WELCOME TO

© 2006 by : Andre Yanuar, Darmadji Ismono

One week internship in dept. of
orthopaedic & traumatology
• Ward-Clinic-OR-Emg
• Morning visits (Monday & Thursday) at 6
a.m
• Morning report (Tuesday,Wednesday &
Saturday) at 7 a.m
• Grand Round (Tuesday)
One week internship in dept. of
orthopaedic & traumatology
• Journal reading & referat (Monday &
Thursday) at 7 a.m or 7.30 a.m
• Apley reading (Tuesday & Friday) at 1.30
p.m
• Pre assessment (Thursday) at 1.30 p.m
• Assessment (Friday) at 7.00 a.m
• CSS, BST, Mini CX
 In Emergency Room…
• Assess all trauma patient for possibility of orthopaedic case!
• If the patient need operation  prepare as soon as possible!
1. Informed consent (resident do, co-ass ask for ps or fam’s signature)
2. Tell to fast at least 6 hours prior to op
3. Make IV line
4. Tetanus prophilactic
5. Antibiotic & analgetic
6. Blood check (SYSMEX for < 40 y.o, complete for > 40 y.o and < 14 y.o)
7. Urine check
8. Cross match & blood reservation in blood bank
9. EKG ( for > 40 y.o)
10. Chest X-Ray, with expertise for < 14 y.o
11. Complete the medical record ! (under resident supervision)
12. IPD or paediatric consultation ( for > 40 or < 14, sometimes no
need)
13. Anesthesiology consultation
Introduction

Orthopaedics is
concerned with bones,
joints, muscles, tendons
and nerves – the
skeletal system and all
that makes it move
Introduction
Scope : Subdivision :
• Congenital & developmental • Traumatology
abnormalities
• Infection & inflammation • Orthopaedi :
• Arthritis & rheumatic 1. Adult Reconstruction
disorders 2. Oncology Orthopaedic
• Metabolic & endocrine
disorders 3. Pediatric Orthopaedic
• Tumours 4. Spine
• Sensory disturbance & 5. Hand & Microsurgery
muscle weakness
• Injury & mechanical
derangement
Introduction
Steps in orthopaedic diagnosis:
1. History taking
2. Physical Examination
* Posture
* Gait
1. Inspection
2. Palpation
3. Examination of movements
4. Conduction of special tests
3. Further investigations
1. Examination of radiographs
2. Examination of blood, sinovial fluid, etc
Inspection
• Is there swelling?
• Is there bruising?
• Is there any discoloration, or edema?
• Is there muscle wasting?
• Is there any alteration in shape or posture,
or is there evidence of shortening?
Inspection
Palpation
• Is the joint warm?
• Is there tenderness?
• How is the artery
pulse?
Movements
• Active ROM
• Passive ROM
• Fixed deformities
• Restriction of ROM
• Movements in abnormal plane
• Crepitus
• Strength of muscle contraction
• Gait
Movements
Conduction of Special Test
• Integrity of certain
joint ligaments
• Examination of
structures associated
with the joint
• Appropriate
neurological
examination
Examination of Radiographs
• Soft tissue
• Bone : shape, size, contour
• Alignment
Examination of Radiographs
• Comparison films
• Oblique projections
• Localized views
• Stress films
Arranging Further Investigations
• ESR, CRP
• Full blood count with differential
• Estimation of RF
• Serum calcium, phosphate & AP
• Serum Uric Acid
• Chest X-Ray
Equipment Requirements
• A tape measure
• A goniometer
• A tendon hammer
• A disposable sharp point
WHAT IS POLYTRAUMA ?
 Objectives
 Establish the principles for assessing the
patient with musculoskeletal injuries.
 Establish treatment priorities.
 Identify the importance of musculoskeletal
injuries in the multiply injured patient.
Emergency in Orthopaedic
• Emergency : trauma cases
- Life threatening
- Limb treatening
• 85 % of blunt trauma affect
musculoskeletal system
• Life saving before limb
saving
Key Questions
• How do musculoskeletal injuries
impact on the primary survey?
• What are my priorities?
• What are my management principles?
Assessment of the Polytrauma Patient
Primary Survey
– A irway with cervical spine control
– B reathing
– C irculation with control of hemorrage
– D isability (neurological state)
– E xposure (take the patient clothes off)
 Primary survey management

