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Management

Musculoskeletal

Trauma

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Musculoskeletal Trauma

Common, occasionally life-threatening

Major musculoskeletal injuries often

indicate other injuries

Hemorrhage, compartment syndrome

Crush syndrome, fat embolism are life-

and limb threatening problems

Continued reevaluation !

Trauma is not

rocket science!

ABCDEF

Initial Assessment: Primary

Survey

• A = Airway

• B = Breathing

• C = Circulation

• D = Disability

• E = Exposure

• F = Fracture

• Clear & establish a good airway

– Consider intubation for coma, shock, and thoracic injuries

• C-spine stabilization

Initial Assessment: Airway

Initial Assessment: Breathing

• Chest excursion & breath sounds

– Flail chest

• Pneumothorax

– Open

– Tension

• Massive Hemothorax

Initial Assessment: Circulation

• Perfusion (mental status, skin, pulse)

• Control bleeding with pressure

• Pericardial Tamponade

– Beck’s Triad

• Establish 2 large bore (16G or larger) IV’s

in upper extremity peripheral veins

• Resuscitate with Lactated Ringers

– After 4 L think about resuscitation with blood

Initial Assessment: Disability

• Neurologic status

– Glasgow Coma Scale

• Eye

• Motor-best predictor of long term outcome

• Verbal

– Spinal Cord Injury

Initial Assessment: Exposure

• Remove clothes

• Temperature

– warm blankets

• Finger and tube in every orifice

• Maintain full spine precautions

– Log Roll

Initial Assessment: Fracture

• Stabilize Fractures

• Relocate dislocated joints

• Reassess pulses

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Primary Survey / Resuscitation

Recognize and control hemorrhage

• Direct pressure

• Splint fractures

Aggressive fluid resuscitation

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Primary Survey Resuscitation

Adjuncts : Fracture immobilization

Goals

• Hemorrhage control

• Pain relief

• Prevent further soft-tissue injury

Apply splint early, but avoid delay in

resuscitation

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Primary Survey/ Resuscitation

Adjuncts : x-rays

Determined by patient’s condition

Obtain AP pelvis early if

hemodynamically abnormal and

no obvious source of bleeding

Secondary Survey

• Patient history

• Head to toe physical exam

• Radiography

– Lateral C-spine, C-xray, pelvis

– One cavity above/below entrance/exit wounds

– FAST

• Urinary bladder drainage

• NGT

• Blood sampling/monitoring

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Secondary Survey

History

Mechanism of injury

Environment

AMPLE history

Prehospital care

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Secondary Survey

Physical Examination

Expose / avoid hypothermia

Goal: Identify life- and limb-threatening,

and occult injuries

Examine

• Skin

• Circulation

• Neuromuscular

• Skeletal

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Secondary Survey

Look

• Bleeding deformity, color

• Posteriorly using modified log roll

• Spontaneous movement

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Secondary Survey

Feel

• Temperature, tenderness, crepitus

• Sensation

• Joint stability

• Back and pelvis: Tenderness, gap

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Secondary Survey

Circulatory Evaluation

Color, temperature

Pulse pressure, capillary refill

Paresthesia

Doppler: Ankle / arm ratio

Bruit / thrill

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Secondary Survey

X-ray

Guided by clinical findings

Joint above and below

Obtain 2 views

Delay x-rays if:

• Vascular compromise

• Impending skin breakdown

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Life- Thereatening Injuries

Major pelvic disruption with hemorrhage

Major arterial hemorrhage

Crush syndrome (rhabdomyolysis)

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Major Pelvic Disruption

Posterior pelvic structures disrupted

Pelvis open : vessels, nerves,rectum, skin

Mechanism of injury

• Motorcycle

• Pedestrian

• Crush

• Falls > 12 feet (3.6 meters)

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Major Pelvic Disruption

Assessment and Management

Hemorrhage occurs rapidly, identify

early

Unexplained hypotension

Open wounds, meatal blood, high

prostate, expanding hematoma

Palpable motion of pelvic ring

Hemorrhage control, fluid resuscitation

Management :

stabilization

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Stabilization for transport

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Operative procedures

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Major Arterial Hemorrhage

Penetrating / blunt injury in close

proximity to artery

Hemorrhage, hematoma, hypotension

Ischemic extremity

Stop the bleeding!

