Musculoskeletal Trauma

Introduction
Primary Survey
Adjuncts to Primary
Secondary Survey
Life-Threats
Limb-Threats
Other Extremity Injuries
Principles of Immobilisation
Table of Associated Injuries

Introduction

Occur in 85% of blunt traumas
- but rarely threaten life or limb.
May not be recognised until repeat exams

Risks
Associated internal torso injury (increased if long-bone #s above or below diaphragm)
Brisk bleeding
Rhabdomyolysis (in crush injury)
Fat embolism

Primary Survey

Musculoskeletal trauma does not warrant reordering of ABCDEs.
- however cannot be ignored if optimal outcome to be achieved.

Recognise and control haemorrhage
- major vessels may exsanguinate
- direct pressure is best.

Recognise long bone blood loss
- Class III shock may result from certain femoral #s alone.
- splinting can reduce bleeding through less motion and greater tamponade.
- if open, sterile pressure dressings can control haemorrhage.

Adjuncts to Primary

Fracture immobilisation
Goal is to realign to as near anatomical as possible.
In-line traction realigns exremity.
Maintained by an immobilisation device.
Reduces blood loss, pain, and further injury.
If open pull bone back into wound (will need surgical debridement anyway)
Splint joint dislocations in position found.
- use splints, pillows, plasters.
Apply splints as soon as possible after resuscitation.

XRs
AP pelvis shd be obtained early in unstable pts without known source of bleeding.
Other views are taken as needed.

Secondary Survey

History
Mechanism should raise suspicion.
Car accident:
- precrash location, postcrash location / ejection.
- external vehicle damage (eg head on and hip dislocation)
- internal damage (eg windscreen and upper girdle damage)
- restraint, air bags.
Fall --> foot and spine injuries
Crushed: ?weight, duration, site.
Explosion: magnitude, distance away.
--> primary blast injury and secondary (from objects accelerated by blast)
Pedestrian vs car --> bumper to leg

Environment
Exposure to temperature extremes, toxins, broken glass, bacterial sources.

Preinjury status
Baseline condition.
AMPLE history
Previous musculoskeletal problems.

Prehospital care
Note position pt found, bleeding, bone/# ends exposed, open wounds near #s, deformity / dislocation.
Note for motor/sensory fx.
Describe delays in extracating pt.
Provide info on neuro state changes, reduction of #s, dressings and splints applied.

Physical exam
Completely undress pt.
- aim to ID life, limb threats and review for missed injury
- skin, neuromuscular fx, circulation and skeletal/ligamentous integrity are key.

1. Look / Ask
- colour / perfusion of limbs
- wounds, deformities, swelling (may indicate crush), discolorations.
- identify sites of major external bleeding
- if unconscious, look for absent spontaneous extremity movement
- if conscious, check neuromuscular fx of all major muscle groups.
- the ability to move all muscles through a full ROM usually indicates intact nerve-muscle unit with a stable jt.

2. Feel
- palpate for sensation and tenderness.
- consider spinal/peripheral nerve damage if sensation loss.
- pain, tenderness, swelling and deformity usually mean #, confirmed if painful abnormal motion (crepitus and abnormal motion are not recommended techniques)
- skin may shear off deeper tissue, losing blood supply or accumulating blood
- be aware for compartment syndrome.
- examine for jt stability: palpate for swelling, stress specific ligaments (guarding may mask injury - reassess later).

3. Circulation
- palpate all distal pulses and cap refills.
- Doppler may help if hypotensive.
- stocking/glove sensory loss is an early sign of vascular impairment.
- arterial injury suggested by pulse discrepancy, coolness, pallor, paraesthesia and motor function abN, as well as proximal open wounds / #s, pulsating haemorrhage or expanding haematomas.
- ankle/brachial index <0.9 is confirmatory of circulation problem.
- auscultation may reveal bruit with thrill.

XRs
XR when haemodynamically stable.
Only reason for not getting an XR is vascular compromise / impending skin breakdown (eg #/dislocation ankle), where immediate reduction recommended.

