Musculoskeletal Trauma. Humaryanto

Size: px

Start display at page:

Download "Musculoskeletal Trauma. Humaryanto"

Kerry Reed
5 years ago
Views:

1 Musculoskeletal Trauma Humaryanto

2 Incidence/Mortality/Morbidity Occur in 70-80% of all multi-trauma patients Blunt or Penetrating Upper extremity rarely life-threatening may result in long-term impairment Lower extremity associated with more severe injuries possibility of significant blood loss femur, pelvic injuries may pose life-threat

3 Incidence/Mortality/Morbidity Problem is not just the bone injury Other injuries caused by the injured bone» Soft tissue» Vascular» Nervous system» Decreased function

4 Prevention Strategies Sports Training Seat Belt use Child Safety Seat use Airbag use Gun Safety and Education Motorcycle education and protective equipment Fall prevention Can you think of others?

5 Musculoskeletal System Function Scaffolding/Support Protection of vital organs Locomotion Production of RBC Storage of minerals

6 Musculoskeletal Structures Skin Muscles Bones Tendons Ligaments Cartilage

7 Musculoskeletal Structures - Skin Holds all structures together Barrier function Protects underlying structures Subcutaneous tissue Fat Fascia Further discussion in Soft-Tissue Trauma

8 Musculoskeletal Structures - Muscle Composed of specialized cells with ability to contract Voluntary (Skeletal) Conscious control Allows mobility Smooth (Bronchi, GI tract, blood vessels) Controlled by ANS Able to alter inner lumen diameter Cardiac Contracts rhythmically on its own

9 Musculoskeletal Structures - Muscle Can only contract Skeletal muscle causes movement by shortening resulting in pulling on bones through cord like bands

10 Musculoskeletal Structures Tendons Bands of connective tissue binding muscles to bones Cartilage Connective tissue covering the epiphysis Surface for articulation Ligaments Connective tissue supporting joints Attach bone ends to each other

11 Bones Living tissue Consists of cells which deposit calcium, phosphorus on protein matrix Constantly remodels itself Able to repair damage without formation of scar tissue

12 Bones Structural form for body Protection Point of attachment for tendons, ligaments, cartilage and muscles Allows for movement Storage of minerals Produce red blood cells

13 Skeletal System Components Axial Skeleton forms the central axis of the body includes skull, vertebral column, bony thorax Appendicular Skeleton limbs Pectoral girdle bones that attach the upper limbs to the axial skeleton Pelvic girdle paired bones of the pelvis that attach the lower limbs to the axial skeleton and sacrum

14 Long Bone Anatomy Diaphysis Long, narrow shaft Dense, compact bone Metaphysis Head of bone Between epiphysis and diaphysis Medullary canal Contains marrow

15 Long Bone Anatomy Periosteum Outer fibrous covering Allows for increase in diameter Vascular Nerves Epiphysis Articulated, widened end Allows bone to lengthen Cancellous bone with red blood marrow Weakest point in child s bone

16 Joints Points of articulation between bones Fused/Fibrous Sutures Synovial» Between bones of skull Fluid filled chamber which lubricates articulated surfaces Allow for movement» gliding, flexion, extension, abduction, adduction, circumduction, rotation

17 Synovial Joints Ball/Socket Shoulder/Hip Hinge Elbow/Knees/Fingers/TMJ Pivot Between radius and ulna Gliding Bones of wrist

18 Fracture Break in continuity of bone Closed Overlying skin intact Open Wound extends from body surface to fracture site Produced either by bones or object that caused Fx Danger of infection Bone end not necessarily visible

19 Mechanism of Injury Direct Break occurs at point of impact Indirect Force is transmitted along bone Injury occurs at some point distant to point of impact Femur, hip, pelvic fracture due to knees hitting dash

20 Mechanism of Injury Twisting Distal limb remains fixed Proximal part rotates Shearing, fracturing occur Football. skiing accidents Avulsion Muscle and tendon unit with attached fragment of bone ripped off bone shaft

21 Mechanism of Injury Stress Occur in feet secondary to prolonged running or walking Pathological Result of Fx with minimal force Cancer, osteoporosis

22 Fracture Descriptions Open vs Closed X-Ray descriptions greenstick oblique transverse comminuted spiral impacted epiphyseal

24 Fracture Types Transverse Cuts shaft at right angle to long axis Often caused by direct injury Greenstick Pliable bone splinters on one side without complete break Occurs in children

25 Fracture Types Spiral Fx site coils through bone like spring Occurs with torsion Oblique Occurs at angle to long axis of shaft Comminuted Bone broken into 3 or more pieces

26 Fracture Type Impacted Bone ends jammed together Occurs with compression Frequently no loss of function

27 Problems Associated with Musculoskeletal Injuries Hemorrhage Interruption of Blood Supply Disability Instability Soft Tissue injury

