MUSCULOSKELETAL TRAUMA

dr. Widiyatmiko Arifin Putro,

SpOT

Faculty of Medicine
Universitas Swadaya
Gunung Jati
Cirebon
Introduction
Scope :
Congenital &
developmental Subdivision :
abnormalities Traumatology
Infection & inflammation Orthopaedi :
Arthritis & rheumatic
disorders 1. Adult Reconstruction
Metabolic & endocrine 2. Oncology
disorders Orthopaedic
Tumours 3. Pediatric Orthopaedic
Sensory disturbance &
muscle weakness 4. Spine
Injury & mechanical 5. Hand & Microsurgery
derangement 6. Sports Injury
7. Ankle and Foot
Introduction
Trauma commonest cause of death in people
from 144 years

1.2 million per year road accidents.

WHO predicts that by 2020 road traffic injuries

will rank third in the causes of premature death
and loss of health from disability
In the UK vehicular accidents causing death or
serious
injury are usually motorcycle and car related
Global Percentage of Deaths Proportion of casualties
due to Injury (1999) by road user type
 major trauma mortality in a high-
income country hospital (6 %) and in
a rural area of a low-income country
(36 %)
Deaths as a result of trauma
classically follow a trimodal pattern
50% < 60 minutes
30% 1-3 hours(Gold)
20% 6 weeks
Trauma Mortality

Early phase-immediate death

severe brain injury, disruption of great vessels,
cardiac disruption
Second phase-minutes to hours
subdural, epidural hematomas,
hemopneumothoraces, severe abdominal
injuries, multiple extremity injuries (bleeding)
Third phase-delayed
multisystem organ failure
sepsis
Emergency Medical Services
(EMS)
effectiveEMS is available to initiate
management at the scene of the injury
and transfer the casualty rapidly to
hospital
Treatment is centred on
Evaluation
resuscitation
stabilization
Trauma Centers

One per population of 5 million or

less
Studies demonstrate a 30-40%
preventable death rate due to
inadequate trauma systems
Multidisciplinary Trauma Team

Trauma Surgeon
TEAM LEADER
Anesthesia Interventional
Musculoskeletal radiology
Intensivist
traumatologist
Neurosurgeon Hospital Staff-
Vascular/CT surgeon Nursing,
Urology, Speech, Admin.
Legal/Security
Gynecology
Social work
Ministry
Trauma Surgeons and
Fracture Care

Europe - General
Surgeon
Traumatologists
treat all injuries
North America -
Multidisciplinary team
Orthopaedic
Traumatologist- broad
knowledge of treatment of
injuries involving other
organ systems to
coordinate care optimally
with colleagues
 Orthopaedic Traumatologist

General resuscitation /
ICU care
Advantages /
disadvantages of early
stabilization of long bone
fractures
Skilled sufficiently to do
a procedure
expeditiously with
minimal risk of
complications
Understands impact of
Polytrauma Patient

Injury Severity Score >15

Hemodynamic instability
Coagulopathy
Closed head injury
Pulmonary injury
Abdominal injury
Injury Severity Score

Def.: scale of anatomic injury

ISS is the sum of the squares of the
three highest AIS categories
AIS (Abbreviated Injury Scale) looks
at five categories: general, head
and neck, chest, abdominal, and
extremities
Maximum ISS is 75
Principles of Resuscitation
ATLS
Phases of
management Priorities in
Primary Survey treatment
Resuscitation Airway + Cspine
Secondary Survey control
Definitive care Breathing
Circulation/CNS
Digestive system
Excretory Tracts
Fractures
Airway

Establish an appropriate airway

obtain patency-jaw lift
oral or nasal airway
surgical airway
Control of the cervical spine
Lateral C-spine radiograph
not included in the initial radiographic
evaluation in the revised ATLS protocol
Breathing

Assess breathing and oxygenation

Evaluation with Arterial Blood Gas
(ABG)
Etiology of decreased oxygenation
has to be determined
Tension pneumothorax-decompress
Open pneumothorax-seal and chest tube
Flail chest, pulmonary contusion-chest
tube
Indications for
Intubation
Control of airway
Prevent aspiration in unconscious
patient
Hyperventilation for increased
intracranial pressure
Obstruction from facial trauma and
edema
Circulation