Life-threats

1. Major pelvic disruption

Injury
Haemorrhage often follows disruption of posterior stability (sacroiliac, sacrospinous, sacrotuberous and fibromuscular pelvic floor complex) from a sacroiliac # and/or dislocation or sacral #.
- force opens the pelvic ring, tears the venous complex and can disrupt the internal iliacs.
- often AP compression injury
- motorcycle crashes, pedistrian-vehicle collisions, direct crushes and falls > 3.6m are common mechanisms.
In MVA, more commonly lateral pelvic force rotates involved hemipelvis
--> closes pelvic volume and stopping bleeding.
--> more lower GU injury

Assessment
Unexplained hypotension may be only indication
- most important signs are progressive flank, scrotal or perianal swelling / bruising.
- look for other signs / indications of lower GU injury as per secondary survey
- failure to respond to initial fluid resuscitation.
Test for mechanical instability once at most.
- look for leg-lenth discrepancy
- rotational deformity without distal #.
- unstable pelvis will migrate cephalid and rotate otward.
--> close by pushing on iliac crests at ASIS level.
AP pelvis XR confirms.

Management
Haemorrhage control and rapid fluid resuscitation.
See management notes

2. Major arterial haemorrhage

Penetrating wounds or blunt trauma close to an artery can disrupt it and cause major haemorrhage, into open or soft tissues.
- assess injured extremities for external bleeding, pulses, Doppler, ankle/brachial index.
- cold pulseless & pale --> interruption
- rapidly expanding haematoma --> significant injury
Management
Consult surgeon immediately
- apply direct pressure
- aggressively fluid resuscitate.
- pneumatic tourniquet is ok; vascuar clamps not recommended unless superficial vessel immediately identifiable.
- realign and splint any associated #
- arteriography is only for a resuscitated haemodynamically normal pt.

3. Crush injury (Rhabdomyolysis)
See rhabdomyolysis

Limb-threats

Open # / Jt Injury
Open #: communication between external environment and bone.
- prone to infection, healing and function problems.
Often treated in the prehospital phase: don't inspect the open wound further unless poor documentation.
- don't probe it, consider it open until proved otherwise.
If an open wound exists over/near a jt, assume it connects with the jt.
- obtain surgical consultation, do not insert dye, saline, or anything to test joint cavity communication.
- needs surgical exploration and debridement.
Management
Describe, determine nv and soft-tissue status
Immobilise
Consult surgeon
Give ADT.

Vascular Injury
& Traumatic Amputation
Suspected in the presence of vascular insufficiency
- eg dusky, long cap refill, diminished pulses, abnormal ABI or if severe: cold, pale, pulseless.
Treat as an emergency:
(Recognise early)
Necrosis will begin at ~6hrs or less & nerves will die.
Early operative revascularisation is required.
- do not delay with arteriography.
Quickly correct any associated fracture deformity.
If associated joint dislocation: one gentle reduction maneuvre may be attempted by a skilled doctor
- else splint in position and call surgeon.
Beware creating vascular compromise in splinting / casting.
Amputation
Either traumatic or lifesaving in an unstable pt.
A pt with multiple injuries who requires intensive resuscitation and emergency surgery is not a candidate for replantation.
- may be if isolated extremity injury; if so negotiate with skilled facility, wash part in isotonic solution and wrap in sterile gauze soaked in acqueous penicillin then in a moistened sterile towel, placed in a plastic bag in a cooling chest with crushed ice (don't freeze it).

Compartment syndrome

Neurological Injury in #/Dislocation
Consider proximity of nerves to muscle/skeletal injury.
- eg sciatic nerve in posterior hip disclocation
- eg axillary nerve in anterior shoulder dislocation.
Examine the neurologic system thoroughly, assessing significant peripheral nerves' voluntary motor function and sensation.
- may be difficult in the multiply-injured; reassess.
- most important is to document progression.
Management
Immobilise
Obtain surgical consult
Carefully reduce a dislocation if skilled doctor available
- then reevaluate nv status.

