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Nothing is more common in childhood athletics than sprains and strains and soft tissue injuries and in this case, we've got a soccer player who obviously was coming up to try to get the ball, either rolled over the ball or kicked another one of the players. But regardless, what we know about this mechanism of injury is that there was a sudden, abrupt stop and the player collapsed to the ground. Now our first assessment is obviously that he's awake, he's conscious, and he's breathing normally. He seems to be in a little bit of discomfort or even some mild to moderate pain. But he's not in an unstable situation. So immediate activation of EMS or 911 may not be our best first option. We can do a little bit more of an investigation first. And right now, what I want to know is, is this an injury that's going to require this player to go to the doctor or to the ER or is it actually a bump or a bruise that this player can deal with and they just want to get back in the game. That's the real question, isn't it? And so here's how we're gonna get to the conclusion of that, with a moderately safe and conservative method of investigation. The first thing I'm gonna do is I'm gonna ask the player, do you hurt anywhere else, other than, it looks like your knee? Do you hurt anywhere? And he shakes his head no. This is all that hurts and he grabs his knee. We call this self-splinting. They'll do it to their arm. They'll hold a rib. They'll hold their knee or their ankle. And in this case, he's stabilizing his knee. What I want to do, in this case he's wearing shorts, obviously. But if they had pants on, I would take my scissors and I would cut the pant leg to be able to reveal the injured part. Now what am I looking for? I'm looking for bruising, swelling, deformity, bone ends possibly poking up through the skin or under the skin. I'm looking for angulation that's not normal. And then, I'm looking for, ultimately, an open bleeding wound that has a bone end sticking out, which is the most serious of these injuries when it comes to fractures due to infection risk and vasculature and nerve endings and things like that. But what I'm gonna do is I'm gonna say, hey, could you just let me take a look at your knee. You don't have to move it. And you can see that there's grass stains and dirt. But I don't see any of those symptoms that tell me, this is a serious injury. I see no bruising, the skin color looks pink, and it looks normal. I could actually take the shoe and the sock off, if it didn't cause any more harm, and I could actually look at the toes to make sure there's good circulation coming to end of the toes. There's no blue toenail beds or purple toenail beds. They're nice and pink. And then I kinda wait to see, does this player want to get back in the game? Because they kinda know what's going on. They know if they're really hurt or not. And if he starts wiggling around and watching the other players or checking for mom and dad, that's starting to indicate to me that, yeah, it hurt. But it may not be a serious injury. If he stays here, keeps splinting his own knee, that's when I'm going to assist, holding the injury, and we're gonna activate emergency medical services and have the paramedics or EMS professionals come out and take a second look. In most cases, if we have this situation going on, we may want to stabilize it further before we move the injured player. So we don't injure the knee worse, we don't cause any secondary problems with neurological deficit or nerve injuries and, most of all, we want to make sure that this player is in as much comfort as possible and we don't aggravate the injury. Now let's take a closer look at a real practical question. Is it okay for them to return to work or play after an injury? And this is a very basic, but a very common sense question that everybody needs to ask themselves, whether it's for school, for work, or for the home. You know, we know that he got hurt initially. But that happens all the time. They rub it off. It kind of wears off. It wasn't a serious injury in the grades of injury. It was more of a shock. It kind of torqued it a little bit, maybe it hurt initially. But now, as he's sitting on the ground resting and I've asked the questions, he begins to say, you know, this doesn't hurt so bad after all. I can tell that because the patient is starting to move their own limb. Remember initially, if it's really serious, they don't want anybody to touch it. Don't touch it. Don't move it. I've got it. So we call this self-splinting. That's the way I found this player initially. But now as we're talking, he's kinda paying attention to the other players in the background, checking out the game, maybe looking for mom and dad, starts to joke and laugh with his friends. And the next thing you know, I see him start to move his leg back and forth, wiggling it around. And I say to him, hey, is it feeling better to you? He acknowledges it is. And I say, would you like to try to just stand up for me and see if it hurts when you try to stand? Just be real careful. You can use my hand if you need to. Take it easy there. How does that feel, standing up, just standing? If it hurts seriously, then we're gonna have him sit back down. And I'm gonna help protect that leg, or we're gonna get a chair or a stool, or we might even help assist them off the field. But in this case, I talked to him and he's kind of walking around and looking like, yeah, it's not so bad. Then I say, well, why don't you just do a little circle here, just kinda put some weight on it. How does that feel? He says, feels pretty good. I feel, I don't feel like it hurts as bad anymore. And at this point, now time is on our side. And I say, looks like you're doing well. If it starts hurting again, then you come off field. And we'll help you, okay. Otherwise, go have fun. He takes off, gets back into play, or goes back to work or back to school. And in the meantime, what we do is we educate parents, we educate the coach, maybe we are the coach, and we make a note of that. There was an injury. We're gonna watch this player, see if it happens again, and if it does, that's when we're gonna to really assess whether this player should be seen at the urgent care center or the hospital.
