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    Musculoskeletal Trauma - Dr. Ismail Bastomi

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    Anggun Dwi Putri

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    Musculoskeletal Trauma - Dr. Ismail Bastomi

    Uploaded by

    Anggun Dwi Putri
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    Musculoskeletal Trauma_Dr. Ismail Bastomi

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    3 views78 pages

    Musculoskeletal Trauma - Dr. Ismail Bastomi

    Uploaded by

    Anggun Dwi Putri

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 78

    Musculoskeletal Trauma

    Dr.ISMAIL BASTOMI Sp.OT, FICS


    GELS/ PPGD
    RSU dr M. Hoesin
    Palembang
    • Major musculoskeletal injuries → dramatic and distracting, but it is
    rare for them to be immediately life-threatening
    • The classic mistake → focus on the attention-grabbing compound
    fracture, and miss the obstructing airway, which is far more likely to
    cause a ‘golden hour’ death
    • The most immediately life-threatening injuries should always be
    treated first.
    • However, although this principle has been known for generations, in
    the stress of the moment a logical sequence may not be followed
    unless the treating doctor is trained and practised.
    Numbers of training systems have been developed over the years, of
    which the best known is the Advanced Trauma Life Support Program
    for Doctors (ATLS®)
    The system taught is based on a three-stage approach:

    1. Primary survey and simultaneous resuscitation


    – A rapid assessment and treatment of life-threatening injuries.

    2. Secondary survey
    – A detailed, head-to-toe evaluation to identify all other injuries.

    3. Definitive care
    – Specialist treatment of identified injuries.
    THE ABCs
    • The underlying principle of ATLS is to identify the most immediately
    life-threatening injuries first and start resuscitation.
    As a general rule,
    • Airway obstruction kills in a matter of minutes,
    • Followed by respiratory failure (Breathing)
    • Circulatory failure and
    • Expanding intracranial mass lesions (Disability)
    The sequence is:

    PRIMARY SURVEY AND RESUSCITATION


    - Airway and cervical spine control
    - Airway
    • Simultaneously, the airway is examined for obstruction by looking,
    listening and feeling for signs such as respiratory distress, use of
    auxiliary muscles of respiration, decreased conscious level and lack of
    detectable breath on hand or cheek.
    • The airway is supported initially by lifting the chin or thrusting the jaw
    forward from under the angles of the mandible
    – Cervical spine control
    • The cervical spine is stabilized immediately on the basis that an
    unstable injury cannot initially be ruled out.
    • There are two techniques for this:
    • manual, in-line immobilization
    • cervical collar, head supports
    and strapping.
    – Breathing

    A clear airway does not mean the casualty is breathing adequately


    enough to enable peripheral tissue oxygenation.
    As soon as the airway is secured, the chest must be exposed and
    examined by looking, listening and feeling
    • Adequate and symmetrical excursion, bruising, open wounds and
    tachypnoea are looked for, and the chest is auscultated for abnormal
    or absent breath sounds, which indicate a pneumothorax or
    haemothorax.
    – Circulation with haemorrhage control
    The circulation is assessed by looking for external bleeding and the
    visible signs of shock such as pallor, prolonged capillary refill and
    decreased conscious level.
    The heart is auscultated to detect the muffled sounds of cardiac
    tamponade, and poor perfusion assessed by feeling for clammy and
    cool skin.
    – Disability
    • The key element of assessing a patient’s neurological status is the
    Glasgow Coma Score (GCS)
    • This score records eye opening, the best motor response and the
    verbal response.
    • The pupils are examined for any difference in size, indicating raised
    intra-cerebral pressure
    – Exposure and environment
    The patient should have all clothing removed to enable a full
    examination of the entire body surface area to take place.
    This will require log rolling to examine the posterior aspects, and allow
    removal of any glass or debris.
    The casualty should be kept warm to maintain body temperature as
    close to 37ºC as possible, and all fluids and ventilated gases warmed.
    SECONDARY SURVEY

    • The secondary survey is a detailed, head-to-toe evaluation to identify


    all injuries not recognized in the primary survey.

