Musculosceletal Trauma

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Advanced Trauma Life Support 205

EIGHT

8Musculoskeletal TraumaCHAPTER

OBJECTIVES:

Upon completion of this topic, the participant will be able to initially assess and manage the patient with life-and limb-threatening musculoskeletal injuries. Specically, the participant will be able to:

A. Recognize and describe the signicance of musculoskeletal injuries in the multiply injured patient.

B. Outline priorities in the assessment of musculoskeletal trauma to identify life- and limb-threatening inju-ries.

C. Outline the proper principles of initial management for musculoskeletal injuries.


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MUSCULOSKELETAL TRAUMA

206 American College of Surgeons

I. INTRODUCTION

Injuries to the musculoskeletal system often appear

dramatic and occur in 85% of patients who sustainblunt trauma, but rarely cause an immediate threatto life or limb. However, musculoskeletal injuriesmust be assessed and managed properly and ap-propriately so life and limb are not jeopardized. Thedoctor must learn to recognize the presence of suchinjuries, dene the anatomy of the injury, protectthe patient from further disability, and anticipateand prevent complications.

Major musculoskeletal injuries indicate signicantforces sustained by the body. The patient with long-bone fractures above and below the diaphragm has

an increased likelihood of associated internal torsoinjuries. Unstable pelvic fractures and open femurfractures may be accompanied by brisk bleeding.Severe crush injuries cause the release of myoglobinthat can precipitate in the renal tubules and result inrenal failure. Swelling into an intact musculofascialspace can cause an acute compartment syndromethat, if not diagnosed and treated, may lead to last-ing impairment and loss of extremity use. Fat embo-lism, an uncommon but highly lethal complicationof long-bone fractures, may lead to pulmonary fail-ure and impaired cerebral function.

Musculoskeletal trauma does not warrant a reor-dering of the priorities of resuscitation (ABCDEs).However, the presence of signicant musculo-skeletal trauma does pose a challenge to the treatingdoctor. Musculoskeletal injuries cannot be ignoredand treated at a later time. The doctor must treat thewhole patient, including musculoskeletal injuries, toassure optimal outcome. Despite careful assessmentand management of the multiply injured patient,fractures and soft-tissue injuries may not be initiallyrecognized. Remember, continued reevaluation ofthe patient is necessary to identify all injuries.

II. PRIMARY SURVEY ANDRESUSCITATION

During the primary survey, it is imperative to recog-nize and control hemorrhage from musculoskeletalinjuries. Deep soft-tissue lacerations may involvemajor vessels and lead to exsanguinating hemor-rhage. Hemorrhage control is best effected by directpressure.

Hemorrhage from long-bone fractures can be sig-nicant. Certain femoral fractures may result in upto 3 to 4 units of blood loss into the thigh, producing

Class III shock. Appropriate splinting of the fracturecan signicantly decrease bleeding by reducingmotion and enhancing a tamponade effect of themuscle. If the fracture is open, application of a sterilepressure dressing usually controls hemorrhage. Ag-gressive uid resuscitation is an important supple-ment to these mechanical measures.

III. ADJUNCTS TO PRIMARY SURVEY

A. Fracture Immobilization

The goal of initial fracture immobilization is to re-

align the injured extremity in as close an anatomicposition as possible and to prevent excessive frac-ture-site motion. This realignment is accomplishedby the application of in-line traction to realign theextremity and is maintained by an immobilizationdevice. The proper application of a splint helps con-trol blood loss, reduces pain, and prevents furthersoft-tissue injury. If an open fracture is present, thedoctor need not be concerned about pulling exposedbone back into the wound because all open fracturesrequire surgical debridement.

Joint dislocations usually require splinting in the po-

sition in which they are found. If a closed reductionhas successfully relocated the joint, immobilizationin an anatomic position can be accomplished in anumber of different ways: prefabricated splints,pillows, or plaster. These devices willmaintain theextremity in its unreduced position.

Application of splints should be applied as soon aspossible, but they must not take precedence over re-suscitation. However, the use of splints may be veryhelpful during this phase to control hemorrhage andpain.

