Med III 2014-2015

Introduction
to

Musculo-Skeletal Trauma

Professor K S Leung
Department of Orthopaedics and Traumatology

Clinical Management
History - list of differential diagnoses
Physical examination - cone down
the list - arriving diagnosis
Investigations - confirm the
diagnosis, assess severity, prognosis
Treatment - definitive, rehabilitation
Management of complications
Objectives
To understand the principles and
practice of acute trauma management
with special reference to
Musculoskeletal system.
To document and analyse the injuries
through physical and radiological
examinations.
An introduction to practical
management of injuries in
musculoskeletal system.
Happen only in children but not in adult. The bone is fractured but the wind stick
fracture. Some part of bone is not broken yet despite a big part fractured. This is
because of the periosteum. Ulna is more curved. Young's module. There is elastic
phase pull and release, go back to original place. and plastic phase.: pull and release

Characteristics
does not go back to original shape. For this bone it is plastic deformation.

Trochlear not yet fused thus a child.

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Work-related injuries
Injury on duty
construction sites, IOD
Injury in factory
is uncommon
given few factory
Not articulated to I capitalum. Thus a dislocation. Because of loss proportion.

Domestic injuries
Biggest share
Don't miss the
concurrent
children and elderly dislocation

Traffic accidents
high energy injuries
Assaults Less
common
Sports injuries
Patterns of Poly-trauma
70% cerebral injury
Musculoskeletal 60% thoraco-abd injury
Injuries
Posterior dislocation
90% with fractures!
Fractures - multiple
Dislocations - combinations
Soft tissue injuries
Multi-system injuries
External

Internal fixation Fracture dislocation. Totally detach Crushed muscle, loss of function
from soft tissue which provide blood even if fractures get fixed. Only
supply. Even if we fix it, a possible amputation works

Practical Approach to Patients

complication is AVN

with Musculoskeletal Injuries

Save Life
resuscitation..A, B, C.
Save Limb
detect and treat neuro-vascular injuries
Fix the fractures
early and speedy fixation
Rehabilitation
Clinical Examination
Inspection (Look)
Palpation (Feel)
Mobilisation (Move)
Auscultation
Most diagnoses can be made by careful
Inspection!

Inspection
Bruises
Swelling
Ischemia thus

Blisters cutting blood

supply. Thus
transudation.

Deformities
Abnormal
position Fracture blisters- always
indicate serious soft tissue
Bubbles of Trouble! injury! Need to exclude compartment
syndrome. 9 compartment in foot
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Need decompression of
compartment to save the
muscles.

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Necrotising fasciitis

Necrotising Fasciitis
Spread of infection from ankle up to thigh. If
uncontrolled, there is septicaemia.
 Inspection
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Dinner fork
deformity
!
Bruises on the
dorsum of
hand
!
Fracture of distal radius.

Colles
fracture

Inspection
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Complete dislocation of talus. Serious
injury: loss of soft tissue supply. Surface
bony
of talus is covered by mostly cartilage,
which is Avascular. Critical blood supply.
prominence ?

Inversion
Pan-talus dislocation

injury of
ankle
during a
Engorged vein. Extensive bruises.
football
match
Other signs of acute injuries ??
 Inspection
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Deformity
observed
in a tibial
fracture

Inspection
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Why a fracute at proximal femur always
present to us the external rotation due
to different of muscle pull.
An old
lady
with
history
of fall
at
home
Excessive external rotation Hip fracture !!
 Palpation
Discolouration. Inconsistent pulse: some
time good pulse, sometime bad pulse.
Peripheral Major arterial proximal damage. Need
nerve exam!! an angiogram
Final MB,
OSCE, EOMA

Tenderness
Swelling
Temperature
Distal pulses
Must be
Consistent
Neurovascular carefully and
injury
Capillary return systematically
Sensation done!!!

Mobilisation
Crepitus: Unconscious patient
Abnormal movements
Active movements
!

May be difficult in
acute stage
due to pain and
muscle spasm!
Acute Management
Advanced Trauma Life Support (ATLS)
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Airway maintenance
Fluid resuscitation
Imaging
Monitoring

Circulation
Commonest cause of hypotension

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Hypovolaemia-
0.5-1 L
hypotension
Haemorrhage -
internal or external
3-4L Intravenous fluid
Patient already
in shock therapy Monitor testament effect
Monitor urine output
1.5 - 2 L
Stop
1L
bleeding !
Blood loss in closed Pressure, bandaging, trap suit
fractures for pain control and stopping
bleeding.
 Skeletal Traction Pressure is proportional to
Tension / radius of cavity

Pain control
Stop bleeding - Laplace law P T/r
R increase, P decrease thus bleeding.
Prevent further damage
Facilitate subsequent
management P r
R
Prevent Fat embolism p
Bone marrow

Trap suit increase pressure

thus reduce bleeding

Fat stained black in

pulmonary capillary 19

Radiological Investigations
Confirm diagnosis
Define extend of injury
comminution and fracture pattern
Include joints proximally and distally
forearm and leg
Special views and stress views
Modalities
Plain films
CT scan
3-D Images
US For fluid in cavity, e.g.
Abdominal injury
MRI
Radiological Investigations

Plain X-rays
Ultrasound
CT Scan
Angiography

How to Describe Radiological Features of

Fractures

Which bone?
Which region?
Which view
Soft tissue status
Fracture pattern
Comminutions
Displacements
Other information K.S. Leung
2014-2015
 Example 1
Dorsal
Volar side

78 years old lady,

Fell on
outstretched
hand. Radial stool is
always more
distal than
ulnar styloid

Colles Fracture

Example 1
78 years old lady,
Fell on
outstretched
hand.
Dinner fork deformity
Normal easier
on flexion
then
dorsiflexion.
Now loss
articulation.