The 3 S’s
 Stop the bleeding!
 Splint the extremity
 Stabilize the pelvis
Primary Survey & Resuscitation

 Recognize and control hemorrhage

• Direct pressure
• Splint fractures
• Fluid resuscitation
BE AWARE OF REPERFUSION
INJURY!
Primary Survey & Resuscitation

Adjuncts : Fracture immobilization

 Goals

• Hemorrhage control
• Pain relief
• Prevent further soft tissue injury
 Apply splint early, but avoid delay in

resuscitation.
 Be careful in dislocation
Primary Survey & Resuscitation
Adjuncts : X-Rays
 Determinited by patient’s condition

 Obtain AP pelvis early if hemodynamically

abnormal and no obvious source of

bleeding
Secondary Survey
• History
AMPLE

• From Head to toe examination

• Every orifice must be examined
• Don’t forget the back!
Secondary Survey

 Look
 Feel
 Listen
For What?
 For What?
Look Feel
 Deformity  Crepitus
 Pain  Skin flaps
 Tenderness  Neurologic
 Wound(s) deficit
 Pulses

Listen
Doppler signals
Bruit
Life- Threatening Injuries
 Major pelvic disruption with hemorrhage
 Major arterial hemorrhage
 Crush syndrome (rhabdomyolysis)
Life Threatening
Musculoskeletal Trauma
Pelvic Trauma with Massive Bleeding
• Posterior pelvic structures disrupted
• Pelvis open : vessels, nerves,rectum, skin
• Mechanism of injury
– Motorcycle
– Pedestrian
– Crush
– Falls > 12 feet (3.6 meters)
Life Threatening
Musculoskeletal Trauma
Pelvic Trauma with Massive Bleeding
Life Threatening
Musculoskeletal Trauma
Pelvic Trauma with Massive Bleeding
 Pelvic
Wrapping
Life Threatening
Musculoskeletal Trauma
Main Arterial Rupture
1. Trauma
- sharp, blunt
2 Examination
- Artery pulse, Doppler
- Ankle / brachial index
3. Management
- Pneumatic tourniquet
- Vascular clamp?
- Traction, Splint
Life Threatening
Musculoskeletal Trauma
Crush Syndrome
 Myoglobinuria
 Metabolic acidosis, ↑K,
↓Ca and coagulopathy
 Compartment syndrome
 IV fluids, alkalization of
urine
Limb- Threatening Injuries
 Open fracture and joint injuries
 Vascular injuries
 Compartment syndrome
 Neurologic injury
 What are my early concerns?

 Vascular compromise
 Open fractures
Limb Threatening
Musculoskeletal Trauma
Open Fractures

 Apply appropriate splint

 Cleanse / debride (now or later)
 Consider time factor
 Obtain orthopaedic consult
Limb Threatening
Musculoskeletal Trauma
Open Fractures

Classifying the injury

Gustilo’s classification (Gustilo et al, 1990)
Open Fracture grade 1
Open Fracture grade 2
Open Fracture grade 3A
Open Fracture grade 3B
Open Fracture grade 3C
Limb Threatening
Musculoskeletal Trauma
Open Fractures
Principles of treatment
• Objectives :
- Prevention of infection
(sepsis/osteomyelitis)
- Promote bone healing
- Restoration of function
Limb Threatening
Musculoskeletal Trauma
Open Fractures
Principles of treatment
• 4 essentials are :
1. Wound irrigation & debridement
2. Antibiotic prophylaxis
3. Stabilization of the fractures
4. Early wound coverage
Open Fracture
Complicated case
Not proper initial management
Limb Threatening
Musculoskeletal Trauma
Vascular Trauma & Traumatic Amputation

 Reduce fracture(s)
 Splint fracture(s)
 Assess by Doppler
 Obtain consult (time
is critical)
 Consider
angiography
Limb Threatening Musculoskeletal Trauma
Vascular Trauma & Traumatic Amputation
Limb Threatening Musculoskeletal Trauma
Vascular Trauma & Traumatic Amputation