B. X-rays

X-ray examination of most skeletal injuries occursas the part of the secondary survey. Which x-rays toobtain and when to obtain them are determined bythe patients initial and obvious clinical ndings, thepatients hemodynamic status, and the mechanismof injury. An anteroposterior (AP) view of the pelvisshould be obtained early for all multiply injured pa-tients who are hemodynamically abnormal and forwhom a source of bleeding has not been identied.


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IV. SECONDARY SURVEY

A. History

1. Mechanism of injury

Information obtained from the transport person-nel, patient, relatives, and bystanders at the sceneof the injury should be documented and includedas a part of the patients medical record. It is par-ticularly important to determine the mechanismof injury, which raises suspicion of injuries thatmay not be immediately apparent. (See Appen-dix 3, Biomechanics of Injury.) The doctor shouldmentally reconstruct the injury scene, identifyother potential injuries that the patient may have

sustained, and determine as much of the follow-ing information as possible.

a. What was the precrash location of the pa-tient in the vehicle, ie, driver or passenger?This may indicate the type of fracture, eg, lat-eral compression fracture of the pelvis result-ing from a side impact in a vehicle collision.

b. What was the postcrash location of thepatient, eg, inside the vehicle or ejected? Thismay indicate patterns of injury. If the patientwas ejected, determine the distance the pa-tient was thrown. Ejection generally results

in increased injury severity and unpredictablepatterns of injury.

c. Was there external damage to the vehicle,eg, deformation to the front of the vehicle froma head-on collision? This information raisesthe suspicion of a hip dislocation.

d. Was there internal damage to the vehicle,eg, bent steering wheel, deformation to thedashboard, damage to the windscreen? Thesendings indicate a greater likelihood of ster-nal, clavicular, or spinal fractures, or hip dislo-cation.

e. Was the patient wearing a restraint; if so,what type (lap or 3-point safety belt), and wasit applied properly? Faulty application of safe-ty restraints may cause spinal fractures and as-sociated intraabdominal visceral injuries. Wasan air bag deployed?

f. Did the patient fall; if so, what was the dis-tance of the fall and how did the patient land?This information helps identify the spectrumof injuries. Landing on the feet may cause foot

and ankle injuries with associated spinal frac-tures.

g. Was the patient crushed by an object? If

so, identify the weight of the crushing object,the site of the injury, and duration of weightapplied to the site. Depending on whether asubcutaneous bony surface or a muscular areawas crushed, different degrees of soft-tissuedamage may occur, ranging from a simple con-tusion to a severe degloving extremity injurywith compartment syndrome and tissue loss.

h. Did an explosion occur? If so, what was themagnitude of the blast and what was the pa-tients distance from the blast? A person closeto the explosion may sustain primary blastinjury from the force of the blast wave. A sec-ondary blast injury may occur from debris andother objects accelerated by the blast effect (eg,fragments), leading to penetrating wounds,lacerations, and contusions. The patient alsomay be violently thrown to the ground oragainst other objects by the blast effect, lead-ing to blunt musculoskeletal and other injuries(tertiary blast effect).

i. Was the patient involved in a vehicle-pedes-trian collision? Musculoskeletal injuries mayfollow predicted patterns (bumper injury toleg) based on the size and age of the patient.

2. Environment

Prehospital care personnel should be asked about(1) patient exposure to temperature extremes,(2) patient exposure to toxic fumes or agents, (3)broken glass fragments (which also may injurethe examiner), and (4) sources of bacterial con-tamination (eg, dirt, animal feces, fresh or saltwater). This information helps the doctor antici-pate potential problems and determine the initialantibiotic treatment.

3. Preinjury status and predisposing factors

It is important to determine the patients baselinecondition prior to injury. This information mayalter the understanding of the patients condition,treatment regimen, and outcome. The AMPLEhistory also should include information about thepatients (1) exercise tolerance and activity level,(2) ingestion of alcohol and/or other drugs, (3)emotional problems or illnesses, and (4) previousmusculoskeletal injuries.