Identifiable bleeding controlled with

direct pressure
Always try direct pressure first
Avoid blind use of vascular clamps
Tourniquets are rarely indicated
except for traumatic amputations
Assessment of Blood Pressure
Peripheral Perfusion

Peripheral Pulse
radial
femoral
Systolic Blood
carotid
Pressure
80 mm Hg
capillary refill > 2 70 mm Hg
secs 60 mm Hg

Hypotensive
Hemorrhage
Classification
Resuscitation
Two peripheral large
bore Ivs (16)
Two liters of Ringers
Lactate
If no response then severe
hemorrhage has occurred
immediate blood is
needed
Monitor
Blood pressure
Urinary output
Base deficit
Initial Hematocrit/Hemoglobin
-unreliable
Types of Shock

Hemorrhagic
Cardiogenic-pericardial tamponade
Neurogenic-CHI, spinal cord injury
hypotension without tachycardia
Vasoconstrictive meds not administered
until volume is restored
Septic-late sequela
Blood Transfusion
Blood warmer-
Crossed Matched prevents hypothermia,
1 hour arrhythmias
Blood filters-160 u
Type Specific
10 minutes
macropore
Coagulation status-
Type O Rh neg Platelets monitored
immediately every 10 units
Platelets < 100,000-
replace
Labile factors
(fibrinogen)-replace with
FFP
Management of Shock
Summary
Direct control of bleeding sources
Large bore IV access-Fluid
replacement
Monitor-urine output, CVP, pH,
lactate level
Blood replacement-indicated by
clinical response
Secondary Survey

Head
skull trauma
reevaluate pupillary size and reaction
blood/fluid at tympanic membranes
and nares
facial and ethmoid fractures
Cervical spine
swelling, crepitus, expanding
hematoma
Neurological Exam

Glascow Coma
Score-GCS
Pupil exam-
intracranial
pressure
Motor and Sensory
- all extremities in
alert patient
Secondary Survey

Chest-reevaluate for
crepitus, fractures, flail
segments,open wounds
Abdomen-inspect,
auscultate, palpate
seat belt injury-spinal
or intraabodominal
injury
Pelvis-exam for
tenderness, instability
Secondary Survey

Rectal exam
tone, sensory, prostate injury
if abnormal, do not pass foley-consult
Urology
Extremity exam
palpate for crepitus, swelling, pain,
instability, range of motion
Neurological exam-document all
findings
Head Injury

Oxygenation and cerebral circulation

Loss of consciousness (LOC) > 5
mins
observation for 24 hours
potential for seizures
CT scan of head
Intracranial Hemorrhage

Meningeal
Brain tissue
Suspect in unconsciousness patient
or lateralizing signs
fixed pupil
Increased Intracranial Pressure
Treatment

Patient positioning
Fluid restriction
Hyperosmotic diuretics-mannitol
Deliberate hypocapnia
controlled hyperventilation
maintain pCO2 at 25-30 mm Hg
Avoidance of stimuli
Thoracic Trauma

Accounts for 50-75 %

of fatalities in blunt trauma
15% of injuries require
surgical intervention
Second leading cause of death
Life saving procedures performed
during the primary survey
Thoracic Trauma

Secondary survey-
pulmonary contusion, aortic
disruption, airway disruption,
traumatic diaphragmatic disruption,
myocardial contusion
CXR-aortic disruption
widened mediastinum, fracture of 1st
and 2nd ribs, sternum fracture,loss of
aortic knob, trachea and esophageal
deviation
Aortagram of the aortic arch
Thoracotomy Indications

Failure of resuscitation
Penetrating injury to the
mediastinum
Continued thoracic hemorrhage
Failed pericardiocentesis
Tracheal, bronchial, esophageal
rupture
Abdominal Trauma

