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musculoskeletal trauma.pptx

  1. 1. MUSCULOSKELETAL TRAUMA Presenter – Dr.Mohit Garg
  2. 2. Major musculoskeletal injuries indicate that body sustained significant forces. Delayed recognition and treatment – hemorrhage and limb loss.
  3. 3. Objectives • Resuscitations of patients with extremities injury. • Adjuncts to the primary survey. • Secondary survey including history and physical examination. • Principles of management of limb threatening musculoskeletal injuries. • Assessment and management of patients with contusions,lacerations,joints ,fractures. • Principles of proper immobilization of patients.
  4. 4. Primary Survey and Resuscitation • Recognize and control hemorrhage. • Potiential life threatning extremity injuries include  Major arterial hemorrhage  Traumatic Amputation  Bilateral femoral fractures  Crush Syndrome • Hemorrhage control best achived with direct pressure.
  5. 5. pitfall prevention Blood loss from musculoskeletal injuries is not immediately recognized. Recognize that femur fractures and any open long-bone fractures with major soft-tissue involvement are potential sites of significant hemorrhage
  6. 6. Assessment • External bleeding • Loss of previously palpable pulse • Changes in pulse quality • Doppler tone • Ankle/brachial index
  7. 7. Management • Lifethreatning bleed • Direct pressure • Pressure dressing • Manual pressure to artery proximal to injury • Manual torniquet
  8. 8. Bilateral Femur Fractures • Patients with B/L femur fractures > Greater risk than U/L fractures • Higher risk for significant blood loss, pulmonary complications, multiple organ failure and death • Consider early transfer to a trauma center.
  9. 9. PITFALL PREVENTION Delayed transfer to a trauma centre. •Transfer patients with vascular injury and concomitant fracture to a trauma center with vascular and orthopedic surgical capabilities. •Bilateral femur fractures result in a significantly increased risk of complications and death; these patients benefit from early transfer to a trauma centre.
  10. 10. Crush Syndrome • Defined as systemic manifestations resulting from crush injury. • If left untreated, can lead to acute renal failure and shock. • Sustained compression injury to significant muscle mass, thigh or calf. • The muscular insult is a combination of – direct muscle injury – muscle ischemia – cell death with release of myoglobin.
  11. 11. Assessment • Dark amber urine - hemoglobinuria. • Amber-colored urine with serum creatine kinase of 10,000 U/L or more is indicative of rhabdomyolysis when urine myoglobinlevels are not available. • Rhabdomyolysis- metabolic acidosis, hyperkalemia, hypocalcemia, and DIC.
  12. 12. Management • Intravenous fluid therapy • Myoglobin-induced renal failure can be prevented with – intravascular fluid expansion, – alkalinization of the urine by intravenous administration of bicarbonate, and osmotic diuresis.
  13. 13. Adjuncts to primary survey • Includes fracture immobilization and xray examination. • Goal – realign the injured extremity in as close to anatomic position as possible – prevent excessive motion at the fracture site. • Accomplished by applying inline traction and maintaining traction with an immobilization device.
  14. 14. • Remove gross contamination and particulate matter from the wound. • Administer weight-based dosing of antibiotics. • If reduction is unsuccessful, , splint the joint in the position in which it was found. • Resuscitation efforts must take priority over splint application.
  15. 15. X ray examination • Based on – patient’s initial and obvious clinical findings – patient’s hemodynamic status – mechanism of injury.
  16. 16. Secondary Survey • Includes history and physical examination. • Key aspects of history – mechanism of injury – environment – preinjury status and predisposing factors – prehospital observations and care.
  17. 17. Mechanism of Injury • Patient located before the crash? type of injury- lateral # pelvis from side impact collision • After the crash—inside the vehicle or ejected? • Was a seat belt or airbag in use? • Was the vehicle’s exterior damaged, such as having its front end deformed by a head-on collision?-suspect hip dislocation
  18. 18. • vehicle’s interior damaged, such as a deformed dashboard? lower extremity injuries • patient fall? distance of the fall, and how did the patient land? –specturum of injuries. • patient crushed by an object? If so, weight of the crushing object, the site of the injury, and duration of weight applied to the site.
  19. 19. • explosion occur? If so, magnitude of the blast, and what was the patient’s distance from the blast? – Primary injury from blast force – Secondary injury from debris and other accelerated objects – Tertiary injury- patient may be thrown to distant places. • Was the patient involved in a vehicle-pedestrian collision?
  20. 20. Environment Questionare • Ask following information about the post crash environment – Did the patient sustain an open fracture in a contaminated environment? – Was the patient exposed to temperature extremes? – Were broken glass fragments, which can also injure the examiner, at the scene? – Were there any sources of bacterial contamination, such as dirt, animal feces, and fresh or salt water?
  21. 21. • This information can help the clinician anticipate potential problems and determine the initial antibiotic treatment.
