MUSCULOSKELETAL TRAUMA

Dr Moh Adib Khumaidi, SpOT

Introduction
85 % of blunt trauma

Resuscitation priority is like another trauma

Reevaluation

Introduction
Millions of cases annually.

Multiple MOI :
Falls, Automobile collisions, Crashes, Violence, etc
Multi-system trauma

Rarely life threatening

Improperly treated can result permanent disability.

Anatomy & Physiology of the

Musculoskeletal System

Structures
Skin
Bones
Joints where bones interact

Muscles
Tendons - connect muscle to bone
Ligaments - connect bone to bone
Neurovascular

The Skeleton

Types of Muscles

The Neurovascular

FUNCTION

Protects organs

Allows for efficient movement

Stores salts and other materials needed for metabolism

Produces RBCis

Scaffolding / Support

Pathophysiology of the Musculoskeletal

System

Injuries to the Musculoskeletal System

Four basic types of musculoskeletal injuries are:
Strain - An extreme stretching or tearing of MUSCLE & / OR
TENDON.

Sprain - partial or complete tearing of LIGAMENTS and tissues at

the joint.

Dislocation - displacement or separation of a bone from its

normal position at the joint.

Fracture - a break or disruption in bone

closed - the broken bones do not penetrate the skin
open - the skin is pierced by broken bone fragments

Accident Scene..

Life before Limb !!

PRIORITY ?

Life threatening
Limb threatening

Primary Survey & Resuscitation

ABCDE
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
Bleeding control direct padding

Splinting bleeding
Fluid resuscitation

Adjunction in Primary Survey

Fracture immobilization
Traction anatomical position
Splint

Be careful in dislocation !

Primary Survey & Resuscitation

Adjuncts : X-Rays

Determinited by patients condition

Obtain AP pelvis early if hemodynamically abnormal and no

obvious source of bleeding

Secondary Survey
Physical Examination
Undress the patient
Component have to be examined :

1. Skin

2. Neuromuscular function
3. Circulatory state
4. Bone & ligament integrity
Dont forget the back!

Secondary Survey
Physical Examination
Look
Feel
Move

Life Threatening Musculoskeletal

Trauma

Pelvic Trauma with Massive Bleeding

Main Arterial Rupture

Crush Syndrome

Life Threatening Musculoskeletal

Trauma
Pelvic Trauma with Massive Bleeding

Examination
- hematoma : pelvic, skrotal,
perianal

- high riding prostate

- meatal bleeding
- leg length discrepancy

Pelvic Trauma with

Massive Bleeding

Life Threatening Musculoskeletal

Trauma
Pelvic Trauma with Massive Bleeding
Management
- Bleeding control & resuscitation

- PSAG
- Traction
- Pelvic sling

- Pelvic Open fracture padding with

tampon
- Pelvic wrapping

Pelvic Wrapping

Pelvic Trauma with Massive Bleeding

Pelvic Wrapping
ADVANTAGES

Easy to use
Rapid stabilization

Inexpensive

DISADVANTAGES
Non anatomical
Soft tissue pressure
Risk of visceral
Risk of Sacral root inj.

Pelvic Trauma with Massive Bleeding

PSAG
ADVANTAGES

Easy to use
Rapid
Reusable

DISADVANTAGES
Decrease vital capacity
Compartmental synd.
Exacerbate CHF

PELVIC C-CLAMP

Life Threatening Musculoskeletal

Trauma
Crush Syndrome
Mechanism
- Crush injury & long compression ;
thigh, leg
Examination
- Dark Urine
- Rhabdomiolisis hipovolemic,
metabolic acidosis, hipercalemia,
hipocalsemia & DIC
Management
- Fluid resuscitation & osmotic diuretic
- Alkalinization

Limb Threatening
Musculoskeletal Trauma

Open Fractures

Vascular Trauma & Traumatic Amputation

Compartement Syndrome
Dislocations

Open Fracture grade 1

Open Fracture grade 2

Open Fracture grade 3A

Open Fracture grade 3B

Open Fracture
grade 3C

Life Threatening
Musculoskeletal Trauma

Open Fractures
Principles of treatment
4 essentilals are :

1. Wound debridement
2. Antibiotic prophylaxis
3. Stabilization of the fractures
4. Early wound cover

Limb Threatening
Musculoskeletal Trauma
Open Fractures

Accident Site

Sterile Dressing
Reduction

Splinting

Limb Threatening
Musculoskeletal Trauma
Open Fractures

Resuscitation !

