Musculoskeletal Trauma

Management
Wiria Aryanta md
• Major musculoskeletal injuries can be dramatic and distracting, but it
is rare for them to be immediately life-threatening
• The classic mistake when treating trauma is to focus on the
attention-grabbing compound fracture, and miss the obstructing
airway, which is far more likely to cause a ‘golden hour’ death
• Hence the most immediately life-threatening injuries should always
be treated first.
• However, although this principle has been known for generations, in
the stress of the moment a logical sequence may not be followed
unless the treating doctor is trained and practised.
Numbers of training systems have been developed over the years, of
which the best known is the Advanced Trauma Life Support Program
for Doctors (ATLS®)
The system taught is based on a three-stage approach:

1. Primary survey and simultaneous resuscitation

– A rapid assessment and treatment of life-threatening injuries.

2. Secondary survey
– A detailed, head-to-toe evaluation to identify all other injuries.

3. Definitive care
– Specialist treatment of identified injuries.
 THE ABCs
• The underlying principle of ATLS is to identify the most immediately
life-threatening injuries first and start resuscitation.
As a general rule,
• Airway obstruction kills in a matter of minutes,
• Followed by respiratory failure (Breathing)
• Circulatory failure and
• Expanding intracranial mass lesions (Disability)
• This likely sequence of deterioration has led to the development of
the trauma ‘ABCs’, a planned sequence of management predicated on
treating the most lethal injuries first.
• Throughout this sequence, the assumption is made (until proved
otherwise) that there may be an unrecognized and unstable cervical
spine injury.
 The sequence is:

PRIMARY SURVEY AND RESUSCITATION

- Airway and cervical spine control
- Airway
• Simultaneously, the airway is examined for obstruction by looking,
listening and feeling for signs such as respiratory distress, use of
auxiliary muscles of respiration, decreased conscious level and lack of
detectable breath on hand or cheek.
• The airway is supported initially by lifting the chin or thrusting the jaw
forward from under the angles of the mandible
– Cervical spine control
• The cervical spine is stabilized immediately on the basis that an
unstable injury cannot initially be ruled out.
• There are two techniques for this:
• manual, in-line immobilization
• cervical collar, head supports
and strapping.
– Breathing

A clear airway does not mean the casualty is breathing adequately

enough to enable peripheral tissue oxygenation.
As soon as the airway is secured, the chest must be exposed and
examined by looking, listening and feeling
• Adequate and symmetrical excursion, bruising, open wounds and
tachypnoea are looked for, and the chest is auscultated for abnormal
or absent breath sounds, which indicate a pneumothorax or
haemothorax.
– Circulation with haemorrhage control
The circulation is assessed by looking for external bleeding and the
visible signs of shock such as pallor, prolonged capillary refill and
decreased conscious level.
The heart is auscultated to detect the muffled sounds of cardiac
tamponade, and poor perfusion assessed by feeling for clammy and
cool skin.
– Disability
• The key element of assessing a patient’s neurological status is the
Glasgow Coma Score (GCS)
• This score records eye opening, the best motor response and the
verbal response.
• The pupils are examined for any difference in size, indicating raised
intra-cerebral pressure
– Exposure and environment
The patient should have all clothing removed to enable a full
examination of the entire body surface area to take place.
This will require log rolling to examine the posterior aspects, and allow
removal of any glass or debris.
The casualty should be kept warm to maintain body temperature as
close to 37ºC as possible, and all fluids and ventilated gases warmed.
SECONDARY SURVEY

• The secondary survey is a detailed, head-to-toe evaluation to identify

all injuries not recognized in the primary survey.

