Primary management

The initial treatment of a musculo-skeletal injury should follow completion of the primary survey. The limbs should be inspected for signs of injury and the neuro-vascular status assessed (sensation, movement, colour and perfusion).

If there is any limb deformity, this should be corrected if possible after adequate analgesia to restore anatomy and possibly circulation. The limb should then be immobilised in an appropriate splint. Neuro-vascular status should be reassessed and documented following reduction. This is often neglected in the pre-hospital setting (Dean 2009).

Following any intervention, the patient should be reassessed and any deterioration corrected if possible. The patient should then be extricated from the pitch safely (with cervical spine immobilisation, if indicated). The limb can then be further managed in a hospital setting.


Adequate analgesia is often forgotten (but not by the patient!) or left late. It should be given as soon as it is safe to do so (after the primary survey and any life threatening conditions managed). Unless there is a contra-indication (head injury/altered level of consciousness or a chest injury), Entonox (inhaled Oxygen: Nitrous Oxide) is quick and effective (this is not licensed or available in parts of Europe).

Traditionally, morphine has been the drug of choice. However, with the restrictions now placed on the storage and use of morphine, either intravenous Tramadol or Paracetamol are alternatives. Another option is ketamine.

Intravenous analgesia can only be administered by professionals trained and certified to administer it.

It is important that a player with a significant musculoskeletal injury is transported correctly and safely to the appropriate Emergency Department. All documentation, including SAMPLE history should accompany the player to hospital.