Immediate surgical consult

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Crush Syndrome

Myoglobinuria

Metabolic acidosis, K , Ca and

coagulopathy

Compartment syndrome

IV fluids, alkalization of urine

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Limb- Threatening Injuries

Open fracture and joint injuries

Vascular injuries

Compartment syndrome

Neurologic injury

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Open Fractures, Joint Injuries

Wide- spectrum of soft-tissue injuries

Open wound = Open fracture

Treatment

• Splint, sterile dressing, tetanus

• Immediate surgical consult

• Tetanus prophylaxis

• Antibiotics?

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Vascular Injury, Amputation

Variable presentation : Assess pulses

Associated with fracture / dislocations

Realign

Check pulses after splinting

Immediate surgical consult

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Compartment Syndrome

Crush Injury with Compartment Syndrome

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Compartment Syndrome

↑ Compartment pressure

Nerve / muscle ischemia → necrosis

Pain, paresthesia, paresis, swelling

Release constricting devices

Suspect in tibial, forearm fracture, after

revascularization, in unconscious patient

Early surgical consult

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Neurologic Injury

Due to fracture / dislocation

• Posterior shoulder : Axillary nerve

• Posterior hip : Sciatic nerve

Recognize injury and immobilize

Early surgical consult

Careful reduction, if possible, → reassess and splint

Traksi

Upaya pengobatan atau rehabilitasi pada

kelainan dan atau cedera sistem

muskuloskeletal dengan menggunakan

traksi (tarikan) padanya secara terus

menerus

Traksi

• Pada Tulang (Traksi Skeletal)

• Pada Kulit (Traksi Kulit)

• Traksi Menetap (Fixed Traction)

• Traksi Berimbang (Balanced Traction)

Tujuan Traksi

• Reposisi (pada fraktur / dislokasi)

• Imobilisasi (setelah reposisi)

• Mengkoreksi deformitas (mis. kontraktur)

• Mengurangi nyeri (Coxitis/Gonitis TB)

• Mencegah deformitas (Coxitis/Gonitis TB,

post poliomielitis)

Prinsip Traksi

• Ada tarikan dan ada kekuatan yang

melawan tarikan (Traksi-Kontra traksi),

kontra traksi yang digunakan biasanya

adalah gravitasi / berat badan pasien

• Traksi-Kontra traksi mengikuti hukum alam

• Traksi-Kontra traksi tidak menimbulkan

komplikasi

Komplikasi Traksi

• Komplikasi akibat tarikannya

– Spasmus pembuluh darah

– Kelumpuhan saraf

– Iskhemi kulit

• Komplikasi akibat perangkat traksi

– Infeksi akibat tusukan kawat/pin

– Alergi plester

Traksi Kulit

Alat : Skin Traction Kit pediatrik, adult

Jenis : plester dengan perekat

foam rubber tanpa perekat

Indikasi : Traksi < 10 lbs ( < 5 Kg )

Kontra indikasi : alergi plester, peny. Kulit

Komplikasi : dermatitis, gangguan

neurologis, gangg. vaskuler

Traksi Kulit

Traksi Tulang

Alat : Skrup/screw

Pin

Wire

Indikasi : traksi waktu lama

beban tarikan besar

Kontra indikasi relatif : anak-anak

Komplikasi : Infeksi, Kerusakan lempeng

pertumbuhan, gangguan neurologis

dan gangguan vaskuler

Traksi Tulang

• Bohler stirrup dg

Steinmann pin

• Denham pin

• Kirschner wire

strainer

Traksi menetap (fixed traction) • Traksi dg bidai Thomas (Thomas splint)

• Keseimbangan bersifat statik

• Digunakan pada transportasi/evakuasi

Arah

tarikan

Bag proksimal

terfiksasi pada paha

Traksi menetap (fixed traction)

Sliding Traction

Traksi Berimbang (balanced traction)

• Ada keseimbangan dinamik antara traksi dengan

kontra traksi

Traksi berimbang dengan bidai Thomas

Traksi berimbang dengan bidai Bohler

Traksi berimbang dengan Traksi Kulit

Bryant Traction

Umur < 2tahun

Berat badan 35-40 lbs

(15,9 – 18,2 Kg)

Komplikasi : gangguan

vaskuler

Traksi berimbang dengan traksi kulit

Buck Extension Traction

Traksi berimbang dengan traksi kulit

Hamilton Russel Traction

Olecranon Traction Dunlop Traction

Spinal Traction

Canvas Head Halter Crutchfield Tongs

Skull Traction

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Pitfalls

Occult injuries

Occult blood loss

Compartment syndrome

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Summary

Primary Survey : Identify life-threatening

injuries

Secondary Survey : Identify limb-

threatening injuries

Mechanism of Injuries : History important

Surgical consult

Early immobilization