Emergency Room

Limb Threatening
Musculoskeletal Trauma
Open Fractures

Examination
Clinical examination
Vascular status
Neurolgic status
X-ray diagnostics

Emergency Room...

Limb Threatening Musculoskeletal Trauma

Vascular Trauma & Traumatic Amputation
History & Examination ?
Time & Initial Management ?
Crush Or Sharp Wound ?

Vascular Trauma &

Traumatic Amputation
Can We Replanted ?
Proper amputee management!
Immediate orthopaedic consult

Limb Threatening
Musculoskeletal Trauma Compartement
Syndrome
Increased Pressure Within
Rigid Osteofascial Compartement
Threaten the Circulation To The Enclosed (Intracompartmental)
Muscle, Nerve, And Vascular

Limb Threatening
Musculoskeletal Trauma Compartement
Syndrome
Clinical features
Five Ps
Pain
Pallor
Paraestesia
Pulseless
Paralysis
Also Check for :

- Out of proportion Pain !

- Pain on Passive Stretching

Limb Threatening
Musculoskeletal Trauma Compartement
Syndrome

Treatment

Decompression by
Open fasciotomy

Joint Dislocations
Displacement of bone from normal joint

Location : hip, shoulder, elbow, finger, patella,

knee, ankle, acromioclavicular

Sign :

loss of normal shape & movement

Always Check For

Neurovascular Injury !

ELBOW DISLOCATION

SHOULDER DISLOCATION

HIP DISLOCATION

Penyembuhan fraktur tergantung pada :

Integritas Jaringan lunak sekitar fraktur

Suplai darah ke tulang

Derajat kontaminasi bakteri
Konfigurasi fraktur
Usia
STABILITAS ujung-ujung fraktur

PRINSIP
PENANGANAN
FRAKTUR

REHABILI

RETAIN

TATION

REDUCE

RECOGNIZE

RECOGNIZE
Tegakkan Diagnosa !

History : Riwayat Trauma ( trivial fall ?? )

Pemeriksaan fisik : tanda fraktur
- Look : bengkak, luka, deformitas
- Feel : Nyeri , NVD
- Move : pastikan gerakan2 pada bagian distal
X Ray : AP, Lat ( 2D)

RECOGNIZE
Gejala yang menyertai :

- Numbness/ weakness
- Skin pallor/ cyanosis
- Blood in urine
- Abdomen pain
- Transient loss of consciousness

REDUCE
Pergeseran fragmen +

Reduce = reposisi
Reposisi tertutup : manipulasi w/o bedah
Reposisi terbuka : manipulasi w/ bedah

RETENTION
Stabilisasi / immobilisasi / fiksasi daerah fraktur

External : bidai , gips, Orthosis , external fixator

Internal : Implant Orthopaedi ;
- extra medular
- intra medular

PRIMARY CARE PHYSICIAN MUST KNOW

Treat common fractures
Refer fracture to specialist / hospital (

ER )

Emergency
Open Fractures

Dislocation/ Subluxation
Closed Fractures w/ NV problems
Spine fractures

Summary

Primary Survey : Identify life-threatening

Injuries

Secondary Survey : Identify limb-threatening injuries

Proper immobilization

Early Orthopaedic consultation

CEDERA SPINAL

Trauma Tulang Belakang

Trauma multipel Cedera

vertebra & medula spinalis

15% cedera diatas klavikula :

cedera servikal

5% cedera kepala : cedera

vertebra

Cedera vertebra :
55% cedera servikal
15% cedera torakal
15% cedera torakolumbal
15% cedera lumbosakral

Pendahuluan
Cedera disingkirkan dengan :
Sadar : neurologis normal & sakit / nyeri tekan (-)
Tidak sadar : pem. radiologis

Kesalahan penanganan dapat memperburuk

kerusakan neurologis dan prognosa.