28 Complications associated with Fractures Hemorrhage Possible loss within first 2 hours» Tib/Fib ml» Femur ml» Pelvis ml Interruption of Blood Supply Compression on artery» decreased distal pulse Decreased venous return

29 Complications associated with Fractures Disability Diminished sensory or motor function» inadequate perfusion» direct nerve injury Specific Injuries Dislocation Amputation/Avulsion Crush Injury (soft tissue trauma discussion)

30 Sprains/Strains Sprain tearing of ligaments surrounding joint Strain overstretching of muscle or tendon

31 Musculoskeletal Assessment The possibilities Life-threatening injuries or conditions, including life/limb threatening musculoskeletal trauma Life/Limb threatening injuries and only simple musculoskeletal trauma Life/Limb threatening musculoskeletal trauma and no other life/limb threatening injuries Only isolated, non-life/limb threatening injuries

32 Musculoskeletal Assessment Initial Assessment ABCDs Life threats managed first Don t overlook life/limb threatening musculoskeletal trauma Don t be distracted by gross but nonlife/limb threatening musculoskeletal injury

33 Musculoskeletal Assessment With few exceptions orthopedic injuries are not life threatening. Do not let drama of obvious or grossly deformed fracture distract you from more serious problems involving ABC s

34 Musculoskeletal Assessment The six P s of musculoskeletal assessment Pain» on palpation» on movement» constant Pallor - pale skin or poor cap refill Paresthesia - pins and needles sensation Pulses - diminished or absent Paralysis Pressure

35 Musculoskeletal Assessment Vascular injury should be suspected in all Fx s/dislocations UPO Evaluate with 5 P s Pain Pallor Pulselessness Paresthesias Paralysis

36 Musculoskeletal Assessment History of Present Injury Where is pain felt? What occurred? What position was limb in? Were deceleration forces involved? Was there direct impact? Has there ever been previous trauma or Fx?

37 Musculoskeletal Assessment Palpation and Inspection Swelling/Ecchymosis» Hemorrhage/Fluid at site of trauma Deformity/Shortening of limb» Compare to other extremity if norm is questioned Guarding/Disability» Presence of movement does not rule out fracture

38 Musculoskeletal Assessment Palpation and Inspection Tenderness» Use two point fixation of limb with palpation with other hand.» Tenderness tends to localize over injury site. Crepitus» Grating sensation» Produced by bones rubbing against each other.» Do not attempt to elicit.

39 Musculoskeletal Assessment Palpation and Inspection Exposed bones» Fx can be open without exposed bones Principal danger is not to bones, but to underlying neurovascular structures around bone.

40 Musculoskeletal Assessment Palpation and Inspection Distal to injury, assess:» skin color» skin temperature» sensation» motor function If uncertain, compare extremities When in doubt splint!

41 Musculoskeletal Assessment Because orthopedic injuries have low priority in multiple systems trauma, all Fx s may not be found in field Long Board Splints every bone and joint No loss of time Focus on critical conditions

42 Key Point Orthopedic injuries are seldom immediately life threatening. Tend to other issues first. Only immediately life threatening orthopedic injury is Pelvic Fx due to potential massive hemorrhage

43 Key Point The problem is not the damage to the bone The problem is the damage the bone does to the surrounding soft tissues. Evaluate Neurovascular Function Distally

44 Management - General Immobilization Objectives Prevent further damage to nerves/blood vessels Decrease bleeding, edema Avoid creating an open Fx Decrease pain Early immobilization of long bone fractures critical in preventing fat embolism

45 Management - General Principles of Fracture Management Splint joint above, below Splint bone ends Loosely cover open fracture sites Neurovascular assessment» before and after splinting Gentle in-line traction of long bone» maintain normal alignment if possible» reduction of angulated fracture site

$patient, entire body is stabilized by using a long board Lower extremity fractures can be splinted as one to the long board$

46 Management - General Principles of Fracture Management (cont) Position of function Pain management Body Splinting In urgent patient, entire body is stabilized by using a long board Lower extremity fractures can be splinted as one to the long board

Splints, Padding, Bandages, Slings, and Swathes Splints.

sticks, tree limbs, rolled magazines, rolled newspapers, or

$used to immobilize a fractured arm and the uninjured leg can$

47 Splints, Padding, Bandages, Slings, and Swathes Splints. Splints may be improvised from such items as boards, poles, sticks, tree limbs, rolled magazines, rolled newspapers, or cardboard. If nothing is available for a splint, the chest wall can be used to immobilize a fractured arm and the uninjured leg can be used to immobilize (to some extent) the fractured leg.

