musculoskeletal trauma

1. Hendy Rachmat Primana Lubis
Departement Bedah /
KSM Orthopaedi dan Traumatologi
FK UNSRI/ RS dr. M. Hoesin
Palembang

2. The Scope of Orthopaedics
• Nicolas Andry (1741) published a
book “Orthopaedia, or the Art of
Preventing and Correcting
Deformities in Children.”
• He coined the term “orthopaedia”
from orthos (straight) and pais (child)
Orthopaedics is concerned with bones, joints, muscles, tendons and nerves – the
skeletal system and all that makes it move

3. Global Orthopaedic Issues
Orthopaedics issues in the developing world :
• Pediatric deformity
• Degenerative conditions
• Musculoskeletal oncology
• Spinal deformity
• Trauma
• Injury : Road Traffic Crashes, Conflict, Disaster

4. Epidemiology
 Injuries to the limbs comprise by far the greatest
number of trauma cases, the limbs being injured in
about 85% of victims of blunt trauma.
 Limb injury, in the survivors of major trauma, is a
common source of disability.

5. Anatomi dan Fisiologi
Sistem musculoskeletal merupakan penunjang bentuk tubuh, terdiri dari
sendi, tulang, otot, tendon dan ligament
A. Sendi
 Sendi Fibrosa / tidak dapat bergerak
( sutura tlg. tengkorak )
 Sendi Kartilago / sedikit bergerak
(simphisis, torakal )
 Sendi Sinovial / dapat begerak bebas
( sendi panggul, siku )

6. B. Jaringan Penyambung
 Tersusun dari sel – sel dan substansi dasar
 Berperan penting dalam reaksi imunitas dan
peradangan
 Terdapat serat – serat dalam substansi dasar
 Adanya proteoglikan yang berfungsi sebagai
bantalan pada sendi dan dapat menahan
beban yang berat

7. Emergency in orthopaedics

8. Life-threatening injuries
Trauma to the musculoskeletal system may represent a
threat to life, place the limb at risk, or interfere with
eventual return to full function and activity.

10. The initial assessment of the casualty should proceed
using the ABC system, identifying and treating life-
threatening injuries as they are found. This
examination identifies injuries and conditions
compromising the airway, breathing and circulation.

11. ATLS Algorithm

12. Limb-threatening injuries
Some injuries may threaten the viability of a limb, or a
portion of that limb. Such injuries often involve
compromise of the blood supply to the limb that may
arise from:
• Direct vascular damage (penetrating or blunt intimal
damage).
• Vascular occlusion in the distorted limb (for example
due to a dislocated joint or severely displaced
fracture).
• Microcirculatory compromise caused by contained
swelling (leading to compartment syndrome).

13. The limbs tolerate vascular compromise poorly, and
irreversible damage to the metabolically active
tissues such as muscle is likely to occur if the limb
remains ischaemic for more than about 6 h.

14. DISLOCATION
• Structural loss of its stability
• 3 structure that prevent normal ROM & also
prevent joint instability
– Joint shape ( joint surface )
– Capsule and ligament
– Muscle that prevent joint instability

15. Most Susceptible Joint Dislocation
• Shoulder
• Elbow
• Interphalangeal
• Hip
• Ankle
Basic Orthopaedic Tutorial

16. Types of Musculoskeletal
Injuries
• Fracture
- Bones break / Bone discontinuity
• Dislocation
- Joints “come apart”
• Soft Tissue Injury
a. Sprain
- Stretching & tearing of ligament
b. Strain
- Overexertion of muscle or tendon

18. Physical factors in the production of fractures
Cortical bone
• Succeptible to tension
Cancellous bone
• Succeptible to compression
Basic Orthopaedic Tutorial
twisting
Sudden pull force
bending

19. Injury to Ekstremities
1. Fracture :
Fracture classification :
a. Open fracture
b. Closed fracture
L
R

20. Definition
• Structural break in continuity of a bone, an epiphyseal
plate, or a cartilaginous joint surface
• Produce soft tissue injury
Sometimes the associated injury may
assume much greater clinical
significance than the fracture itself.

21. Fraktur
Open Fraktur :
 Ujung tulang yang patah sangat tajam
 Saraf dan pembuluh darah bisa cedera
 Berbahaya bagi jaringan disekitarnya
Closed Fraktur :
 Mempunyai tingkat bahaya yang sama
 Perdarahan yang cukup banyak khususnya
pada tulang panjang

22. 2. Fracture Site

23. 3. Configuration of Fracture :

24. THE DIAGNOSIS OF FRACTURES
• HISTORY :
–Fall, Direct Trauma.
–Mechanism of injury.
–Common symptom of # :
• Localized pain.
• Decreased function of the involved
part.

25. THE DIAGNOSIS OF FRACTURES
• PHYSICAL EXAMINATION:
– INSPECTION ( LOOKING ):
• Swelling ( edema )
• Deformity( angulations, rotation, shortening )
• Abnormal movement
• Echymosis( subcutaneous extravasations of blood )
– PALPATION ( FEELING ) :
• Localized tenderness at the # site.
• Crepitus (not necessary)
– RANGE OF MOVEMENT (MOVE):
• Limitation.