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4. Prehospital observations and care

Findings at the incident site that may help thedoctor identify potential injuries include (1)the position in which the patient was found, (2)bleeding or pooling of blood at the scene andthe estimated amount, (3) bone or fracture endsthat may have been exposed, (4) open wounds inproximity to obvious or suspected fractures, (5)obvious deformity or dislocation, (6) presenceor absence of motor and/or sensory function ineach extremity, and (7) delays in extrication pro-cedures or transport. Time of the injury should benoted, especially if there is ongoing bleeding anddelay in reaching the hospital.

Prehospital observations and care must be re-ported and documented. Other informationthat may be important includes (1) changes inlimb function, perfusion, or neurologic state,especially after immobilization or during trans-fer to the hospital; (2) reduction of fractures ordislocations during extrication or splinting at thescene; and (3) dressings and splints applied withspecial attention to excessive pressure over bonyprominences that may result in peripheral nervecompression injuries, compartment syndromes,or crush syndromes.

B. Physical ExaminationThe patient must be completely undressed foradequate examination. Obvious extremity injuriesshould be splinted prior to the patients arrivalin the emergency department. Assessment of thetrauma patients extremities has three goals: (1)identication of life-threatening injury (primarysurvey), (2) identication of limb-threatening inju-ries (secondary survey), and (3) systematic reviewto avoid missing any other musculoskeletal injury(continuous reevaluation).

Assessment of musculoskeletal trauma can beachieved by looking at and talking to the patient,and should include palpation of the patients ex-tremities and performing a logical systematic re-view of each extremity. The 4 components that mustbe assessed are (1) skin, which protects the patientfrom excessive uid loss and infection; (2) neuro-muscular function; (3) circulatory status; and (4)skeletal and ligamentous integrity. This evaluationprocess reduces the risk of missing an injury.

1. Look and ask

Visually assess the extremities for (1) color andperfusion, (2) wounds, (3) deformity (angulation,shortening), (4) swelling, and (5) discoloration orbruising.

A rapid visual inspection of the entire patient isnecessary to identify sites of major external bleed-ing. A pale or white distal extremity is indicativeof a lack of arterial inow. The extremity that isswollen in the region of major muscle groupsmay represent a crush injury with an impendingcompartment syndrome. Swelling in or arounda joint and/or over the subcutaneous surfaceof a bone is a sign of a musculoskeletal injury.Extremity deformity is an obvious sign of majorextremity injury. (See Table 1, page 209, Common

Joint Dislocation Deformities.) Inspection of thepatients entire body for lacerations and abrasionsis accomplished in the secondary survey. Openwounds are obvious unless on the dorsum of thebody. The patient must be carefully logrolled toassess for an injury or skin laceration. If a boneprotrudes or is visualized in the wound, an openfracture exists. Any open wound to a limb withan associated fracture also is considered an openfracture until proven otherwise by a surgeon.

Observation of the patients spontaneous extrem-ity motor function helps identify any neurologicand/or muscular impairment. If the patient is un-conscious, absent spontaneous extremity move-ment may be the only sign of impaired function.With a cooperative patient, active voluntarymuscle and peripheral nerve function can beassessed by asking the patient to contract majormuscle groups. The ability to move all major

joints through a full range of motion usually indi-cates that the nerve-muscle unit is intact and the

joint is stable.

2. Feel

The extremities should be palpated to determinesensation to the skin (neurologic function) and ar-eas of tenderness (fracture or deep muscle injury).Loss of sensation to pain and touch demonstratesthe presence of a spinal or peripheral nerve in-

jury. Areas of tenderness or pain over musclesmay indicate a muscle contusion or a fracture.Pain, tenderness, swelling, and deformity overa subcutaneous bony surface usually conrm thediagnosis of a fracture. If pain or tenderness is as-


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sociated with painful abnormal motion throughthe bone, the diagnosis of a fracture is made.However, attempts to elicit crepitus or demon-strate abnormal motion are not recommended.At the time of logrolling, the patients back mustbe palpated to identify any lacerations, palpablegaps between the spinous processes, hematomas,or defects in the posterior pelvic region that areindicative of unstable axial skeletal injuries.