  22. 22. Preinjury status and predisposing factors • exercise tolerance • activity level • ingestion of alcohol and/or other drugs, emotional problems or illnesses • previous musculoskeletal injuries.
  23. 23. Prehospital observations and care • Time of injury • Position in which found • Bleeding or pooling of blood at the scene - the estimated amount • Bone or fracture ends that may have been exposed • Open wounds in proximity to obvious or suspected fractures • Obvious deformity or dislocation • Any crushing mechanism that can result in a crush syndrome
  24. 24. • Presence or absence of motor and/or sensory function in each extremity • Any delay in extrication procedures or transport. • Changes in limb function, perfusion, or neurologic state. • Dressings and splints applied, with special attention to excessive pressure over bony prominences that can result in peripheral nerve compression or compartment syndrome. • Time of tourniquet placement.
  25. 25. Physical Examination • The three goals for assessing the extremities are: • 1. Identify life-threatening injuries (primary survey). • 2. Identify limb-threatening injuries (secondary survey). • 3. Conduct a systematic review to avoid missing any other musculoskeletal injury.
  26. 26. Look and Ask • Visual inspection helps identify sites of major external bleeding. • A pale or white distal extremity is indicative of a lack of arterial inflow. • Inspect the patient’s entire body for lacerations and abrasions. • Open wounds may not be obvious on the dorsum of the body; therefore, carefully logroll patients to assess for possible hidden injuries.
  27. 27. • Observe the patient’s spontaneous extremity motor function to help identify any neurologic and/or muscular impairment. • If the patient is unconscious, absent spontaneous extremity movement may be the only sign of impaired function.
  28. 28. JOINT DIRECTION DEFORMITY Shoulder Anterior Posterior Squared of Locked in internal rotation Elbow Posterior Olecranon prominent posteriorly Hip Anterior Posterior Extended, abducted, externally rotated Flexed, adducted, internally rotated Knee Anteroposterior Loss of normal contour, extended *May spontaneously reduce prior to
  29. 29. Feel • Palpate the extremities to determine sensation to the skin (i.e., neurologic function) and identify areas of tenderness, which may indicate fracture • Loss of sensation to pain and touch - spinal or peripheral nerve injury. • Joint stability can be determined only by clinical examination. • Abnormal motion through a joint segment is indicative of a tendon or ligamentous rupture.
  30. 30. Circulatory Evaluation • Palpate the distal pulses in each extremity, and assess capillary refill of the digits. • The Doppler signal must have a triphasic quality to ensure no proximal lesion. • Arterial injury indications – pulse discrepancies – coolness, pallor – paresthesia, and even motor function abnormalities.
  31. 31. • Knee dislocations can reduce spontaneously and may not present with any gross external or radiographic anomalies until a physical exam of the joint is performed and instability is detected clinically. • An ankle/brachial index of less than 0.9 indicates abnormal arterial flow secondary to injury or peripheral vascular disease.
  32. 32. X ray Examination • The clinical examination of patients with musculoskeletal injuries often suggests the need for x-ray examination. • The only reason to forgo x-ray examination before treating a dislocation or a fracture is the presence of vascular compromise or impending skin breakdown. This condition is commonly seen with fracture-dislocations of the ankle.
  33. 33. Limb threatening injuries • open fractures and open joint injuries • vascular injuries • compartment syndrome • neurological injury secondary to fracture or dislocation
  34. 34. Open fractures and open joint injuries • Open fractures and open joint injuries result from communication between the external environment and the bone or joint • The diagnosis of an open fracture is based on a physical examination of the extremity that demonstrates an open wound on the same limb segment as an associated fracture. At no time should the wound be probed.
  35. 35. Assessment • Presence of an open joint injury may be identified using CT. The presence of intra articular gas on a CT of the affected extremity is highly sensitive and specific for identifying open joint injury. • If CT is not available, consider insertion of saline or dye into the joint to determine whether the joint cavity communicates with the wound.
  36. 36. Management • Treat all patients with open fractures as soon as possible with intravenous antibiotics using weight-based dosing.
  37. 37.  treat all patients with open fractures as soon as possible with intravenous antibiotics using weight-based dosing. pitfall prevention Failure to give timely antibiotics to patients with open fractures •Recognize that infection is a significant risk in patients with open fractures. •Administer weight-based doses of appropriate antibiotics as soon as an open fracture is suspected
  38. 38. • WOUND <1CM –1st gen cephalosporins> clinda • 1-10 CM MODERATE TISSUE DAMAGE –same • SEVERE SOFT TISSUE DAMGE + VASCULAR INJURY • Cefazolin+ genta(AG). • FARM YARD, SOILED-PIPTAZ
  39. 39. Vascular injuries • Limb initially appear viable because of collateral circulation. • Non-occlusive – coolness and prolonged capillary refill in distal part of extremity as well as dimnished peripheral pulses and abormal ankle/brachial index. • Occlusive – cold , pale and pulseless.
