dr. Ahmad Fauzi, Sp.OTDept. Bedah Div. Orthopaedi dan Traumatologi

FK UNILA2014

MUSCULOSKELETAL TRAUMA

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 Musculoskeletal injuries injuries High morbidityLowLow mortality

Related with Multiple Multiple injuriesinjuriesHigh morbidityHighHigh mortality

Musculoskeletal trauma

• Traffic, factory, domestic, school and sport.

• Fractures,• Bones, cartilages, epiphyseal plate

• Dislocations, • joints

• Ruptures• Tendon, ligaments, nerve, vessels

Emergency

Emergencies in Musculoskeletal Trauma :1. Open fracture2. Fractures with neuro-vascular disturbances3. Joint dislocations

Extremity injuries

First aids“Life Life beforebefore limblimb”

LifeLife saving ~ ATLSLimbLimb saving

Realignment SplintNeurovaskular !

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 toeEvery 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 maskC Circulation w/hemorrhage control (pelvic stabilisation)D Disability, neurological status(GCS), paraparese or paralysis

spine fractures suspected inline immobilizationE 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

HistoryFall, twisting injury, direct blow, MVALocalized pain, aggravated by movementCrepitus

Physical ExaminationGeneral condition associated injuriesLook : deformity, swelling, abN movementFeel : localized tenderness, muscle

spasm, NVDMove : ROM

Diagnostic ImagingExact nature & extent of fractureX-ray : min AP & lat (ocassional : oblique)CT / MRI : spine, pelvis

Salter RB. Textbook of Disorders and Injury of Musculoskeletal System

Diagnosis Diagnosis

HistoryHistory :Biomechanics ~ Forces.Time of injuryPossibilities or serious injuries.Decrease / lost of functions.Previous management, transportation.

Physical examination

GeneralGeneral condition conditionVital signsABC’s

LocalLocal condition condition :Look Feel Move

Local ConditionLocal ConditionLook Look :

Deformities : angulations, discrepancy, rotation.

Bone exposedSwelling

FeelFeel :Pain, crepitation, edema

MoveMove :Functio laesa

NEURO – VASCULAR !!NEURO – VASCULAR !!

Neuro-vasculardisturbance

Supporting examinations

LaboratoryImaging

SplintStraight, strong, flat + padding

StableSafe

Immobilization Immobilization 2 joints3 dimension

AlignmentAlignment / anatomic positionNeuro-vascularNeuro-vascular conditions

Splints

Immobilization

Splinting

Immobilize 2 joints / 2 bonesNeuro-vascular functions

AdvantagesAdvantages :Decreasing pain.Prevent further damagesDecrease or stop the bleedingEasy transportation.

Extrication, stabilization & Transportation

Treatment

1. First do No harmo harm2. Base treatment on an AccurateAccurate Diagnosis Diagnosis

and PrognosisPrognosis3. Select Treatment with Specific AimsSpecific Aims4. Cooperate with the “Law of NatureLaw of Nature”5. Make Treatment Realistic and PracticalRealistic and Practical 6. Select treatment for your patient as an

individualindividual

S P R A I N

A Sprain is an injury to a joint and its ligaments

Sprain R I C E

R I C E

S T R A I N

An injury to a musclemuscle in which the muscle fibers teartear as a result of over stretching 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 tendonsInability to use the muscle at all

P R I C E

Protection, Rest, Ice, Compression, and Elevation

Joint DislocationJoint Dislocation

Joint contactComplete / incompleteRisk of avascular necrosis of the joint cartilage and bones

Dislocation Diagnosis / dd : Diagnosis / dd :

DislocationFractureFracture – dislocation

Pain and limitation of movementFresh vs neglected dislocations

Joint Dislocation

Treatment Treatment Reposition ~ instabilityImmobilization ~ stable positionRehabilitation ~ stability, tissue healing

Button hole dislocationClosed reduction vs open reduction

Dislocation Dislocation

Fractures

Trauma that produce discontinuity of bone, cartilage or epiphyseal plate

RelatedRelated to the SOFT TISSUE INJURIESSOFT TISSUE INJURIES

SIMPLE MUSKULOSKLETAL TRAUMA

Treatment of Fracture4 R 4 R :

RecognitionRecognition diagnosis, soc ec, religion, etcRepositionReposition displaced /deformity to anatomic

/ acceptable positionRetainingRetaining fixation of fragments : external,

internalRehabilitationRehabilitation early joint ROM, muscle

action, edema, psychological consideration , previous activity

Closed Fractures Management

IntactIntact skinClosedClosed reduction + immobilization (cast, traction)SurgerySurgery :

If closed treatment was failed (reduction and stability)

Open FracturesOpen Fractures

Open wound, relations between bone fragments and the environmentenvironment

InfectionInfection risk

Gustillo Gustillo ;Type IType IIType 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 Open Fracture ManagementManagement

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 less than 1%Type II 1-10 %Type III 10-50%

Fractures with vascular injuries

Fractures with a high risk of haemorrhagic shock haemorrhagic shock : Fracture of pelvisfracture of femur

Both are an emergencyemergency conditions that needs an immediate management.

Blood vessels may injuredinjured by the bone fragmentsfragments, so it always needs a good examination of the circulation at distaldistal part of the limb.

Deformity and impairment

Compartment Syndrome

A condition of increasingincreasing the closed muscle compartmental pressurepressure that produce a disturbances of neuro-vascularneuro-vascular functionfunction of the extremity .

Sign & Symptoms

Classic signs 5 PPain

Severe extremity pain out of proportion to injury

Early sign, worse with passively stretching involved muscleParesthesia or anesthesia to light touchParalysisPulselessness

Not present in early cases Pallor

• MuscleMuscle

– 3-4 hours - reversible

– 6 hours - variable

– 8 hours - irreversible

• Nerve Nerve

– 2 hours - lose nerve conduction

– 4 hours - neuropraxia

– 8 hours - irreversible

No perfusion = Cell Death

Compartment Syndrome

Clinical Signs :Clinical Signs :ClassicalClassical signs : 5 P (pain,

paresthesia, pallor, paralysis, pulselessnes).

BulaeSignificantSignificant sign : strecth

pain and paresthesia, decompresion fasciotomy.

MeasurementMeasurement of the intra compartment pressure fasciotomy

Volkmann’s Volkmann’s ContractureContracture

• 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 contracturesIschemic contractures– AmputationAmputation– DeathDeath

ManagementRemove 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 BONEEARLY INTERVENTION OF MSK TRAUMA SHOULD BE

DONE PROPERLY, FOR BETTER PROGNOSISTO 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 -