• It takes place after the primary survey has been completed, if the
patient is stable enough and not in immediate need of definitive care.
• The importance of the secondary survey is that relatively minor
injuries can be missed during the primary survey and resuscitation,
but cause longterm morbidity if overlooked, for example small joint
dislocations.
The components of the secondary survey are:
• History
• Physical examination
• ‘Tubes and fingers in every orifice’
• Neurological examination
• Further diagnostic tests
• Re-evaluation.
History
• A useful mnemonic is AMPLE: allergies; medications; past illnesses;
last meal; events and environment.
• Physical Examination follows a logical sequence from the head down
to the extremities, including a log-roll to ensure that all the body
surfaces are examined.
• The guiding injunctions are look, listen and feel.
• Musculoskeletal injury  Look, Feel, Move
Musculoskeletal Examination
Look
• Swelling, bruising and deformity may be obvious, but the important
point is whether the skin is intact; if the skin is broken and the wound
communicates with the fracture, the injury is ‘open’ (‘compound’).

• Note also the posture of the distal extremity and the colour of the
skin (for tell-tale signs of nerve or vessel damage).
Feel
• The injured part is gently palpated for localized tenderness.
• Crepitus and abnormal movement may be present, but why inflict
pain when x-rays are available?
• Some fractures would be missed if not specifically looked for.
• Vascular and peripheral nerve abnormalities should be tested for
both before and after treatment.
Move
• It is more important to ask if the patient can move the joints distal to
the injury.
• INTRA-HOSPITAL AND INTER-HOSPITAL TRANSFER

• DEFINITIVE CARE
Describes the specialist care required to manage the injuries
identified during the initial assessment and subsequent investigations
Adjunt Examination
X-RAY
X-ray examination is mandatory.
• Remember the rule of twos:
• • Two views – A fracture or a dislocation may not be
• seen on a single x-ray film, and at least two views
• (anteroposterior and lateral) must be taken.

• • Two joints – The joints above and below the

• fracture must both be included on the x-ray films.
• Two limbs – In children, the appearance of immature epiphyses may
confuse the diagnosis of a fracture; x-rays of the uninjured limb are
needed for comparison.
• Two occasions – Some fractures are notoriously difficult to detect
soon after injury, but another x-ray examination a week or two later
may show the lesion.
TREATMENT OF CLOSED FRACTURES
REDUCTION
CLOSED REDUCTION
• Under appropriate anaesthesia and muscle relaxation,
• the fracture is reduced by a three-fold manoeuvre:
(1) the distal part of the limb is pulled in the line of the
bone;
(2) as the fragments disengage, they are repositioned
(by reversing the original direction of force if this can be reduced) and
(3) alignment is adjusted in each plane.
• This is most effective when the periosteum and muscles on one side of the fracture remain intact;
the soft-tissue strap prevents over-reduction
In line traction
Disengagement
Alignment  fixation
• HOLD REDUCTION

Hold reduction Showing how, if the soft tissues

around a fracture are intact, traction will align the bony
fragments.
• CONTINUOUS SKIN TRACTION
• CAST SPLINTAGE
OPEN REDUCTION
Operative reduction of the fracture under direct vision is indicated:
(1) when closed reduction fails, either because of difficulty in controlling the
fragments or because soft tissues are interposed between them;

(2) when there is a large articular fragment that needs accurate positioning, or

(3) for traction (avulsion) fractures in which the fragments are held apart.
• INTERNAL FIXATION
External fixation
Complications of traction

• Circulatory embarrassement
• Nerve injury
• Pin site infection
Complications
Plaster immobilization
• Pressure sores and abrasion or laceration of skin
• Tight cast
The cast may be put on too tightly, or it may become tight if the limb
swells.
• Loose cast Once the swelling has subsided
Complications of internal fixation

• Infection
• Non-union
• Implant failure
Complications External Fixation

• Damage to soft-tissue structures

• Overdistraction
If there is no contact between the fragments, union is unlikely.
• Pin-track infection
SKILL Lab
FRACTURES:
• Femur
• Clavicula
• Antebrachii
• Primary survey
• Secondary survey
• Physical examination
• How to STABILIZE the patient
• Transfering
Splinting
THANK YOU