The musculoskeletal system is actually the combination of two specific systems – the muscular system and the skeletal system, including each of your 206 bones. And let's not forget the ligaments, tendons, and joints that hold it all together.
Breaks, strains, sprains, and soft tissue injuries are some of the most common types of injuries that you'll likely encounter, in everyone from the elderly to youth sports participants.
How to Assess and Handle a Musculoskeletal Injury
As always, the first thing you want to do is make sure the scene is safe and that your gloves are on. Make sure you have your rescue mask with a one-way valve handy and begin calling out to the victim.
Are you OK? Can you hear me?
If the patient is conscious and responsive, ask yourself if there are other medical emergencies that would warrant calling 911 and activating EMS? If not, continue with your assessment.
Introduce yourself to the victim: "Hi, my name's _____. I'm a paramedic. I'm going to ask you some questions."
"Do you remember what just happened?"
"How much pain or discomfort are you in?"
So long as the patient is conscious, alert, and breathing normally, activating EMS can likely wait while you investigate further, as calling 911 is often not required with these types of injuries.
Pro Tip #1: The real question that needs answering is this: Does this injury require activating EMS, a visit to the ER, or is it something the patient can shake off?
So, how do we answer that question?
With musculoskeletal injuries, the patient will often times be self-splintering – instinctively holding the area in pain – when you find them. That injury will be obvious, so make sure you also look for those that aren't.
"Do you hurt anywhere else?"
Also begin to further assess the injured area. If clothing is in the way, cut around that area to expose the injury. Look for bruising, swelling, some kind of deformity or abnormal angulation, bone fragments, bleeding, etc.
Do you see any signs of a serious injury? Or a developing condition?
How is the victim's skin color? Are the nail beds bluish or pink and normal? Poor circulation can be serious and warrants an immediate 911 call.
Ask the patient how he or she feels. People, especially adults, have a sense of whether or not an injury is serious. With children, you may have to read between the lines a bit and pay more attention to body language and whether they're becoming more concerned about the injury or less concerned.
If the two of you are coming to the same conclusion – that maybe the injury isn't that bad, help them walk it off, so to speak. Assist them in whatever way they need – getting to their feet or by helping to support their body weight.
If it's not bad, as you suspected, they'll be fine. However, if the inverse is obvious, that the patient is in pain and the injury is now causing more discomfort, help them back into a comfortable position, call 911, and help protect and stabilize the injured area as best as you can until help arrives.
Pro Tip #2: If you can safely stabilize an injury, do so. But make sure stabilization won't cause secondary problems, increase the patient's discomfort, or aggravate the injury.
Continue to assess for signs of something more serious. How are the pupils? Is the patient breathing normally? Is the patient still responsive and seemingly alert? And continue to monitor the patient for signs of shock.
Remember, if you begin seeing signs of shock, cover the patient with a blanket or coat and try to keep them as warm as possible. Any signs of shock demand an immediate 911 call.
A Word About the Musculoskeletal System
Injuries to muscles, bones, and joints can be difficult to detect. Knowing the specific mechanisms of the injury will provide important clues about which body parts are likely injured.
There are three basic mechanisms of injury:
- Direct force – when the injury is located at the point of impact
- Indirect force – when the injury is located some distance from the point of impact
- Twisting force – when the injury is caused by a rotating force
There are four basic types of musculoskeletal injuries to keep in mind when assessing patients, each of which is caused by one of the mechanisms above.
Fractures
Fractures are bones that are broken or damaged – chipped, cracked, etc. Fractures can either be closed, meaning the skin over the injury is intact. Or they can be open, in that the injury is exposed, making it much more serious.
Open fractures are more prone to infection. And they can include excessive bleeding that may be difficult to control.
Dislocations
Dislocations are the displacement of a bone. When a severe force causes a bone to move one joint away from its normal position, this is known as a dislocation.
Dislocations also typically result in ligaments and tendons that have been stretched, torn, or displaced. Shoulders and fingers dislocate more easily than other areas of the body.
Sprains
Sprains occur when ligaments are torn or stretched. The greater the number of ligaments involved, the more severe the sprain.
Strains
Strains are similar to sprains but involve muscles and tendons instead of ligaments. And as tendons are stronger than muscles, making them more resistant to injury, when dealing with strains, they're more likely to involve a muscle than a tendon.