Musculoskeletal

Trauma
Primary Survey and Resuscitation

What impact do musculoskeletal injuries have on

the primary survey?

• Hemorrhage control is best effected by direct pressure

• If the fracture is open, application of a sterile pressure
dressing usually controls hemorrhage.
• Appropriate fluid resuscitation is an important
supplement to these mechanical measures
 Adjuncts to Primary Survey
• FRACTURE IMMOBILIZATION
The proper application of a splint
helps control blood loss, reduce
pain, and prevent further soft
tissue injury
This is accomplished by the
application of in-line traction to
realign the extremity and maintained
by an immobilization device

Splints should be applied as soon as possible

• X-RAY EXAMINATION
 Secondary Survey

• mechanism of injury
A. HISTORY
• Environment
• preinjury status and predisposingfactors
• and prehospital observations and care.

B. PHYSICAL EXAMINATION
• Look and Ask
• Feel
• Circulatory Evaluation
• X-Ray Examination
 Potentially Life-Threatening
Extremity Injuries
What are my priorities and management
principles?
MAJOR ARTERIAL HEMORRHAGE
• Injury
Penetrating extremity wounds may result in major arterial vascular injury. Blunt
trauma resulting in an extremity fracture or joint dislocation in close proximity
to an artery also may disrupt the artery. These injuries may lead to significant
hemorrhage through the open wound or into the soft tissues.
• Assessment
Assess injured extremities for external bleeding, loss of a previously palpable
pulse, and changes in pulse quality, Doppler tone, and ankle/brachial index. A
cold, pale, pulseless extremity indicates an interruption in arterial blood
supply. A rapidly expanding hematoma suggests a significant vascular injury.

• Management
If a major arterial injury exists or is suspected, immediate consultation with a
surgeon is necessary. Management of major arterial hemorrhage includes
application of direct pressure to the open wound and appropriate fluid
resuscitation
CRUSH SYNDROME (TRAUMATIC RHABDOMYOLYSIS)
• Injury
 Crush syndrome refers to the clinical effects of injured muscle that, if left
untreated, can lead to acute renal failure.
 The muscular insult is a combination of direct muscle injury, muscle
ischemia,and cell death with release of myoglobin.

• Assessment
 The myoglobin produces dark amber urine that tests positive for
hemoglobin.

• Management
 The initiation of early and aggressive intravenous fluid therapy during the
period of resuscitation is critical to protecting the kidneys and preventing
renal failure in patients with rhabdomyolysis.
 Limb-Threatening Injuries
OPEN FRACTURES AND JOINT INJURIES
• Injury
Open fractures represent a communication
between the external environment and the bone
• Assessment
Diagnosis of an open fracture is based on the
history of the incident and physical examination
of the extremity that demonstrates an open
wound on the same limb segment with or
without significant muscle damage,
contamination, and associated fracture.

• Management
Apply appropriate immobilization after an
accurate description of the wound is made and
associated soft tissue, circulatory, and
neurologic involvement is determined.
VASCULAR INJURIES, INCLUDING TRAUMATIC
AMPUTATION

• Injury
with a history of blunt, crushing, twisting, or penetrating injury to an
extremity
• Assessment
Partial vascular injury results in coolness and 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
• Management
COMPARTMENT SYNDROME
• Injury
Compartment syndrome develops when the pressure within an
osteofascial compartment of muscle causes ischemia and subsequent
necrosis. This ischemia may be caused by an increase in
compartment size (e.g., swelling secondary to revascularization of an
ischemic extremity) or by decreasing the compartment size
• Assessment
Any injury to an extremity has the potential to cause a
compartment syndrome. However, certain injuries or activities
are considered high risk, including:
 Tibial 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
Signs and Symptoms of Compartment
Syndrome
 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
• Management
All constrictive dressings, casts, and splints applied over
the affected extremity must be released
 NEUROLOGIC INJURY SECONDARY TO
FRACTURE-DISLOCATION
• Injury TABLE 8.2 Peripheral Nerve Assessment of Upper Extremities
NERVE MOTOR SENSATION INJURY
• Assessment Ulnar Index and little finger Little finger Elbow injury
abduction
• Management Median distal Thenar contraction Index Wrist fracture
with opposition finger or dislocation
Median, anterior Index tip flexion None Supracondylar
interosseous fracture of
humerus
(children)
Musculocutaneous Elbow flexion Radial Anterior
forearm shoulder
dislocation
Radial Thumb, finger First dorsal Distal
metacarpophalangeal web space humeral
extension shaft, anterior
shoulder
dislocation
Axillary Deltoid Lateral Anterior
shoulder shoulder
dislocation,
proximal
humerus
fracture
TABLE 8.3 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 Fibular neck
foot fracture, knee
dislocation
Deep peroneal Ankle/toe Dorsal first to Fibular neck
dorsiflexion second fracture,
web space compartment
syndrome
Sciatic nerve Plantar dorsiflexion Foot Posterior hip
dislocation
Superior gluteal Hip abduction Upper buttocks Acetabular fracture
Inferior gluteal Gluteus maximus Lower buttocks Acetabular fracture
hip extension
 Other Extremity Injuries

