Musculoskeletal Trauma

Purwoko Sugeng H.
 Incidence/Mortality/Morbidity

 Occur in 70-80% of all multi-trauma

patients
 Blunt or Penetrating
 Upper extremity rarely life-threatening
– may result in long-term impairment
 Lower extremity associated with more
severe injuries
– possibility of significant blood loss
– femur, pelvic injuries may pose life-threat
 Incidence/Mortality/Morbidity

 Problem is not just the bone injury

– Other injuries caused by the injured bone
» Soft tissue
» Vascular
» Nervous system
» Decreased function
 Musculoskeletal System Function

 Support
 Protection of vital organs
 Locomotion
 Production of RBC
 Storage of minerals
 Musculoskeletal Structures

 Skin
 Muscles
 Bones
 Tendons
 Ligaments
 Cartilage
 Bones

 Living tissue
 Consists of cells which deposit
calcium, phosphorus on protein
matrix
 Constantly remodels itself
 Able to repair damage without
formation of scar tissue
 Bones

 Structural form for body

 Protection
 Point of attachment for tendons, ligaments,
cartilage and muscles
 Allows for movement
 Storage of minerals
 Produce red blood cells
 Skeletal System Components
 Axial Skeleton
– forms the central axis of the body
– includes skull, vertebral column, bony thorax
 Appendicular Skeleton
– limbs
 Pectoral girdle
– bones that attach the upper limbs to the axial
skeleton
 Pelvic girdle
– paired bones of the pelvis that attach the lower
limbs to the axial skeleton and sacrum
 Long Bone Anatomy
 Periosteum
– Outer fibrous covering
– Allows for increase in
diameter
– Vascular
– Nerves
 Epiphysis
– Articulated, widened end
– Allows bone to lengthen
– Cancellous bone with red
blood marrow
 Fracture

 Break in continuity of bone

 Closed
– Overlying skin intact
 Open
– Wound extends from body surface to fracture
site
– Produced either by bones or object that caused
Fx
– Danger of infection
– Bone end not necessarily visible
 Mechanism of Injury

 Direct
– Break occurs at point of impact
 Indirect
– Force is transmitted along bone
– Injury occurs at some point distant to point of
impact
– Femur, hip, pelvic fracture due to knees hitting
dash
 Mechanism of Injury

 Twisting
– Distal limb remains fixed
– Proximal part rotates
– Shearing, fracturing occur
– Football. skiing accidents
 Avulsion
– Muscle and tendon unit with attached fragment
of bone ripped off bone shaft
 Mechanism of Injury

 Stress
– Occur in feet secondary to prolonged running
or walking
 Pathological
– Result of Fx with minimal force
– Cancer, osteoporosis
 Fracture Descriptions

 Open vs Closed
 X-Ray descriptions
– greenstick
– oblique
– transverse
– comminuted
– spiral
– impacted
– epiphyseal
Types of Fractures
 Complete
 Incomplete
 Closed or simple
 Open or compound/complex
– Grade I
– Grade II
– Grade III

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 Complications associated with
Fractures
 Hemorrhage
– Possible loss within first 2
hours
» Tib/Fib - 500 ml
» Femur - 500 ml
» Pelvis - 2000 ml
 Interruption of Blood
Supply
– Compression on artery
» decreased distal pulse
– Decreased venous return
 Emergency Care (Continued)

 Elevate extremity to the level of heart

 Remove cast
 Fasciotomy may be performed to relieve pressure.
 Pack and dress
the wound after
fasciotomy.
 Complications associated with
Fractures
 Disability
– Diminished sensory or motor function
» inadequate perfusion
» direct nerve injury
 Specific Injuries
– Dislocation
– Amputation/Avulsion
– Crush Injury (soft tissue trauma discussion)
 Complications associated with
Fractures
Acute Compartment Syndrome
 Serious condition in which increased
pressure within one or more compartments
causes massive compromise of circulation
to the area
 Pathophysiologic changes sometimes
referred to as ischemia-edema cycle
 Pain continues to increase despite the
administration of opioids and seems out of
proportion to the injury
 Other Complications of Fractures