Curiga cedera :
Imobilisasi adekuat
Long spine board : transportasi, dilepas secepatnya
Log rolling / 2 jam : mencegah dekubitus.

Anatomi Vertebra
Kolumna Vertebralis :
7 vertebra servikal,
12 torakal,
5 lumbal,
sakrum &
koksigeus.

Anatomi Vertebra
Bagian :
Anterior : korpus, diskus
intervertebralis,
ligamentum longitudinal
anterior dan posterior.
Posterior : pedikel,
lamina, sendi faset,
ligamentum
interspinosus dan
muskulus paraspinalis.

Pemeriksaan
Sensibilitas

C5

: area diatas deltoid

C6

: jempol

C7

: jari tengah

C8

: jari kelingking

T4

: papila mamae

T8

: xifosternum

T10 : umbilikus

T12

: simfisis

L4

: medial betis

L5

: web jari kaki I - II

S1

: lateral pedis

S3

: tuberositas iskhii

S4 & S5 : perianal

Pemeriksaan
Motoris
C5

: Abduksi bahu

C6

: Ekstensi wrist

C7

: Ekstensi siku

C8

: Fleksi jari tangan

T1

: Abduksi kelingking

L2

: Fleksi panggul

L3

: Ekstensi lutut

L4

: Dorsifleksi ankle

L5

: Ekstensi jari kaki I

S1

: Fleksi ankle

(+) Otot sfinger ani eksterna (colok

dubur)

Gradasi kekuatan Otot

0 : Kelumpuhan total

1 : Teraba kontraksi
2 : Gerakan tanpa menahan gaya berat
3 : Gerakan melawan gaya berat
4 : Gerakan melawan gaya berat dengan

tahanan kurang dari normal

5 : Kekuatan normal

Syok Neurogenik dan Syok Spinal

Syok neurogenik
Akibat kerusakan jalur simpatis

Vasodilatasi viseral dan

ekstermitas bawah : hipotensi

Atoni simpatis jantung :
bradikardia
Responsif thd resusitasi cairan
(-)
Vasopresor : mempertahankan
perfusi jaringan
Atropin : mengatasi bradikardia

Syok spinal
Terjadi setelah cedera medula

spinalis
flasid dan arefleksia

Lama berlangsungnya

bervariasi
Efek terhadap organ lain :
Hipoventilasi ; paralisis otot

interkostal
Paralisis otot diafragma (cedera

C3-C5)
Anestesia ; dapat menutupi

cedera lain

Pengelolaan Umum
Imobilisasi
Sejak fase pra rumah sakit.
Meliputi bagian atas & bawah dari lokasi cedera

Dipertahankan s/d cedera disingkirkan.

Posisi netral : terlentang tanpa rotasi / fleksi-ekstensi

Bila tdp deformitas, jangan direduksi.

Kolar semirigid tidak menjamin stabilisasi, perlu penyangga

tambahan pada long spine board.

Bila dilakukan intubasi : pada posisi netral.
Gelisah / agitasi : sedativa / pelumpuh otot.

Pengelolaan Umum
Cairan intravena
Dibatasi untuk maintenance, kecuali pada syok.
Syok neurogenik : vasopresor

Kateter schwann ganz : monitor cairan.

Kateter urine : monitor urin.

Pipa nasogastrik
Mengosongkan lambung & mencegah aspirasi.

Pengelolaan Umum
Obat-obatan
Metilprednisolon, pd 8 jam pertama, dosis :
30 mg/kgBB dalam 15 menit pertama.

5,4 mg/kgBB/jam untuk 23 jam berikutnya.

Transfer
Dilakukan setelah KU stabil

Telah difiksasi : bidai / backboard / kolar

Bila pernafasan tidak adekuat : intubasi

 Thoracolumbosacral orthosis (TLSO) fabricated from a

body cast mold:

Anterior (A), lateral (B), and posterior (C) views of a patient

fit with a custom. Note the contouring over the iliac crests.

PEDICLE SCREW SUBLAMINARY

WIRING

PEDICLE SCREW PLATING

SYNTHES SYSTEM

Cervical Plate