Closed soft-tissue injuries are more difcult toevaluate. Soft-tissue avulsion may shear the skin

from the deep fascia, allowing for signicant ac-cumulation of blood. Alternatively, the skin maybe sheared from its blood supply and undergo ne-crosis over a few days. This area may show localabrasions or bruised skin that are clues to a moresevere degree of muscle damage and potentialcompartment syndromes or crush syndromes.These soft-tissue injuries are best evaluated byknowing the mechanism of injury and by palpa-tion of the specic involved component.

Joint stability can be determined only by clini-cal examination. Any abnormal motion through

a joint segment is indicative of a ligamentousrupture. The joint is palpated to identify anyswelling and tenderness of the ligaments aswell as intraarticular uid. Following this, cau-tious stressing of the specic ligaments can beperformed. Excessive pain may mask abnormalligament motion because of guarding of the jointby muscular contraction or spasm and may needto be reassessed later.

3. Circulatory evaluation

The distal pulses in each extremity are palpatedand capillary rell of the digits is assessed. If hy-potension limits digital examination of the pulse,the use of a Doppler probe can detect blood owto an extremity. The Doppler signal must havea triphasic quality to assure no proximal lesion.Loss of sensation in a stocking or glove distribu-tion is an early sign of vascular impairment.

In the hemodynamically normal patient, pulse

discrepancies, coolness, pallor, paresthesia, andeven motor function abnormalities are suggestiveof an arterial injury. Open wounds and fracturesin proximity to arteries may be a clue to an arte-rial injury. The Doppler ankle/brachial index ofless than 0.9 is indicative of an abnormal arterialow secondary to injury or peripheral vasculardisease. The ankle/brachial index is determinedby taking the systolic blood pressure value asmeasured by the Doppler at the ankle of theinjured leg and dividing it by the Doppler-deter-mined systolic blood pressure of the uninjuredarm. Auscultation may reveal a bruit with an

associated palpable thrill. Expanding hematomasor pulsatile hemorrhage from an open woundalso are indicative of arterial injury.

4. X-rays

The clinical examination often suggests the needfor x-rays. Any area over a bone that is tenderand deformed probably represents a fracture. Ifthe patient is hemodynamically normal, an x-ray

Table 1Common Joint Dislocation Deformities

JOINT DIRECTION DEFORMITY

Shoulder AnteriorPosterior

Squared offLocked in internal rotation

Elbow Posterior Olecranon prominent posteriorly

Hip AnteriorPosterior

Flexed, abducted, externally rotatedFlexed, adducted, internally rotated

Knee Anteroposterior Loss of normal contour, extended

Ankle Externally rotated, prominent medial malleous

Subtalar joint Lateral is most common Laterally displaced os calcis


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should be obtained. Joint effusions, abnormaljoint tenderness, or joint deformity represent ajoint injury or dislocation that also must be x-

rayed. The only reason for not obtaining an x-rayprior to treatment of a dislocation or a fracture isrelated to a vascular compromise or impendingskin breakdown. This is seen commonly withfracture dislocations of the ankle. Immediate re-duction or realignment of the extremity should beperformed to reestablish the arterial blood supplyand reduce the pressure on the skin if there is go-ing to be a delay in obtaining x-rays. Alignmentcan be maintained by appropriate immobilizationtechniques.

V. POTENTIALLY LIFE-THREATENINGEXTREMITY INJURIES

A. Major Pelvic Disruption with Hemorrhage

1. Injury

Pelvic fractures associated with hemorrhagecommonly exhibit disruption of the posteriorosseous-ligamentous (sacroiliac, sacrospinous,sacrotuberous, and the bromuscular pelvicoor) complex from a sacroiliac fracture and/ordislocation, or from a sacral fracture. The forcevector opens the pelvic ring, tears the pelvicvenous plexus, and occasionally disrupts theinternal iliac arterial system (anterior-posteriorcompression injury). This mechanism of pelvicring injury can be caused by motorcycle crashesor pedestrian-vehicle collisions, direct crushinginjury to the pelvis, and falls from heights greaterthan 12 feet (3.6 meters).