 Shock
 Fat embolism syndrome: serious complication
resulting from a fracture; fat globules are
released from yellow bone marrow into
bloodstream
 Venous thromboembolism
 Infection
 Ischemic necrosis
 delayed union, nonunion, and malunion
 Sprains/Strains

 Sprain
– tearing of ligaments surrounding joint
 Strain
– overstretching of muscle or tendon
 Musculoskeletal Assessment

 Initial Assessment
– ABCDs
– Life threats managed first
– Don’t overlook life/limb threatening
musculoskeletal trauma
– Don’t be distracted by “gross” but non-
life/limb threatening musculoskeletal injury
 Musculoskeletal Assessment
 The six “P”s of musculoskeletal assessment
– Pain
» on palpation
» on movement
» constant
– Pallor - pale skin or poor cap refill
– Paresthesia - “pins and needles” sensation
– Pulses - diminished or absent
– Paralysis
– Pressure
 Musculoskeletal Assessment

 Vascular injury should be suspected in all

Fx’s/dislocations
 Evaluate with 5 P’s
– Pain
– Pallor
– Pulselessness
– Paresthesias
– Paralysis
 Musculoskeletal Assessment

 History of Present Injury

– Where is pain felt?
– What occurred? What position was limb in?
– Were deceleration forces involved?
– Was there direct impact?
– Has there ever been previous trauma or Fx?
 Musculoskeletal Assessment
 Palpation and Inspection
– Swelling/Ecchymosis
» Hemorrhage/Fluid at site of trauma
– Deformity/Shortening of limb
» Compare to other extremity if norm is questioned
– Guarding/Disability
» Presence of movement does not rule out fracture
 Musculoskeletal Assessment

 Palpation and Inspection

– Tenderness
» Use two point fixation of limb with palpation with
other hand.
» Tenderness tends to localize over injury site.
– Crepitus
» Grating sensation
» Produced by bones rubbing against each other.
» Do not attempt to elicit.
 Musculoskeletal Assessment

 Palpation and Inspection

– Exposed bones
» Fx can be open without exposed bones

– Principal danger is not to bones, but to

underlying neurovascular structures around
bone.
 Musculoskeletal Assessment

 Palpation and Inspection

– Distal to injury, assess:
» skin color
» skin temperature
» sensation
» motor function
– If uncertain, compare extremities
– When in doubt splint!
 Musculoskeletal Assessment

 Because orthopedic injuries have low

priority in multiple systems trauma, all
Fx’s may not be found in field
 Long Board
– Splints every bone and joint
– No loss of time
– Focus on critical conditions
 Key Point

Orthopedic injuries are seldom immediately

life threatening.
Tend to other issues first.
Only immediately life threatening orthopedic
injury is Pelvic Fx due to potential massive
hemorrhage
 Management - General

 Immobilization Objectives
– Prevent further damage to nerves/blood vessels
– Decrease bleeding, edema
– Avoid creating an open Fx
– Decrease pain
– Early immobilization of long bone fractures
critical in preventing fat embolism
 Management - General
 Principles of Fracture
Management
– Splint joint above, below
– Splint bone ends
– Loosely cover open fracture sites
– Neurovascular assessment
» before and after splinting
– Gentle in-line traction of long bone
» maintain normal alignment if possible
» reduction of angulated fracture site
 Management - General
 Principles of Fracture Management (cont)
– Position of function
– Pain management

 Body Splinting
– In urgent patient, entire body is stabilized by
using a long board
– Lower extremity fractures can be splinted as
one to the long board
 Management - General

 Pain Management
– Avoid pain management until head/thoracic
injury is ruled out
– Appropriate for isolated musculoskeletal
injuries (fracture/sprain/dislocation)
– Morphine sulfate titrated to pain relief without
compromising adequate BP and ventilations
Management of Specific Specific
Injury Types
Elbow Injuries

 Fractures and dislocations often occur

around the elbow.
 Injuries to nerves and blood vessels
common.
 Assess neurovascular function carefully
– Realignment may be needed to improve
circulation.
Fractures of the Forearm

 Usually involves
both radius and
ulna
 Use a padded board,
air, vacuum, or
pillow splint.
Injuries to the Wrist and Hand

