The skeletal system

There are 206 bones in the human skeleton, the functions of which are:

• To provide support to the body’s soft tissue. This gives the body its shape.
• To provide protection for vital organs such as the brain, lungs and spinal cord.
• To allow movement by incorporating different types of joints and attachment for muscles.
• To produce red blood cells, some white blood cells and platelets within the marrow of bones
such as the femur.  To provide a store of minerals and energy, such as calcium and fats.
 Causes of injury

Different types of force can cause injury to the bones, muscles and joints.

Direct force Damage will result at the location of the force, such as a kick or blow.

Indirect force Damage will result away from the point where the force was applied,
for example a fractured collar bone may result from landing on an
outstretched arm.

Twisting force Damage will result from torsion force on the bones and muscles, for
example a twisted ankle.

Violent movement Damage will result from sudden, violent movements, for example a knee
injury from violently kicking.

Pathological Damage will result from the bones becoming weak or brittle due to
disease or old age.

Types of fracture

A fracture is a ‘break in the continuity of the bone’. These are the basic categories for a fracture:

Closed A clean break or crack to the bone with no complications arising.

Open A broken bone will break the skin, and may or may not still be protruding from
the wound. Please bear in mind that these types of injury carry a high risk of
infection.

Complicated There are usually complications with this type of fracture, such as trapped
blood vessels or nerves.

Green stick These are more likely to occur in children who have young, more flexible
bones. The bone splits, but is not completely severed. Green stick fractures
can easily be mistaken for sprains and strains as only a few of the signs of
fracture are present.

Dislocations

A dislocation occurs when a bone becomes partially or completely dislodged at the joint, usually
resulting from a wrenching movement or sudden muscular contraction. The most common areas
of dislocation are the jaw, thumb, knee cap, shoulder or finger.
Fractures can occur at or near the site of a dislocation, along with damage to ligaments, tendons
and cartilage. It is sometimes difficult to distinguish between a fracture and a dislocation.

Never try to manipulate a dislocated joint back into place as this is best left to medical experts,
and the process can be extremely painful and traumatic to the casualty. Also, you may
inadvertently cause further damage.

Sprains and strains

A sprain is an injury to the ligament at a joint. A strain is an injury to a muscle. These types of
injury are usually caused by sudden wrenching which causes the joint to over stretch tearing the
surrounding muscles and ligaments.

Minor fractures can be easily mistaken for a sprain or a strain. If you have any doubts, treat the
injury as if it were a fracture to be on the safe side. The only way you can be sure if it is or is not
a fracture is by x-ray.

Signs and symptoms of fracture:

Pain Pain will occur at the site of the fracture. The casualty may have
taken strong pain killers, have nerve damage or dementia, so be
aware.

Loss of power For example, the casualty will not be able to lift anything with a
fractured arm.

Unnatural movement If a limb is moving in an unnatural way, it is likely to be an

‘unstable’ fracture and care should be taken to prevent the fracture
from moving and causing further damage.

Swelling and bruising This usually occurs around the site of the fracture.

Deformity If the limb is bent in the wrong place, it is broken.

Irregularity There will be lumps or depressions along the surface of a bone

where the broken ends overlap.

Crepitus This is the feeling, or sound, of bone grating on bone when

the broken ends rub together.
Tenderness This occurs at the site of the injury.

Treatment of a basic fracture:

• Reassure the casualty and tell them not to move.

• Use your hands to keep the injury still until it can be immobilised professionally. The casualty
may be able to do this on their own, but bear in mind they may be in shock.
• Do not move the casualty before the injury is immobilised, unless they are in direct danger (as
in the middle of a road).
• Do not try to bandage the injury if you have already called for an ambulance, just keep it still.
If there is an open wound, you may cover it with a sterile dressing while you wait for help.
• Do not allow the casualty to eat, drink or smoke, as they may need surgery later.

For injury to an upper limb:

• Carefully, and gently place the arm in a sling against the body. It is common to use a support
sling for arm fractures. For collar bone fractures, it is common to use an elevated sling (keep
the casualty’s elbow down at their side when using an elevated sling for a fractured collar
bone).
• Should the casualty be in severe pain, circulation or nerves to the arm are affected, the casualty
is having problems breathing or you are at all unsure dial 999 for an ambulance immediately.
• Arrange for the casualty to be transported to hospital.

