Musculoskeletal

Emergency

Purwoko Sugeng H.

Incidence/Mortality/Morbid
ity
Occur

in 70-80% of all multi-trauma

patients
Blunt or Penetrating
Upper extremity rarely lifethreatening
may result in long-term impairment
Lower

extremity associated with

more severe injuries
possibility of significant blood loss
femur, pelvic injuries may pose life-threat

Incidence/Mortality/Morbid
ity
Problem

is not just the bone injury

Other injuries caused by the injured

bone
Soft tissue
Vascular
Nervous system
Decreased function

Prevention Strategies
Sports

Training
Seat Belt use
Child Safety Seat use
Airbag use
Gun Safety and Education
Motorcycle education and
protective equipment
Fall prevention
Can you think of others?

Musculoskeletal System
Function
Support
Protection

of vital organs
Locomotion
Production of RBC
Storage of minerals

Musculoskeletal
Structures
Skin
Muscles
Bones
Tendons
Ligaments
Cartilage

Bones
Living

tissue
Consists of cells which deposit
calcium, phosphorus on
protein matrix
Constantly remodels itself
Able to repair damage without
formation of scar tissue

Bones
Structural

form for body

Protection
Point

of attachment for tendons,

ligaments, cartilage and muscles
Allows for movement
Storage of minerals
Produce red blood cells

Skeletal System
Components

Axial

Skeleton

forms the central axis of the body

includes skull, vertebral column, bony thorax
Appendicular

Skeleton

limbs
Pectoral

girdle

bones that attach the upper limbs to the

axial skeleton
Pelvic

girdle

paired bones of the pelvis that attach the

lower limbs to the axial skeleton and sacrum

Long Bone Anatomy

Periosteum

Outer fibrous covering

Allows for increase in
diameter
Vascular
Nerves
Epiphysis

Articulated, widened end

Allows bone to lengthen
Cancellous bone with red
blood marrow

Fracture
Break

in continuity of bone
Closed
Overlying skin intact
Open

Wound extends from body surface to

fracture site
Produced either by bones or object
that caused Fx
Danger of infection
Bone end not necessarily visible

Mechanism of Injury
Direct

Break occurs at point of impact

Indirect

Force is transmitted along bone

Injury occurs at some point distant to
point of impact
Femur, hip, pelvic fracture due to
knees hitting dash

Mechanism of Injury
Twisting

Distal limb remains fixed

Proximal part rotates
Shearing, fracturing occur
Football. skiing accidents
Avulsion

Muscle and tendon unit with attached

fragment of bone ripped off bone
shaft

Mechanism of Injury
Stress

Occur in feet secondary to prolonged

running or walking
Pathological

Result of Fx with minimal force

Cancer, osteoporosis

Fracture Descriptions
Open

vs Closed
X-Ray descriptions
greenstick
oblique
transverse
comminuted
spiral
impacted
epiphyseal

Types of Fractures
Complete
Incomplete
Closed

or simple
Open or compound/complex
Grade I
Grade II
Grade III

16

Problems Associated with

Musculoskeletal Injuries
Hemorrhage
Interruption

of Blood Supply

Disability
Instability
Soft

Tissue injury

Complications associated
with Fractures
Hemorrhage

Possible loss within first

2 hours
Tib/Fib - 500 ml
Femur - 500 ml
Pelvis - 2000 ml

Interruption

Supply

of Blood

Compression on artery
decreased distal pulse

Decreased venous return

Complications of Fractures
Acute Compartment Syndrome
Serious

condition in which increased

pressure within one or more
compartments causes massive
compromise of circulation to the area
Pathophysiologic changes sometimes
referred to as ischemia-edema cycle
A hallmark sign is pain that occurs or
intensifies with passive ROM
Pain continues to increase despite the
administration of opioids and seems
out of proportion to the injury

Emergency Care (Continued)

Elevate

extremity to the level of heart

Remove cast
Fasciotomy may be performed to relieve
pressure.
Pack and dress
the wound after
fasciotomy.