 BSI.
 Cover all wounds.
 Position of function,
roller bandage in
palm of hand.
 Apply padded
board splint.
 Secure entire splint.
 Apply a sling and
swathe.
Fractures of the Pelvis
 May involve life-
threatening internal
bleeding
 Assess pelvis for
tenderness.
 Sheet patients to a
backboard or scoop
stretcher to
immobilize isolated
fractures of the
pelvis.
Pelvic Sling
 Fractures of the Proximal Femur

 Characteristic deformity
 Best managed with traction splint or
PASG and a spine board.
 Isolated fracture in elderly can be
managed with BB or a scoop
stretcher.
Femoral Shaft Fractures

 Muscle spasms can

cause deformity of
the limb
 Significant amount
of blood loss will
occur.
 Immobilize with
traction splint.
 Dislocation of the Hip

 Hip dislocation requires

significant MOI.
 Anterior dislocations: leg
extended straight out, and
rotated, pointing away from
midline.
 Posterior dislocations: hip
joint flexed and thigh rotated
inward
 Splint in position of
deformity and transport.
 Dislocation of the Patella

 Usually dislocates to
lateral side.
 Produces significant
deformity.
 Splint in position
found.
 Support with pillows.
 Injuries to the Tibia and Fibula

 Both bones fracture at the same

time.
 Open fracture of tibia common.
 Immobilize with a padded rigid
long leg/air splint that extends
from the foot to upper thigh.
Ankle Injuries

 Most commonly
injured joint
 Assess CMS!
 Single attempt to
realign by applying
gentle longitudinal
traction to the heel.
Foot Injuries

 Falls or jumps.
 Immobilize ankle
joint and foot.
 Leave toes exposed to
assess neurovascular
function.
 Possibility of spinal
injury from a fall?
Fracture of Clavicle and Immobilization
Device
Immobilizers for Proximal Humeral
Fractures

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Functional Humeral Brace

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 Dislocations

 Displacement of bone end from

articulating surface at joint
 Pain or pressure is most common symptom
 Principal sign is deformity
 May experience loss of motion of joint
 Dislocations

 Nerves, blood vessels pass very close to

bone. Pressure on these structures can
occur
 Checking distally essential
– Pulse presence
– Pulse strength
– Sensation
 Management - Dislocations
 Principles of fracture/dislocation
management
– Usually splinted in position of injury
– Neurovascular assessment before, after splinting
– Attempt realignment of dislocations if
» distal circulation is impaired
» long transport
– Discontinue realignment if pain increased
significantly or resistance is encountered
– Immobilize proximal. distal joints and bones
– Analgesia, possible cold application
 Sprains

 Stretching. tearing of ligaments

surrounding joint
 Occur when joint is twisted beyond normal
range of motion
 Most common = Ankle
 Sprain Management

 Characteristics
– Pain
– Tenderness
– Swelling
– Discoloration
 Typically does not manifest deformity
 Ice, compression, elevation, immobilize
 When in doubt, splint
 Consider analgesia
 Strains

 Tearing, stretching of musculotendonous

unit.
 Spasm, pain on active movement
 Usually no deformity, swelling
 Pain present on active movement
 Avoid active movement, weight bearing
 Traumatic Amputation

 First priority - ABC’s

– Bleeding from stump usually not a problem
 Next priority is to save limb

COLD
WATER
 Traumatic Amputation
Management
 Control Bleeding
 Elevate
 Apply direct pressure to stump
 Avoid tourniquet except as last resort
 Traumatic Amputation - Limb
Management
 Place in saline moist gauze
 Place in plastic bag
 Place bag on ice
 Do not
– Warm amputated part
– Place part in water
– Place directly on ice
– Use dry ice
 Hemorrhage Management
 Direct Pressure
– Most effective method
– Pressure bandage
 Elevation
– Combination with direct pressure
 Pressure Point
– Brachial, Femoral, Carotid
 Tourniquet
– last resort
– rarely required
 Tourniquet

 Last resort, but do not wait too long.

 Use flat wide material
 BP cuff
 Close to the wound as possible
 Do not remove
 Leave in plain view
 Note time applied and clearly
communicate during transfer of care
Thank you…….