CONTUSIONS AND LACERATIONS

• Need to lacerations require debridement and closure
JOINT INJURIES

Injury
Joint injuries that are not dislocated
Assessment
• Physical examination reveals tenderness throughout the affected
ligament. A hemarthrosis usually is 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 usually
reveals no significant injury.
Management
• Joint injuries should be immobilized.
• The vascular and neurologic status of the limb distal to the injury
• should be reassessed.
FRACTURES

Injury
• Fractures are defined as a break in the continuity of the bone cortex.
• They may be associated with abnormal motion
• some form of soft tissue injury
• bony crepitus, and pain
Assessment
• Examination of the extremity demonstrates pain,
• swelling, deformity
• Tenderness
• Crepitation
• and abnormal motion at the fracture site
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
FEMORAL FRACTURES
• Femoral fractures are immobilized
temporarily with traction splints (n
FIGURE 8-9). The traction splint’s
force is applied distally at the
ankle or through the skin.
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

• The use of commercially available knee immobilizers or the

application of a long-leg plaster splint is very helpful in
maintaining comfort and stability.
• The knee should not be immobilized in complete extension,
but should be immobilized with about 10 degrees of flexion to
reduce tension on the neurovascular structures
TIBIA FRACTURES
• Tibia fractures are best immobilized with a
well-padded cardboard or metal gutter long-
leg splint. If readily available, plaster splints
immobilizing the lower thigh, the knee, and
the ankle may be used.
ANKLE FRACTURES
• Ankle fractures may be immobilized with a pillow splint or
padded cardboard splint, thereby avoiding pressure over bony
prominences
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 metacarpophalangeal joints
• Siku biasanya diimobilisasi dalam posisi tertekuk, baik dengan
menggunakan splint berlapis atau dengan imobilisasi langsung berkenaan
dengan bodi menggunakan selempang dan alat petak.
• The upper arm usually is 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
Velcro-type of dressing. Pain Control
 Pain Control
• Analgesics are indicated for joint injuries and
fracture
• The appropriate use of splints significantly
 Associated Injuries
TABLE 8.4 Injuries Associated with Musculoskeletal Injuries
INJURY MISSED/ASSOCIATED INJURY
Clavicular fracture Major thoracic injury, especially
Scapular fracture pulmonary contusion and rib fractures
Fracture and/or dislocation of shoulder
Displaced thoracic spine fracture Thoracic aortic rupture
Spine fracture Intraabdominal injury
Fracture/dislocation of elbow Brachial artery injury Median, ulnar, and
radial nerve injury
Femur fracture Femoral neck fracture Posterior hip
dislocation
Posterior knee dislocation Femoral fracture
Posterior hip dislocation
Knee dislocation or displaced tibial plateau Popliteal artery and nerve injuries
fracture
Calcaneal fracture Spine injury or fracture
Fracture-dislocation of hind foot
Tibial plateau fracture
Open fracture 70% incidence
of associated nonskeletal injury
 Steps to ensure recognition and management of these injuries
include:
1. Review the injury history
2. Thoroughly reexamine all extremities
3. Visually examine the patient’s dorsum, including the spine
and pelvis.
4. Review the x-rays obtained in the secondary
 Occult Skeletal Injuries
• Remember, not all injuries can be diagnosed
during the initial assessment and
management of injury. Joints or bones that
are covered or well padded within muscular
areas may contain occult injuries. It can be
difficult to identify nondisplaced fractures or
joint ligamentous injuries, especially if the
patient is unresponsive