KEGAWATAN

MUSKULOSKELETAL
TRAUMA
Dr. Su Djie To Rante, Sp.OT

FK UNDANA
 Unstable Pelvis Fracture
• Unstable fracture of pelvis represent a major
therapeutic challenge in orthopaedic trauma
• The initial survival of the patient will depend on
prevention of death fromhemorrhage
adequate replacement for blood lost, and
control ongoing bleeding
• In most cases, hemorrhage in the pelvis will stop
with time and natural tamponadereplacement
of loss is adequate for survival
 Unstable Pelvic Fracture
• Commonly exhibit disruption of the posterior
osseus-ligamentous(sacroiliac,
sacrospinous,sacrotuberous)~sacroiliac fracture,
sacral fracture
• Unexplained hypotension may be the only
indication of major pelvic disruption
• Physical signs: progressive flank, scrotal, perianal
swelling and bruising
• Mechanical instability, is test by manual
manipulation (should be performed only once!)
• Sign of instability:
– leg length discrepancy or rotational deformity usually
external
– Open wound in flank, perinium, rectum
• Management
– Hemorrhage control and rapid fluid resuscitation
– Pelvic C-clamp
– Longitudinal skin or skeletal traction
– Pelvic sling
– PASG
– Open pelvic fracturepacking the open wound
 Major Arterial Hemorrhage
• Injury:
– Penetrating wound
– Blunt trauma
• Assesment:
– Loss of palpable pulse/changes in pulse quality
– Change in Doppler quality
– Cold, pale, pulseless
– Rapidly expanding hematoma
• Management
– Application of direct pressures to the open wound
– Aggressive fluid resuscitation
– Pneumatic torniquet
– Vascular clamp is not recommended unless
superficial vessel is clearly identified
– If a fracture is associated with an open
hemorrhaging wound, fracture should be
realignment and splinting
 Crush Syndrome
• Synonime: ~ TraumaticRhabdomyolysis
~ Bywaters’ Syndrome
• Serious medical condition characterized by
major shock and renal failure following a
crushing injury to skeletal muscle
• Pathophysiology: muscle damagerelease the
product of rhabdomyolysis(myoglobin, K,
P)reperfusion injury
 Crush Syndrome
Patophysiology of Crush Syndrome

Prolonged Compression of Limb

Fluid Increased
Extravasation Compartment
Pressure

Hypovolemia
Rhabdomyolisis

Acute Tubular Necrosis

Renal Failure
 Crush Syndrome
• Diagnosis criterias:
1. Crushing injury to a large mass of skeletal muscle
2. The sensory and motor disturbances, tense and
swollen
3. Myoglobinuria and/or hematuria
4. Peak creatine kinase (CK) > 1000 U/L
 Crush Syndrome
• Treatment: prevention of hypovolemia and
ARF
– Fluid resuscitation:
– Cristaloid 2 liter
– NaCl 0,9% 1-1,5 ltr/hrs
– Sodium bicarbonate: 50-100 mEq/l alkaline
diuresis (pH urine >6,5)
– Manitol 20%: osmotic diuresis, initial 25 g  5g/hr
• Amputation
• Fasciotomy: controversial
• Hyperbaric Oxygen Therapy
 Compartment Syndrome
• Is a devastating condition that occurs when the pressure in a
close fascial space rises enough to occlude capillary blood
flow, rendering the enclosed muscles and nerves ischemic
• The causes:
1. Bleeding into a compartment from arterial injury
2. Infiltration of fluid
3. Overly tight bandages
4. Swelling of the muscle due to injury
5. Reperfusion after ischemia
6. Burns
7. Prolong pressure
8. Marked and prolong elevation of the extremity
 Compartment Syndrome
Etiologies of CS
– Decrerased Compartment Size:
• Crush syndrome
• Closure of fascial defect
• Tight dressing or cast
• External pressure(PASG or direct pressure)
– Increased Compartment Content:
• Bleeding
• Edema
• Postischemic swelling
• Exercise
• Trauma
• Burn
• Intra arterial drug
• Orthopaedic surgery or trrauma
• Venous obstruction
The Causes of Compartment Syndrome
 Compartment Syndrome
• Occurs most commonly in the calf and
forearm, but may also in thigh, buttock, foot,
hand, or upper arm
Compartment Syndrome

Compartment of the Lower Leg

 Compartment Syndrome
• Increase pressure of progressive edema within
osteofascial compartment
• Edemaincrease pressurecompromise
capillary blood flowmore edema: vicious
cycle
• Periferal nerve: 2-4 hrsregenerate
• Muscle :>6 hrs can’t regenerate
 Compartment Syndrome
• Etiology
– Proximal(extracompartmental)occlusion of main artery
supplying the compartment
– Intracompartment injury:bone or soft tissue or both
• The injury~CS
1. Displace supracondyler fracture
2. Excessive longitudinal traction for femur fracture
3. Fr.of prox. Tibia
4. Drug induce coma
 Compartment Syndrome
• Clinical picture: 6~P
1. Pain
2. Pallor
3. Puffiness
4. Paresthesia
5. Paralysis
6. Pulselessness
 Compartment Syndrome
• Early Diagnosis is essential, because early
treatment restore blood flow and prevents
irreversible ischemia and resultant muscle and
nerve necrosis
• The earliest, most consistent, and most reliable
sign is deep, unrelenting, vague but progressive
PAIN that is out of proportion to the injury and
not responsive to normal doses of pain
medication
 Compartment Syndrome
• The pain is exacerbated by passive motion
stretch of the involve muscles
 Compartment Syndrome
• Diagnostic
– 6~P
– Intracompartment pressure, normal: 0 – 8 mmHg (CS>
30 mmHg)
– Diastolic pressure-compartment pressure </= 30 mmHg

