United States Department of Transportation

National Highway Traffic Safety Administration

Paramedic: National Standard Curriculum

(Reprinted with permission)

http://www.nhtsa.dot.gov/people/injury/ems/

Trauma: 4

Musculoskeletal Trauma: 9

UNIT TERMINAL OBJECTIVE

4-9 At the completion of this unit, the paramedic student will be able to integrate pathophysiological principles and the assessment findings to formulate a field impression and implement the treatment plan for the patient with a musculoskeletal injury.

COGNITIVE OBJECTIVE

At the completion of this unit, the paramedic student will be able to:

4-9.1 Describe the incidence, morbidity, and mortality of musculoskeletal injuries. (C-1)

4-9.2 Discuss the anatomy and physiology of the musculoskeletal system. (C-1)

4-9.3 Predict injuries based on the mechanism of injury, including: (C-3)

1. Direct

2. Indirect

3. Pathologic

4-9.4 Discuss the types of musculoskeletal injuries: (C-1)

a. Fracture (open and closed)

4. Dislocation/ fracture

5. Sprain

6. Strain

4-9.5 Discuss the pathophysiology of musculoskeletal injuries. (C-1)

4-9.6 Discuss the assessment findings associated with musculoskeletal injuries. (C-1)

4-9.7 List the six "P"s of musculoskeletal injury assessment. (C-1)

4-9.8 List the primary signs and symptoms of extremity trauma. (C-1)

4-9.9 List other signs and symptoms that can indicate less obvious extremity injury. (C-1)

4-9.10 Discuss the need for assessment of pulses, motor and sensation before and after splinting. (C-1)

4-9.11 Identify the need for rapid intervention and transport when dealing with musculoskeletal injuries. (C-1)

4-9.12 Discuss the management of musculoskeletal injuries. (C-1)

4-9.13 Discuss the general guidelines for splinting. (C-1)

4-9.14 Explain the benefits of cold application for musculoskeletal injury. (C-1)

4-9.15 Explain the benefits of heat application for musculoskeletal injury. (C-1)

4-9.16 Describe age associated changes in the bones. (C-1)

4-9.17 Discuss the pathophysiology of open and closed fractures. (C-1)

4-9.18 Discuss the relationship between volume of hemorrhage and open or closed fractures. (C-3)

4-9.19 Discuss the assessment findings associated with fractures. (C-1)

4-9.20 Discuss the management of fractures. (C-1)

4-9.21 Discuss the usefulness of the pneumatic anti-shock garment (PASG) in the management of fractures. (C-1)

4-9.22 Describe the special considerations involved in femur fracture management. (C-1)

4-9.23 Discuss the pathophysiology of dislocations. (C-1)

4-9.24 Discuss the assessment findings of dislocations. (C-1)

4-9.25 Discuss the out-of-hospital management of dislocation/ fractures, including splinting and realignment. (C-1)

4-9.26 Explain the importance of manipulating a knee dislocation/ fracture with an absent distal pulse. (C-1)

4-9.27 Describe the procedure for reduction of a shoulder, finger or ankle dislocation/ fracture. (C-1)

4-9.28 Discuss the pathophysiology of sprains. (C-1)

4-9.29 Discuss the assessment findings of sprains. (C-1)

4-9.30 Discuss the management of sprains. (C-1)

4-9.31 Discuss the pathophysiology of strains. (C-1)

4-9.32 Discuss the assessment findings of strains. (C-1)

4-9.33 Discuss the management of strains. (C-1)

4-9.34 Discuss the pathophysiology of a tendon injury. (C-1)

4-9.35 Discuss the assessment findings of tendon injury. (C-1)

4-9.36 Discuss the management of a tendon injury. (C-1)

4-9.37 Integrate the pathophysiological principles to the assessment of a patient with a musculoskeletal injury. (C-3)

4-9.38 Differentiate between musculoskeletal injuries based on the assessment findings and history. (C-3)

4-9.39 Formulate a field impression of a musculoskeletal injury based on the assessment findings. (C-3)

4-9.40 Develop a patient management plan for the musculoskeletal injury based on the field impression. (C-3)

AFFECTIVE OBJECTIVES

At the completion of this unit, the paramedic student will be able to:

4-9.41 Advocate the use of a thorough assessment to determine a working diagnosis and treatment plan for musculoskeletal injuries. (A-3)

