Musculoskeletal trauma in polytrauma victims
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Musculoskeletal Trauma in Polytrauma Victims. Kris Arnold, MD, MPH. Musculoskeletal Trauma in Multitrauma Patients. 85% of multi trauma patients have musculoskeletal trauma Rare immediate threat to life or extremity viability Indicator of risk for torso injury

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Musculoskeletal trauma in polytrauma victims

Musculoskeletal Traumain Polytrauma Victims

Kris Arnold, MD, MPH

Musculoskeletal trauma in multitrauma patients

Musculoskeletal 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

Musculoskeletal injury issues during primary survey

Musculoskeletal 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

Pelvic fractures

Pelvic Fractures

  • Pelvis fracture severity based on breaking ring structure

Image Source:

Pelvic fractures1

Pelvic 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

Pelvic fractures2

Pelvic 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

Pelvic fractures3

Pelvic 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

Emergency pelvic fracture stabilization

Emergency Pelvic Fracture Stabilization

Binding force at level of trochanters

Image source: Michael T. Archdeacon, MD

Pelvic fracture stabilization

Pelvic Fracture Stabilization


Pelvic fracture management

Pelvic Fracture Management

  • Rule out urethra injury

    • Retrograde urethrogram (RUG)

Musculoskeletal injury management during secondary survey

Musculoskeletal Injury Management During Secondary Survey


  • Mechanism of extremity injury

    • Direct blunt force

    • Crush

    • Fall

  • Initial extremity positioning

Extremity injury assessment

Extremity Injury Assessment

  • Look

    • Undress completely

    • Deformity

    • Swelling

  • Listen

    • Pain

    • Crepitance

  • Feel

    • Crepitance

    • Abnormal mobility

Initial fracture management

Initial 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.

Angulated fracture management during prehospital management

Angulated Fracture Management during Prehospital Management

Extremity Vascular Injury Evaluation

Evaluate Distal Perfusion







Reevaluate Distal Perfusion

Extremity fracture assessment

Extremity Fracture Assessment

  • Imaging

    • Plain x-rays

    • Two views

      • Anterior-posterior

      • Lateral

        • Must be correctly aligned

    • Image one joint above and below

      • Maissoneuve

Open fractures

Open Fractures

  • Realign and splint as for closed

Upper extremity nerve injury

Upper Extremity Nerve Injury

Lower extremity nerve injuries

Lower Extremity Nerve Injuries

Crush injury

Crush Injury

  • Compartment syndrome

  • Rhabdomyolysis

Compartment syndrome

Compartment Syndrome

  • Lower Extermity

    • Lower leg

    • Thigh

    • Gluteal

    • Foot

  • Upper Extremity

    • Forearm

    • Hand

Compartments lower leg

Compartments Lower Leg

Compartment syndrome clinical evaluation

Compartment 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)






Fractures and Crush Injurues

Electrocution/ Thermal Burns

Burned Muscle

“Tea colored” urine

Heme + urinalysis dip

No red blood cells on microscopic

Small but important

Small but Important

Posterior knee dislocation

Posterior Knee Dislocation

Posterior hip dislocation

Posterior Hip Dislocation

Reduction posterior hip dislocation

Reduction Posterior Hip Dislocation

Anterior hip dislocation

Anterior Hip Dislocation

Thank you

Thank You



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