Nerve	Motor	Sensation	Injury
Ulnar	Index f. abduction	Little f,	Elbow
Median distal	Thenar opposition	Index f.	Wrist disl.
Median ant inteross	Index tip flexion		Supracondylar hum.
Musculocutaneous	Elbow flexion	Lat forearm	Ant shoulder disloc.
Radial	Thumb, f MCP ext	1st dorsal web	Distal humeral shaft Ant shoulder disloc.
Axillary	Deltoid	Lat shoulder	Ant shoulder disloc. Prox humeral #
Femoral	Knee extension	Ant knee	Pubic rami
Obturator	Hip adduction	Medial thigh	Obturator ring #
Post tibial	Toe flexion	Sole of foot	Knee dislocation
Sup peroneal	Ankle eversion	Lat dorsum foot	Fib neck #/ knee disl.
Deep peroneal	Ankle dorsiflex	Dorsal 1-2 webs	Fib neck # / comp syn
Sciatic	Plantar dorsiflex	Foot	Post hip disloc
Sup gluteal	Hip abduction		Acetabular #
Inf gluteal	Glut max hip ext.		Acetabular #

Other Extremity Injuries

Contusions and Lacerations
Exclude neurovascular injury
Debride and close
- if below fascial level, needs operative examination for debridement / damage evaluation
Contusions: limit function and apply cold packs.
Small wounds: can have significant devascularisation and crushing beneath if mechanism suggestive (eg crush)
Tetanus risk: higher if >6hrs old, contused / abraided, >1cm deep, high-velocity missile, burn/cold, contaminated.

Joint Injuries
Non-dislocated jt injuries do not threaten limb but impair function.
Check for tenderness, haemarthosis, instability.
- manage with immobilisation, reassessment of neurovascular status and surgical consult.

Fractures
Examine for pain, swelling, deformity, tenderness.
Crepitus, abnormal #-site motion must not be done routinely or repetitively.
XRs at right angles confirm #s, may delay until stabilised.
- manage with immobilisation at jt above and below #, and reassess neurovascular status after splinting.
- surgical consult.

Principles of Immobilisation

Principles
Leave until secondary survey
However all should be splinted prior to transport.
Assess neurovascular status before/after each splint.
See techniques.

Femoral #s
Traction splint

Knee Injuries
Immobilise in 10 degrees of flexion to take pressure off neurovascular structures.
A long-leg splint of plaster is helpful.

Tibia
Well-padded cardboard or metal gutter long-leg splint.

Ankle
Immobilise with pillow or padded cardboard.

Upper extremity / Hand
Put hand in anatomical function position: wrist slightly dorsiflexed, fingers flexed to 45o at MCP jts
Forearm/wrist on padded or pillow splints.
Elbow in a flexed position, either with padded splints or direct immobilisation with sling/swath device.
Upper arm with splinting or sling/swath device.
Shoulder with sling/swath device or velcro-dressing.

Table of Associated Injuries

To increase recognition of injuries:
- review history
- reexamine all extremities especially hands / feet / jts above/below a # or dislocation
- examine dorsum
- review XRs for subtle findings.

Injury	Associations
Clavicle, scapular, shoulder	Thoracic injury, pulm contusion, rib #s
Displaced T-spine #	Thoracic aortic rupture
Spine #	Intra-abdominal injury
#/dislocation elbow	Brachial art, median / ulnar / radial n.
Pelvic disruption (car)	Abdo/thoracic/head injury
Pelvic disruption (other)	Pelvic vascular haemorrhage
Femur #	Femoral neck #, post hip dislocation
Posterior knee dislocation	Fem #, post hip dislocation
Knee dislocation or tib plat #	Popliteal a & n damage
Calcaneal #s	Spine #, hindfoot #/dislocation, tib plat #
Open #	70# risk of nonskeletal injury.