MUSCULOSKELETAL

TRAUMA: CURRENT CONCEPT

Ali Abdullah, MD
Orthopaedic Surgeon

Online Lecture, 08 December 2021

Rumah Sakit Islam Jakarta - Pondok Kopi
 Presentation Outline

Introduction Soft Tissue Compartment

Injuries Syndrome

Initial
Fractures
Management
 Introduction

Trauma :
• Injuries which are caused by external force or violence.
• They may range from minor to major, obvious to not apparent, single
injury to multiple.
• Bone/articular cartilage  Fracture
• Joint  Dislocation
• Soft tissue  Soft tissue injuries
 Introduction

SAVE LIFE BEFORE LIMB

 Initial Management
The ATLS Protocol (Primary Survey)

• A irway maintenance with cervical spine protection

• B reathing and ventilation
• C irculation with hemorrhage control
• D isability (assessment of neurological status)
• E xposure and environmental control

Life threatening conditions are identified and simultaneous management is required

Adjuncts to primary survey:
Lateral projection cervical X-Ray, Thorax X-Ray, Pelvis X-Ray, Femur X-Ray, and
FAST.
 Initial Management
The ATLS Protocol (Secondary Survey)
• If patient already stable Adjuncts to secondary survey:
• Complete history and PE Other X-Ray and CT-Scan

- History  AMPLE
- PE: Head to toe
Look
• Always re-evaluate the patient Swelling
Deformities
Open wounds

Feel
Localized pain
NVD functions
Crepitations

Move Crepitations
Abnormal movements
ROM
 Initial Management
Splinting

• Is the process of immobilizing & stabilizing painful, swollen,

deformed extremities

• Any object that can be used

for this purpose is considered
splint
 Initial Management
Splinting Why do we splint?

• To reduce pain

• Limit damage to soft tissues

• Limit internal & external bleeding

• Help relieve pressure against blood vessels

• Prevent closed fractures from becoming open fractures

 Soft Tissue Injuries

Contusion: soft tissue injury produced by blunt force

Pain, swelling, and discoloration: ecchymosis

Strain: pulled muscle-injury to the musculocutaneous unit

Pain, edema, muscle spasm, ecchymosis, and loss of function are

on a continuum graded 1st , 2nd, and 3rd degree
 Soft Tissue Injuries

Sprain: injury to ligaments and supporting muscle fiber around a

joint
Joint is tender and movement is painful; edema, disability, and
pain increase during the first 2 to 3 hours

Dislocation: articular surfaces of the joint are not in contact

A traumatic dislocation is an emergency with pain change in
contour, axis, and length of the limb and loss of mobility
 PRICE
Protection Stopping activity immediately and
protect the injured part for additional
damage.
Rest Rest the area to allow the tissues time to
heal.
Ice Reduces swelling and pain
Compression Keep swelling to a minimum
Elevation To reduce the blood flow and swelling
to the area.

PRICE, within the first 48 hours after injury occurs will help to initially relieve pain,
reduce swelling and promote the healing process.
 Fractures

Types of Fractures

• Complete
• Incomplete
• Closed or simple
• Open or compound/complex
• Grade I
• Grade II
• Grade III (A, B, C)
 Fractures

TREATMENT OF FRACTURE

• RECOGNITION

4R •
•
•
REPOSITION

RETAINING

REHABILITATION
 Fractures

Look Feel
• Bruises
• Pain
• Crepitation
• Swelling • Pressure pain
• Fragment of bone are visible • Pulse
form outside • Temperature of distal
• Deformity part
• Length • Sensory
• Angulation
• Rotation

Move
• Active
• Passive
• Power
• Functio laesa
• False movement
• Locked joint
 Fractures

• Splinting: joints distal and proximal to the suspected fracture site must be supported
and immobilized
• Open fracture: cover with sterile dressing to prevent contamination

• X-ray

• “fracture configuration
& planning of definitive treatment” ,
prognosis.

• 2 VIEWS (AP-lateral)

• 2 JOINTS (proximal & distal)

• 2 SIDES (IF Necessary)

• Special order
 Fractures

Choices of Risk and Benefit

Treatment

Available
Treatment Modality

Patient Profile
Characteristic of Fracture
 Fractures

1. PROTECTION alone On upper

Undisplaced, stable fracture extremity

2. IMMOBILIZATION alone
“ Unstable but
acceptable”
 Fractures

3. Closed Reduction and

Immobilization

“ Unacceptable and
Unstable”
 Fractures

4. Closed Reduction With

Continuous Traction
Closed reduction against
muscle traction

5. Closed Reduction &

Functional Fracture Bracing
 Fractures

6. Closed Reduction + External Fixation

• Severe soft tissue damage

7. Closed Reduction + Closed Pinning

• Femoral neck fracture in children
• Colles fracture

8. Open Reduction and Internal Fixation (ORIF)

• Open reduction followed by plating and nailing
 Fractures

9. Excision of Fracture Fragment and

Replacement by an Endoprosthesis

• Partial joint replacement or Total

joint replacement

Bipolar THR
 Fractures

OPEN FRACTURES
• Five different types of open
fractures:

• Cuts-smooth/jagged

• Punctures

• Avulsions

• Amputations

• Crush injuries
 Fractures

PRINCIPLES OF MANAGEMENT

• PREVENTION OF INFECTION
• SOFT TISSUE HEALING AND BONE UNION
• RESTORATION OF ANATOMY
• FUNCTIONAL RECOVERY

AO Principles of Fracture Management, 2000,

 Fractures

Gustilo, Burgess, Tscherne, the AO-ASIF group, recommended the

following steps for open injuries:

• Treat OF as emergencies
• Initial evaluation to diagnose life & limb-threatening injuries
• Appropriate antibiotic in the emergency OR and continue treatment for 2 to
3 days only
• Immediately debride the wound of contaminated and devitalized tissue,
copiously irrigate, repeat debridement within 24 to 72 hours
• Stabilize the fracture with the method determined at initial evaluation
• Rehabilitate the involved extremity aggressively
 Dislocation

• Dislocation is shifting of a joint

surface from another one, could
be complete or partial
(subluxation).
• Risk: avascular necrosis
• EMERGENCY
 Dislocation

• Symptoms : pain and

restrictive/obstructed joint
movement
 Dislocation

• Treatment
• Reposition ~ instability
• Immobilization ~ stable position
• Rehabilitation ~ stability, tissue healing

• Button hole dislocation

• Closed reduction vs open reduction
 Dislocation

• Neglected case is difficult to

reduce  soft tissue contracture
 surgical

• If closed reduction maneuver was

failed in acute phase 
possibility of button hole

• Closed reduction vs open

reduction
 Compartment Syndrome

Condition in which elevated

intramuscular pressure reduces local
blood flow and impairs function of the
tissues within that compartment
Compartment Syndrome

ETIOLOGY AND PATHOGENESIS

 Compartment Syndrome

INCREASED VOLUME OF THE COMPARTMENT CONTENTS

• FRACTURES
• SOFT TISSUE TRAUMA
• SURGICAL TREATMENT
• EXERCISE
• VASCULAR INJURY
• HEMATOMA
 Compartment Syndrome

DECREASED SIZE OF THE COMPARTMENT

• FASCIAL DEFECT/TIGHT DRESSINGS

• BURN INJURY
• EXTERNAL PRESSURES
• CASTS, SPLINTS , BURN ESCHAR, LYING ON LIMB FOR LONG
PERIOD, LITHOTOMY POSITION
 THE VICIOUS CYCLE OF
VOLKMANN'S ISCHEMIA
PATHOPHYSIOLOGY
intracompartmental Pressure ↑↑

Local venous Pressure ↑↑

narrowed AV perfusion gradient

compartment tamponade

capillary blood flow ↓↓

O2 deprivation

local tissue necrosis

S. Terry Canele. Campeell’s Operative Orthopedics Volume 3. 11th edition.

Philadelphia, Pensylvania. Mosby Elsevier, 2003. nerve injury & muscle ischemia
 Compartment Syndrome

PAIN OUT
OF PROPORTION
PARAESTHESIA
7 1 EARLIEST & MOST
RELIABLE SIGN

PAIN WITH
PARALYSIS 6 Compartment
2 PASSIVE STRETCHING
Syndrome
is a clinical diagnosis

PALLOR
5 3 PAIN
4
PULSELESSNESS
Clifford R. Wheeles, Wheeless' Textbook of Orthopaedics
Duke Orthopaedics : North Calorina, 2013.
Compartment Syndrome

A solid-state transducer
intracompartmental catheter (STIC)
• More accurate and reliable
• Can monitor ICP for u p to 16 hours
 Compartment Syndrome

Normal tissue pressure

• 0-4 mmHg
• 8-10 with exercise

Absolute pressure
theory
• 30 mmHg - Mubarak
• 45 mmHg - Matsen

Pressure gradient
theory
• Difference 10 - 30 mmHg of
diastolic pressure 
compromise perfusion
• Whitesides, McQueen,et al
 Step 1.
Intramuscular pressure decreases by cutting all dressings that give external compression.

Step 2.
Local perfusion pressure in the leg increases when elevation of the injured limb is concluded.

Step 3.
Mean arterial pressure increases by treating hypovolemia.

Step 4.
Surgical treatment by acute fasciotomy normalizes intramuscular pressure.

Step 5.
Treatment of post ischemic reperfusion prevents crush syndrome from developing.

Step 6.
Post ischemic swelling following fasciotomy may be reduced by early active edema reduction.
Thank You