48 Splints, Padding, Bandages, Slings, and Swathes Padding. Padding may be improvised from such items as a jacket, blanket, poncho, shelter half, or leafy vegetation. Bandages. Bandages may be improvised from belts, rifle slings, bandoliers, kerchiefs, or strips torn from clothing or blankets. Narrow materials such as wire or cord should not be used to secure a splint in place.

49 Splints, Padding, Bandages, Slings, and Swathes Slings. A sling is a bandage (or improvised material such as a piece of cloth, a belt and so forth) suspended from the neck to support an upper extremity. The triangular bandage is ideal for this purpose. Remember that the casualty's hand should be higher than his elbow, and the sling should be applied so that the supporting pressure is on the uninjured side. Swathes. Swathes are any bands (pieces of cloth, pistol belts, and so forth) that are used to further immobilize a splinted fracture. Triangular and cravat bandages are often used as or referred to as swathe bandages. The purpose of the swathe is to immobilize, therefore, the swathe bandage is placed above and/or below the fracture--not over it.

50 Management - General Pain Management Avoid pain management until head/thoracic injury is ruled out Appropriate for isolated musculoskeletal injuries (fracture/sprain/dislocation) Underutilized Morphine sulfate titrated to pain relief without compromising adequate BP and ventilations

51 Management - Pediatric Green stick Fx may go unrecognized Fx can occur in epiphyseal plate, early closure can prevent further growth of affected bone If no explanation from patient or parents or injury does not follow mechanism, suspect child abuse.

52 Management Error Oversight of volume loss when evaluating pt with multiple Fx s Estimate blood loss at each Fx site Evaluation of neurovascular deficiencies in distal extremity

53 Dislocations Displacement of bone end from articulating surface at joint Pain or pressure is most common symptom Principal sign is deformity May experience loss of motion of joint

54 Dislocations Nerves, blood vessels pass very close to bone. Pressure on these structures can occur Checking distally essential Pulse presence Pulse strength Sensation

55 Management - Dislocations Principles of fracture/dislocation management Usually splinted in position of injury Neurovascular assessment before, after splinting Attempt realignment of dislocations if» distal circulation is impaired» long transport Discontinue realignment if pain increased significantly or resistance is encountered Immobilize proximal. distal joints and bones Analgesia, possible cold application

56 Sprains Stretching. tearing of ligaments surrounding joint Occur when joint is twisted beyond normal range of motion Most common = Ankle

57 Sprain Management Characteristics Pain Tenderness Swelling Discoloration Typically does not manifest deformity Ice, compression, elevation, immobilize When in doubt, splint Consider analgesia

58 Strains Tearing, stretching of musculotendonous unit. Spasm, pain on active movement Usually no deformity, swelling Pain present on active movement Avoid active movement, weight bearing

59 Minor Musculoskeletal Injury Management Cold/Heat application cold best if in first 48 hours to reduce swelling heat best if after 48 hours to increase circulation no direct application to soft tissue» wrap in towel or gauze

60 Minor Musculoskeletal Injury Management Other care Is immobilization/splinting needed? Is an X-ray needed? Is there a need for MD follow? ED visit? What type of transport is needed?

61 Traumatic Amputation First priority - ABC s Bleeding from stump usually not a problem Next priority is to save limb

62 Traumatic Amputation Management Control Bleeding Elevate Apply direct pressure to stump Avoid tourniquet except as last resort

63 Traumatic Amputation - Limb Management Place in saline moist gauze Place in plastic bag Place bag on ice Do not Warm amputated part Place part in water Place directly on ice Use dry ice

64 Upper Extremity Fx Proximal Humerus Usually from a fall on outstretched hand. Manage with sling, swathe Deltoid bulge often accentuated Shaft of Humerus Usually obvious due to deformity Wrist drop may occur Vascular compromise may be present

65 Upper Extremity Fx Colles Fx (silver fork) Distal radius Usually secondary to fall on outstretched hand Common in children

$Figure-of-eight splint Use the figure-of-eight splint to treat fractures of the medial twothirds of the clavicle.$

66 Figure-of-eight splint Use the figure-of-eight splint to treat fractures of the medial twothirds of the clavicle. Apply this splint while the patient is erect, with the hands on the iliac crests and the shoulders held in abduction. Wrap a stockinette or padding snugly around both shoulders. A premade version of this splint is available. The figureof-eight splint loosens with time; a simple sling may be used if loosening of the splint is a concern

67 Shoulder Dislocation Realignment One attempt if neurovascular compromise Do not attempt if associated with other severe injuries or spine injuries Provide analgesia Pull into anatomical position Splinting Be creative Sling, swathe if possible Cravats are our friends!