In motor vehicle collisions, the more commonmechanism of pelvic fracture is a force appliedto the lateral aspect of the pelvis that tends torotate the involved hemipelvis internally, closingdown the pelvic volume and relieving any ten-sion on the pelvic vascular system (lateral com-pression injury). This rotational motion drives thepubis into the lower genitourinary system, creat-ing injury to the bladder and/or urethra. Thisinjury rarely kills the patient from hemorrhageor its sequelae, as does the completely unstablepelvic injury.

2. Assessment

Major pelvic hemorrhage occurs rapidly and thediagnosis must be made quickly to initiate ap-

propriate resuscitative treatment. Unexplainedhypotension may be the only initial indicationof major pelvic disruption with instability in

the posterior ligamentous complex. The mostimportant physical signs are progressive ank,scrotal, or perianal swelling and bruising. Thisis associated with failure to respond to initialuid resuscitation. Open fracture wounds aboutthe pelvis (especially if the open area is in theperineum, rectum, or buttocks), a high-ridingprostate gland, blood at the urethral meatus, anddemonstrable mechanics instability are signs ofunstable pelvic ring injury.

Mechanical instability of the pelvis ring is testedby manual manipulation of the pelvis. This pro-

cedure should be performed only once during thephysical examination. Repeated testing for pelvicinstability may result in further hemorrhage. Therst indication of mechanical instability is leg-length discrepancy or rotational deformity (usu-ally external) without a fracture of that extremity.The unstable hemipelvis migrates cephalad dueto muscular pull and rotates outward secondaryto the effect of gravity on the unstable hemipel-vis. As the unstable pelvis is able to rotate exter-nally, the pelvis can be closed by pushing on theiliac crests at the level of the anterior superioriliac spine. Motion can be felt if the iliac crests

are grasped and the unstable hemipelvis(es) ispushed inward and then outward (compression-distraction maneuver). With posterior disruption,the involved hemipelvis can be pushed cephaladas well as pulled caudally. This translationalmotion can be felt by palpating the posterioriliac spine and tubercle while pushing-pullingthe unstable hemipelvis. The identication ofneurologic abnormalities or open wounds in theank, perineum, and rectum may be evidence ofpelvic ring instability. When appropriate, an APx-ray of the pelvis conrms the clinical examina-tion. (See Skills Station IV, Shock Assessment and

Management.)

3. Management

Initial management of a major pelvic disruptionassociated with hemorrhage requires hemor-rhage control and rapid uid resuscitation. Hem-orrhage control is achieved through mechanicalstabilization of the pelvic ring and externalcounter pressure (pneumatic antishock garment).Patients with these injuries may be initially as-sessed and treated in hospitals that do not have


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the resources to denitively manage the degreeof associated hemorrhage. Simple techniquesmay be employed to stabilize the pelvis before

patient transfer. Longitudinal traction appliedthrough the skin or the skeleton is a rst-linemethod. Because these injuries externally rotatethe hemipelvis(es), internal rotation of the lowerlimbs also reduces the pelvic volume. This proce-dure can be supplemented by applying a supportdirectly to the pelvis. A sheet wrapped aroundthe pelvis as a sling, a vacuum-type long-spinesplinting device, or the pneumatic antishock gar-ment (PASG) can apply sufcient stability for theunstable hemipelvis(es). These temporary meth-ods are suitable to gain early pelvic stabilization.Denitive care of the hemodynamically abnor-

mal patient demands the cooperative efforts ofa team that must include a trauma surgeon andan orthopaedic surgeon, as well as any othersurgeon whose expertise is required because ofthe patients injuries. (See Chapter 5, AbdominalTrauma.)

Open pelvic fractures with obvious bleeding re-quire pressure dressings to control hemorrhage,which is done by packing the open wounds. Earlysurgical consultation is essential.

B. Major Arterial Hemorrhage

1. Injury

Penetrating wounds of an extremity can resultin major arterial vascular injury. Blunt traumaresulting in an extremity fracture or joint dislo-cation in close proximity to an artery also maydisrupt the artery. These injuries may lead tosignicant hemorrhage through the open woundor into the soft tissues.

2. Assessment

An injured extremity should be assessed for exter-nal bleeding, loss of a previously palpable pulseor changes in pulse quality, and changes in Dop-pler tone and ankle/brachial index. A cold, pale,pulseless extremity indicates an interruption inarterial blood supply. A rapidly expanding he-matoma suggests a signicant vascular injury.

