A Clinical Review of Musculoskeletal Trauma

Harbor – UCLA Hospital

Department of Oral and Maxillofacial Surgery
Mary Carter, D.D.S.
Essentials of Physical Examination
• Look
– Splint deformed extremities before patient
transport or as soon as safely possible
– Assess the color of the extremity
• Bruising indicates muscle or soft tissue injury
– Note the position of the extremity
– Observe spontaneous activity to determine severity
of injury
– Note Gender and Age
– Observe drainage from the urinary catheter
• Bloody urine could mean pelvic fracture
Essentials of Physical Examination
• Feel
– Palpate the pelvis anteriorly and posteriorly to
assess for deformity, motion, and gap
• Compression-distraction and push-pull tests should only
be performed once; these could dislodge clots and cause
rebleeding
– Palpate pulses in all extremities
• If an extremity has no pulses and no capillary refill, a
surgical emergency exists
Essentials of Physical Examination
• Feel
– Palpate the muscle compartments of all the
extremities for compartment syndromes and
fractures
• Suspect compartment syndrome if the muscle
compartment is hard
– Assess joint stability by asking the cooperative
patient to move the joint through a range of
motions
• Do not perform if there is an obvious fracture or
uncooperative patient
Essentials of Physical Examination
• Feel
– Perform a thorough neurological exam
• C5- Lateral Aspect of the upper arm
• C6- Palmar aspect of the thumb and index finger
• C7- Palmar aspect of the middle finger
• C8- Palmar aspect of the pinky finger
• T1- Inner aspect of the forearm
• L3- Inner aspect of the thigh
• L4- Inner aspect of the lower leg (over the medial
malleoulus)
• L5- Dorsum of the foot between the first and second toes
• S1- Lateral aspect of the foot
Essentials of Physical Examination
• Feel
– Perform Motor examination of the extremities
• Shoulder abduction (Axillary nerve)
• Elbow flexion (Musculocutaneous nerve)
• Elbow extension (Radial Nerve)
• Hand and wrist- power grip tests and flexion of the
wrist and fingers
• Finger add/abduction (Ulnar Nerve)
• Lower extremity- Dorsoflexion of the ancle and toes
• Muscle power
Essentials of Physical Examination
• Feel
–Assess the deep tendon
reflexes

–Assess the patient’s back

Getting it in!
Principles of Extremity Immobilization
• Assess the ABCDEs and life threatening
situations first
• Remove all clothing and completely expose
the patient, including extremities
• Assess the neurovascular status of the
extremity prior to applying splint
• Cover open wounds
• Select proper size and type of splint
• Apply padding over bony prominences
 Principles of Extremity Immobilization

• Splint the extremity in the position in which it

is found if distal pulses are present in the
injured extremity

• Place the extremity in a splint if normally

aligned
– If malaligned, the extremity needs to be realigned
and then splinted (DO NOT FORCE!)
Principles of Extremity Immobilization

• Get Otho Consult

• Document Neurovascular Status of the
extremity before and after manipulation
• Administer Tetanus Prophylaxis
Oh yeah! Im gonna score 24 points on you…
#24!
 Realigning a Deformed Extremity

• Humerus

– Grasp the elbow and apply distal traction

– Apply a plaster splint and secure the arm to the

chest wall with a sling and swath
 Realigning a Deformed Extremity

• Forearm
– Apply distal traction through the wrist while
holding the elbow and applying countertraction

– Secure a splint to the forearm and elevate the

injured extremity
 Realigning a Deformed Extremity

• Femur
– Realign by applying traction through the ankle if
the tibia and fibia are not fractured

– The leg will straighten as the muscle spasm is

overcome
 Realigning a Deformed Extremity

• Tibia

– Apply distal traction at the ankle and

countertraction just above the knee, if femur is
intact
 Realigning a Deformed Extremity
• Fractures associated with neurovascular
deficits require prompt realignment. If the
vascular or neurologic status worsens after
realignment and splinting, the splint should be
removed and the extremity returned to the
position in which blood flow and neurologic
status are maximized.
 Application of a Traction Splint
• Remove all clothing
• Apply sterile dressings to open wounds
• Assess the neurovascular status of the extremity
• Cleanse any exposed bone and muscle of dirt
and debris before applying traction
• Determine the length of the splint by measuring
the uninjured leg
– The distal end of the splint should be beyond the
ankle by 6 inches
 Application of a Traction Splint

• Align the fumur by applying traction through the ankle

• Reassess neurovascular status of the distal extremity
• Position the ankle hitch around the patient’s ankle and
foot
• Attach the ankle hitch to the traction hook; apply
traction in incriments
• Secure remaining straps
• Reevaluate neurovascular status
• Administer Tetanus Prophylaxis
 Compartment Syndrome: Assessment and
Management
• Compartment Syndrome:
– Can develop insidiously
– Can develop in extremity as a result of compression or
crushing forces and without obvious injury
– Hypotensive and unconscious patients at increased risk
– Pain is the earliest symptom that harbor ischemia
– Unconscious or intubated patients cannot
communicate signs of extremity ischemia
– Loss of pulses occur late after irreversible damage
 Compartment Syndrome: Assessment and
Management
• Palpate the muscular compartments of the
extemeities
– Asymmetry is a significant finding
– Conduct frequent examination for tense muscular
compartments
– Measure compartment pressures
 Pelvic Fractures: Identification and
Management
• Identify the mechanism of injury
• Inspect area for echimosis, hematoma, and
blood in the urethral meatus
• Inspect legs for differences in length or
asymmetry in rotation
• Perform rectal exam (Full cavity search!)
• Perform vaginal exam
 Pelvic Fractures: Identification and
Management
• Obtain AP Xray if evidence points to Pelvic
Fracture
• If no evidence of Pelvic Fracture, palpate to
identify painful areas
• Identity pelvic stability by anterior-posterior
compression and lateral-medial compression
over the anterosupeior iliac crests
 Pelvic Fractures: Identification and
Management
• Cautiously insert urinary catheter if urethal
injury is suspected
• Interpret the pelvic xray
– Evaluate
• Width of symphysis pubis
• Integrity of the superior and inferior pubic rami
bilaterally
• Integrity of the acetabula
• Symmetry of the ilium and width of the sacroiliac joints
• Symmetry of the sacral foramina
• Fractures of the transverse processes of L5
 Pelvic Fractures: Identification and
Management
• Techniques to Reduce Blood Loss
– Avoid excesive and repeated manipulation
– Internally rotate the inner legs to close an open book
type fracture
– Apply pelvic external fixation device
– Apply skeletal limb traction
– Embolize pelvic vessels via angiography
– Place sandbags under buttock if no indication of spinal
injury and only if no other techniques are available
 Pelvic Fractures: Identification and
Management

• Techniques to Reduce Blood Loss

– Apply a pelvic binder

 Identification of Arterial Injury
• Recognize that Ischemia is both limb-
threatening and Life-threatening
• Palpate peripheral pulses bilaterally
• Document and evaluate any evidence of
asymmetry in peripheral pulses
• Reevaluate peripheral pulses frequently
• Obtain early surgical consultation
It’s Gonna Be a Rough Night! Go OKC!