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

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

Pelvic Fractures

  • Pelvis fracture severity based on breaking ring structure

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


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


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 http://www.aaos.org/news/aaosnow/jul09/clinical8.asp


Pelvic fracture stabilization

Pelvic Fracture Stabilization

C-clamp


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

History

  • 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

Compromised

“Normal”

Realign

Immobilize

Compromised

“Normal”

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)


Fasciotomy

Fasciotomy


Rhabdomyolsysis

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

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


Questions

Questions??


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