Download - Musculoskeletal Trauma
dr. Ahmad Fauzi, Sp.OTDept. Bedah Div. Orthopaedi dan Traumatologi
FK UNILA2014
MUSCULOSKELETAL TRAUMA
Musculoskeletal System
The system of muscles, tendons, ligaments, bones, joints, nerves, vessels and associated tissues that provides form, support, stability, and movement to the body.
Musculoskeletal Trauma
Musculoskeletal Musculoskeletal injuries injuries High morbidityLowLow mortality
Related with Multiple Multiple injuriesinjuriesHigh morbidityHighHigh mortality
Musculoskeletal trauma
• Traffic, factory, domestic, school and sport.
• Fractures,• Bones, cartilages, epiphyseal plate
• Dislocations, • joints
• Ruptures• Tendon, ligaments, nerve, vessels
Emergency
Emergencies in Musculoskeletal Trauma :1. Open fracture2. Fractures with neuro-vascular disturbances3. Joint dislocations
Extremity injuries
First aids“Life Life beforebefore limblimb”
LifeLife saving ~ ATLSLimbLimb saving
Realignment SplintNeurovaskular !
LIFE SAVING MEASURES
A Airway and cervical spine immobilisation
B Breathing and ventilation
C Circulation (treatment and diagnosis of cause) : w/ hemorrhage control
D Disability (head injury) : neurological status
E Exposure (musculo-skeletal injury) : completely undress but prevent hypothermia
Life threatening conditions are identified and simultaneous management is instituted
SECONDARY SURVEY
Done after the patient “stable”
Head to toeEvery orificiums/every tubes
Early Intervention on trauma/multitrauma patient (included MSK trauma problems)
A Airway and cervical spine protection, protect the cervical : inline imobilisation, collar brace (head injury, cervical injury)
B Breathing w/ Oxygen maskC Circulation w/hemorrhage control (pelvic stabilisation)D Disability, neurological status(GCS), paraparese or paralysis
spine fractures suspected inline immobilizationE Exposure : deformity of extremity immobilization/splinting
Early Intervention on trauma/multitrauma patient (included MSK trauma problems)
The first step toward cure is to know what the disease is (latin proverb)
Solving the mysteri of a diagnosis is the “detective work of medicine” (Sherlock Holmes)
Diagnosis of Fractures
HistoryFall, twisting injury, direct blow, MVALocalized pain, aggravated by movementCrepitus
Physical ExaminationGeneral condition associated injuriesLook : deformity, swelling, abN movementFeel : localized tenderness, muscle
spasm, NVDMove : ROM
Diagnostic ImagingExact nature & extent of fractureX-ray : min AP & lat (ocassional : oblique)CT / MRI : spine, pelvis
Salter RB. Textbook of Disorders and Injury of Musculoskeletal System
Diagnosis Diagnosis
HistoryHistory :Biomechanics ~ Forces.Time of injuryPossibilities or serious injuries.Decrease / lost of functions.Previous management, transportation.
Physical examination
GeneralGeneral condition conditionVital signsABC’s
LocalLocal condition condition :Look Feel Move
Local ConditionLocal ConditionLook Look :
Deformities : angulations, discrepancy, rotation.
Bone exposedSwelling
FeelFeel :Pain, crepitation, edema
MoveMove :Functio laesa
NEURO – VASCULAR !!NEURO – VASCULAR !!
Neuro-vasculardisturbance
Supporting examinations
LaboratoryImaging
SplintStraight, strong, flat + padding
StableSafe
Immobilization Immobilization 2 joints3 dimension
AlignmentAlignment / anatomic positionNeuro-vascularNeuro-vascular conditions
Splints
Immobilization
Splinting
Immobilize 2 joints / 2 bonesNeuro-vascular functions
AdvantagesAdvantages :Decreasing pain.Prevent further damagesDecrease or stop the bleedingEasy transportation.
