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Emergency in Musculoskeletal

Trauma and Spine Injury


Asrafi Rizki Gatam

Questions
Is it important?
Is it consider as priority
in management?
Will the patient survive?
Will the patient die
from such an injury?
Will it cause long term
morbidity?

Epidemiology
70-80% of trauma patients will involve
musculoskeletal system
Abdominal trauma 16%
Thoracic trauma 8%
Morbidity
Musculoskeletal trauma + Abdominal injury
Musculoskeletal trauma + Head injury

Scope of Musculoskeletal Injury


Fractures Open or Closed
Dislocation Open or Closed
Soft Tissue Injury
Compartment syndrome Volksman contracture
Neurologic injury
Vessel injury

Sequele
Early Pressure sore, infection, gas gangren
Late Non union, malunion, myositis ossificans, AVN,
contracture, nerve compression, joint stiffness

Acute Management
ATLS Protocol
ABCDE
True life
threatening
musculoskeletal
emergency

C Spine control is important

Acute Management
When to consider
cervical spine injury
1. Unconcious patient
2. Bruises above the
clavicle
3. Midline tenderness
4. High energy injury/
dangerous mechanism

Acute management

Acute Management

Bilateral femoral fractures


Risk of bleeding Hypovolemic shock
Risk of fat emboli Respiratory distress

GENERAL MANAGEMENT OF
FRACTURES AND DISLOCATION

Bone Healing Phase

Principles of Fracture Management

1.
2.
3.
4.

Recognize
Reduce
Retain
Rehabilitation

Recognize
Look
Swelling
Deformities
Open wounds

Feel
Localized pain
Neurovascular
functions
crepitations

Move
Crepitations
Abnormal
movements
ROM

Recognize
Xray Examination
2 sides
AP/Lateral/Oblique
2 joints
Distal and proximal of
the suspected fracture
2 extremities
In paediatric patients
only
2 times

Fragmented Fractures
Apposition
Angulation
Rotation
Shortening/Length

Dislocation
A complete separation (no contact)
of two bones that made up a joint
Clinical findings:
Severe joint pain
Deformity of joint contoure
Pain on joint motion

Subluxation: partial separation of


joints
Management: reposition and
fixation

Reduce
Closed reduction:
manual manipulation of
the fracture
General anesthesia
muscle relaxation
3 manouvers
1. traction of distal
fragment
(disengagement)
2. Reposition to anatomical
position
3. Realignment in 2
dimensions

Open reduction:
surgery direct reduction
in open fractures:
Conducted along with
debridement

In closed fractures:
Unsuccesful closed
reduction
Intra-articular fractures
Avulsion fractures

Retain

Splinting
Skin traction
Circular cast
Internal
fixation
External
fixation

Rehabilitation

To prevent fracture disease


Patient should be as active as possible
ROM exercise of the joint
Muscle exercise
Isometric
Isotonic
Isokinetic

Gait excercise

Management of Open Fractures


Risk of infections and
contaminations
Important to eradicate infections
Administration of IV antibiotics as
therapy, not prophylaxis
Prophylaxis: tetanus toxoid, ATS

Counted as an emergency case


Irrigation to get rid og debris and
foreign bodies
Indication for debridement
Indication for open reduction

Complications of fractures
Early
Visceral injuries
Vascular injuries
Compartment syndrome
Neural injuries
Hemarthrosis
infections

late
Delayed union, non-union,
malunion
Muscle athropy
Myositis ossificans
Avascular necrosis
Algodystrophy
Osteoathritis
CRPS

Compartment syndrome
Hallmarks: 5P
1. Pain
2. Paresthesis
3. Pallor
4. Paralysis
5. Pulselessness
Management: Fasciotomy

Delayed Union
Fracture takes
longer than the
estimated union
time
Causes:
Heavy soft tissue
injury
Inadequate blood
supply
Infections
Inadequate
stabilization
Over-traction

Management: Bone
graft

Non-Union

Fracture fails to
heal
Caused by
fibrotic tissue
covering the
fractured area

Clinical finding:
pseudoathrosis
X-ray: visible
fracture line

Type:
Hypertrophic
athropic

Mal-union

Union in a
pathological
position
Types:
Angulation
Rotation
shortening

Myositis Ossificans
Abnormal, heterotopic bone formation
in muscles, commonly found in elbow
dislocations
Clinical findings:

Local swelling
Pain on palpation
Limited ROM
X-ray: calcification on soft tissues

Management:
Bone mass excision
Indometacin
radiation

Avascular necrosis
Injuries that causes bone
ischemia and eventually
necrosis
Commonly found in
injuries to :
caput femoris,
proximal part of os
schapoid,
os lunatum,
os talus

Ligament sprain
Injuries to the
ligaments without any
structural damage
Due to rotational or
attractional force
Clinical findings:
Joint pain
Swollen joints

Ligament rupture
Partial or total
discontinuity of a
ligament
Commonly found in:
Knee joint
Ankle
Fingers

Clinical findings:
Swelling
Severe joint pain
Subcutaneous bleeding

SPINE INJURY

Scope of Spine Injury


Bony injury
Upper cervical C1, C2
injury
Subaxial cervical spine
C3-C7 injury
Thoracolumbar injury

Soft tissue injury


Posterior ligamentous
complex
Neurologic injury

Epidemiology
Cervical spine 5-15% of spine trauma
Thoracolumbar fracture 1/20.000 per year,
common in productive age men
Most common T11-L2
High morbidity due to spinal cord injury

Recognizing Spine Injury

Motor vehicle crashes


Motorcycle crashes
Pedestrian car crashes
Falls
Diving accident
Hangings
Blunt trauma
Penetrating trauma to the head, neck or torso
Gunshot wounds
Any unresponsive trauma patient

Prehospital Evaluation and Management


Protection begins at the accident scene
25% pts poor immobilization and improper
handling further neurologic injury
Current recommendations for patients
immobilization during transport:
Rigid cervical collar
Lateral supports
Tape and body straps into a backboard

Assesment
Sign and Symptoms
Respiratory distress
Tenderness at the site of injury on spinal column
Pain along the spinal column with movement
Deformity of the spine (rare)
Numbness, weakness or tingling in the arms or
legs
Loss of sensation or paralysis in the upper or lower
extremity
Incontinence or loss of bowel or bladder control
Priapism

Assesment

Radiology

Management
Objectives
Prevent or reserve neurologic deficit
Restore spinal stability
Prevent deformity or restore spinal alignment
Allow early mobilization

Medical Management
Managing spinal cord injury
High dose steroid (NASCIS III) No clear
evidence
<3 hours : initial dose 30 mg/kgbw/hour,
maintenance 5.4 mg/kgbw/24 hours
3-8 hours : maintenance 5.4 mg/kgbw/48 hours

9% patients with ASIA A improved to ASIA D


15% patients with ASIA D improved to ASIA C
No patient regain full neurologic function

Orthopaedic Management
Conservative treatment

Orthopaedic Management
Operative treatment
Best timing if <6 hours Debatable
Vertebroplasty
Posterior stabilization only
Decompression and Posterior stabilization
Combination of Posterior and anterior procedure

THANK YOU