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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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E ssentials of Physical E xamination
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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E ssentials of Physical E xamination
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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E ssentials of Physical E xamination
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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8/7/2019 A Clinical Review of Musculoskeletal Trauma
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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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Principles of Extremity Immobilization
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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Principles of Extremity Immobilization
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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Realigning a Deformed Extremity
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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Realigning a Deformed Extremity
Tibia
Apply distal traction at the ankle andcountertraction just above the knee, if femur isintact
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Realigning a Deformed Extremity
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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Pelvic Fractures: Identification andManagement
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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Pelvic Fractures: Identification andManagement
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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Pelvic Fractures: Identification andManagement
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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Pelvic Fractures: Identification andManagement
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!