musculoskeletal injury kul

Musculoskeletal EmergencyPurwoko Sugeng H.

Incidence/Mortality/MorbidityOccur in 70-80% of all multi-trauma patientsBlunt or PenetratingUpper extremity rarely life-threatening

may result in long-term impairmentLower extremity associated with more severe injuries

possibility of significant blood lossfemur, pelvic injuries may pose life-threat

Incidence/Mortality/MorbidityProblem is not just the bone injury

Other injuries caused by the injured boneSoft tissueVascularNervous systemDecreased function

Prevention StrategiesSports TrainingSeat Belt useChild Safety Seat useAirbag useGun Safety and EducationMotorcycle education and protective equipmentFall preventionCan you think of others?

Musculoskeletal System FunctionSupportProtection of vital organsLocomotionProduction of RBCStorage of minerals

Musculoskeletal StructuresSkinMusclesBonesTendonsLigamentsCartilage

BonesLiving tissue Consists of cells which deposit calcium, phosphorus on protein matrixConstantly remodels itselfAble to repair damage without formation of scar tissue

BonesStructural form for bodyProtectionPoint of attachment for tendons, ligaments, cartilage and musclesAllows for movementStorage of mineralsProduce red blood cells

Skeletal System ComponentsAxial Skeleton

forms the central axis of the bodyincludes skull, vertebral column, bony thoraxAppendicular Skeleton

limbsPectoral girdle

bones that attach the upper limbs to the axial skeletonPelvic girdle

paired bones of the pelvis that attach the lower limbs to the axial skeleton and sacrum

Long Bone AnatomyPeriosteum

Outer fibrous coveringAllows for increase in diameterVascularNervesEpiphysis

Articulated, widened endAllows bone to lengthenCancellous bone with red blood marrow

FractureBreak in continuity of boneClosed

Overlying skin intactOpen

Wound extends from body surface to fracture siteProduced either by bones or object that caused FxDanger of infectionBone end not necessarily visible

Mechanism of InjuryDirect

Break occurs at point of impactIndirect

Force is transmitted along boneInjury occurs at some point distant to point of impactFemur, hip, pelvic fracture due to knees hitting dash

Mechanism of InjuryTwisting

Distal limb remains fixedProximal part rotatesShearing, fracturing occurFootball. skiing accidentsAvulsion

Muscle and tendon unit with attached fragment of bone ripped off bone shaft

Mechanism of InjuryStress

Occur in feet secondary to prolonged running or walkingPathological

Result of Fx with minimal forceCancer, osteoporosis

Fracture DescriptionsOpen vs ClosedX-Ray descriptions

greenstickobliquetransversecomminutedspiralimpactedepiphyseal

Types of FracturesCompleteIncompleteClosed or simpleOpen or compound/complex

Grade IGrade IIGrade III *

Problems Associated with Musculoskeletal InjuriesHemorrhageInterruption of Blood SupplyDisabilityInstabilitySoft Tissue injury

Complications associated with FracturesHemorrhage

Possible loss within first 2 hoursTib/Fib - 500 mlFemur - 500 mlPelvis - 2000 mlInterruption of Blood Supply

Compression on arterydecreased distal pulseDecreased venous return

Complications of FracturesAcute Compartment Syndrome Serious condition in which increased pressure within one or more compartments causes massive compromise of circulation to the areaPathophysiologic changes sometimes referred to as ischemia-edema cycleA hallmark sign is pain that occurs or intensifies with passive ROMPain continues to increase despite the administration of opioids and seems out of proportion to the injury

*S&P

Emergency Care (Continued)Elevate extremity to the level of heartRemove castFasciotomy may be performed to relieve pressure.Pack and dress

the wound after fasciotomy.

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Other Complications of FracturesShockFat embolism syndrome: serious complication resulting from a fracture; fat globules are released from yellow bone marrow into bloodstreamVenous thromboembolismInfectionIschemic necrosisdelayed union, nonunion, and malunion

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Possible Results of Acute Compartment SyndromeInfectionMotor weaknessVolkmanns contractures: (a deformity of the hand, fingers, and wrist caused by a lack of blood flow (ischemia) to the muscles of the forearm)

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Musculoskeletal Complications (continued)Muscle Atrophy, loss of muscle strength range of motion, pressure ulcers, and other problems associated with immobilityEmbolism/Pneumonia/ARDS

TREATMENT hydration, albumin, corticosteroidsConstipation/AnorexiaUTIDVT

*Fat embolus occur within 24 hours of injury 60% or within 48 hrs in 85%.

Patho FaT fat molecules or globules are released from bone marrow enter into the blood. Fat in blood and urine but most experience decrease in arterial Po2, increase Pco2, petechiae and altered mental state mental confusion.

Complications associated with FracturesDisability

Diminished sensory or motor functioninadequate perfusiondirect nerve injurySpecific Injuries

DislocationAmputation/AvulsionCrush Injury (soft tissue trauma discussion)

Sprains/StrainsSprain

tearing of ligaments surrounding jointStrain

overstretching of muscle or tendon

Musculoskeletal AssessmentInitial Assessment

ABCDsLife threats managed firstDont overlook life/limb threatening musculoskeletal traumaDont be distracted by gross but non-life/limb threatening musculoskeletal injury

Musculoskeletal AssessmentThe six Ps of musculoskeletal assessment

Painon palpationon movementconstantPallor - pale skin or poor cap refillParesthesia - pins and needles sensationPulses - diminished or absentParalysisPressure

Musculoskeletal Assessment Vascular injury should be suspected in all Fxs/dislocations Evaluate with 5 Ps

PainPallorPulselessnessParesthesiasParalysis

Musculoskeletal AssessmentHistory 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 AssessmentPalpation and Inspection

Swelling/EcchymosisHemorrhage/Fluid at site of traumaDeformity/Shortening of limbCompare to other extremity if norm is questionedGuarding/DisabilityPresence of movement does not rule out fracture


TendernessUse two point fixation of limb with palpation with other hand. Tenderness tends to localize over injury site.CrepitusGrating sensation Produced by bones rubbing against each other. Do not attempt to elicit.