68 Hip Dislocation Anterior Blow to abducted leg, external rotation of affected extremity Posterior Blow to flexed/abducted knee More severe than anterior dislocation Associated with rupture of joint capsule, acetabular Fx, sciatic nerve injury

69 Management - Hip Dislocation Realignment One attempt if severe neurovascular compromise Do not attempt if associated with other severe injuries Provide analgesia Steady and slow pull along shaft of femur If successful, pops into joint, sudden relief of pain, leg can easily return to extension Immobilization Flexion of hip/knee for comfort acceptable

70 Pelvic Fracture Direct or indirect force Pelvic ring tends to break in two places Bone fragments can cause damage Major vessels Urinary bladder Rectum resulting in contamination Nerves (Lumbrosacral plexus or sciatic)

71 Pelvic Injury Introduction significant blood loss if bilateral may settle in retroperitoneal space 3% of all fractures mortality 8-50% 2 nd most common cause of traumatic death

73 Pelvic Fracture Signs & Symptoms pelvic instability pain (suprapubic also) crepitus bloody meatus neurovascular deficits

75 Polytrauma

76 Pelvis Interventions Stable patient» analgesia» Repair vs mobilization Unstable patient» Immobilize» Ex-fix» Angiography embolization

77 Pemeriksaan fraktur pelvis Tekan kearah posterior dan anterior pada krista iliaka (stabilitas anteroposterior) Lakukan traksi pada salah satu tungkai dengan memfiksasi pelvis (stabilitas vertikal)

78 Pemeriksaan radiologis Bila keadaan pasien memungkinkan segera dilakukan pemeriksaan foto pelvis AP CT scan 3 dimensional CT

79 Radiographic examination

80 Outlet and inlet view I O

81 Pelvic Fx Management Treat as potential critical trauma patient Comfortable position if possible Splint = Minimize movement Scoop stretcher Body to long board MAST for splint Replace volume prn Possible 4000cc blood loss 2 IV of LR

82 Femur Fx Femoral Neck (Hip) Most common in mid to late 60 s age group. Leg tends to rotate outward» looks like anterior hip dislocation Minimal blood loss tends to occur due to joint capsule Management NO traction splint long board, scoop or MAST

83 Femur Fx Mid-Shaft Result from torsion in very young or old High speed deceleration with impact» Hypovolemic shock» Fat Embolism Early immobilization with traction splint will help prevent 1000 to 2000 cc blood loss

opposite extremity and then to long board (premise for the Sager

84 Femur Fx - Management Assess for traction splint contraindications May use PASG, secure to long board Secure to opposite extremity and then to long board (premise for the Sager splint) Assess for : Soft tissue, vascular, or nerve injury Assess for hypovolemia

$Femur Fx - Management Traction Splints Used on mid-shaft femur fractures Do not use if suspected fracture involves» proximal or distal 1/3 of femur» pelvis» hip$

85 Femur Fx - Management Traction Splints Used on mid-shaft femur fractures Do not use if suspected fracture involves» proximal or distal 1/3 of femur» pelvis» hip (or hip dislocation)» knee (or knee dislocation)» ankle (or ankle dislocation) What if time (patient instability) does not allow for traction splint application?

86 Lower Extremity Fx Patellar Due to direct impact Tibia/Fibula High potential for:» Open fracture» Hemorrhage» Infection Calcaneal Results from falls (foot landing) High incidence of lumbar sacral compression

87 Management - Lower Extremity Fx Patellar, Tibia/Fibula, and Calcaneal Assess for neurovascular impairment Realign long bones Splinting possibilities» board splint or cardboard splint» vacuum splint» pillow

88 Elbow Dislocation Presentation High neurovascular traffic Volkmann s contracture - ischemia secondary to trauma causes ischemic contractions Management assess for neurovascular impairment sling swathe analgesia and position of comfort

89 Knee Dislocation Presentation Trauma to popliteal artery Many reduce spontaneously Knee dislocation has a 50% incidence of associated vascular injury Presence of distal pulse does not rule out vascular injury

90 Management - Knee Dislocation Management Assess for neurovascular impairment One attempt at realignment if impairment or delayed transport Do not realign if associated with other severe injuries analgesia and position of comfort gentle, steady traction to move into normal position» success by pop into joint, less deformity and pain, and increased mobility

91 Hemorrhage Management Direct Pressure Most effective method Pressure bandage Elevation Combination with direct pressure Pressure Point Brachial, Femoral, Carotid Tourniquet last resort rarely required

92 Tourniquet Last resort, but do not wait too long. Use flat wide material BP cuff Close to the wound as possible Do not remove Leave in plain view Note time applied and clearly communicate during transfer of care

MUSCULOSKELETAL INJURIES

WHAT ARE THEY They are injuries to muscles, nerves, tendons ligaments, joints, cartilage and spinal discs. WHAT KIND OF INJURIES ARE MUSCULOSKELETAL INJURIES 1. Fractures- -Open -Closed 2. Dislocations