Most common site for occult

hemorrhage
liver, spleen, kidney, pancreas, bowel
No peritoneal signs in 40% of
hemoperitoneum
NG tube to decompress gastric
contents
Foley to decompress bladder
Contraindications
blood at the meatus, scrotal or perineal
 Peritoneal Lavage
Indications

Blunt trauma when PE is not

adequate to
assess- altered mental status
Unexplained hypotension
pelvis, lumbar spine, lower ribs fractures
Polytrauma patient lost to
continual monitoring- General
Anesthesia
Contraindications-multiple
abdominal operations, obvious
need for operation
Peritoneal Lavage Positive
Criteria
Frank blood
Fluid aspirate-unspun
> 100,000 RBC/mm3
> 500 WBC/ mm3
hematocrit > 2%
presence of bile, bacteria, fecal material
Other Methods of Abdominal
Evaluation

Ultrasound
CT scan
Method used for abdominal
evaluation is often institutionally
dependent
Genitourinary Injuries
Seen in 15% of blunt
abdominal injuries
Clinical signs
lower rib fracture, flank
discoloration, lower
abdominal mass, genitalia
discoloration, inability to
void, blood at the meatus,
hematuria
Evaluation
Retrograde urethrogram-
before foley is placed
Hematuria-IVP, cystogram,
excretory urethrogram
Trauma Severity Scores
Physiologic
Trauma Index-
Kirkpatrick and
Youman
Glascow Coma Scale
Anatomic Damage
Abbreviated Injury
Scale (AIS)
Injury Severity Score
(ISS)
Biochemical
Indices
Orthopaedic Surgeon

Experienced and familiar with a

number of acceptable procedures
Some more demanding in terms of
EBL, duration, equipment required
Potential EBL
pelvis/acetabulum - 8-10 units
IM nail femur - 2-3 units
Tibia - 1-2 units
 Orthopaedic
Emergencies
Open fractures
Dislocations (hip
and spine)
Compartment
syndromes
Cauda equina
syndrome
Extremities with
neurological or
vascular compromise
Bone Mechanics
Bone Density
Subtle density
Cortical Bone
changes greatly
changes strength
and elastic
modulus Trabecular Bone
Density changes
Normal aging
Disease
Use
Disuse Figure from: Browner et al: Skeletal Trauma
2nd Ed. Saunders, 1998.
 Basic Biomechanics

Bending
Axial Loading

Bending Compression Torsion Tension

Compression
Torsion
Fracture Mechanics

Figure from: Browner et al: Skeletal Trauma 2nd Ed, Saunders, 1998.
Fracture Mechanics
Bending load:
Compression
strength greater
than tensile
strength
Fails in tension

Figure from: Tencer. Biomechanics in Orthopaedic

Trauma, Lippincott, 1994.
Fracture Mechanics
Combined
bending & axial
load
Oblique fracture
Butterfly fragment

Figure from: Tencer. Biomechanics in

Orthopaedic
Trauma, Lippincott, 1994.
 Orthopaedic Priorities
Reduce and stabilize
dislocations
Fasciotomies in
compromised limbs
Proper debridement and
irrigation of open injuries
Stabilization of long bone
injuries
Secure fixation of intra-
articular fractures
Proper splinting of other
injuries
Orthopaedic Options

Pelvic ring injuries

Lower extremity
long bone fractures
Fractures with
vascular injuries
Complex periarticular
fractures
Open fractures
Life Threatening
Musculoskeletal Trauma
Pelvic Trauma with Massive
Bleeding
Patient Stability
Adequacy of resuscitation
Vital signs of resuscitation
Laboratory parametersbase deficit, lactic acidosis
Anesthesia-agents-myocardial depressants
Coagulopathy-dilution, DIC, thrombocytopenia
As long as homeostasis is maintained no
evidence of duration of the procedure alone
results in pulmonary or other organ dysfunction
or worsens the prognosis of the patient
Must be ready to change plan as the
patient status dictates
Summary
Dynamic process
Requires cooperation of entire
team
Doctor must:
Appreciate the interrelationships between
organ system injuries to include
musculoskeletal injury
Understand
options for treatment of orthopaedic injury
impact on the polytrauma patient
Provide timely and effective treatment
Thank You