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MUSCULOSKELETAL TRAUMA

dr. Ahmad Fauzi, Sp.OT


Dept. Bedah Div. Orthopaedi dan
Traumatologi
FK UNILA
2014

Musculoskeletal System
The system of muscles, tendons, ligaments,

bones,
joints,
nerves,
vessels
and
associated tissues that provides form,
support, stability, and movement to the
body.

Musculoskeletal Trauma
Musculoskeletal injuries
High morbidity
Low mortality

Related with Multiple injuries


High morbidity
High mortality

Musculoskeletal trauma
Traffic, factory, domestic, school and
sport.
Fractures,

Dislocations,

Bones, cartilages, epiphyseal plate


joints

Ruptures

Tendon, ligaments, nerve, vessels

Emergency
Emergencies in Musculoskeletal Trauma :
1. Open fracture
2. Fractures with neuro-vascular disturbances
3. Joint dislocations

Extremity injuries
First aids

Life before limb


Life saving ~ ATLS
Limb saving
Realignment
Splint
Neurovaskular !

LIFE SAVING MEASURES


A Airway and cervical spine immobilisation
B Breathing and ventilation
C Circulation (treatment and diagnosis of cause) : w/ hemorrhage

control

D Disability (head injury) : neurological status


E Exposure (musculo-skeletal injury) : completely undress but prevent

hypothermia

Life threatening conditions are identified and simultaneous management is


instituted

SECONDARY SURVEY
Done after the patient

stable
Head to toe
Every orificiums/every
tubes

Early Intervention on trauma/multitrauma


patient (included MSK trauma problems)
A Airway and cervical spine protection, protect the

cervical : inline imobilisation, collar brace (head injury,


cervical injury)
B Breathing w/ Oxygen mask
C Circulation w/hemorrhage control (pelvic
stabilisation)
D Disability, neurological status(GCS), paraparese or
paralysis spine fractures suspected inline
immobilization
E Exposure : deformity of extremity
immobilization/splinting

Early Intervention on trauma/multitrauma


patient (included MSK trauma problems)

The first step toward cure is to know what the


disease is (latin proverb)

Solving the mysteri of a diagnosis is the


detective work of medicine (Sherlock Holmes)

Diagnosis of Fractures
History
Fall, twisting injury, direct blow, MVA
Localized pain, aggravated by movement
Crepitus

Physical Examination
General condition associated injuries
Look : deformity, swelling, abN movement
Feel : localized tenderness, muscle
spasm, NVD
Move : ROM
Diagnostic Imaging
Exact nature & extent of fracture
X-ray : min AP & lat (ocassional : oblique)
CT / MRI : spine, pelvis
Salter RB. Textbook of Disorders and Injury of

Diagnosis
History :
Biomechanics ~ Forces.
Time of injury
Possibilities or serious injuries.
Decrease / lost of functions.
Previous management, transportation.

Physical examination
General condition
Vital signs
ABCs
Local condition :
Look
Feel
Move

Local Condition
Look :
Deformities : angulations, discrepancy, rotation.
Bone exposed
Swelling
Feel :
Pain, crepitation, edema
Move :
Functio laesa

NEURO VASCULAR !!

Neurovascular
disturbance

Supporting examinations
Laboratory
Imaging

Splint
Straight, strong, flat + padding
Stable
Safe
Immobilization
2 joints
3 dimension
Alignment / anatomic position
Neuro-vascular conditions

Splints

Immobilization

Splinting
Immobilize 2 joints / 2 bones
Neuro-vascular functions

Advantages :
Decreasing pain.
Prevent further damages
Decrease or stop the bleeding
Easy transportation.

Extrication, stabilization &


Transportation

Treatment
1.
2.
3.
4.
5.
6.