4-9.42 Advocate for the use of pain management in the treatment of musculoskeletal injuries. (A-3)

PSYCHOMOTOR OBJECTIVES

At the completion of this unit, the paramedic student will be able to:

4-9.43 Demonstrate a clinical assessment to determine the proper treatment plan for a patient with a suspected musculoskeletal injury. (P-1)

4-9.44 Demonstrate the proper use of fixation, soft and traction splints for a patient with a suspected fracture. (P-1)

DECLARATIVE

I. Introduction

A. Epidemiology

1. Incidence

a. 70-80% of polytrauma patients suffer musculoskeletal injuries

b. Blunt trauma

c. Penetrating trauma

2. Mortality/ morbidity

a. Upper extremity injury

(1) Contribute to long-term impairment

(2) Rarely life-threatening

b. Lower extremity injury

(1) Associated with higher magnitudes of injury

(2) More significant blood loss

(3) More difficult to manage in polytrauma patient

(4) Femur and pelvic injuries may constitute life threats

3. Risk factors

4. Prevention strategies

a. Proper sports training

b. Wearing seat belts

c. Child safety seats

d. Airbags

e. Gun safety and education

f. Motorcycle driver education

g. Fall prevention

h. Highrise window guards

i. Other means of preventing musculoskeletal trauma

5. Review of musculoskeletal anatomy

a. Skin

(1) Layer

(2) Thickness

b. Subcutaneous

(1) Fat

(2) Fascia

c. General breakdown of the skeletal system

(1) Axial skeleton

(a) Forms the central (longitudinal) axis of the body, includes the following bones

i) Skull

ii) Vertebral column

iii) Bony thorax

(b) Appendicular skeleton

i) Clavicle

ii) Scapula

(d) Pelvic girdle - consists of the paired bones of the pelvis that attach the lower limbs to the axial skeleton, and the sacrum

