Musculoskeletal Trauma in Polytrauma Victims Kris Arnold, MD, MPH

Musculoskeletal Trauma

in Polytrauma Victims

Musculoskeletal Trauma

in Polytrauma Victims

Kris Arnold, MD, MPHKris Arnold, MD, MPH

Musculoskeletal Traumain Multitrauma PatientsMusculoskeletal Traumain Multitrauma Patients

• 85% of multi trauma patients have musculoskeletal trauma

• Rare immediate threat to life or extremity viability

• Indicator of risk for torso injury• Common cause of prolonged or permanent

disability if not treated properly

Musculoskeletal Injury Issues During Primary SurveyMusculoskeletal Injury Issues During Primary Survey

• Bleeding from open fractures • Bleeding from closed long bone

fractures– Humerus 1-2 units blood – Femur 3-4 units blood

• Bleeding from pelvic fracture – May be exsanguinating

• Vascular & Neurologic injury from dislocations

ABC…

Pelvic FracturesPelvic Fractures

• Pelvis fracture severity based on breaking ring structure

Image Source: http://basicxray.blogspot.com/2009/08/normal-pelvic-anatomy.html

Pelvic FracturesPelvic Fractures

• Type A – No instability of ring– Avulsion of single bone – low risk

• Rehabilitation – progressive weight-bearing• Late surgical intervention

Image source: Michael E. Stadnick, M.D http://www.radsource.us/clinic/0806

Pelvic FracturesPelvic Fractures

• Type B • Disruption anteriorly and posteriorly with

intact posterior ligaments• Problems

– Rotational instability– Increased risk of bleeding– Associated injuries

• Urethra• Pelvic organs• Abdominal organs

Open Book

Pelvic FracturesPelvic Fractures

• Type C• Anterior and posterior disruption with

disruption of posterior sacro-iliac complex– Rotational and vertical instability– High risk of bleeding– High risk associated injuries

• Urethral• Pelvic organs• Abdominal organs

Emergency Pelvic Fracture StabilizationEmergency Pelvic Fracture Stabilization

Image source: Michael T. Archdeacon, MD http://www.aaos.org/news/aaosnow/jul09/clinical8.asp

Binding force at level of trochanters

Pelvic Fracture StabilizationPelvic Fracture Stabilization

C-clamp

Pelvic Fracture ManagementPelvic Fracture Management

• Rule out urethra injury– Retrograde urethrogram (RUG)

• Mechanism of extremity injury– Direct blunt force – Crush – Fall

• Initial extremity positioning

Musculoskeletal Injury Management During Secondary SurveyMusculoskeletal Injury Management During Secondary Survey

History

Extremity Injury AssessmentExtremity Injury Assessment

• Look– Undress completely– Deformity– Swelling

• Listen– Pain– Crepitance

• Feel– Crepitance– Abnormal mobility

Initial Fracture ManagementInitial Fracture Management

• Angulated – realign & stabilize– Prevent further soft tissue injury– Reduce pain– Potentially decrease bleeding

Photo source: Bush LA, Chew FS. Subtrochanteric femoral insufficiency fracture in woman on bisphosphonate therapy for glucocorticoid-induced osteoporosis. Radiology Case Reports. [Online] 2009;4:261.

Evaluate Distal Perfusion

“Normal”

Immobilize Realign

Compromised

Reevaluate Distal

Perfusion

“Normal” Compromised

Extremity Vascular Injury Evaluation

Angulated Fracture Management during Prehospital ManagementAngulated Fracture Management during Prehospital Management

• Imaging– Plain x-rays– Two views

• Anterior-posterior• Lateral

– Must be correctly aligned

– Image one joint above and below• Maissoneuve

Extremity Fracture AssessmentExtremity Fracture Assessment

Open FracturesOpen Fractures

• Realign and splint as for closed

Upper Extremity Nerve InjuryUpper Extremity Nerve Injury

Injury Nere Motor Sensation

Elbow Ulnar Index finger abduction Little finger

Wrist dislocation Median (distal) Thenar contraction with opposition

Index finger

Supracondylar humerus (children)

Median (anterior interosseous)

Index finger tip flexion

Anterior shoulder dislocation Musculocutaneous Elbow flexion Lateral forearm

Distal Humeral shaft/Ant. Shoulder dislocation

Radial Thumb, finger, metacarpal extension

1st dorsal web space

Anterior shoulder dislocation/proximal hmerus fracture

Axillary Deltoid Lateral shoulder

Lower Extremity Nerve InjuriesLower Extremity Nerve Injuries

Injury Nerve Motor Sensation

Pubic rami fracture Femoral Knee extension Anterior knee

Obturator ring fractures Obturator Hip adduction Medial thigh

Knee dislocation Posterior tibial Toe flexion Sole of foot

Fibular neck fracture, knee dislocation

Superficial peroneal Ankle eversion Lateral dorsum of foot

Fibular neck fracture, compartment syndrome

Deep peroneal Ankle/toe dorsiflexion Dorsal 1st & 2nd web space

Posterior hip dislocation Sciatic nerve Plantar dorsiflexion Foot

Acetabular fracture Superior gluteal Hip abduction

Acetabular fracture Inferior gluteal Gluteus maximus hip extension

Crush InjuryCrush Injury

• Compartment syndrome• Rhabdomyolysis

Compartment SyndromeCompartment Syndrome

• Lower Extermity– Lower leg– Thigh– Gluteal– Foot

• Upper Extremity– Forearm– Hand

Compartments Lower LegCompartments Lower Leg

Compartment Syndrome Clinical EvaluationCompartment Syndrome Clinical Evaluation

• Pain out of proportion to injury or worsening• Pain with stretching involved muscles• Pain with using involved muscles• Possible decrease in sensation or paresthesias over or

distal to involved compartment• Late or inconsistent

– Loss of peripheral pulse– Loss of normal color – pale– Paralysis of involved muscles

• Tissue pressure >35-40cm H2O w/ normal systemic BP –lower w/ hypotension (normal <10cm H2O)

FasciotomyFasciotomy

RhabdomyolsysisRhabdomyolsysisRhabdomyolsysisRhabdomyolsysis

• TraumaTrauma• Fractures and Crush InjuruesFractures and Crush Injurues

• Electrocution/ Thermal BurnsElectrocution/ Thermal Burns• Burned MuscleBurned Muscle

• ““Tea colored” urineTea colored” urine• Heme + urinalysis dipHeme + urinalysis dip

• No red blood cells on microscopicNo red blood cells on microscopic

Small but ImportantSmall but Important

Posterior Knee DislocationPosterior Knee Dislocation

Posterior Hip DislocationPosterior Hip Dislocation

Reduction Posterior Hip DislocationReduction Posterior Hip Dislocation

Anterior Hip DislocationAnterior Hip Dislocation

Thank YouThank You

Questions??Questions??