Exposed bonesFx can be open without exposed bones

Principal danger is not to bones, but to underlying neurovascular structures around bone.


Distal to injury, assess:skin color skin temperaturesensationmotor functionIf uncertain, compare extremitiesWhen in doubt splint!

Musculoskeletal AssessmentBecause orthopedic injuries have low priority in multiple systems trauma, all Fxs may not be found in field Long Board

Splints every bone and jointNo loss of timeFocus on critical conditions

Key PointOrthopedic 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 - GeneralImmobilization Objectives

Prevent further damage to nerves/blood vesselsDecrease bleeding, edemaAvoid creating an open FxDecrease painEarly immobilization of long bone fractures critical in preventing fat embolism

Management - GeneralPrinciples of Fracture Management

Splint joint above, belowSplint bone endsLoosely cover open fracture sitesNeurovascular assessmentbefore and after splintingGentle in-line traction of long bone maintain normal alignment if possiblereduction of angulated fracture site

Management - GeneralPrinciples of Fracture Management (cont)

Position of functionPain management

Body Splinting

In urgent patient, entire body is stabilized by using a long boardLower extremity fractures can be splinted as one to the long board

Fracture of Clavicle and Immobilization Device*

Immobilizers for Proximal Humeral Fractures*

Functional Humeral Brace*

Stable Pelvic FracturesMost fractures of pelvis heal rapidly because the pelvic bones has a rich blood supply

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Unstable Pelvic Fractures*

Management - GeneralPain Management

Avoid pain management until head/thoracic injury is ruled outAppropriate for isolated musculoskeletal injuries (fracture/sprain/dislocation)Morphine sulfate titrated to pain relief without compromising adequate BP and ventilations

DislocationsDisplacement of bone end from articulating surface at jointPain or pressure is most common symptomPrincipal sign is deformityMay experience loss of motion of joint

DislocationsNerves, blood vessels pass very close to bone. Pressure on these structures can occur Checking distally essential

Pulse presencePulse strengthSensation

Management - DislocationsPrinciples of fracture/dislocation management

Usually splinted in position of injuryNeurovascular assessment before, after splintingAttempt realignment of dislocations ifdistal circulation is impairedlong transportDiscontinue realignment if pain increased significantly or resistance is encounteredImmobilize proximal. distal joints and bones Analgesia, possible cold application

SprainsStretching. tearing of ligaments surrounding joint Occur when joint is twisted beyond normal range of motionMost common = Ankle

Sprain ManagementCharacteristics

PainTendernessSwellingDiscolorationTypically does not manifest deformityIce, compression, elevation, immobilizeWhen in doubt, splintConsider analgesia

StrainsTearing, stretching of musculotendonous unit. Spasm, pain on active movementUsually no deformity, swellingPain present on active movementAvoid active movement, weight bearing

Traumatic AmputationFirst priority - ABCs

Bleeding from stump usually not a problemNext priority is to save limb

Traumatic Amputation ManagementControl BleedingElevateApply direct pressure to stumpAvoid tourniquet except as last resort

Traumatic Amputation - Limb ManagementPlace in saline moist gauzePlace in plastic bagPlace bag on iceDo not

Warm amputated partPlace part in waterPlace directly on iceUse dry ice

Hemorrhage ManagementDirect Pressure

Most effective methodPressure bandageElevation

Combination with direct pressurePressure Point

Brachial, Femoral, CarotidTourniquet

last resortrarely required

TourniquetLast resort, but do not wait too long.Use flat wide materialBP cuffClose to the wound as possibleDo not removeLeave in plain viewNote time applied and clearly communicate during transfer of care

Fracture Goal and CareReduction and ImmobilizationImmobilize: to retain reduction or anatomical alignmentReduction: medical procedure to restore a fracture or dislocation to normal alignment. Needed for displaced fractures.

Reduction:

Closed ReductionOpen Reduction

Anatomical Alignment of FracturesClosed Reduction

NonsurgicalTraction/counter tractionUnder local anesthesia (joint block) or conscious sedationsBobjgalindo, Wikimedia Commons

Joint block-physician injects lidocaine into joint or area of fracture to numb and reduce.

Anatomical Alignment of FracturesOpen Reduction

Surgical Wires, pins, screwsInternal fixationExternal fixation

*ORIF: Open reduction internal fixationSource undetermined, E-Radiography

External FixationPin careInfection riskPain control

Source undetermined, Journal of Bone and Joint Surgery

Common musculo-skeletal problemsHypovolemiaImpaired bone integrityPainImpaired physical mobilitySelf-care deficits

Thank you.

*S&P*

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*Fat embolus occur within 24 hours of injury 60% or within 48 hrs in 85%.

Patho FaT fat molecules or globules are released from bone marrow enter into the blood. Fat in blood and urine but most experience decrease in arterial Po2, increase Pco2, petechiae and altered mental state mental confusion. Joint block-physician injects lidocaine into joint or area of fracture to numb and reduce.

musculoskeletal injury kul

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