(2) Vessels

(a) Arteries

i) Axillary

ii) Brachial

iii) Radial

iv) Ulnar

v) Hand arcade

vi) Digital

vii) Femoral

viii) Popliteal

ix) Dorsalis pedis

x) Posterior tibial

xi) Anterior tibial

xii) Foot arcade

xiii) Digital

(3) Muscles

(a) Latissimus dorsae

(b) Trapezius

(d) Deltoid

(e) Triceps

(f) Biceps

(g) Forearm extensors

(h) Intrinsic muscles of hand

(i) Hamstring group

(j) Quadriceps group

(k) Adductor group

(l) Gastrocenemius solius

(m) Intraosseos

(4) Tendons

(a) Extensors

(b) Flexors

(5) Bones

(a) Components of a longbone

i) Diaphysis

a) Long, narrow shaft

b) Very dense, compact bone

c) Yellow bone marrow that stores fat

ii) Periosteum

a) Outer covering for long bones

b) Vascular and full of nerves

c) Haversian canals allow circulation of blood

iii) Epiphysis

a) Articulated, widened end

b) Cancellous bone filled with red blood marrow

c) Responsible for growth in the infant and child

d) Weakest point in a child’s bone and weaker than a child’s ligaments

iv) Metaphysis

a) Area between the epiphysis and diaphysis

(6) Scapulae

(a) Upper division

(b) Lower division

(7) Clavicle

(a) Claviclulo-sternal joint

(b) Acromio-clavicular joint

(8) Humerus

(a) Head

i) Anatomical neck

ii) Surgical neck

(b) Tuberosities

(d) Neck

(e) Shaft

(f) Medial condyle

(g) Lateral condyle

(h) Elbow

(9) Radius

(a) Elbow

(b) Head

(d) Wrist

(10) Ulna

(a) Elbow

(b) Olecranon

(d) Wrist

(11) Carpals

(a) Articulation

(b) Wrist

(12) Metacarpals

(a) Articulations

(b) Shaft

(13) Phalanges

(a) Metacarpal-phalange joint

(b) Proximal intraphalange joint

(14) Pelvis

(a) Ilium

(b) Ischium

(d) Acetabulum

(15) Femur

(a) Hip joint

(b) Head

(d) Trochanters

i) Greater trochanter

ii) Lesser trochanter

(e) Shaft

(f) Medial and lateral condyles

(16) Tibia

(a) Knee joint

(b) Articular surfaces/ plateaus

(d) Medial malleolus

(17) Fibula

(a) Head

(b) Shaft

(18) Talus

(a) Ankle joint

(b) Articulation

(19) Calcaneus

(a) Heel

(b) Articulation

(20) Tarsals

(a) Articulations

(b) Arch

(21) Metatarsal

(a) Arch

(b) Articulations

(22) Phalanges

(a) Shaft

(b) Joints

d. Function

(1) Flexion

(2) Extension

(3) Rotation

e0 Age associated changes in bones

(1) Morphological changes

(a) Water content of intervertebral disks decreases

(b) Increased risk of disk herniation

(d) Bone tissue disorders shorten the trunk

(e) Vertebral column gradually assumes an arc shape

(f) Costal cartilages ossify making the thorax more rigid

(g) Shallow breathing due to rigid thoracic cage

(h) Facial contours change

(2) Fractures

(a) Bones are more prone to fracture since they are more porous and brittle

(b) Vertebral and femoral neck fractures are most common

6 Physiology

a0 Purpose of the muscles

(1) Cardiac muscle

(a) Contracts rhythmically on its own

(b) Generates electrical impulses

i Automaticity

ii Excitability

iii Conductivity

(2) Smooth muscle

(a) Found in lower airways, blood vessels, intestines

(b) Under control of automatic nervous system

(3) Skeletal muscle

(a) Under conscious control

(b) Major muscle mass of the body, allows mobility

b0 Muscular support of skeleton

(1) Tendons

(a) Bands of connective tissue binding muscles to bones (M-T-B)

(b) Allows for power of movement across the joints

(2) Cartilage

(a) Connective tissue covering the epiphysis

(b) Act as surface for articulation

(3) Ligaments

(a) Connective tissue which support joints

(b) Attach to bone ends

c0 Purpose of the bones

(1) Acts as a structural form, protects vital organs

(2) Acts as point of attachment for tendons, cartilage, and ligaments

(3) Structure for muscles to allow movement

(4) Stores salts and metabolic materials

(5) Produces red blood cells

d0 Structural classifications of joints

(1) Fibrous

(a) Sutures - immovable

i An immovable joint with one exception

ii All bones of the skull are united by sutures

(b) Syndesmoses

(2) Cartilaginous

(a) Defined

(b) Synchondroses

(3) Synovial

(a) Defined - fluid filled chamber which lubricates articulated surfaces

(b) Types of synovial joints

i Plane

ii Hinge

iii Pivot

iv Condyloid

v Saddle

vi Ball and socket

e0 Movements allowed by synovial joints

(1) Gliding

(2) Angular movements

(a) Flexion

(b) Extension

(d) Adduction

(e) Circumduction

(3) Rotation

f0 The interrelationship of the musculoskeletal system working together to move a complex joint (e.g., the knee)

II Musculoskeletal pathophysiology-adult

A0 Problems associated with musculoskeletal injuries

1 Hemorrhage

2 Instability

3 Loss of tissue

4 Simple lacerations and contamination

5 Interruption of blood supply

6 Long term disability

B0 Fractures

1 Types

a0 Open (compound)

b0 Closed (simple)

2 Location

a0 Humerus

b0 Radius

(1) Silver fork deformity

c0 Ulna

d0 Metacarpal

e0 Phalange

f0 Pelvis

(1) Complications

(a) Hemorrhage

(b) Associated organs

(d) Associated dislocations

g0 Femur

(1) Head

(2) Neck

(3) Intertrochanteric

(4) Subtrochanteric

(5) Shaft

(6) Condylar

(7) Supra condylar

h0 Tibia

(1) Plateau

(2) Shaft

(3) Ankle

i0 Fibula

(1) Shaft

(2) Isolated

(3) Ankle

j0 Ankle

(1) Dislocation/ fracture

(2) Malleal fracture

(3) Tri malleolar

k0 Foot

(1) Calcanei

(2) March fracture

(3) Meta tarsal dislocation

(4) Phalanges

3 X-ray descriptions of fractures

a0 Greenstick

b0 Oblique

c0 Transverse

d0 Comminuted

e0 Spiral

f0 Impacted

g0 Epiphyseal fractures (in children)

