Committee on Trauma Presents
Musculoskeletal Trauma
Initial Assessment and Management
Case Scenario
A wall collapses on a 44-year-old male worker
BP: 130/75; Pulse: 110; RR: 22
GCS score: 15 Painful, bruised, deformed right leg
What are your priorities? Is this life- or limb-threatening?
Objectives
Describe the principles for assessing patients with musculoskeletal injuries.
Identify treatment priorities. Explain the importance of musculoskeletal injuries in multiply injured patients.
Primary Survey
How do musculoskeletal injuries impact on the primary survey?
Primary Survey
How do musculoskeletal injuries impact on the primary survey?
External bleeding Occult blood loss
Pelvic fractures
Long bone fractures
Primary Survey
What are my priorities and management principles?
Primary Survey
What are my priorities and management principles?
During the Primary Survey The 3 Ss
Stop the bleeding!
(pressure / tourniquet)
Splint the extremity Stabilize the pelvis
Primary Survey
Rationale for Splinting
Prevents further blood loss and injury
Can restore or maintain perfusion
Relieves pain
Important during evaluation Do not delay
Primary Survey
Stabilization
Secondary Survey
Look
Listen
Feel
Secondary Survey
Rationale for Splinting
Look Deformity Pain Tenderness Wound(s) Listen Doppler signals Bruit Feel Crepitus Skin flaps Neurologic deficit
Pulses
Secondary Survey
Key Information
Preinjury status and predisposing factors Mechanism of injury Time of injury Associated factors (eg, environment)
Prehospital observations and care
Secondary Survey
Early Concerns
Vascular compromise Open fractures
Secondary Survey
Assess and Manage Vascular Compromise
Reduce fracture(s) Splint fracture(s) Assess by Doppler Obtain surgical consult Time is critical! Consider angiography
Secondary Survey
Managing Open Fractures
Apply appropriate splint Cleanse / debride (now or later) Consider time factor Obtain orthopedic consult Antibiotic / tetanus status
Secondary Survey
X-Ray Studies
What x-rays do I need?
Any suspected area One joint above and below
When do I obtain them?
Patient is hemodynamically normal
Secondary Survey
X-Ray Studies
When should I delay getting x-rays?
If life-threatening injuries take priority If patient transfer will be delayed
Compartment Syndrome
What injuries can cause compartment syndrome?
Compartment Syndrome
What injuries can cause compartment syndrome?
Tibia and forearm fractures
Vascular and bony injuries Injuries immobilized in tight dressings or casts Severe crush injuries to muscle Burns
Compartment Syndrome
How do I recognize compartment syndrome?
Compartment Syndrome
How do I recognize compartment syndrome?
Pain
Disproportionate Passive stretch
Tense compartments
Asymmetry
Paresthesia Tissue pressures > 35 to 45 mm Hg
Pitfalls
Pitfalls
Altered sensation Compartment syndrome Vascular injury Crush injuries / myoglobinuria Occult fractures / soft tissue injuries
Coagulation disorders
Summary
Manage life-threatening injuries first Stop the bleeding! Reduce and immobilize fractures and dislocations
Recognize vascular compromise
Consider compartment syndrome
