MUSCULO-SKELETAL TRAUMA

Dr D VENKATESWARA RAO MS MCh (UK)

PROFESSOR AND HOD
DEPARTMENT OF ORTHOPAEDICS
GOVERNMENT GENERAL HOSPITAL
VIJAYAWADA
• Injuries to the
musculoskeletal system
occur in many patients
who sustain blunt
trauma

• Major musculoskeletal
injuries indicate that
significant forces were
sustained by the body
• Musculoskeletal injuries cannot be ignored and treated
at a later time. The clinician must treat the whole
patient, including musculoskeletal injuries, to ensure
an optimal outcome.

• Despite careful assessment and management of

multiple injuries, fractures and soft tissue injuries may
not be initially recognized.

• Continued reevaluation of the patient is necessary to

identify all injuries.
PRIMARY SURVEY AND RESUSCITATION
AIM
• recognize and control hemorrhage from
musculoskeletal injuries
– Deep soft tissue lacerations involving major
vessels

– Hemorrhage from long-bone fractures

• Treatment:

– DIRECT PRESSURE

– If the fracture is open, apply a sterile pressure

dressing

– Appropriate fluid resuscitation

– contusions are treated by limiting function of the

injured part and applying cold packs

 ADJUNCTS TO PRIMARY SURVEY

FRACTURE IMMOBILIZATION

• Goal
– realign the injured extremity in as close to anatomic position
as possible

– prevent excessive fracture-site motion.

– helps control blood loss- tamponade effect

– reduce pain

– prevent further soft tissue injury

• Application of in-line traction to realign
the extremity and maintained by an
immobilization device

• Joint dislocations--splinting in the

position in which they are found.

• Splints should be applied as soon as

possible, as they can control
hemorrhage and pain. However, splint
application should not take precedence
over resuscitation.
 X-RAY EXAMINATION
Depends on clinical findings and the mechanism of injury

• Clinical examination—Joint effusions, abnormal bone and

joint tenderness or deformity

• X-ray examination in patients who have no hemodynamic

abnormalities. No X-ray in the presence of vascular
compromise or impending skin breakdown.

• If delay in obtaining x-rays, immediate reduction or

realignment of the extremity and immobilization--to
reestablish the arterial blood supply and reduce the pressure
 SECONDARY SURVEY

• History
• Physical Examination
 HISTORY
• Mechanism Of Injury
• Environment
• Pre-injury status and predisposing factors
• Pre-hospital observations and care
 MECHANISM OF INJURY
• mentally reconstruct the injury scene, identify other
potential injuries that the patient may have
sustained- reveals biomechanics of Injury
• Pre-crash location of the
patient in the vehicle-driver
or passenger??
– Eg: lateral compression fracture
of the pelvis resulting from a
side impact in a vehicle
collision.
• External damage to the vehicle?
deformation to the front of the
vehicle from a head-on collision?
– suspicion of a hip dislocation.

• Internal damage to the vehicle?

bent steering wheel, air bag
deployment, deformation to the
dashboard, or damage to the
windscreen?
– likelihood of sternal, clavicular, or
spinal fractures or hip dislocation
• Wearing a seat belt?
– spinal fractures and associated
intraabdominal visceral injuries

• Did the patient fall? If so,

what was the distance of the
fall, and how did the patient
land?
– Landing on the-foot and ankle
injuries with associated spinal
fractures.
• Crushed by an object
-- different degrees of soft tissue damage - simple contusion
or severe degloving extremity injury with compartment
syndrome and tissue loss.

• Vehicle-pedestrian
collision?
– bumper injury to leg
– Lateral compression fracture
of the pelvis
 ENVIRONMENT
• Whether the patient sustained an open
fracture in a contaminated environment
• Patient exposure to temperature extremes,
broken glass fragments (which may also injure
the examiner)
• Sources of bacterial contamination
– dirt, animal feces, fresh or salt water
 PRE-HOSPITAL OBSERVATIONS AND
CARE FINDINGS
• Bleeding or pooling of blood at the scene, including the
estimated amount

