A Clinical Review of Musculoskeletal Trauma

8/7/2019 A Clinical Review of Musculoskeletal Trauma

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A Clinical Review of Musculoskeletal Trauma

Harbor UCLA Hospital

Department of Oral and Maxillofacial SurgeryMary Carter, D.D.S.


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E ssentials of Physical E xaminationLook

Splint deformed extremities before patienttransport or as soon as safely possible

Assess the color of the extremityBruising 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


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E ssentials of Physical E xamination

Feel Palpate the pelvis anteriorly and posteriorly to

assess for deformity, motion, and gapCompression-distraction and push-pull tests should onlybe performed once; these could dislodge clots and causerebleeding

Palpate pulses in all extremitiesIf an extremity has no pulses and no capillary refill, asurgical emergency exists


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Feel Palpate the muscle compartments of all the

extremities for compartment syndromes andfractures

Suspect compartment syndrome if the musclecompartment is hard

Assess joint stability by asking the cooperativepatient to move the joint through a range of motions

Do not perform if there is an obvious fracture oruncooperative patient


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Feel Perform a thorough neurological exam

C5- Lateral Aspect of the upper arm

C6- Palmar aspect of the thumb and index fingerC7- Palmar aspect of the middle fingerC8- Palmar aspect of the pinky fingerT1- Inner aspect of the forearmL3- Inner aspect of the thighL4- Inner aspect of the lower leg (over the medialmalleoulus)L5- Dorsum of the foot between the first and second toesS1- Lateral aspect of the foot


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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 thewrist and fingers

Finger add/abduction (Ulnar Nerve)Lower extremity- Dorsoflexion of the ancle and toesMuscle power


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G etting it in!


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Principles of Extremity Immobilization

Assess the ABCDEs and life threateningsituations firstRemove all clothing and completely expose

the patient, including extremitiesAssess the neurovascular status of theextremity prior to applying splintCover open woundsSelect proper size and type of splintApply padding over bony prominences


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Splint the extremity in the position in which itis found if distal pulses are present in theinjured extremity

Place the extremity in a splint if normallyaligned

If malaligned, the extremity needs to be realignedand then splinted (DO NOT FORCE!)


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G et Otho Consult

Document Neurovascular Status of theextremity before and after manipulationAdminister Tetanus Prophylaxis


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Oh yeah! Im gonna score 24 points onyou #24!


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Realigning a Deformed Extremity

Humerus

G rasp the elbow and apply distal traction

Apply a plaster splint and secure the arm to thechest wall with a sling and swath


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Forearm Apply distal traction through the wrist while

holding the elbow and applying countertraction

Secure a splint to the forearm and elevate theinjured extremity


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Tibia

Apply distal traction at the ankle andcountertraction just above the knee, if femur isintact


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Fractures associated with neurovascular deficits require prompt realignment. If thevascular or neurologic status worsens after realignment and splinting, the splint should beremoved and the extremity returned to theposition in which blood flow and neurologic

status are maximized.


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Application of a Traction Splint

Align the fumur by applying traction through the ankleReassess neurovascular status of the distal extremity

Position the ankle hitch around the patient s ankle andfootAttach the ankle hitch to the traction hook; applytraction in incriments

Secure remaining strapsReevaluate neurovascular statusAdminister Tetanus Prophylaxis


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Compartment Syndrome: Assessmentand 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 cannotcommunicate signs of extremity ischemia Loss of pulses occur late after irreversible damage


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Compartment Syndrome: Assessmentand Management

Palpate the muscular compartments of theextemeities

Asymmetry is a significant finding Conduct frequent examination for tense muscular

compartments Measure compartment pressures


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Pelvic Fractures: Identification andManagement

Identify the mechanism of injuryInspect area for echimosis, hematoma, and

blood in the urethral meatusInspect legs for differences in length orasymmetry in rotation

Perform rectal exam (Full cavity search!)Perform vaginal exam


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Obtain AP Xray if evidence points to PelvicFracture

If no evidence of Pelvic Fracture, palpate toidentify painful areasIdentity pelvic stability by anterior-posteriorcompression and lateral-medial compressionover the anterosupeior iliac crests


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Cautiously insert urinary catheter if urethalinjury is suspectedInterpret the pelvic xray

EvaluateWidth of symphysis pubisIntegrity of the superior and inferior pubic ramibilaterally

Integrity of the acetabulaSymmetry of the ilium and width of the sacroiliac jointsSymmetry of the sacral foraminaFractures of the transverse processes of L5


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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 areavailable


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Techniques to Reduce Blood Loss

Apply a pelvic binder


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Identification of Arterial Injury

Recognize that Ischemia is both limb-threatening and Life-threatening

Palpate peripheral pulses bilaterallyDocument and evaluate any evidence of asymmetry in peripheral pulses

Reevaluate peripheral pulses frequentlyObtain early surgical consultation


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It sG onna Be a Rough Night! G o OKC!

Documents

A Clinical Review of Musculoskeletal Trauma