First do No harm
Base treatment on an Accurate Diagnosis
and Prognosis
Select Treatment with Specific Aims
Cooperate with the Law of Nature
Nature
Make Treatment Realistic and Practical
Select treatment for your patient as an
individual

SPRAIN
A Sprain is an injury to a joint and its ligaments

Sprain
RICE

RICE

STRAIN
An injury to a muscle in which the muscle fibers
tear as a result of over stretching

Muscle Strain Symptoms


Swelling, bruising or redness, or open cuts as a

consequence of the injury


Pain at rest
Pain when the specific muscle or the joint in
relation to that muscle is used
Weakness of the muscle or tendons
Inability to use the muscle at all

PRICE
Protection, Rest, Ice, Compression, and Elevation

Joint Dislocation
Joint contact
Complete / incomplete
Risk of avascular necrosis of the joint cartilage

and bones

Dislocation
Diagnosis / dd :
Dislocation
Fracture
Fracture dislocation

Pain and limitation of movement


Fresh vs neglected dislocations

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

Button hole dislocation


Closed reduction vs open reduction

Dislocation

Fractures
Trauma that produce discontinuity of bone,

cartilage or epiphyseal plate


Related to the SOFT TISSUE INJURIES

SIMPLE MUSKULOSKLETAL TRAUMA

Treatment of Fracture
4 R :
Recognition diagnosis, soc ec, religion, etc
Reposition displaced /deformity to anatomic

/ acceptable position
Retaining fixation of fragments : external,
internal
Rehabilitation early joint ROM, muscle
action, edema, psychological consideration ,
previous activity

Closed Fractures
Management
Intact skin
Closed reduction + immobilization (cast, traction)
Surgery :
If closed treatment was failed (reduction and

stability)

Open Fractures
Open wound, relations between bone fragments

and the environment


Infection risk
Gustillo ;
Type I
Type II
Type III A,B and C

OPEN FRACTURES

Type I open
fracture

Type II open
fracture

Type III A open fracture

Type III B open fracture

Type III C open fracture

Open Fracture
Management
Emergency
Other life threatening injuries
Multiple injuries ?
Antibiotics
Debridement
Fracture fragment Stabilization
Wound coverage
Bone grafting
Rehabilitation

Rehabilitation

LATE COMPLICATION OF FRACTURES

INFECTION IN OPEN
FRACTURE
Type I
Type II
Type III

less than 1%
1-10 %
10-50%

Fractures with vascular


injuries
Fractures with a high risk of

haemorrhagic shock :
Fracture of pelvis
fracture of femur
Both are an emergency
conditions that needs an
immediate management.
Blood vessels may injured by
the bone fragments,
fragments so it
always needs a good
examination of the circulation
at distal part of the limb.

Deformity and
impairment

Compartment Syndrome

A condition of increasing the closed muscle


compartmental pressure that produce a
disturbances of neuro-vascular function of the
extremity .

Sign & Symptoms


Classic signs 5 P
Pain

Severe extremity pain out of proportion to injury


Early sign, worse with passively stretching
involved muscle
Paresthesia or anesthesia to light touch
Paralysis
Pulselessness

Not present in early cases


Pallor

No perfusion = Cell Death


Muscle
3-4 hours - reversible
6 hours

- variable

8 hours

- irreversible

Nerve
2 hours

- lose nerve conduction

4 hours

- neuropraxia

8 hours

- irreversible

Compartment
Syndrome
Clinical Signs :
Classical signs : 5 P (pain,
paresthesia, pallor,
paralysis, pulselessnes).
Bulae
Significant sign : strecth
pain and paresthesia,
decompresion fasciotomy.
Measurement of the intra
compartment pressure
fasciotomy

Progressive elevation of interstitial pressure


in a closed space resulting in impaired
perfusion :
Causing functional compromise
Will result in cell death
Consequences when missed

Ischemic contractures
Amputation
Death

Volkmanns
Contracture

Management
Remove extrinsic compression
Elevate to at least level of heart
Compartment pressure measurement?
Fasciotomy

INDICATION OF CONSULTATION
ALL FRACTURES & DISLOCATION ARE PATOLOGIC

CONDITION

IMMOBILISATION/SPLINT FIRST
STRICTLY NO DELAY OF TRANSFERING PATIENTS W/

FRACT + NEUROVASCULAR INJURY, OPEN FRACTURES,


DISLOCATION

DO NOT DO HARM

SUMMARY

FRACTURES IS NOT ONLY LESION ON THE BONE


EARLY INTERVENTION OF MSK TRAUMA SHOULD BE

DONE PROPERLY, FOR BETTER PROGNOSIS


TO KNOW THE BASIC KNOWLEDGE FOR MAKING
DIAGNOSIS OF MSK TRAUMA IS MANDATORY
BEFORE TREATING PATIENTS
DO NOT DO HARM

Thank you
to cure sometimes, to relieve often, to comfort
always.
- Edward Livingston Trudeau -