C0 Relate kinematics to the following injuries

1 Open fractures - break where protruding bone causes a soft tissue injury

a0 Some bones are very close to the surface - reach down and touch your shin

b0 EMS objective not to turn a closed fracture into an open fracture

2 Closed fractures - break in the bone which has not yet penetrated the soft tissue

a0 May not be as obvious, yet serious potential for other injuries

3 Comminuted fractures - a break which involves several breaks in the bone causing bone fragment damage; consider the combined blood loss and potential for other injuries

4 Greenstick fractures - a bone break in which the bone is bent but only broken on the outside of the bend; children are most likely to have these

5 Spiral fracture - a bone break caused by a twisting motion

6 Oblique fracture - a bone break at a slanting angle across the bone

7 Transverse fracture - a broken bone that occurs at right angles to the long part of the bone involved

8 Dislocations - a bone moved from its normal position at a joint and may have associated fractures

9 Sprains - an injury to the tendons, muscles or ligaments around a joint, marked by pain, swelling, and dislocation of the skin over the joint

10 Strains - damage, usually muscular, that results from excessive physical effort

11 Joint injury - may be a fracture, dislocation or sprain

12 Stress fracture - a bone break, especially one or more of the foot bones, caused by repeated, long-term, or abnormal stress

D0 Pathological fractures

E0 Vascular injuries

F0 Dislocations and subluxations

1 Subluxation

a0 Partial dislocation of a joint with great damage and instability

2 Luxation

a0 Complete dislocation of a joint

3 Dislocation

a0 Frank displacement of bone ends at the joint

4 Specific injuries

a0 Acromio clavicular

b0 Shoulder

c0 Elbow

d0 Wrist

e0 Metacarpal-phalange

f0 Phalange

g0 Hip

(1) Posterior

(2) Anterior

(3) Associated with fracture

h0 Knee

(1) Posterior

(2) Anterior

(3) Patella

i0 Ankle

(1) Posterior

(2) Fracture association

j0 Foot

k0 Hand

G0 Lacerations

1 Protection

2 Hemostasis

3 Dressing

H0 Hematoma

I0 Sprains and strains

1 Sprain

a0 Tearing of the ligaments surrounding a joint

b0 Grades

(1) Grade I

(2) Grade II

(3) Grade III

(4) Repeated Grade I sprains can result in ligamentous stretching

(5) Grade III sprains can present the same as a fracture

2 Strain

a0 Overstretching of a muscle or tendon

b0 Examples

J0 Typical blood loss in an uncomplicated fracture during the first two hours

1 Tibia/ fibula - 550 ml

2 Femur - 1000 ml

3 Pelvis - 2000 ml

K0 Complications associated with fractures

1 Can exsanguinate from a fracture involving an artery laceration (e.g., femoral)

2 Major blood loss can occur at the beak point

3 Decreased distal pulse

4 Diminished distal sensory or motor function

5 Crushing injury

6 Amputation/ avulsion

L0 Inflammatory and degenerative conditions

1 Bursitis and tendinitis

2 Arthritis

a0 Osteoarthritis

b0 Rheumatoid arthritis

c0 Gouty arthritis

III Musculoskeletal assessment

A0 Four classes of patients with musculoskeletal trauma

1 Patients with life/ limb-threatening injuries or conditions, including life/ limb-threatening musculoskeletal trauma

2 Patients with other life/ limb-threatening injuries and only simple musculoskeletal trauma

3 Patients with life/ limb-threatening musculoskeletal trauma and no other life/ limb-threatening injuries

4 Patients with only isolated, non-life/ limb-threatening injuries

B0 Conduct the initial survey first to determine if there are any life-threats

1 Care for life-threatening conditions first

2 Never overlook life/ limb-threatening musculoskeletal trauma

3 Never allow a horrible looking, but noncritical musculoskeletal injury to distract you

C0 The six “p”s of musculoskeletal assessment

1 Pain

a0 Pain on palpation (tenderness)

