Musculoskeletal Trauma

Learning Objectives
 Recognize and describe the significance of
musculoskeletal injuries in the multiply
injured patient
 Outline priorities in the assessment of
musculoskeletal trauma to identify life and
limb-threatening injuries
 Outline the proper principles of initial
management for musculoskeletal injuries
Learning Objectives - Skills
 Demonstrate the ability to assess,
assign priorities to, and initially manage
musculoskeletal injuries on a simulated
patient, including the application of
dressings, splints, and traction splints.
Introduction
 Major musculoskeletal injuries indicate significant
forces sustained by the body.
 The patient with long-bone fractures above and
below the diaphragm has an increased likelihood of
associated internal torso injuries.
 Swelling into an intact musculofascial space can
cause an acute compartment syndrome that, if not
diagnosed and treated, may lead to lasting
impairment and loss of extremity use.
 Fat embolism is an uncommon but highly lethal
complication of long-bone fractures
 Continued reevaluation of the patient is necessary to
identify all injuries.
Primary Survey and
Resuscitation
 Recoginize and control hemorrhage
 Major vessels may be involved
 Direct pressure over wound
 Appropriate splinting
 Aggressive fluid resuscitation
 Adjuncts to Primary Survey
 Fracture Immobilization
 The goal of fracture immobilization is to realign the
injured extremity in as close an anatomic position
as possible and to prevent excessive fracture-site
motion.
 The proper application of a splint helps control
blood loss, reduces pain, and prevents further soft-
tissue injury.
 Joint dislocations usually require splinting in the
position in which the are found.
 Application of splints should be applied as soon as
possible, but they must not take precedence over
resuscitation.
Priority X ray
 X-Ray
 An anteroposterior (AP) view of the pelvis
should be obtained early on all multiply
injured patients who are hemodynamically
abnormal and for whom a source of
bleeding has not been identified.
Secondary Survey
 History
 Mechanism of injury
 What was the precrash location of patient in the
vehicle.
 What was the postcrash location of patient, eg,
inside the vehicle or ejected.
 Was there external /internal damage to the
vehicle.
 Was the patient wearing a restraint.
 Did the patient fall and,if so, what was the
distance of the fall and how did the patient land.
 Was the patient involved in a vehicle-pedestrian
History
 Environment
 Patient’s exposure to temperature
extremes
 Sources of bacterial contamination (eg,
dirt, animal feces, fresh or salt water.
History
 Pre-injury status and predisposing
factors
 Exercise tolerance and activity level.
 Ingestion of alcohol and or other drugs.
 Emotional problems or illnesses.
 Previous musculoskeletal injuries.
Physical Examination
 Three Goals
 Identification of life-threatening injury
(primary survey).
 Identification of limb threatening injuries
(secondary survey).
 Systematic review to avoid missing any
other musculoskeletal injury (continuous
reevaluation).
Physical examination
 Look and ask
 Color and perfusion
 Wounds
 Deformity (angulations, shortening)
 Swelling
 Discoloration or bruising.

 Feel
 The extremities should be palpated to determine
sensation to the skin and areas of tenderness.
Physical Examination
 Circulatory Evaluation
 The distal pulses in each
extremity are palpated
and capillary refill of the
digits is assessed.
 Use Doppler - The
Doppler ankle/brachial
index of less than 0.9 is
indicative of and
abnormal arterial flow
secondary to injury or
peripheral vascular
disease.
X-rays

 Ifthe patient is hemodynamically normal,

an x-ray should be obtained.
 The only reason for not obtaining an x-ray
prior to treatment of a dislocation or
fracture is related to a vascular
compromise or impending skin breakdown.
Potentially life-threatening extremity injuries

 Major pelvic disruption with hemorrhage

 Injury
 The force vector opens the pelvic ring, tears the pelvic
venous plexus, and occasionally disrupts the internal
iliac arterial system (anterior posterior compression
injury).
 Assessment
 Major pelvic hemorrhage occurs rapidly and the
diagnosis must be made quickly to initiate appropriate
resuscitative treatment.
 Management
 Hemorrhage control
 Rapid fluid resuscitation
Potentially life-threatening extremity injuries