Other Complications of Fractures

Shock
Fat

embolism syndrome: serious

complication resulting from a fracture;
fat globules are released from yellow
bone marrow into bloodstream
Venous thromboembolism
Infection
Ischemic necrosis
delayed union, nonunion, and malunion

Possible Results of Acute Compartment

Syndrome
Infection
Motor

weakness
Volkmanns contractures:

(a deformity
of the hand, fingers, and wrist caused by a lack
of blood flow (ischemia) to the muscles of the
forearm)

Musculoskeletal Complications

(continued)

Muscle

Atrophy, loss of muscle

strength range of motion, pressure
ulcers, and other problems
associated with immobility
Embolism/Pneumonia/ARDS
TREATMENT hydration, albumin,
corticosteroids
Constipation/Anorexia
UTI
DVT

Complications associated
with Fractures
Disability

Diminished sensory or motor function

inadequate perfusion
direct nerve injury

Specific

Injuries

Dislocation
Amputation/Avulsion
Crush Injury (soft tissue trauma
discussion)

Sprains/Strains
Sprain

tearing of ligaments surrounding joint

Strain

overstretching of muscle or tendon

Musculoskeletal
Assessment
Initial

Assessment

ABCDs
Life threats managed first
Dont overlook life/limb threatening
musculoskeletal trauma
Dont be distracted by gross but
non-life/limb threatening
musculoskeletal injury

Musculoskeletal
Assessment
The six Ps of musculoskeletal
assessment
Pain
on palpation
on movement
constant

Pallor - pale skin or poor cap refill

Paresthesia - pins and needles sensation
Pulses - diminished or absent
Paralysis
Pressure

Musculoskeletal
Assessment
Vascular

injury should be
suspected in all Fxs/dislocations
Evaluate with 5 Ps
Pain
Pallor
Pulselessness
Paresthesias
Paralysis

Musculoskeletal
Assessment
History

of Present Injury

Where is pain felt?

What occurred? What position was
limb in?
Were deceleration forces involved?
Was there direct impact?
Has there ever been previous trauma
or Fx?

Musculoskeletal
Assessment

Palpation

and Inspection

Swelling/Ecchymosis
Hemorrhage/Fluid at site of trauma

Deformity/Shortening of limb
Compare to other extremity if norm is
questioned

Guarding/Disability
Presence of movement does not rule out
fracture

Musculoskeletal
Assessment
Palpation

and Inspection

Tenderness
Use two point fixation of limb with
palpation with other hand.
Tenderness tends to localize over injury
site.

Crepitus
Grating sensation
Produced by bones rubbing against each
other.
Do not attempt to elicit.

Musculoskeletal
Assessment
Palpation

and Inspection

Exposed bones
Fx can be open without exposed bones

Principal danger is not to bones, but

to underlying neurovascular
structures around bone.

Musculoskeletal
Assessment
Palpation

and Inspection

Distal to injury, assess:

skin color
skin temperature
sensation
motor function

If uncertain, compare extremities

When in doubt splint!

Musculoskeletal
Assessment
Because

orthopedic injuries have

low priority in multiple systems
trauma, all Fxs may not be found
in field
Long Board
Splints every bone and joint
No loss of time
Focus on critical conditions

Key Point
Orthopedic injuries are seldom
immediately life threatening.
Tend to other issues first.
Only immediately life threatening
orthopedic injury is Pelvic Fx due to
potential massive hemorrhage

Management - General
Immobilization

Objectives

Prevent further damage to

nerves/blood vessels
Decrease bleeding, edema
Avoid creating an open Fx
Decrease pain
Early immobilization of long bone
fractures critical in preventing fat
embolism

Management - General
Principles

of Fracture
Management
Splint joint above, below
Splint bone ends
Loosely cover open fracture sites
Neurovascular assessment
before and after splinting