Management
• Muscle necrosis : 6 h
• Warm & Cold Ischemic
• Reimplatantation &
Revascularization
• Proper amputee
management!
Limb Threatening
Musculoskeletal Trauma
Compartement Syndrome
• Fractures of the arm or leg  ischemia
• Infarcted muscles  fibrous tissue
(Volkmann’s ischemic contracture)
Limb Threatening
Musculoskeletal Trauma
Compartement Syndrome
Clinical features
• Elbow, forearm bones, 1/3 prox.
of tibiae, multiple fractures of
the foot or hand, crush injuries
& circumferential burns
• Five Ps
• The presence of a pulse does
not exclude the diagnosis
• Be careful in unconscious
patient !
Limb Threatening
Musculoskeletal Trauma
Compartement Syndrome

Treatment
• Decompression
• Open fasciotomi
Limb Threatening
Musculoskeletal Trauma
Dislocations
• Displacement of bone from normal joint

• Location : hip, shoulder, elbow, finger,

patella, knee, ankle, acromioclavicular

• Sign : loss of normal shape &

loss of movement
Posterior Hip Dislocation
Neurologic Injury
 Due to fracture /dislocation
• Posterior shoulder : Axillary nerve
• Posterior hip : Sciatic nerve
 Recognize injury and immobilize
 Early orthopaedic consult

Careful reduction, if possible →
reassess and splint
Limb Threatening
Musculoskeletal Trauma
Massive skin avulsion
Abdominal flap following
skin avulsion of the hand
Limb Threatening Musculoskeletal Trauma
Massive skin avulsion
‘Kelirumologi’ in Fracture
Management
Pitfalls

 Occult injuries
 Occult blood loss
 Compartment syndrome
Case 1 : Male, 40 y.o
ICD 9-CM 79.63, 93.44
Question
Summary
 Primary Survey : Identify life-threatening
Injuries
 Secondary Survey : Identify limb-
threatening injuries
 Mechanism of Injuries : History important
 Orthopaedic consult
 Early immobilization
Spine and Spinal
Cord Trauma
Objectives
 Evaluate for suspected spinal injury.
 Appropriately manage spinal injury.
 Determine appropriate patient disposition.
Suspect Spinal Injury
 High-Speed Crash
 Unconscious patient
 Multiple injuries
 Neurologic deficit
 Spinal pain / tenderness
Spinal Injury

 ≥ 5% of Patients worsen neurologically at

hospital
 Protection — priority
 Detection — secondary
 Spinal evaluation complicated by brain
injury
 Remove spine board as soon as possible
Cord injury Severity
 Complete : No motor or sensory
function↓ below injury level
 Incomplete :
• Any motor or sensory preservation ↓
injury level
• Sacral sparing may be only residual
function
Sensory Examination

Cervical Thoracic Lumbosacral

C-5 Deltoid T-4 Nipple L-4 Medial Leg
C-6 Thumb T-8 Xiphoid L-5 1st/2nd toes
C-7 Middle T-10 Umbilicus S-1 Lateral foot
finger T-12 S-4 Perianal
C-8 Little finger Symphysis
Motor Examination

Cervical / Thoracic Lumbosacral

C-5 Shoulder abduction L-2 Hip flexion
C-6 Wrist Extension L-3 Knee extension
C-7 Elbow extension L-4 Ankle dorsiflexion
C-8 Middle finger flexion L-5 Big toe extension
T-1 Little finger S-1 Big toe / ankle
abduction plantar flexion
Neurologic Assessment
Neurogenic Shock
 Hypotension associated with cervical /

high thoracic spine injury

 Bradycardia

 Treatment : Maintenance fluids,

atropine and occasionally vasopressors

Case : Male, 37 y.o
Cervical Fracture with Neurogenic Shock
Case : Male, 37 y.o
Cervical Fracture with Neurogenic Shock
Case : Male, 37 y.o
Cervical Fracture with Neurogenic Shock
Case : Male, 37 y.o
Cervical Fracture with Neurogenic Shock
Neurologic Assessment
Spinal “Shock”
 Neurologic Not hemodynamic

phenomenon
 Occurs shortly after cord injury

 Flaccidity

 Loss of reflexes

 Bulbocavernosus reflex (-)