    • It takes place after the primary survey has been completed, if the
    patient is stable enough and not in immediate need of definitive care.
    The components of the secondary survey are:
    • History
    • Physical examination
    • ‘Tubes and fingers in every orifice’
    • Neurological examination
    • Further diagnostic tests
    • Re-evaluation.
    History
    • A useful mnemonic is AMPLE: allergies; medications; past illnesses;
    last meal; events and environment.
    • Physical Examination follows a logical sequence from the head down
    to the extremities, including a log-roll to ensure that all the body
    surfaces are examined.
    • The guiding injunctions are look, listen and feel.
    • Musculoskeletal injury → Look, Feel, Move
    Musculoskeletal Examination
    Look
    • Swelling, bruising and deformity may be obvious, but the important
    point is whether the skin is intact; if the skin is broken and the
    wound communicates with the fracture, the injury is ‘open’
    (‘compound’).

    • Note also the posture of the distal extremity and the colour of the
    skin (for tell-tale signs of nerve or vessel damage).
    Feel
    • The injured part is gently palpated for localized tenderness.
    • Crepitus and abnormal movement may be present, but why inflict
    pain when x-rays are available?
    • Some fractures would be missed if not specifically looked for.
    • Vascular and peripheral nerve abnormalities should be tested for
    both before and after treatment.
    Move
    • It is more important to ask if the patient can move the joints distal to
    the injury.
    Fracture
    Adjunt Examination
    X-RAY
    X-ray examination is mandatory.
    • Remember the rule of twos:
    • • Two views – A fracture or a dislocation may not be
    • seen on a single x-ray film, and at least two views
    • (anteroposterior and lateral) must be taken.

    • • Two joints – The joints above and below the


    • fracture must both be included on the x-ray films.
    • Two limbs – In children, the appearance of immature epiphyses may
    confuse the diagnosis of a fracture; x-rays of the uninjured limb are
    needed for comparison.
    • Two occasions – Some fractures are notoriously difficult to detect
    soon after injury, but another x-ray examination a week or two later
    may show the lesion.
    Management for First Responders

    Splinting for Extremity Fracture

    • Purposes :
    • Imobillization
    • Pain reduction
    • Decrease/ minimize bleeding
    • Prevent further complication

    33
    Principles of Extremity Splinting

    • Evaluate neurovascular before & after


    splinting
    • Severe deformity & pulseless → in line
    traction
    • Dislocation → splint in the existing position
    • Close every wound
    • Imobillization through 2 joints

    34
    Splint

    Soft splint : sling dan air splint

    Rigid splint Traction splint

    35
    TREATMENT OF CLOSED FRACTURES
    REDUCTION
    ❑CLOSED REDUCTION
    • Under appropriate anaesthesia and muscle relaxation,
    • the fracture is reduced by a three-fold manoeuvre:
    (1) the distal part of the limb is pulled in the line of the
    bone;
    (2) as the fragments disengage, they are repositioned
    (by reversing the original direction of force if this can be reduced) and
    (3) alignment is adjusted in each plane.
    • This is most effective when the periosteum and muscles on one side of the fracture remain intact;
    the soft-tissue strap prevents over-reduction
    In line traction
    Disengagement
    Alignment → fixation
    • HOLD REDUCTION

    Hold reduction Showing how, if the soft tissues


    around a fracture are intact, traction will align the bony
    fragments.
    • CONTINUOUS SKIN TRACTION
    • CAST SPLINTAGE
    Open Reduction & Internal Fixation
    Operative reduction of the fracture under direct vision is indicated:
    (1) when closed reduction fails, either because of difficulty in controlling the
    fragments or because soft tissues are interposed between them;