Extrication, stabilization & Transportation
Treatment
1. First do No harmo harm2. Base treatment on an AccurateAccurate Diagnosis Diagnosis
and PrognosisPrognosis3. Select Treatment with Specific AimsSpecific Aims4. Cooperate with the “Law of NatureLaw of Nature”5. Make Treatment Realistic and PracticalRealistic and Practical 6. Select treatment for your patient as an
individualindividual
S P R A I N
A Sprain is an injury to a joint and its ligaments
Sprain R I C E
R I C E
S T R A I N
An injury to a musclemuscle in which the muscle fibers teartear as a result of over stretching over stretching
Muscle Strain Symptoms
Swelling, bruising or redness, or open cuts as a consequence of the injury
Pain at rest Pain when the specific muscle or the joint in relation to that
muscle is used Weakness of the muscle or tendonsInability to use the muscle at all
P R I C E
Protection, Rest, Ice, Compression, and Elevation
Joint DislocationJoint Dislocation
Joint contactComplete / incompleteRisk of avascular necrosis of the joint cartilage and bones
Dislocation Diagnosis / dd : Diagnosis / dd :
DislocationFractureFracture – dislocation
Pain and limitation of movementFresh vs neglected dislocations
Joint Dislocation
Treatment Treatment Reposition ~ instabilityImmobilization ~ stable positionRehabilitation ~ stability, tissue healing
Button hole dislocationClosed reduction vs open reduction
Dislocation Dislocation
Fractures
Trauma that produce discontinuity of bone, cartilage or epiphyseal plate
RelatedRelated to the SOFT TISSUE INJURIESSOFT TISSUE INJURIES
SIMPLE MUSKULOSKLETAL TRAUMA
Treatment of Fracture4 R 4 R :
RecognitionRecognition diagnosis, soc ec, religion, etcRepositionReposition displaced /deformity to anatomic
/ acceptable positionRetainingRetaining fixation of fragments : external,
internalRehabilitationRehabilitation early joint ROM, muscle
action, edema, psychological consideration , previous activity
Closed Fractures Management
IntactIntact skinClosedClosed reduction + immobilization (cast, traction)SurgerySurgery :
If closed treatment was failed (reduction and stability)
Open FracturesOpen Fractures
Open wound, relations between bone fragments and the environmentenvironment
InfectionInfection risk
Gustillo Gustillo ;Type IType IIType III A,B and C
OPEN FRACTURES
Type I open fracture
Type II open fracture
Type III A open fracture
Type III B open fracture
Type III C open fracture
Open Fracture Open Fracture ManagementManagement
Emergency Other life threatening injuries Multiple injuries ? Antibiotics Debridement Fracture fragment Stabilization Wound coverage Bone grafting Rehabilitation
Rehabilitation
LATE COMPLICATION OF FRACTURES
INFECTION IN OPEN FRACTURE
Type I less than 1%Type II 1-10 %Type III 10-50%
Fractures with vascular injuries
Fractures with a high risk of haemorrhagic shock haemorrhagic shock : Fracture of pelvisfracture of femur
Both are an emergencyemergency conditions that needs an immediate management.
Blood vessels may injuredinjured by the bone fragmentsfragments, so it always needs a good examination of the circulation at distaldistal part of the limb.
Deformity and impairment
Compartment Syndrome
A condition of increasingincreasing the closed muscle compartmental pressurepressure that produce a disturbances of neuro-vascularneuro-vascular functionfunction of the extremity .
Sign & Symptoms
Classic signs 5 PPain
Severe extremity pain out of proportion to injury
Early sign, worse with passively stretching involved muscleParesthesia or anesthesia to light touchParalysisPulselessness
Not present in early cases Pallor
• MuscleMuscle
– 3-4 hours - reversible
– 6 hours - variable
– 8 hours - irreversible
• Nerve Nerve
– 2 hours - lose nerve conduction
– 4 hours - neuropraxia
– 8 hours - irreversible
No perfusion = Cell Death
Compartment Syndrome
Clinical Signs :Clinical Signs :ClassicalClassical signs : 5 P (pain,
paresthesia, pallor, paralysis, pulselessnes).
BulaeSignificantSignificant sign : strecth
pain and paresthesia, decompresion fasciotomy.
MeasurementMeasurement of the intra compartment pressure fasciotomy
Volkmann’s Volkmann’s ContractureContracture
• Progressive elevation of interstitial pressure in a closed space resulting in impaired perfusion :– Causing functional compromise– Will result in cell death
• Consequences when missed
– Ischemic contracturesIschemic contractures– AmputationAmputation– DeathDeath
ManagementRemove extrinsic compression
Elevate to at least level of heart
Compartment pressure measurement?
Fasciotomy
INDICATION OF CONSULTATION
ALL FRACTURES & DISLOCATION ARE PATOLOGIC CONDITION
IMMOBILISATION/SPLINT FIRST
STRICTLY NO DELAY OF TRANSFERING PATIENTS W/ FRACT + NEUROVASCULAR INJURY, OPEN FRACTURES, DISLOCATION
DO NOT DO HARM
SUMMARY
FRACTURES IS NOT ONLY LESION ON THE BONEEARLY INTERVENTION OF MSK TRAUMA SHOULD BE
DONE PROPERLY, FOR BETTER PROGNOSISTO KNOW THE BASIC KNOWLEDGE FOR MAKING
DIAGNOSIS OF MSK TRAUMA IS MANDATORY BEFORE TREATING PATIENTS
DO NOT DO HARM
Thank you“to cure sometimes, to relieve often, to comfort always.”
- Edward Livingston Trudeau -