  40. 40. Management • Early operative revascularization is required. • Muscle necrosis begins when lack of arterial blood supply for more than 6 hours. • Correct associated fracture deformity. It restores blood flow when artery is kinked by shortening and deformity at fracture site. • CT angiography may be used but must not delay reestablishing arterial blood flow. • Important to perform and document careful neurovascular examination before and after reduction and application of splint.
  41. 41. Compartment Syndrome • Develops when increased pressure within a musculofascial compartment causes ischemia and subsequent necrosis. • Compartment syndrome can occur wherever muscle is contained within a closed fascial space. Remember, the skin acts as a restricting layer in certain circumstances.
  42. 42. • Delayed recognition and treatment of compartment syndrome is catastrophic and can result in neurologic deficit, muscle necrosis, ischemic contracture, infection, delayed healing of fractures, and possible amputation.
  43. 43. signs and symptoms of compartment syndrome • Pain greater than expected and out of proportion to the stimulus or injury • Pain on passive stretch of the affected muscle •Tense swelling of the affected compartment • Paresthesias or altered sensation distal to the affected compartment activities are considered high risk for compartment syndrome •Tibia and forearm fractures • Injuries immobilized in tight dressings or casts • Severe crush injury to muscle • Localized, prolonged external pressure to an extremity • Increased capillary permeability secondary to reperfusion of ischemic muscle • Burns • Excessive exercise
  44. 44. Management • The only treatment for a compartment syndrome is a fasciotomy • A delay in performing a fasciotomymay result in myoglobinuria, which may cause decreased renal function. • Immediately obtain surgical consultation for suspected or diagnosed compartment syndrome.
  45. 45. pitfall prevention Delayed diagnosis of compartment syndrome •Maintain a high index of suspicion for compartment syndrome in any patient with a significant musculoskeletal injury. •Be aware that compartment syndrome can be difficult to recognize in patients with altered mental status. •Frequently reevaluate patients with altered mental status for signs of compartment syndrome.
  46. 46. Neurological injury secondary to fracture or dislocation • Neurologic injury due to the anatomic relationship and proximity of nerves to bones and joint • Sciatic nerve compression from posterior hip dislocation • Axillary nerve injury from anterior shoulder dislocation • Diffcult to assess nerve function initially. However, assessment must be continually repeated, especially after the patient is stabilized.
  47. 47. PERIPHERAL NERVE ASSESSMENT OF UPPER ExTREMITIES NERVE MOTOR SENSATION INJURY Ulnar Index and litle finger abduction Litle finger Elbow injury Median distal Thenar contraction with opposition Distal tip of index finger Wrist fracture or dislocation Median, anterior interosseous Index tip flexion None Supracondylar fracture of humerus (children) Musculocutaneous Elbow flexion Radial forearm Anterior shoulder dislocation Radial Thumb, finger metocarpo- phalangeal extension First dorsal web space Distal humeral shaft, anterior shoulder dislocation Axillary Deltoid Lateral shoulder Anterior shoulder dislocation, proximal humerus fracture
  48. 48. PERIPHERAL NERVE ASSESSMENT OF LOWER ExTREMITIES NERVE MOTOR SENSATION INJURY Femoral Knee extension Anterior knee Pubic rami fractures Obturator Hip adduction Medial thigh Obturator ring fractures Posterior tibial Toe flexion Sole of foot Knee dislocation Superficial peroneal Ankle eversion Lateral dorsum of foot Fibular neck fracture, knee dislocation Deep peroneal Ankle/toe dorsiflexion Dorsal first to second web space Fibular neck fracture, compartment syndrome Sciatic nerve Ankle dorsiflexion or plantar flexion Foot Posterior hip dislocation Superior gluteal Hip abduction Upper butocks Acetabular fracture Inferior gluteal Gluteus maximus hip extension Lower butocks Acetabular fracture
  49. 49. Other extremity injuries • Lacerations – Require debridement and closure. – If a laceration extends below the fascial level, it may require operative intervention. • Contusions – recognized by pain, localized swelling, and tenderness – treated by limiting function of the injured part and applying cold packs.
  50. 50. • soft-tissue injuries are best evaluated by knowing the mechanism of injury and by palpating the specific component involved • Soft-tissue avulsion can shear the skin from the deep fascia, allowing for the significant accumulation of blood in the resulting cavity (i.e., Morel-Lavalléelesion) • drainage or debridement may be indicated
  51. 51. • Risk of tetanus is increased with – wounds that are more than 6 hours old, – contused or abraded – more than 1 cm in depth – from high-velocity missiles, due to burns or cold – significantly contaminated, particularly wounds with denervated or ischemic tissue .