Colles Fracture
 Example 2
28 years old man
Right forearm
injury while driving
with elbow on the
window.
Loss of extension of wrist
Drop wrist! joint actively.

Open fracture of proximal radius,

Posterior Inter-osseous nerve
(PIN) palsy

Example 3

18 years old boy,

Arm wrestling
with his friend.
Fracture in 2 plain:
anterior and sagittal.
Usually low energy injury

Spiral fracture shaft of

humerus
 Holstein-Lewis Fracture

27

Example 4
45 yrs. old Squaring of shoulder--
anterior dislocation

woman, fell
from double
decker bed.
Complained
severe pain in
left shoulder.
Numbness
lateral upper
Mx: close reduction

arm 28
 Example 5

31 years old
motorcyclist,
hit a tree.
Remember pelvis is a ring, separation
comes in a pair.

Pubic Symphysis Diastasis

Pelvi-acetabular Fractures

Ureter

Severe
haemorrhage in
a closed pelvic
Bladder
fracture!! 3-4 L

30
 Example 6
Femur looks smaller and lesser trochanter is
hidden, thus internally rotated. And adducted.
35-years old
female dead
seat
passenger,
Head-on
collision in the
highway.

Posterior dislocation of hip

Anterior dislocated. Rare coz usually

more protected anteriorly. Extended,
abducted and externally rotated.

Flexion
Internal rotation
Adduction
 Example 7
86-years old
lady, slipped
and fell at
home.

neck-shaft angle

Intertrochanteric
fracture

Example 8

76-years old
lady, slipped
and fell at
home.
External rotation

Fracture neck of femur

 Fracture neck of femur very common

Prosthetics replacement . Or use screw for

internal fixation. Intrtrocahteric is extra
capsular.????

Example 9

46-years old
man, jumped
from 20 meters
height.
High energy injury coz this part of body is
strongest bone in body. Need to exclude injury in
other area
Fracture shaft of
femur-subtrochanteric with
comminutions
 Radiolucency: fat or air. This case is fat
Example 10 from marrow. Must be a break in bone

A 25 years old
man hit by car
on the lateral
side of his left
knee.
Marked
swelling noted
No external
wound
Diagnosis:
Sprained knee

Example 11
34 years old motorcyclist, fell during high
speed riding. He was admitted to the Accident
and Emergency Department one hour after the
accident. He was conscious, pulse 120/minutes,
BP 80/50 mm Hg.

Open segmental fracture of tibia

Open // segmental : always high enerygy
 Example 12

64 years old
lady,
eversion injury
of ankle in
market.
Difference in joint space at ankle joint: subluxation.
The bone may be displaced to form a radiopacity.

Tri-malleolar
fracture of ankle
 Secondary Survey
Odental fracture

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Systemic
Detailed
Repeated
Additional imaging

Spinal Injuries
All trauma patients are
assumed to have cervical
Usually post trauma have
spinal injuries hypotension and tachycardia
Neurogenic (Spinal) shock
! Hypotension and bradycardia
Coz not actual
blood loss but
damage on
Burst fracture sympathetic
loss of tone.
The heart does
not respond to
loss of blood
causing
Osteoporotic
hypotension.
Pelvic Fractures Bine the trochanter together to
bring pelvis together

Stabilisation of pelvis
Bed-sheet binder
`
External fixator
G - suite
Stop bleeding
Tamponade effect

Open Fracture
Contamination
Soft tissue trauma
Fracture
comminution
Bleeding
Limb survival?
Limb salvage?
Always demands
urgent treatment!
Emergency Treatment
Esp hip dislocation. If untreated up to 6 hours with peculiar blood supply of proximal femur,
then very high risk of AVN

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Life saving
Limb saving
arterial injuries
nerve injuries
Reduction of
dislocation
Open fractures
Stabilisation of
pelvis
Control haemorrhage

Timing of Orthopaedic
Surgery for Trauma
Early fixation of
fractures
Decreases adult
respiratory distress
syndrome (ARDS)
Decreases fat embolic
syndrome
Facilitates nursing care
Makes surgery easier
 Definitive Treatments
Major articular fractures
Complex fractures
Reconstructive surgery

Complications
Look for them proactively!
0.5-1 L

Acute phase 3-4L

Hypovolaemic shock 1.5 - 2 L

Definitive phase 1L

Infection
Late phase Blood loss in closed fractures

Organ failure
Surgical 14-19%
complications
Poor gaseous exchange and respiratory failure.
ARDS - 12-15%
Disturbance on physiology, loss of cellular
integrity and accumulate of interstitial fluid
thus lung edema and whitish lung in CXR.
Long Term Complications
Bone- osteomyelitis, deformities
Cartilage - osteoarthrosis
Tendon and ligaments -
adhesions, instability of joints
Muscles - atrophy
Nerve - paralysis

Life-long disabilities
Complication of unfixed posterior hip dislocation. Pelvis
tilted forward to undo the internally rotated and addicted
femur to walk.

Rehabilitation
A very important part of
management in patients with
musculoskeletal system injuries
Physical
Psychological
Social
FHKAM(Rehabilitation)
FHKCOS - Orth Rehabilitation
 END
Trauma Rounds for Medical Students:
Med III: Wednesday 8:30 AM Case rd;
Med V: Wednesday 2:30PM Ward rd
Thursday 8:30AM Ward rd
9C Trauma Ward.
References:
KS Leung & PS Ko, Practical Manual for Musculoskeletal Trauma, Vol. I, Springer 2001.
ATLS Course manual, American College of Surgeons.