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

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Musculoskeletal Traumain Polytrauma Victims

Kris Arnold, MD, MPH


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

ABC…

  • 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

  • Pelvis fracture severity based on breaking ring structure

Image Source: http://basicxray.blogspot.com/2009/08/normal-pelvic-anatomy.html


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 http://www.radsource.us/clinic/0806


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 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

Binding force at level of trochanters

Image source: Michael T. Archdeacon, MD http://www.aaos.org/news/aaosnow/jul09/clinical8.asp


Pelvic Fracture Stabilization

C-clamp


Pelvic Fracture Management

  • Rule out urethra injury

    • Retrograde urethrogram (RUG)


Musculoskeletal Injury Management During Secondary Survey

History

  • Mechanism of extremity injury

    • Direct blunt force

    • Crush

    • Fall

  • Initial extremity positioning


Extremity Injury Assessment

  • Look

    • Undress completely

    • Deformity

    • Swelling

  • Listen

    • Pain

    • Crepitance

  • Feel

    • Crepitance

    • Abnormal mobility


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

Extremity Vascular Injury Evaluation

Evaluate Distal Perfusion

Compromised

“Normal”

Realign

Immobilize

Compromised

“Normal”

Reevaluate Distal Perfusion


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

  • Realign and splint as for closed


Upper Extremity Nerve Injury


Lower Extremity Nerve Injuries


Crush Injury

  • Compartment syndrome

  • Rhabdomyolysis


Compartment Syndrome

  • Lower Extermity

    • Lower leg

    • Thigh

    • Gluteal

    • Foot

  • Upper Extremity

    • Forearm

    • Hand


Compartments Lower Leg


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)


Fasciotomy


Rhabdomyolsysis

Trauma

Fractures and Crush Injurues

Electrocution/ Thermal Burns

Burned Muscle

“Tea colored” urine

Heme + urinalysis dip

No red blood cells on microscopic


Small but Important


Posterior Knee Dislocation


Posterior Hip Dislocation


Reduction Posterior Hip Dislocation


Anterior Hip Dislocation


Thank You


Questions??


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