For injury to a lower limb:

• Keep the casualty still, and ensure they are kept warm. Dial 999 for an ambulance
immediately.
• If there is any delay to the ambulance reaching you (for example you are in a remote part of the
country) immobilise the injury by gently bandaging the injured leg to the uninjured one.
• Check that their circulation has not been cut off beyond the injury and bandages. If necessary,
loosen the bandages.

Treatment of sprains and strains: The best way to treat sprains and strains is to follow the
PRICE mnemonic:
Protect meant to prevent further injury
Rest Ensure the casualty rests the injury. For example, do not allow a sportsman to
continue (remind them it is better to miss one game than the next ten!).

Ice As soon as you can, apply an ice pack (frozen vegetables such as peas or, if
you have it, a refrigerant gel pack). This helps to reduce swelling and speeds
recovery. Be sure not to place the ice pack directly onto the skin, as this can
 cause frostbite. A tea towel or any sort of thin barrier will suffice. Do this for
10 minutes every 2 hours for 24 hours for maximum effect.

Compression Apply a firm (not constricting) bandage to the injured area. This also will help
reduce the swelling, and provide support. The bandage can be applied over an
ice pack for the first ten minutes, but be sure to remove the ice pack after this
time.

Elevate Elevate the injury, as this helps reduce swelling.

Please bear in mind that minor fractures can very easily be mistaken for a sprain or strain. The
only way to be sure there is no fracture is to send or take the casualty to hospital for an x-ray.

Spinal injuries

Approximately 2% of trauma (injury) casualties suffer spinal

injury. Although this percentage appears to be fairly low,
suspecting and correctly treating a spinal injury is essential.
Poor treatment of a casualty with a suspected spinal injury
may result in them being crippled for life, or even in death.

The spinal cord is an extension of the brain stem, and is

located down the back of the spinal vertebrae. The spinal
cord houses vital nerves which control breathing and
movement. The most vulnerable part of the spinal column is
the neck, and a neck injury can often be the most severe type
of spinal injury. This is because as mentioned, the nerves
controlling breathing are housed here and may become
severed.

Suspected spinal injury:

Always assume the worst if the casualty has:
• Received a blow to the head, neck or back (this is
especially important if the blow results in a loss of consciousness).
• Fallen from a height. For example, from a horse, a ladder or off a roof.
• Dived into shallow water.
• Been involved in a speed accident like a car accident, or been knocked down.
• Been in a ‘cave in’ type accident (e.g. crushing, or a scrum in rugby union).
• Multiple injuries.
• Any pain or tenderness to the neck or back after being involved in an accident. However, be
aware that strong pain killers or other severe injuries may mask the pain that would normally
alert you to a spinal injury.
• You are in any doubt at all. Remember with this kind of injury it is better to be safe than sorry.

Possible signs and symptoms of a spinal injury:

Please remember – if any of the signs and symptoms below are present, nerves may already
have suffered damage. Always treat a casualty that you suspect of having a spinal injury to
prevent the signs and symptoms developing.

• Any pain or tenderness in the neck or back.

• Any sign of a fracture to the neck or back.
• Loss of control or sensation in limbs below the site of the injury.
• A feeling of pins and needles, or a burning sensation in the limbs.
• Difficulty breathing.
• Incontinence.

Treatment of spinal injury:

If the casualty is conscious:
• Tell the casualty not to move and keep reassuring them.
• Do not allow the casualty to move or be moved, keep them in the position you found them in
until help arrives. They should only be moved if they are in severe and immediate danger.
• It is vitally important to immobilise the casualty’s head. Do this with your hands on either side
and try to keep their head and neck in line with the upper body.
• Dial 999 for an ambulance immediately. Keep the casualty still and warm until help arrives.

