Management

Musculoskeletal
Trauma

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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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Trauma is not
rocket science!
ABCDEF
 Initial Assessment: Primary
Survey
• A = Airway
• B = Breathing
• C = Circulation
• D = Disability
• E = Exposure
• F = Fracture
 Initial Assessment: Airway

• Clear & establish a

good airway
– Consider intubation for
coma, shock, and
thoracic injuries

• C-spine stabilization
 Initial Assessment: Breathing

• Chest excursion & breath sounds

• Flail chest
• Pneumothorax
• Open
• Tension
• Massive Hemothorax
 Initial Assessment: Circulation
• Perfusion (mental status, skin, pulse)
• Control bleeding with pressure
• Pericardial Tamponade
– Beck’s Triad
• Establish 2 large bore (16G or larger) IV’s
in upper extremity peripheral veins
• Resuscitate with Lactated Ringers
– After 4 L think about resuscitation with blood
 Initial Assessment: Disability
• Neurologic status
– Glasgow Coma Scale
• Eye
• Motor-best predictor of long term outcome
• Verbal
– Spinal Cord Injury
 Initial Assessment: Exposure
• Remove clothes
• Temperature
– warm blankets
• Finger and tube in every orifice
• Maintain full spine precautions
– Log Roll
 Initial Assessment: Fracture
• Stabilize Fractures
• Relocate dislocated joints
• Reassess pulses
Primary Survey / Resuscitation

 Recognize and control hemorrhage

•Direct pressure
•Splint fractures
 Aggressive fluid resuscitation

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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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Primary Survey/ Resuscitation

Adjuncts : x-rays
Determined by patient’s condition
Obtain AP pelvis early if hemodynamically

abnormal and
no obvious source of bleeding

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 Secondary Survey
• Patient history
• Head to toe physical exam
• Radiography
– Lateral C-spine, C-xray, pelvis
– One cavity above/below entrance/exit wounds
– FAST
• Urinary bladder drainage
• NGT
• Blood sampling/monitoring
Secondary Survey

History
Mechanism of injury
Environment

AMPLE history

Prehospital care

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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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Secondary Survey

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

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Secondary Survey

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

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Secondary Survey

Circulatory Evaluation
Color, temperature
Pulse pressure, capillary refill

Paresthesia

Doppler: Ankle / arm ratio

Bruit / thrill

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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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Life- Thereatening Injuries

Major pelvic disruption with

hemorrhage
Major arterial hemorrhage

Crush syndrome (rhabdomyolysis)

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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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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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Management :
stabilization

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Stabilization for transport

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Operative procedures

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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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Crush Syndrome

Myoglobinuria
Metabolic acidosis,  K , Ca and

coagulopathy
Compartment syndrome

IV fluids, alkalization of urine

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Limb- Threatening Injuries

Open fracture and joint injuries

Vascular injuries

Compartment syndrome

Neurologic injury

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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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Vascular Injury, Amputation

Variable presentation : Assess pulses

Associated with fracture / dislocations

Realign

Check pulses after splinting

Immediate surgical consult

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Compartment Syndrome

Crush Injury with Compartment Syndrome

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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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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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Traksi

Upaya pengobatan atau rehabilitasi

pada kelainan dan atau cedera
sistem muskuloskeletal dengan
menggunakan traksi (tarikan)
padanya secara terus menerus
Traksi

•Pada Tulang (Traksi Skeletal)

•Pada Kulit (Traksi Kulit)

•Traksi Menetap (Fixed Traction)

•Traksi Berimbang (Balanced
Traction)
Tujuan Traksi

•Reposisi (pada fraktur / dislokasi)

•Imobilisasi (setelah reposisi)
•Mengkoreksi deformitas (mis.
kontraktur)
•Mengurangi nyeri (Coxitis/Gonitis TB)
•Mencegah deformitas (Coxitis/Gonitis
TB, post poliomielitis)
Prinsip Traksi

•Ada tarikan dan ada kekuatan yang

melawan tarikan (Traksi-Kontra traksi),
kontra traksi yang digunakan biasanya
adalah gravitasi / berat badan pasien
•Traksi-Kontra traksi mengikuti hukum
alam
•Traksi-Kontra traksi tidak menimbulkan
komplikasi
Komplikasi Traksi

•Komplikasi akibat tarikannya

•Spasmus pembuluh darah
•Kelumpuhan saraf
•Iskhemi kulit
•Komplikasi akibat perangkat traksi
•Infeksi akibat tusukan kawat/pin
•Alergi plester
Traksi Kulit
Alat : Skin Traction Kit  pediatrik, adult
Jenis : plester  dengan perekat
foam rubber  tanpa perekat
Indikasi : Traksi < 10 lbs ( < 5 Kg )
Kontra indikasi : alergi plester, peny. Kulit
Komplikasi : dermatitis, gangguan
neurologis, gangg. vaskuler
Traksi Kulit
Traksi Tulang

Alat : Skrup/screw
Pin
Wire
Indikasi : traksi waktu lama
beban tarikan besar
Kontra indikasi relatif : anak-anak
Komplikasi : Infeksi, Kerusakan lempeng
pertumbuhan, gangguan neurologis
dan gangguan vaskuler
Traksi Tulang

• Bohler stirrup dg
Steinmann pin

• Denham pin

• Kirschner wire strainer

Traksi menetap (fixed traction)
• Traksi dg bidai Thomas (Thomas splint)
• Keseimbangan bersifat statik
• Digunakan pada transportasi/evakuasi

Arah
tarikan
Bag proksimal
terfiksasi pada paha
Traksi menetap (fixed traction)

Sliding Traction
Traksi Berimbang (balanced traction)
• Ada keseimbangan dinamik antara traksi dengan
kontra traksi

Traksi berimbang dengan bidai Thomas

Traksi berimbang dengan bidai Bohler
Traksi berimbang dengan Traksi Kulit
Bryant Traction

Umur < 2tahun

Berat badan 35-40 lbs

(15,9 – 18,2 Kg)

Komplikasi : gangguan
vaskuler
Traksi berimbang dengan traksi kulit
Buck Extension Traction
Traksi berimbang dengan traksi kulit
Hamilton Russel Traction
Olecranon Traction Dunlop Traction
Spinal Traction
Canvas Head Halter Crutchfield Tongs
Skull Traction
Pitfalls

Occult injuries
Occult blood loss

Compartment syndrome

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Summary

Primary Survey : Identify life-threatening

injuries
Secondary Survey : Identify limb-

threatening injuries
Mechanism of Injuries : History important

Surgical consult

Early immobilization

© ACS 56