Neurologic Assessment
Effect on Other Organ Systems
 Inadequate ventilation

 Abdominal evaluation compromised

 Occult compartment syndrome

Classifications of injury
Levels of injury
 Clinical exam

• Most caudal
• Normal bilaterally
• Motor / sensory function
 Bony : Site of vertebral column damage
Classification of Injury

Incomplete Complete
 Any sensation  No motor /

 Position sense sensory function

 No sacral sparing
 Voluntary

 May have
movement in
lower extremity reflexes
 Sacral sparing
Classifications of Injury

Spinal Cord Syndromes

 Central cord

 Anterior cord

 Brown – Sequard

 Posterior cord

 Conus medullaris

 Cauda equina
Classification of Injury

Morphology
 Fracture or fracture / dislocation

 Spinal cord injury without radiographic

abnormality (SCIWORA)
 Penetrating
Classification of Injury

Morphology
 Consider unstable if :

• X-ray evidence of injury

• Neurologic deficit
• Severe pain on spine movement or
palpation
X-ray Guidelines
 Adequacy
 Alignment
 Bony abnormality
 Base of skull
 Cartilage , Contours
 Disc space
 Soft tissue
C-spine x-rays
 Cross table lateral film excludes 85% of
fracture
 Additional 2 views excludes most fractures
 Also may require
• Swimmers view
• CT scan for bony detail
• MRI/CT myelogram
• Open mouth view
C – Spine X-rays
 10% of patients with a C-spine fracture
have a 2nd, associated noncontiguous
vertebral column fracture
 Identify one abnormality ?
 Look for another!
 Radiographic screening of entire spine
required in this instance
 Screening for Spinal Injury
Conscious Patient
Presence of
paraplegia/quadriplegia

Presume spinal instability

Identify bony Early

fracture subluxation orthopaedic consult
Screening for spinal injury
Alert,sober, neurologically normal
patient :

1. If no neck or spine
pain or tenderness to
palpation or voluntary No further spine
movement evaluation or c-spine
x-ray necessary
2. If no painful
3. If still no pain or tenderness
Remove C-colar
with voluntary movement
distracting injury
Screening for Spinal Injury
Alert, sober, neurologically normal patient :

 Neck or spine pain  If “ yes” to any

or tenderness to question
palpation or • Protect c-spine
voluntary • Obtain
movement ? necessary
 After removal of c- • x-ray exams
collar ?
Screening for Spinal Injury
Altered LOC
 Radiographic visualization of entire spine

 Plain films

 CT scan of suspicious areas

Screening for Spinal Injury
 Radiographic : Normal x-rays
 Clinical :
• Normal Neurologic exam and
• Absence of spinal pain/tenderness

Drugs,alcohol
distracting
injuries may mask an
injury
Management
Immobilization
 Entire Patient

 Proper padding

 Maintain until spine

injury excluded
 Avoid prolonged

use of backboard!
Medical Management
 Ensure adequate ventilation especially for
high level (C-4) quadriplegic
 Maintain blood pressure
 Atropine as needed for bradycardia
 Methylprednisolone
Medical Management
Intravenous Fluids
 Treat hypovolemia first

 Consider neurogenic shock

 Insert urinary catheter

Medical Management

Steroids
• IV Methylprednisolone
• Proven spinal cord injury
• Start within 1st 8 hours from injury only
• 30 mg/kg over 15 minutes
• 5.4 mg/kg over next 23 hours (if < 3 h)
• 5.4 mg/kg over next 47 hours (if 3-8 h)
Proven in blunt trauma only
Medical Management

Transfer
 Unstable fractures

 Neurologic deficit

Avoid delay
 Properly Immobilized

 Respiratory support as needed

Male, 27 y.o

•MVA victim
•Referred to RSHS from Cikampek

Hospital without cervical

protection.
•He was unable to move his lower
leg & upper extremity
Questions
Is This Cervical X Ray Normal?
Summary
 Treat life threatening injuries first
 Immobilize
 Appropriate spine films
 Document examination
 Orthopaedic consult
 Transfer unstable fracture /cord injury