3. Management

If a major arterial injury exists or is suspected, im-mediate consultation with a surgeon is warrant-

ed. Management of major arterial hemorrhage in-cludes application of direct pressure to the openwound and aggressive uid resuscitation.

The judicious use of a pneumatic tourniquetmay be helpful and lifesaving. The applicationof vascular clamps into bleeding open wounds inthe emergency department is not recommended,unless a supercial vessel is clearly identied. Ifa fracture is associated with an open hemorrhag-ing wound, the fracture should be realigned andsplinted while direct pressure is applied to theopen wound. A joint dislocation simply requiresimmobilization because joint reduction may beextremely difcult, and therefore should be man-aged by emergency surgical intervention. The

use of arteriography or other investigations areindicated only in the resuscitated, hemodynami-cally normal patient. Urgent consultation with asurgeon skilled in vascular and extremity traumais necessary.

C. Crush Syndrome (Traumatic Rhabdomyolysis)

1. Injury

Crush syndrome refers to the clinical effectscaused by injured muscle that, if untreated, maylead to acute renal failure. This condition is seen

in individuals who have sustained a crush injuryof a signicant muscle mass, most often a thighor calf. The muscular insult is a combination ofdirect muscle injury, muscle ischemia, and celldeath with release of myoglobin.

2. Assessment

The myoglobin produces dark amber urine thattests positive for hemoglobin. The myoglobinassay must be specically requested to conrmits presence. Rhabdomyolysis may lead to hy-povolemia, metabolic acidosis, hyperkalemia,hypocalcemia, and disseminated intravascularcoagulation (DIC).

3. Management

The initiation of intravenous uid therapy duringthe period of resuscitation is critical to protectingthe kidney and preventing renal failure. Myo-globin-induced renal failure may be preventedby intravascular uid expansion and osmoticdiuresis to maintain a high tubular volume andurine ow. Alkalization of the urine with sodium


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bicarbonate reduces intratubular precipitation ofmyoglobin and is indicated in most patients. It isrecommended to maintain the patients urinary

output at 100 mL/hour until the myoglobinuriais cleared.

VI. LIMB-THREATENING INJURIES

A. Open Fractures and Joint Injuries

1. Injury

Open fractures represent a communication be-tween the external environment and the bone.Muscle and skin must be injured for this to occur.The degree of soft-tissue injury is proportional

to the energy applied. This damage, along withbacterial contamination, makes open fracturesprone to problems with infection, healing, andfunction.

2. Assessment

Diagnosis is based on the history of the incidentand physical examination of the extremity thatdemonstrates an open wound with or withoutsignicant muscle damage, contamination, andassociated fracture. Management decisions shouldbe based on a complete history of the incident and

assessment of the injury.

Documentation of the open wound commencesin the prehospital phase with the initial descrip-tion of the injury and any treatment renderedat the scene. No further inspection of the openwound is warranted, providing documentationis adequate. If documentation or history is inad-equate, the dressing should be removed under assterile conditions as possible to visually examinethe wound. A sterile dressing is then reapplied.At no time should the wound be probed. If a frac-ture and an open wound exist in the same limb

segment, the fracture is considered open untildisproved.

If an open wound exists over or near a joint,it should be assumed that this injury connectswith or enters the joint, and surgical consultationshould be obtained. The insertion of dye, saline,or any other material into the joint to determinewhether the joint cavity communicates with thewound is not recommended. The only safe wayto determine communication between an open

wound and a joint is to surgically explore anddebride the wound.

3. Management

The presence of an open fracture or a joint injuryshould be promptly recognized. Appropriate im-mobilization should be applied after an accuratedescription of the wound is made and associatedsoft-tissue, circulatory, and neurologic involve-ment is determined. Prompt surgical consultationis necessary. The patient should be adequately re-suscitated and hemodynamic stability achievedif possible. Wounds then may be operativelydebrided and fractures stabilized. Tetanus pro-phylaxis should be administered. Antibiotics are

used only after consultation with a surgeon.