    (2) when there is a large articular fragment that needs accurate positioning, or

    (3) for traction (avulsion) fractures in which the fragments are held apart.
    • INTERNAL FIXATION
    External fixation
    Amputation
    • Partial or total
    • ‘Life over limb’
    • Sharp edges → better
    prognosis for replantation
    • Preserve technique for the
    amputee

    46
    Preservation of the amputated parts for transportation
    STRAIN MUSCLE
    Ankle Sprain
    • Rest: Don’t put weight on the
    RICE injured area for 24 to 48 hours

    • Ice: Put a bag of ice on the


    injured area for 10 minutes

    • Compression: Wrap an injured


    wrist, ankle, knee, or elbow in
    an elastic bandage, or a
    compression sleeve

    • Elevation: Lie down and place


    the injured area on a pillow, and
    raise it above the level of your
    heart
    Life Threatening
    Musculoskeletal Injuries

    • Pelvic fracture with massive blood loss


    • Major artery rupture
    • Crush syndrome (rhabdomyolysis)

    56
    Pelvic Fracture

    • Damage to the posterior pelvic ring


    structures

    57
    Pelvic Fracture
    Examination & Treatment

    • Identify rapid blood loss


    • Hypotension with no visible bleeding (Primary
    surve→ ABCDE)
    • Open wound, blood in the OUE, high riding
    prostate, hematoma in pelvic region
    • Pelvic ring instability/ movement
    • Bleeding control, Rescucitation
    58
    Pelvic Fracture
    Stabilization ( Bleeding control)

    • Pelvic wrapping
    • C Clamp

    59
    Major Artery Rupture

    • Sharp/ blunt trauma


    • Active-pulsating-bleeding, Haematoma,
    Hypotension
    • Extremity → ischaemia
    • Stop bleeding → external compression, pressure
    bandage
    • Consult

    60
    Crush syndrome
    (Rhabdomyolysis)

    • Myoglobinuria
    • Metabolic acidosis
    • Fluid resuscitation
    Limb Threatening Injury

    • Open fracture
    • Vascular injury
    • Compartement syndrome
    • Nerve injury
    • Dislocation

    62
    Open Fracture
    Gustillo – Andersen Classification
    • Grade I : Wound < 1cm, minimal contamination
    • Grade II : Wound 1 – 10 cm, moderate contamination
    • Grade IIIA: Extensive soft tissue damage & high degree
    contamination, adequate soft tissue coverage
    • Grade IIIB: Extensive soft tissue damage & high degree
    contamination, nonadequate soft tissue coverage,
    need coverage procedure (flap)
    • Grade IIIC: Open fracture with arterial injury requiring repair

    63
    • Management:

    • Steril gauge/ bandage


    • Splint
    • Tetanus profilactic
    • Analgetic
    • Antibiotic
    • Consult
    Vascular Injury

    • Vascular insufficiency
    • With/out fracture or dislocation
    • Neurovascular evaluation after
    splintage
    • Consult

    65
    Compartment Syndrome
    • High pressure within fascial compartment
    • Features:
    • Severe pain not resolved with normal meds
    • Tense swelling, blisters
    • SpO2 drop, pale, pulseless
    • Muscle/ soft tissue ischaemic
    →necrosis
    Management
    • Open all tight strap/ splint
    • Perform emergency fasciotomy
    Nerve Injury

    • With/out Fracture or dislocation


    • Hip dislocation : sciatic nerve
    • Humeral fracture : radial or ulnar nerve
    • Neurologic examination
    • Immobilitation
    • Consult

    68
    Median Nerve injury
    Nerve Injury of the Hand
    Nerve Exploration
    Dislocation
    • Emergency in
    Orthopaedy
    • Deformity
    • Pain

    72
    Splint in the existing position
    Limb Threatening
    Summary
    • Primary Survey → Life Threatening
    • Secondary survey → Limb Threatening
    • Musculoskeletal → Immobilization
    THANK YOU

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