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Musculoskeletal Trauma
in Polytrauma Victims
Musculoskeletal Trauma
in Polytrauma Victims
Kris Arnold, MD, MPHKris Arnold, MD, MPH
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Musculoskeletal Traumain Multitrauma PatientsMusculoskeletal Traumain Multitrauma Patients
• 85% of multi trauma patients have musculoskeletal trauma
• Rare immediate threat to life or extremity viability
• Indicator of risk for torso injury• Common cause of prolonged or permanent
disability if not treated properly
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Musculoskeletal Injury Issues During Primary SurveyMusculoskeletal Injury Issues During Primary Survey
• Bleeding from open fractures • Bleeding from closed long bone
fractures– Humerus 1-2 units blood – Femur 3-4 units blood
• Bleeding from pelvic fracture – May be exsanguinating
• Vascular & Neurologic injury from dislocations
ABC…
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Pelvic FracturesPelvic Fractures
• Pelvis fracture severity based on breaking ring structure
Image Source: http://basicxray.blogspot.com/2009/08/normal-pelvic-anatomy.html
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Pelvic FracturesPelvic Fractures
• Type A – No instability of ring– Avulsion of single bone – low risk
• Rehabilitation – progressive weight-bearing• Late surgical intervention
Image source: Michael E. Stadnick, M.D http://www.radsource.us/clinic/0806
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Pelvic FracturesPelvic Fractures
• Type B • Disruption anteriorly and posteriorly with
intact posterior ligaments• Problems
– Rotational instability– Increased risk of bleeding– Associated injuries
• Urethra• Pelvic organs• Abdominal organs
Open Book
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Pelvic FracturesPelvic Fractures
• Type C• Anterior and posterior disruption with
disruption of posterior sacro-iliac complex– Rotational and vertical instability– High risk of bleeding– High risk associated injuries
• Urethral• Pelvic organs• Abdominal organs
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Emergency Pelvic Fracture StabilizationEmergency Pelvic Fracture Stabilization
Image source: Michael T. Archdeacon, MD http://www.aaos.org/news/aaosnow/jul09/clinical8.asp
Binding force at level of trochanters
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Pelvic Fracture StabilizationPelvic Fracture Stabilization
C-clamp
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Pelvic Fracture ManagementPelvic Fracture Management
• Rule out urethra injury– Retrograde urethrogram (RUG)
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• Mechanism of extremity injury– Direct blunt force – Crush – Fall
• Initial extremity positioning
Musculoskeletal Injury Management During Secondary SurveyMusculoskeletal Injury Management During Secondary Survey
History
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Extremity Injury AssessmentExtremity Injury Assessment
• Look– Undress completely– Deformity– Swelling
• Listen– Pain– Crepitance
• Feel– Crepitance– Abnormal mobility
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Initial Fracture ManagementInitial Fracture Management
• Angulated – realign & stabilize– Prevent further soft tissue injury– Reduce pain– Potentially decrease bleeding
Photo source: Bush LA, Chew FS. Subtrochanteric femoral insufficiency fracture in woman on bisphosphonate therapy for glucocorticoid-induced osteoporosis. Radiology Case Reports. [Online] 2009;4:261.
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Evaluate Distal Perfusion
“Normal”
Immobilize Realign
Compromised
Reevaluate Distal
Perfusion
“Normal” Compromised
Extremity Vascular Injury Evaluation
Angulated Fracture Management during Prehospital ManagementAngulated Fracture Management during Prehospital Management
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• Imaging– Plain x-rays– Two views
• Anterior-posterior• Lateral
– Must be correctly aligned
– Image one joint above and below• Maissoneuve
Extremity Fracture AssessmentExtremity Fracture Assessment
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Open FracturesOpen Fractures
• Realign and splint as for closed
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Upper Extremity Nerve InjuryUpper Extremity Nerve Injury
Injury Nere Motor Sensation
Elbow Ulnar Index finger abduction Little finger
Wrist dislocation Median (distal) Thenar contraction with opposition
Index finger
Supracondylar humerus (children)
Median (anterior interosseous)
Index finger tip flexion
Anterior shoulder dislocation Musculocutaneous Elbow flexion Lateral forearm
Distal Humeral shaft/Ant. Shoulder dislocation
Radial Thumb, finger, metacarpal extension
1st dorsal web space
Anterior shoulder dislocation/proximal hmerus fracture
Axillary Deltoid Lateral shoulder
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Lower Extremity Nerve InjuriesLower Extremity Nerve Injuries
Injury Nerve Motor Sensation
Pubic rami fracture Femoral Knee extension Anterior knee
Obturator ring fractures Obturator Hip adduction Medial thigh
Knee dislocation Posterior tibial Toe flexion Sole of foot
Fibular neck fracture, knee dislocation
Superficial peroneal Ankle eversion Lateral dorsum of foot
Fibular neck fracture, compartment syndrome
Deep peroneal Ankle/toe dorsiflexion Dorsal 1st & 2nd web space
Posterior hip dislocation Sciatic nerve Plantar dorsiflexion Foot
Acetabular fracture Superior gluteal Hip abduction
Acetabular fracture Inferior gluteal Gluteus maximus hip extension
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Crush InjuryCrush Injury
• Compartment syndrome• Rhabdomyolysis
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Compartment SyndromeCompartment Syndrome
• Lower Extermity– Lower leg– Thigh– Gluteal– Foot
• Upper Extremity– Forearm– Hand
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Compartments Lower LegCompartments Lower Leg
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Compartment Syndrome Clinical EvaluationCompartment Syndrome Clinical Evaluation
• Pain out of proportion to injury or worsening• Pain with stretching involved muscles• Pain with using involved muscles• Possible decrease in sensation or paresthesias over or
distal to involved compartment• Late or inconsistent
– Loss of peripheral pulse– Loss of normal color – pale– Paralysis of involved muscles
• Tissue pressure >35-40cm H2O w/ normal systemic BP –lower w/ hypotension (normal <10cm H2O)
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FasciotomyFasciotomy
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RhabdomyolsysisRhabdomyolsysisRhabdomyolsysisRhabdomyolsysis
• TraumaTrauma• Fractures and Crush InjuruesFractures and Crush Injurues
• Electrocution/ Thermal BurnsElectrocution/ Thermal Burns• Burned MuscleBurned Muscle
• ““Tea colored” urineTea colored” urine• Heme + urinalysis dipHeme + urinalysis dip
• No red blood cells on microscopicNo red blood cells on microscopic
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Small but ImportantSmall but Important
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Posterior Knee DislocationPosterior Knee Dislocation
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Posterior Hip DislocationPosterior Hip Dislocation
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Reduction Posterior Hip DislocationReduction Posterior Hip Dislocation
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Anterior Hip DislocationAnterior Hip Dislocation
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Thank YouThank You
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Questions??Questions??