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ACS

Musculoskeletal
Trauma
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ACS

Objectives
Recognize and describe the significance of
musculoskeletal injuries.
Outline assessment priorities to identify
life and limb-threatening injuries.
Outline principles of management.
Demonstrate ability to assess, assign
priorities to, and initially manage injuries.
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ACS

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 !
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ACS

Primary Survey / Resuscitation

Recognize and control hemorrhage

Direct pressure
Splint fractures
Aggressive fluid resuscitation
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ACS

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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ACS

Primary Survey/ Resuscitation

Adjuncts : x-rays
Determined by patients condition
Obtain AP pelvis early if
hemodynamically abnormal and
no obvious source of bleeding
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ACS

Secondary Survey

History
Mechanism of injury
Environment
AMPLE history
Prehospital care
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ACS

Secondary Survey
Physical Examination
Expose / avoid hypothermia
Goal: Identify life- and limb-threatening,
and occult injuries
Examine
Skin Neuromuscular
Circulation Skeletal
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ACS

Secondary Survey

Look
Bleeding deformity, color
Posteriorly using modified log roll
Spontaneous movement
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ACS

Secondary Survey

Feel
Temperature, tenderness, crepitus
Sensation
Joint stability
Back and pelvis: Tenderness, gap
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ACS

Secondary Survey
Circulatory Evaluation
Color, temperature
Pulse pressure, capillary refill
Paresthesia
Doppler: Ankle / arm ratio
Bruit / thrill
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ACS

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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ACS

Life- Thereatening Injuries

Major pelvic disruption with hemorrhage

Major arterial hemorrhage
Crush syndrome (rhabdomyolysis)
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ACS

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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ACS

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

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ACS

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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ACS

Crush Syndrome

Myoglobinuria
Metabolic acidosis, K , Ca and
coagulopathy
Compartment syndrome
IV fluids, alkalization of urine
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ACS

Limb- Threatening Injuries

Open fracture and joint injuries

Vascular injuries
Compartment syndrome
Neurologic injury
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ACS

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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ACS

Vascular Injury, Amputation

Variable presentation : Assess pulses
Associated with fracture / dislocations
Realign
Check pulses after splinting
Immediate surgical consult
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ACS

Compartment Syndrome

Crush Injury with Compartment Syndrome

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ACS

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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ACS

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
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ACS

Pitfalls

Occult injuries
Occult blood loss

Compartment syndrome
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ACS

Question
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ACS

Summary
Primary Survey : Identify life-threatening
injuries
Secondary Survey : Identify limb-
threatening injuries
Mechanism of Injuries : History important
Surgical consult
Early immobilization