26. THE DIAGNOSIS OF FRACTURES
!!!! CAREFULL ASSESSMENT
• Patient’s General Condition
• Search for associated injuries:
– Brain
– Spinal Cord
– Peripheral Nerves
– Major vessels
– Thoraces
– Abdominal viscera

27. THE DIAGNOSIS OF FRACTURES
• RADIOGRAPHIC EXAMINATION:
# : PHYSICAL EXAMINATION
Confirmation by X-Ray  Accurate Diagnosis
• To determine extent and configuration of the fracture.
• Include entire length of the bone and the joints at each
end.
• 2 Projection : AP / Lat, particularly oblique
• Spine and pelvis :  (+) CT

28. Normal Healing of Fracture
Bone heals without a scar
• Primary bone healing – no stages
• Secondary bone healing – stages
• Mechanical factors
– Immobilization
• Biological factors
– Cooperate with “laws of nature” concerning biological healing

29. Normal Healing of Fracture
Secondary bone healing (AO):
1. Hematoma
2. Soft callus
3. Hard callus
4. Remodelling

30. Diagnosis of Fractures
• History
 Fall, twisting injury, direct blow, MVA
 Localized pain, aggravated by movement
 Crepitus
• Physical Examination
 General condition  associated injuries
 Look : deformity, swelling, abN movement
 Feel : localized tenderness, muscle spasm, NVD
 Move : ROM (limited or not)
• Diagnostic Imaging
 Exact nature & extent of fracture
 X-ray : min AP & lat (other position)
 CT / MRI : spine, pelvis

31.  Pada amputasi tertentu dapat
mengancam nyawa
 Perdarahan yang timbul bisa masif
 Bisa dilakukan torniket, tetapi
sebisa mungkin dihindari
 Bawa bagian yang terpotong ke
rumah sakit
 Pada suhu dingin dapat
memperlambat proses kimiawi
 Re-implantasi (6-8 jam) hanya bisa
pada amputasi tertentu (bukan
Crushing)

32. Management of the Musculoskeletal
Trauma
 Assessment of:
• Casualty
• Limb as a whole
• Traumatized structures and the extent of injury.

33. • Look: for deformity, discoloration, wounds, swelling,
shortening.
• Feel: for abnormal movement, crepitus, pulses,
temperature, sensation.
• Move: assess the ranges of active and passive
movement as well as joint stability.

34. Spesific Methode of Treatment
• Protection alone (no reduction or immobilization)
• Immobilization by External Splinting (no reduction)
• Closed reduction by manipulation + immobilization
• Closed reduction by continuous traction + immobilization
• Closed reduction + External skeletal Fixation
• Closed reduction + Internal Fixation
• Open reduction + Internal Fixation

35. Immediate treatment
• Orthopaedic consultation (evaluation of stable versus
unstable injury pattern)
• Temporary splintage (Mast trousers, binding feet
together, pelvic wrapping)
• Skeletal stabilization (pelvic Ex-fix, clamp)
• Assessment of related injuries (visceral, rectal,
urological)

36. Types of injury
 Pelvic fracture

37. Akibat dari Fraktur
 Fraktur femur dapat kehilangan darah
hingga 1 ltr
 Fraktur pelvis dapat menyebabkan
perdarahan di rongga abdomen dan
rongga retroperitonial
 Fraktur pelvis juga dapat mencederai
buli – buli

38. Pelvic Fracture Stabilization

39. Pelvic Wrap
Prepare backboard.

40. Pelvic Wrap
Logroll patient & bring sheets around
patient.

41. Pelvic Wrap
Secure sheets without over-compressing.

42. Leg Splint
Fast Splinting

43. Mast trousers
pelvic Ex-fix

44.  Major limb haemorrhage
Immediate treatment
• Direct pressure on sites of compressible
• haemorrhage
• Dressings and compression applied to
• wounds
• Splintage of limbs

45.  Large/contaminated open wound
Immediate treatment
• Sterile wound dressing
• Splintage
• Irrigation if appropriate
• Attention to tetanus immune status

46. Splintage
 Splintage helping to:
 Reduce haemorrhage
 Prevent further tissue damage
 Aid analgesia
 Reduce the incidence of fat embolism.

47. Splinting – General Rules
• Immobilization of the limb, including the joint above
and below the fractured segment.
• Realignment of the limb.
• Application so as not to compromise arterial supply or
venous return.
• Application to allow examination and re-assessment
of distal neurovascular status.

48. Types of Splints

49. Long-Bone Splinting
Stabilize extremity manually.

50. Assess distal neurovascular

51. Make sure splint extends several inches
beyond joints above/below injury.

52. Apply splint. Immobilize joints
above/below injury.

53. Secure extremity to splint.

54. Secure foot or hand in the position
of function.

55. Reassess distal neurovascular.

56. Splint for Injured Finger

57. SOFT TISSUE INJURY

58. • Sprain
- Stretching & tearing of ligament
• Strain
– Chronic Overstretching  overuse
– Most common site : musculotendinous junction
• Rupture
– Severe tension on contracted muscle
– Charley horse
• Recover : 50% muscle strength

59. Tendon Injuries
• Tendon healing :
– Weakest 7-10 days
– Most original strength 21-28 days
– Maximal strength 6 months
• Closed Tendon Injuries
– Mallet finger
• Open Tendon Injuries
– Need immediate surgical repair
Salter RB.Textbook of Disorders and Injury of Musculoskeletal System

60. Tendon Achilles

61.  Largest tendon in the
body
 Origin from
gastrocnemius and
soleus muscles
 Insertion on calcaneal
tuberosity

62.  Pathophysiology
Repetitive microtrauma
in a relatively
hypovascular area.
Reparative process
unable to keep up
May be on the
background of a
degenerative tendon

63. Partial
Localized tenderness +/-
nodularity
Complete
Defect
Cannot heel raise
Positive Thompson test

66. This lateral x-ray of the
calcaneus shows an
avulsion fracture at the
insertion of the Achilles
tendon, with marked
separation of fragments.
.

67. Restore
musculotendinous length
and tension.
Optimize gastro-soleous
strength and function
Avoid ankle stiffness