• Treatment
1. Cast and bandage must be completely removed
2. Distorsion of fracture limb of extreme position or nearby
joint should be lessened
3. Traction should be decreased
4. Surgical: fasciotomy.
 Compartment syndrome

Fasciotomy of the Lower Leg

 Open Fracture
• Are fractures in which a breach in the overlying
skin forms, allowing contamination of bone
and tissues
• High risk for infection and other complications:
nonunion, delayed union, malunion
• The primary determinant of risk level is
severity of the associated soft tissue injury
 Open Fracture
• Classification: Gustilo&Anderson
– Type ~ I
• A clean wound <1 cm
• No significant muscle necrosis or stripping of periosteum
• Relatively low energy trauma
– Type ~ II
• A laceration 1-10 cm, without extensive soft tissue
damage, skin flaps or avulsions, no stripping of
periosteum
– Type ~ III
• Extensive laceration or soft tissue damage >10cm
• Gross contamination and/or high energy fracture pattern
 Open Fracture
• Type ~IIIA
– Extensive lacerations or soft tissue flaps, or
– Lesser skin lesions with gross contamination, an or
high energy fracture pattern
• Type ~IIIB
– Significant stripping of periosteum and muscle from
bone, and frequently require some type of soft tissue
flap
 Open Fracture
• Type~ IIIC
– Fractures have a major vasculer or nerve injury
that requires repair for the limb to be save
Type~I of Open Fracture of the Lower Leg
Type~II Open Fracture of the Lower Leg
Type~III Open Fracture of the Fore Arm
Type~IIIC Open Fracture of Femur
 Open Fracture
• Treatment
1. Cleansing the wound
2. Excision of Devitalized Tissue (Debridement)
3. Treatment of fracture
4. Closure of the Wound
5. Antibacterial Drugs
6. Prevention of Tetanus
 Dislocation of Shoulder
• Anterior dislocation of shoulder is one of the
most common presenting problem to the
emergency department
• 50% of all major joint dislocation
• 3 type of ant. dislocation:
– Subclavicular
– Subcoracoid
– subglenoid
 Dislocation of Shoulder
• Clinical picture of ant. dislocation
– The arm held to the side
– Acromion is prominent and loss of normal rounded
contour of the shoulder
– Abduction and external rotation of the arm and
resist any attempts at internal rotation and adduction
 Dislocation of Shoulder
• Treatment: close reduction,
– Stimson’s Technique
– Traction and counter traction
– Hippocratic Technique
– Milch’s Technique
• Complication
– Tear of rotator cuff
– Avulsion of greater tuberosity
– Brachial plexus or axillary nerve injury
– Instabilityreccurrence (the most common
complication)
Closed Reduction of Shoulder Dislocation
 Dislocation of the Hip
• Hip dislocation require large forces
• Frequently associated with acetabular fracture or
ipsilateral extremity injuries
• 25% associated with knee injury, and 4% with
ipsilateral femoral fractures
• Must be regarded as true emergencies and
reduced promptly in order to minimize the
incidence of avascular necrosis of the femoral
head
 Dislocation of Hip
• Posterior dislocations are the more common
than anterior blow to the knee with the hip
and knee in flexion
• Anterior dislocation: abduction-external
rotation-flexion
• Posterior dislocation: adduction-internal
rotation-extension (limb shortening)
Dislocation of Hip
Dislocation of Hip
 Dislocation of Hip
• Treatment:
– Close reduction under general anesthesia
– Traction
• Complication
– Avascular necrosis of the femoral head: 15% of 17
months to 2 years
– Sciatic nerve contusion
– Traumatic arthritis
 Dislocation of Hip

Closed Reduction of the Dislocation of the Hip

 Dislocation of Knee
• Traumatic knee dislocation is a true emergency
with or without vasculer disruption
– 25% -30% associated with vascular injury
– 10% associated with nerve injury
• Associated ligament disruptions are better
managed operatively in young active patient
• Late instability is common in closed dislocation
• Limited motion is common in open dislocation
 Dislocation of Knee
• Classification
– Anterior dislocation: most common
– Posterior dislocation
– Superior dislocation
Dislpcation of Knee
Anterior and Posterior Dislocation of the Knee
 Dislocation of Knee
• Treatment:
– Close reduction under general anesthesia
• Ant. dislocations: longitudinal traction and lifting
the femur up to tibia
• Post..dislocations: tibia is lifted up to the femur
– Immobilized in a direct opposite to the dislocation
– Immobilized in circular cast for 6 weeks slight
flexion
– If ligament repair is done, immobilization period is
shorter, and ROM exercises may be started early in
cast brace
 Dislocation of Knee
• Complication:
– Peroneal nerve injury: 5%
– Degenerative joint disease with arthritis
– Persistent joint instability