b0 Pain upon movement

2 Pallor - pale skin or poor capillary refill

3 Paresthesia - pins and needles sensation

4 Pulses - diminished or absent

5 Paralysis - inability to move

6 Pressure

D0 Assessment of musculoskeletal injury

1 General findings - inspect and palpate DCAP-BTLS

a0 Deformity

b0 Contusions

c0 Abrasions

d0 Penetrations or punctures

e0 Burns

f0 Tenderness

g0 Lacerations

h0 Swelling

2 Specific findings - inspect and palpate

a0 Position found

b0 Hematoma

c0 Dislocation

d0 Cyanosis

e0 Motion - reduced or abnormally enlarged range

f0 Bleeding

g0 Guarding or self-splinting

h0 Crepitus

E0 Assessment findings - palpation

1 Tenderness or pain

2 Deformation

3 Crepitation

4 Swelling/ skin tension

5 Pulses

6 Capillary refilling

7 Innervation

F0 Special sports considerations

1 Mechanism of injury

a0 Football

b0 Basketball

c0 In-line skating

d0 Skiing or snow boarding

e0 Wrestling

f0 Soccer

g0 Rock climbing

2 Special sports injuries

a0 Shoulder

b0 Elbow

c0 Wrist

d0 Clavicle

e0 Knee

f0 Ankle

g0 Foot

h0 Tibia/ fibula

3 Interfacing with athletic trainers

IV Management

A0 General principles

1 Splint joint above and below as well as bone ends

2 Immobilize open and closed fracture the same

3 Cover open fracture to minimize contamination

4 Check pulses, sensation, and motor function before and after splinting

5 Stabilize with gentle in-line traction to position of normal alignment

6 Immobilize where they are found not in the exact position the limb is found

a0 It makes most sense to move a long bone injury into a “splintable” straight position

b0 Joint injuries are only moved if there is no distal pulse

7 Immobilize dislocation/ fractures in position of comfort and good vascular supply

8 Immobilize joints as found

9 Application of cold

a0 Reduce swelling

b0 Reduce pain

10 Compression

11 Elevation of extremities

B0 Splints - rigid, formable, traction

1 Cardboard

2 Wood

3 Air

4 Traction

a0 History

b0 Principle

c0 Types

(1) Unipolar

(2) Bipolar

5 Vacuum

6 Pillow/ blanket

7 Short spinal immobilization devices

a0 Refer to spinal injury section

8 Long spinal immobilization devices

a0 Ultimate body splint

b0 Refer to spinal injury section

C0 Dislocation/ fractures

1 Realignment

a0 Typically dislocated joints should be immobilized in the position of injury and transported for reduction

b0 Delayed or prolonged transport requires a different approach

c0 An attempt to reposition any dislocated joint into anatomical position should be made if distal circulation is impaired and if transportation is long or prolonged

d0 Check circulation and nerve function before and after any manipulation of any injured bone or joint

e0 Discontinue an attempt at repositioning if

(1) Pain is increased significantly by manipulation, and/ or

(2) Resistance to movement is encountered

2 Limb-threatening injuries

a0 Knee dislocation/ fracture

b0 Dislocation/ fracture of the ankle

c0 Subcondular fractures of the elbow

3 Always assess pulses, sensation, and motor function before and after manipulating the injury

4 Specific techniques for specific joints

a0 Finger realignment

b0 Hip realignment

(1) One attempt if there is severe neurovascular compromise

(2) As soon as possible after the injury

(3) Do not attempt if associated with other severe injuries

(4) Analgesics

(5) Procedure

(a) Traction

(b) Hip 90 degrees

(d) Along shaft of femur

(e) Steady and slow to relax muscle spasm

(f) Success

i “Pop” into joint

ii Sudden relief of pain

iii Leg can easily and painlessly be returned to full extension

(g) Immobilization, full extension, long backboard, reevaluation of pulses and innervation

(h) Immobilization, comfortable flexion not to exceed 90 degrees, pillows, chair, cardboard, supine position of patient

c0 Knee realignment - do not confuse with a patella dislocation, this is a limb-threatening injury

(1) One attempt if there is severe neurovascular compromise

(2) As soon as possible after the injury

(3) An attempt to reposition a dislocation of the knee into anatomical position should be made if transport time is delayed or prolonged greater than two hours, even if distal circulation is normal

(4) Do not attempt if associated with other severe injuries

(5) Analgesics

(6) Procedure

(a) Apply gentle and steady traction and then move the injured joint into normal position