Gentle in-line traction of long

bone
maintain normal alignment if
possible
reduction of angulated fracture site

Management - General
Principles

(cont)

of Fracture Management

Position of function
Pain management
Body

Splinting

In urgent patient, entire body is

stabilized by using a long board
Lower extremity fractures can be
splinted as one to the long board

Fracture of Clavicle and

Immobilization Device

39

Immobilizers for Proximal

Humeral Fractures

40

Functional Humeral Brace

41

Stable Pelvic Fractures

Most

fractures of pelvis heal rapidly

because the pelvic bones has a rich
blood supply

42

Unstable Pelvic Fractures

43

Management - General
Pain

Management

Avoid pain management until

head/thoracic injury is ruled out
Appropriate for isolated
musculoskeletal injuries
(fracture/sprain/dislocation)
Morphine sulfate titrated to pain
relief without compromising adequate
BP and ventilations

Dislocations
Displacement

of bone end from

articulating surface at joint
Pain or pressure is most common
symptom
Principal sign is deformity
May experience loss of motion of
joint

Dislocations
Nerves,

blood vessels pass very

close to bone. Pressure on these
structures can occur
Checking distally essential
Pulse presence
Pulse strength
Sensation

Management Dislocations
Principles of fracture/dislocation
management

Usually splinted in position of injury

Neurovascular assessment before, after
splinting
Attempt realignment of dislocations if
distal circulation is impaired
long transport

Discontinue realignment if pain increased

significantly or resistance is encountered
Immobilize proximal. distal joints and bones
Analgesia, possible cold application

Sprains
Stretching.

tearing of ligaments
surrounding joint
Occur when joint is twisted beyond
normal range of motion
Most common = Ankle

Sprain Management
Characteristics

Pain
Tenderness
Swelling
Discoloration
Typically

does not manifest deformity

Ice, compression, elevation,
immobilize
When in doubt, splint
Consider analgesia

Strains
Tearing,

stretching of
musculotendonous unit.
Spasm, pain on active movement
Usually no deformity, swelling
Pain present on active movement
Avoid active movement, weight
bearing

Traumatic Amputation
First

priority - ABCs

Bleeding from stump usually not a

problem
Next

priority is to save limb

COLD
WATER

Traumatic Amputation
Management
Control

Bleeding

Elevate
Apply

direct pressure to stump

Avoid tourniquet except as last
resort

Traumatic Amputation Limb Management

Place

in saline moist gauze

Place in plastic bag
Place bag on ice
Do not
Warm amputated part
Place part in water
Place directly on ice
Use dry ice

Hemorrhage Management
Direct

Pressure

Most effective method

Pressure bandage
Elevation

Combination with direct pressure

Pressure

Point

Brachial, Femoral, Carotid

Tourniquet

last resort
rarely required

Tourniquet
Last

resort, but do not wait too long.

Use flat wide material
BP cuff
Close to the wound as possible
Do not remove
Leave in plain view
Note time applied and clearly
communicate during transfer of care

Fracture Goal and Care

Reduction and Immobilization
Immobilize: to retain reduction or
anatomical alignment
Reduction: medical procedure to restore a
fracture or dislocation to normal
alignment. Needed for displaced fractures.
Reduction:

Closed Reduction
Open Reduction

Anatomical Alignment of
Fractures
Closed

Reduction
Nonsurgical
Traction/counter
traction
Under local
anesthesia
(joint block) or
conscious
sedations

Bobjgalindo, Wikimedia Commons

Anatomical Alignment of
Fractures
Open

Reduction

Surgical
Wires, pins,
screws
Internal fixation
External fixation
*ORIF: Open
reduction
internal fixation

Source undetermined, E-Radiography

External Fixation
Pin

care
Infection risk
Pain control

Source undetermined, Journal of Bone and Joint Surgery

Common musculo-skeletal
problems
Hypovolemia
Impaired

bone integrity

Pain
Impaired

physical mobility
Self-care deficits

Thank you.