• Open wounds in proximity to obvious or suspected fractures

• Obvious deformity or dislocation

• Presence or absence of motor and/or sensory function in

each extremity

• Delays in extrication procedures or transport

• Changes in limb function, perfusion, or neurologic state
• Reduction of fractures or dislocations during extrication or
splinting at the scene
• Dressings and splints applied, with special attention to
excessive pressure over bony prominences that may result
in peripheral nerve compression injuries, compartment
syndromes, or crush syndromes.
• Time of the injury
• All pre-hospital observations and care must be reported and
documented
 PHYSICAL EXAMINATION
• Completely undressed for adequate
examination.
• Three goals for the assessment of trauma
patients’ extremities:
– Identification of life-threatening injuries (primary
survey)
– Identification of limb-threatening injuries
(secondary survey)
– Systematic review to avoid missing any other
musculoskeletal injury (continuous reevaluation)
 LOOK
• A rapid visual inspection of the entire patient- identify
lacerations and abrasions, sites of major external bleeding.
• Carefully logroll to assess for an injury over the dorsum of
the body
• Extremities: color and perfusion, wounds, deformity,
swelling, and discoloration or bruising.
– pale or white distal extremity-lack of arterial inflow.
• Swelling in the region of major muscle -a crush injury with
an impending compartment syndrome.
• Swelling or ecchymosis in or around a joint and/or over the
subcutaneous surface of a bone
• Deformity- fracture.
 ASK
• Ask to move all major joints- full range of
motion usually indicates that the nerve
muscle unit is intact and the joint is stable
• Obey commands, consciousness and coherent
 FEEL
• Loss of sensation to pain and touch-spinal or
peripheral nerve injury.
• Areas of tenderness or pain over muscles-muscle
contusion
• Pain, tenderness, swelling, crepitus, abnormal
motion and deformity over bony surface-fracture.
• Palpate the patient’s back to identify lacerations,
palpable gaps between the spinous processes,
hematomas, or defects in the posterior pelvic
region - unstable axial skeletal injuries.
 POTENTIALLY LIFE-THREATENING
EXTREMITY INJURIES
• MAJOR ARTERIAL HEMORRHAGE
– Injury-penetrating extremity wounds
– Assess
• external bleeding
• loss of a previously palpable pulse
• changes in pulse quality
• Doppler tone
• Ankle/brachial index.
 CIRCULATORY EVALUATION
• Assess
– distal pulses in each extremity
– capillary refill of the digits.
– Loss of sensation in a stocking or glove distribution -
early sign of vascular impairment.
– Pulse discrepancies, coolness, pallor, paraesthesia, and
even motor function abnormalities can suggest an
arterial injury.
– Open wounds, fractures in proximity to arteries,
expanding hematomas or pulsatile hemorrhage from
an open wound can be clues to an arterial injury.
• Management-
– If a major arterial injury exists or is suspected,
immediate consultation with a surgeon
– application of direct pressure to the open wound
– appropriate fluid resuscitation.
– The judicious use of a tourniquet may be helpful
and lifesaving
 CRUSH SYNDROME
(TRAUMATIC RHABDOMYOLYSIS)
• Injury: clinical effects of injured muscle, if left
untreated, can lead to acute renal failure
• Most often involved region- thigh or calf.
• direct muscle injury--muscle ischemia--cell death-
-rhabdomyolysis--release of myoglobin.
• Causes elevation of the creatine kinase, acute
renal failure and disseminated intravascular
coagulation (DIC).
• Assessment:
– dark amber urine that tests positive for hemoglobin.
– myoglobin assay
– metabolic acidosis, hyperkalemia, hypocalcemia, and
DIC.
• Management
– early and aggressive intravenous fluid therapy -critical
to protect the kidneys and prevent renal failure
– intravascular fluid expansion and osmotic diuresis to
maintain a high tubular volume and urine flow.
– maintain the patient’s urinary output at 100 ml/hr
until the myoglobinuria is cleared.
 PELVIC INJURIES
• Pelvic fractures hypotension and have a high
mortality
• Disruption of the pelvic ring tears the pelvic venous
plexus internal iliac arterial system
• Management:
• hemorrhage control and fluid resuscitation.
• mechanical stabilization of the pelvic ring and external
counter pressure.
• Longitudinal traction applied through the skin or the
skeleton
• internal rotation of the lower limbs
• A sheet, pelvic binder, or
other device can apply
sufficient stability for the
unstable pelvis at the
level of the greater
trochanters of the femur
 LIMB THREATENING INJURIES
• OPEN FRACTURES AND JOINT INJURIES
– Injury- Open fractures represent a
communication between the external
environment and the bone
Assessment- history of
the incident and
physical examination
of the extremity that
demonstrates an open
wound and associated
fracture
• If an open wound exists over or near a joint, it
should be assumed that this injury connects with or
enters the joint. The insertion of dye, saline, or any
other material into the joint to determine whether the
joint cavity communicates with the wound is not
recommended.
• Intravenous antibiotics as soon as possible. Currently
first-generation cephalosporins are given to all
patients with open fractures and aminoglycosides or
other Gram-negative appropriate antibiotics in more
severe injuries.
• Tetanus prophylaxis should be administered
• Increased risk
– more than 6 hours old
– contused and/or abraded
– more than 1 cm in depth
– high-velocity missiles
– burns or cold
– significant contamination
• Passive immunization with 250 units of human
tetanus immune globulin (TIG) intramuscularly
• TIG provides longer protection than antitoxin of
animal origin and causes few adverse reactions