(b) Full extension

(d) Success

i “Pop” into joint

ii Loss of deformity

iii Relief of pain

iv Knee is now more mobile

(e) Immobilization, full extension, backboard, long board splints, no traction, assess pulses, position of greatest comfort, slight flexion

d0 Ankle realignment

(1) One attempt if there is severe neurovascular compromise

(2) As soon as possible after the injury

(3) Do not attempt if associated with other severe injuries

(4) Analgesic

(5) Procedure

(a) Pull traction on the talus while stabilizing the tibia

(b) Slow and steady to relax spasm

(d Immobilization, as per fracture, check distal pulse

e. Shoulder realignment

(1 One attempt if there is severe neurovascular compromise

(2 As soon as possible after the injury

(3 Do not attempt if associated with other severe injuries or back injuries

(4 Analgesic

(5 Procedure

(a Pull traction in the anatomical position only

D. Specific fracture pointers and immobilization techniques

1. Pelvis

a. Backboard and PASG

b. Treat the hypoperfusion as pelvic fractures cause severe hemorrhage, losing greater than 2 liters of blood into the pelvic cavity

2. Femur

a. Traction splinting procedure

(1 Direct manual stabilization of the injured leg

(2 Assess distal motor ability, sensory response, and circulation

(3 Rule out any contraindication to traction splinting

(4 Direct application of manual traction if elevating the leg from the ground

(5 Adjust and position splint at the injured leg

(6 Apply proximal securing device (e.g., ischial strap)

(7 Apply distal securing device (e.g., ankle hitch)

(8 Apply mechanical traction

(9 Position and secure support straps

(10 Re-evaluate the proximal/ distal circulation

(11 Reassess distal motor ability, sensory response, and circulation

(12 Secure patient’s torso and traction splint to long backboard for transport

b. PASG and long backboard

c. Long backboard and long board splints

d. Opposite extremity and long backboard

e. Fractures of the proximal femur present similar to the anterior hip dislocation

f. Midshaft or distal femur fractures can have soft tissue, vascular and nerve damage

3. Tibia/ fibula

a. Pneumatic splint

b. Long board splint procedure

(1 Take body substance isolation

(2 Direct application of manual stabilization

(3 Assess distal motor ability, sensory response, and circulation

(4 Measure splint

(5 Apply splint

(6 Immobilize joints above and below the injury site

(7 Secure the entire injured extremity in a distal to proximal direction

(8 Immobilize hand/ foot in the position of function

(9 Reassess distal motor ability, sensory response, and circulation

c. Splinting to the opposite leg

d. Cardboard

4. Ankle - same as tibia/ fibula fractures, generally involves the distal tibia and fibula

a. Pillow splint and leg immobilization

b. Air splint

5. Foot

a. Pneumatic

b. Cardboard

c. Ladder splint

6. Shoulder dislocation/ fracture

a. Anterior - arm close to the chest and hollow shoulder

b. Posterior - arm may be over the head

c. Splinting - be creative, improvise to hold the injury in place (e.g., blanket roll)

(1 Use a rolled blanket with a cravat through the center

(2 Position the roll under the elevated arm and secure it like a sling with the cravat through the blanket

(3 Swathe the arm to prevent upward movement

(4 If the arm is over the head - splint in position, or pull traction along the long axis of the arm

7. Knee

a. High incidence of vascular and nerve damage

b. Any fracture within three inches of a joint should be treated similar to a dislocation

c. Use triangulation with cravats and two long padded splints

d. SAM splints are not strong enough for the knee while some ladder splints if properly padded will be effective with immobilization of the hip and ankle

e. Do not use a traction splint

f. If found straight use two board splints or cardboard splint

8. Humerus

a. Difficult to stabilize

b. Potential for severe circulatory problems

c. If the patient has a potential neck injury do not tie a sling around the neck

d. Use a sling and swathe with splints surrounding the humerus or splint with the extremity extended

9. Elbow

a. High probability for blood vessel and nerve damage

b. Especially dangerous in children (supracondylar fractures)

c. Volkman’s contracture may result

d. Padded wire splint and sling and swathe

10. Forearm fracture

a. May involve radius, ulna, or both

b. Colle’s fracture of the wrist presents with the wrist in a “silver fork” position

c. Splint like a lower leg fracture described above

11. Hand and wrist fractures

a. Common with direct trauma

b. Noticeable deformity

c. Significant pain

d. High incidence for nerve and vessel damage

e. Splint on a padded board splint with the hand in position of function

12. Epiphyseal fractures

a. Weakest part a child’s joint

b. Presents as a sprain in an adult

c. May result in a permanent angulation or deformed extremities

d. May cause premature arthritis

E. Application of cold/ heat

1. Cold in the first 48 hours to reduce swelling

2. Heat after 48 hour to increase circulation