehicle collisions, sporting accidents, falls and physical assaults.

Musculoskeletal injuries are a significant source of pain,1 and their proper management not only reduces this pain but also reduces further injury to surrounding tissues and prevents long-term damage.

Isolated musculoskeletal injuries, as well as those occurring during multi-system trauma, all deserve the same proper management to provide the patient optimal care.

Musculoskeletal System

The musculoskeletal system is a living organ system comprised of connective tissues, ligaments, tendons, muscles and bones that work together to provide the body with stability, form, support, protection and the ability to move. Bones are living organs that serve many additional functions. They are a major storage area for calcium and phosphorus and the bone marrow produces red blood cells. When the body has a surplus of calcium and phosphorus, it has the ability to deposit the surplus of these minerals in the bones. Conversely, when the body experiences a shortage of either mineral it will pull the mineral from the bone.

There are 206 bones in the adult human body. These bones are broken down into five bone types: long bones (e.g., femur), short bones (e.g., patella), flat bones (e.g., scapula), irregular bones (e.g., vertebrae), and sesamoid bones. Sesamoid bones are bones that have a tendon embedded in them, and include the patella, the first metacarpals, the first metatarsals and in the great toe.

All bones have the same essential structures (Figure 1). The outer lining of each bone, termed the periosteum, is a fibrous skin-like layer of connective tissue that can be torn. The periosteum is also heavily innervated with nociceptor nerve endings, making injury to the periosteum highly painful. Directly beneath this is the compact bone, which makes up the majority of the bone mass and gives it its white and smooth appearance, and also provides the bone with its strength and ability to provide support and structure. The spongy bone, also called the trabecular bone, is a porous structure that allows nerves and blood vessels to pass through it. Bone marrow can also be found in the spongy bone. At the center of each bone is bone marrow, which is highly vascularized with arteries and veins. Yellow bone marrow, often found at the center of long bones, is primarily fatty cells. Red bone marrow is found in the flat bones and is responsible for the development of red blood cells, platelets and most white blood cells.

When a bone is fractured the blood vessels and nerves in all layers of the bone are interrupted. Additionally, yellow (fatty) bone marrow, if also broken loose, can enter into a bloodstream, and become an embolism.

Physics of Fractures

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