 VASCULAR INJURIES
• Partial vascular injury—coolness, prolonged
capillary refill in the distal part of an extremity, as
well as diminished peripheral pulses and an
abnormal ankle/brachial index.
• Alternatively, the distal extremity may have the
complete disruption of flow and be cold, pale,
and pulseless
• Vascular compromise can also exists whenever an
injured extremity is splinted or placed in a cast.
– loss of or change in the distal pulse, but excessive pain
after cast application also must be investigated.
• Doppler study to demonstrate triphasic flow
• Computed tomography (CT) angiography may
be helpful in institutions in which
arteriography is not available
• Management:
– The use of a tourniquet may occasionally be lifesaving
and/or limb-saving in the presence of ongoing
hemorrhage uncontrolled by direct pressure.
– If deformity- correct it quickly by gently realigning and
splinting the injured extremity.
– The splint, cast, and any other circumferential dressings
must be released promptly and the vascular supply
reassessed.
– Fractures with prolonged ischemia, neurologic injury,
and muscle damage may require amputation.
Amputation of an injured extremity may be lifesaving in
patients with hemodynamic abnormalities who are
difficult to resuscitate
 REIMPLANTATION
• Patient with multiple injuries who requires
intensive resuscitation and emergency surgery
is not a candidate for replantation
• Performed with an injury of an isolated
extremity.
• Early operative revascularization is required to
restore arterial flow to the impaired distal
extremity.
• A patient with clean, sharp amputations of
fingers or of a distal extremity, should be
transported appropriately replantation
procedures.
• The amputated part should be thoroughly
washed in isotonic solution - wrapped in sterile
gauze that has been soaked in aqueous penicillin
(100,000 units in 50 mL of Ringer’s lactate
solution)-wrapped in a similarly moistened sterile
towel, placed in a plastic bag, and transported
with the patient in an insulated cooling chest
with crushed ice. Care must be taken not to
freeze the amputated part
 COMPARTMENT SYNDROME INJURY
• When the pressure within an osteofascial
compartment of muscle causes ischemia and
subsequent necrosis.
• Causes
– an increase in compartment size (e.g., swelling
secondary to revascularization of an ischemic
extremity)
– decreasing the compartment size (e.g., a constrictive
dressing).
• Common areas lower leg, forearm, foot, hand,
gluteal region, and thigh
 ASSESSMENT
• Increasing pain greater than expected and out
of proportion to the stimulus
• Palpable tenseness of the compartment
• Asymmetry of the muscle compartments
• Pain on passive stretch of the affected muscle
• Altered sensation
• absence of a palpable distal pulse late finding ,
not reliable
• Compartment syndrome is a clinical diagnosis
and is not one that is solely determined by
pressure measurements. Compartment
pressure measurements are only intended to
aid the physician in the diagnosis of
compartment syndrome.
• Clinical diagnosis is based on the history of
injury and physical signs, coupled with a high
index of suspicion.
• The key to the successful treatment of acute
compartment syndrome is early diagnosis
• Management
– All constrictive dressings, casts, and splints applied over
the affected extremity must be released and carefully
assessed.
– If no significant changes occur, emergency fasciotomy is
required.
• Complications
– Neurologic deficit
– Muscle necrosis
– Ischemic contracture
– Infection
– Delayed healing of a fracture
– Amputation.
NEUROLOGIC INJURY SECONDARY TO
FRACTURE-DISLOCATION
• Fractures and particularly dislocations--significant
neurologic injury because of the anatomic
relationship and proximity of the nerve to the
joint
– sciatic nerve compression from posterior hip
dislocation
– axillary nerve injury from anterior shoulder
dislocation.
• Muscle testing must include palpation of the
contracting muscle.
• Progression of neurologic findings is indicative of
continued nerve compression
 MANAGEMENT
• The injured extremity should be immobilized
in the dislocated position
• A careful reduction of the dislocation may be
attempted by a qualified surgeon.
• After reducing a dislocation, neurologic
function should be reevaluated and the limb
splinted.
 FRACTURES
• Fractures are defined as a break in the
continuity of the bone cortex.
• Assessment :
– pain, swelling, deformity, tenderness, crepitus,
abnormal motion at the fracture site.
• X-ray films: taken at right angles to one
another
• Management: 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
• Spine fracture- Long spine board provides a
total body splint for patients with multiple
injuries
• Tibia fractures- Plaster splints immobilizing
the lower thigh, the knee, and the ankle may
be used.
• Ankle fractures- Pillow splint or padded
cardboard splint
Femoral fracture- Proximally,
the splint is pushed into the
thigh and hip areas by a ring
that applies pressure to the
buttocks, perineum, and groin

• Knee injuries- knee immobilizers or the application of a

long-leg plaster splint with about 10 degrees of flexion
to reduce tension on the neurovascular structures
• Hand injuries :anatomic,
functional position in a short
arm splint with the wrist slightly
dorsiflexed and the fingers
gently flexed 45 degrees at the
metacarpophalangeal joints.

• Shoulder injuries: sling-and-

swath device or a Velcro-type of
dressing.
 PAIN CONTROL
• Splints- significantly decreases the patient’s
discomfort by controlling the amount of
motion that occurs at the injured site
• Narcotics- small doses intravenously and
repeated as needed.
• Muscle relaxants and sedatives should be
administered cautiously
• Regional nerve blocks