  52. 52. Joint and ligament injuries • Physical examination reveals tenderness throughout the affected joint. • A hemarthrosisis usually present unless the joint capsule is disrupted and the bleeding diffuses into the soft tissues. • Passive ligamentous testing of the affected joint reveals instability. • X-ray examination is usually negative, although some small avulsion fractures from ligamentous insertions or origins may be present radiographically.
  53. 53. Management • Immobilize joint injuries, and serially reassess the vascular and neurologic status of the limb distal to the injury. • In a patient with a multiligament knee injury, a dislocation may have occurred and placed the limb at risk for neurovascular injury. Surgical consultation is usually required for joint stabilization.
  54. 54. Fractures • Examination of the extremity typically demonstrates pain, swelling, deformity, tenderness, crepitus, and abnormal motion at the fracture site. • X-ray films taken at right angles to one another confirm the history and physical examination findings of fracture. • To exclude occult dislocation and concomitant injury, x-ray films must include the joints above and below the suspected fracture site.
  55. 55. Management • Immobilization must include the joint above and below the fracture. After splinting, be sure to reassess the neurologic and vascular status of the extremity.
  56. 56. Principles of immobilization • FEMORAL FRACTURES-Femoral fractures are immobilized temporarily with traction splints. • The traction splint’s force is applied distally at the ankle. • Proximally, the post is pushed into the gluteal crease to apply pressure to the buttocks, perineum, and groin. • Hip fractures can be similarly immobilized with a traction splint but are more suitably immobilized with skin traction or foam boot traction with the knee in slight flexion.
  57. 57. Knee injuries • Application of a commercially available knee immobilizer or a posterior long-leg plaster splint is effective in maintaining comfort and stability. • Do not immobilize the knee in complete extension, but with approximately 10 degrees of flexion to reduce tension on the neurovascular structures.
  58. 58. Tibial fractures • Immobilize tibial fractures to minimize pain and further soft- tissue injury and decrease the risk of compartment syndrome. • If readily available, plaster splints immobilizing the lower thigh, knee, and ankle are preferred.
  59. 59. Upper extremity and hand injuries • The hand may be temporarily splinted in an anatomic, functional position with the wrist slightly dorsiflexed and the fingers gently flexed 45 degrees at the metacarpophalangealjoints. • The forearm and wrist are immobilized flat on padded or pillow splints. • The elbow is typically immobilized in a flexed position, either by using padded splints or by direct immobilization with respect to the body using a sling-and-swath device.
  60. 60. • The upper arm may be immobilized by splinting it to the body or applying a sling or swath, which can be augmented by a thoracobrachial bandage. • Shoulder injuries are managed by a sling-and-swath device or a hook-and loop type of dressing.
  61. 61. Associated Injuries • Certain musculoskeletal injuries are associated with other injuries that are not immediately apparent may be missed. • Steps to ensure recognition and management of these injuries include – Review the injury history especially mechanism of injury – Thoroughly reexamine all extremities. – Examine patient back including spine and pelvis. – Document open injuries and closed soft tissue injuries – Review x rays.
  62. 62. INJURY MISSED/ASSOCIATED INJURY • Clavicular fracture • Scapular fracture • Fracture and/or dislocation of shoulder Major thoracic injury, especially pulmonary contusion and rib fractures • Scapulothoracic dissociation • Fracture/dislocation of elbow Brachial artery injury • Median, ulnar, and radial nerve injury • Femur fracture • Femoral neck fracture • Ligamentous knee injury • Posterior hip dislocation • Posterior knee dislocation • Femoral fracture • Posterior hip dislocation • Calcaneal fracture Spine injury or fracture • Fracture- dislocation of talus and calcaneus • Tibial plateau fracture
  63. 63. occultskeletalinjuries pitfall prevention Occult injuries may not be identified during the primary assessment or secondary survey •Logroll the patient and remove all clothing to ensure complete evaluation and avoid missing injuries. •Repeat the head-to-toe examination once the patient has been stabilized to identify occult injuries.
  64. 64. Summary • Musculoskeletal injuries can pose threats to both life and limb. • life-threatening musculoskeletal injuries must be promptly assessed and managed. • hemorrhage control is utilized by applying direct pressure, splints, and tourniquets. • Most extremity injuries are appropriately diagnosed and managed during the secondary survey. • A thorough history and careful physical examination, including completely undressing the patient, is essential to identify musculoskeletal injuries.
  65. 65. • Essential to recognize and manage arterial injuries, compartment syndrome, open fractures, crush injuries, and dislocations in a timely manner. • Knowledge of the mechanism of injury and history of the injury-producing event can guide clinicians to suspect potential associated injuries. • Early splinting of fractures and dislocations can prevent serious complications and late sequelae. • Careful neurovascular examination must be performed both prior to and after application of a splint or traction device.
  66. 66. THANK YOU