If the casualty is unconscious:

• Do not move, or allow the casualty to be moved unless they are in severe and immediate
danger.
• Check their airway and breathing. If they are breathing fine on their own, the airway is clear so
there is no need to move the head back. However, if need be you can use the ‘jaw thrust’
technique to keep the airway open without moving the head (this technique is explained on
page 58). Keep a close eye on their breathing.
• Dial 999 for an ambulance immediately.
• Using your hands, keep their head still and in line with their upper body.
• If for any reason you have to leave the casualty, if they begin to vomit or if you have concerns
about their airway at all, place the casualty in the recovery position. Make sure you keep the
head, neck and upper body in line when you turn the casualty. To do this effectively, you will
inevitably need more than one rescuer, so get local help if you can
• Keep the casualty still and warm. Keep a close eye on the airway and breathing until help
arrives.
If the casualty is not breathing normally:
• If the casualty is having trouble breathing the airway will need to be opened. The head tilt may
be used, but the tilt should be kept to a minimum to allow unobstructed rescue breaths to be
administered.
• Only if you are trained and confident, you can try to use the ‘jaw thrust’ technique. If
this does not work and the casualty is still not breathing normally, you should open the airway
using the head tilt method before carrying out resuscitation.
• Check their breathing once the airway has been opened.
• If this does not help and the casualty is still having problems breathing dial 999 for an
ambulance immediately, then carry out resuscitation.
• Try to obtain the help of others; they can support the head while you perform resuscitation.

Remember – if the resuscitation results in paralysis from a neck injury it is a tragedy, but failing
to maintain an open airway will result in death.

Managing the airway with a spinal injury casualty

If an unconscious casualty is laid on their back, the airway is in danger of becoming blocked by
vomit or their tongue sliding back.

An uninjured but unconscious casualty can simply be turned into the recovery position to help
protect the airway. However, if a spinal injury is suspected, you must take great care not to
move the spine.

If the casualty is already lying on their side (not on their backs) you may not need to move them
at all. Check that the airway is not in danger of becoming blocked by vomit or their tongue. If
not, keep the casualty in the position you find them.

Try to monitor the casualty’s breathing, if it is normal you may be able to keep them still until
the ambulance arrives, even if the casualty is on their back.

However, should the tongue slide back or the casualty vomit then immediate action is required to
keep their airway clear.

Jaw thrust:
If the casualty is breathing, but the tongue is starting to slide back and obstruct the airway (the
casualty starts making a snoring sound when they breathe) then the jaw thrust technique can be
employed to keep the airway open:
• Kneel at the casualty’s head, knees apart to keep your balance.
• Rest your elbows on your legs (or the floor) for support and hold the casualty’s head with your
hands, keeping their head and neck in line with the body.
• Place your middle and index fingers under their jaw line (under the ears).
• Keeping their head still, lift the jaw upwards with your fingers. This action gently lifts the
tongue away from the back of the throat keeping the airway clear.

Do not attempt the jaw thrust technique during CPR – tilt their head back instead to open
the airway.

Log roll:
If you have to leave the casualty for any reason, if they begin to vomit or you are at all
concerned about their airway being clear, the casualty will have to be put on their side. Always
remember to keep the head, neck and upper body in line when you turn the casualty.

The most effective method of turning a casualty with a suspected spinal injury is the log roll
technique.
However, you will need at least three helpers to perform this on the casualty:
• Supporting the head of the casualty, keep the head, neck and upper body in line.
• The helpers should kneel along one side of the casualty. Ask them to gently straighten the
casualty’s arms and legs.
• Ensuring that you all work together, ask the helpers to roll the casualty towards them on your
count of three. You should gently move the head in time with the body as the helpers roll the
casualty onto their side.
• Make sure you keep the head, neck, body and legs in line the whole time. If you can, keep the
casualty in this position until the ambulance arrives.

Recovery position:
In the event that you have to turn a casualty onto their side to protect their airway, but you are on
your own, you will have to use the recovery position method. Keep the head, neck and body in
line to the best of your ability as you roll the casualty onto their side. Have some form of
padding to hand (e.g. a folded coat or jumper) to help support the casualty’s head once they are
on their side.

If you do have one or two others with you, you should keep the casualty’s head supported while
the helper(s) turn the casualty.
• Start by keeping the casualty’s head supported, keeping the head, neck and upper body in line.
• Ask your helper(s) to gently manoeuvre the casualty’s arms and legs into position, ready to turn
the casualty into the recovery position.
• Ensuring that you work together, the helper(s) should roll the casualty into the recovery
position.
• The helper(s) should pull equally on the casualty’s far leg and shoulder as they turn the
casualty, keeping the spine in line.
• You need to gently move the head to keep it in line with the upper body as the casualty is
turned.