 Major Arterial Hemorrhage

 Injury
 Penetrating wounds
 Blunt trauma resulting in extremity fracture or joint
dislocation in close proximity to an artery also may
disrupt the artery.
 Assessment
 External Bleeding
 A cold, pale, pulse less extremity indicates an
interruption in arterial blood supply
 A rapidly expanding hematoma suggests a significant
vascular injury
Major Arterial Hemorrhage
 Management
 Directpressure
 Aggressive fluid resuscitation.
 The application of vascular clamps into
bleeding open wounds in the emergency
department is not recommended, unless a
superficial vessel is clearly identified.
 Crush Syndrome
Limb-threatening Injuries

 Open fractures and joint

injuries.
 Vascular injuries, including
traumatic amputation
 Compartment syndrome
 Neurologic injury
secondary to fracture
dislocation.
Other Extremity Injuries
 Contusions and lacerations
 The risk of tetanus is increased with wound
that
 Are more than 6 hours old.
 Are contused and/or abraded.

 Are more than 1cm in depth.

 Result from high velocity missiles.

 Are due to burn or cold and

 Have significant contamination

Gas gangrene developing from inadequate care of
a compound # causing limb loss in a young boy
Joint Injuries
Joint injuries should be immobilized.
Vascular and neurologic status of the
limb, distal to the injury, should be
reassessed.
Other Extremity Injuries
 Fractures
 Fractures are defined as a break in the continuity
of the bone cortex leading to abnormal motion
associated with crepitus and pain
 Closed
 Open
 Immobilization must include the joint above and
below the fracture
 After splinting,the neurologic and vascular status
of the extremity must be reassessed.
Principles of Immobilization
 Splinting of extremity injuries, unless
associated with life-threatening injuries,
usually can be left until the secondary survey.
 All such injuries must be splinted before
patient transport
 Assess the limb’s neurovascular status after
applying splints or realigning a fracture.
Principles of Immobilization
 Femoral Fractures
 Femoral fractures are immobilized
temporarily with traction splints.
 Hip fractures can be similarly immobilized
with a traction splint, but are more suitably
immobilized with skin traction or a foam
boot traction with the knee in slight flexion
Principles of Immobilization
 Knee Injuries
 Application of a long-leg splint of plaster is
very helpful in maintaining comfort and
stability.
 The leg should not be immobilized in
complete extension, but should be
immobilized with about 100 of flexion to
take pressure off the neurovascular
structures.
Principles of Immobilization
 Tibia fractures
A well-padded cardboard or metal gutter,
long-leg splint.
 Ankle Fractures
A pillow splint or padded cardboard splint,
thereby avoiding pressure over bony
prominences.
Principles of Immobilization
 Upper Extremity and Hand Injuries
 The hand can be temporarily splinted in an
anatomic, functional position, with the wrist slightly
dorsiflexed and the fingers gently flexed 450 at the
metacarpal phalangeal joints.
 The forearm and wrist are immobilized flat on
padded or pillow splints.
 The elbow usaually is immobilized in a flexed
position.
 The upper arm usually is immobilized by a
thoracobrachial bandage. Shoulder injuries are
managed by a sling and swath device or Velpeau
type of dressing
Pain Control
 Analgesics are generally indicated for joint injury or a fracture.
 The appropriate use of splints significantly decreases the
patient’s discomfort by controlling the amount of motion that
occurs at the injured site.
 Patients who do not appear to have significant pain and
discomfort from a major fracture may have other associated
injuries, eg, intracranial lesions, hypoxia, or may be under the
influence of alcohol and/or other drugs.
 Effective pain relief usually requires administration of narcotics,
which should be given in small doses intravenously and
repeated as needed.
 Whenever analgesics, muscle relaxants, or sedatives are
administered to an injured patient, the potential exists for
respiratory depression
Pitfalls
 Musculoskeletal injuries are a potential source of
occult blood loss in the hemodynamically
abnormal patient.
 A compartment syndrome is limb-threatening.
Clinical findings must be recognized and surgical
consultation obtained early.
 Despite a thorough examination, occult and
associated injuries may not be appreciated during
the initial evaluation of the patient. It is imperative
to repeatedly reevaluate the patient to assess for
these injuries.
Acute renal Failure following
crush injury
?
Summary
 The goal of initial assessment and
management of musculoskeletal
trauma is to identify injuries that pose
a threat to life and / or limb.
 A knowledge of the mechanism of
injury and history of the injury-
producing event enables the doctors
to be aware of what associated
conditions potentially exist with the
injured extremity.
Summary - 2
 Early splinting of fractures and
dislocations can prevent serious
complications and late sequelae.
 An awareness of the patient’s tetanus
immunization status, particularly in
cases of open fractures or significantly
contaminated wounds, can prevent
serious complications.