B. Vascular Injuries, Including TraumaticAmputation

1. History and assessment

A vascular injury should be strongly suspected ifthere is presence of vascular insufciency associ-ated with a history of blunt, crushing, twisting, orpenetrating injury to an extremity. The limb mayinitially appear viable because extremities oftenhave some collateral circulation that providesenough retrograde ow. Partial vascular injuryresults in the distal part of the extremity beingcool and having prolonged capillary rell, dimin-ished peripheral pulses, and an abnormal ankle/brachial index. Alternatively, the distal extremitymay have a complete disruption of ow and becold, pale, and pulseless.

2. Management

An acutely avascular extremity must be recog-nized promptly and treated emergently. Muscledoes not tolerate a lack of arterial blood ow forlonger than 6 hours before necrosis commences.Nerves also are very sensitive to an anoxic envi-ronment. Therefore, early operative revascular-ization is required to restore arterial ow to theimpaired distal extremity. If there is an associatedfracture deformity, it can be corrected quickly bygently realigning and splinting the injured ex-tremity.

If an arterial injury is associated with a disloca-tion of a joint, a doctor, skilled in joint reduction,may attempt one gentle reduction maneuver.


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Otherwise, splinting of the dislocated joint andemergency surgical consultation is necessary.Arteriography must not delay reestablishing arte-

rial blood ow and is indicated only after surgicalconsultation.

The potential for vascular compromise also ex-ists whenever an injured extremity is splinted orplaced in a cast. This may be identied by the lossor change in distal pulse exam, but excessive painafter cast application also must be investigated.The splint, cast, or any circumferential dressingsmust be released promptly and the vascular sup-ply reassessed.

Amputation is a traumatic event for the patientboth physically and emotionally. A traumaticamputation is a severe form of open fracturethat results in loss of the extremity and requiresconsultation with and intervention by a surgeon.Certain open fractures with prolonged ischemia,neurologic injury, and muscle damage mayrequire amputation. Amputation of an injuredextremity may be lifesaving in the hemodynami-cally abnormal patient who is difcult to resus-citate.

Although the potential for replantation should beconsidered, it must be put into perspective withthe patients other injuries. Remember, a patientwith multiple injuries who requires intensiveresuscitation and emergency surgery is not acandidate for replantation. Replantation usuallyis performed with an isolated extremity injury. Apatient with clean, sharp amputations of ngersor of a distal extremity, below the knee or elbow,should be transported to an appropriate surgicalteam skilled in the decision making and manage-ment of replantation procedures.

The amputated part should be thoroughly washedin isotonic solution (eg, Ringers lactate solution)and wrapped in sterile gauze soaked in aqueouspenicillin (100,000 units in 50 mL Ringers lactatesolution). The amputated part is then wrappedin a similarly moistened sterile towel, placed ina plastic bag, and transported with the patient inan insulated cooling chest with crushed ice. Caremust be taken not to freeze the amputated part.

C. Compartment Syndrome

1. Injury

A compartment syndrome may occur in any site

in which muscle is contained within a closed fas-cial space. Remember, the skin also may act asa restricting membrane in certain circumstances.

Common areas where compartment syndromeoccurs are the lower leg, forearm, foot, hand,the gluteal region, and the thigh. Compartmentsyndrome develops when the pressure withinan osteofascial compartment of muscle causesischemia and subsequent necrosis. This ischemiacan be caused by an increase in compartmentsize, eg, swelling secondary to revascularizationof an ischemic extremity or by decreasing thecompartment size, eg, constricting dressing. Theend-stage of this neuromuscular injury is calledVolkmanns ischemic contracture.

2. Assessment

Any injury to an extremity has the potential tocause a compartment syndrome. However, cer-tain injuries as listed herein are considered ashigh-risk injuries.

a. Tibial and forearm fractures

b. Injuries immobilized in tight dressings orcasts

c. Severe crush injury to muscle

d. Localized, prolonged external pressure toan extremity

e. Increased capillary permeability secondaryto reperfusion of ischemic muscle

f. Burns

g. Excessive exercise

A high degree of awareness is important, espe-cially if the patient has an altered mental senso-rium and is unable to respond appropriately topain.

The signs and symptoms of compartment syn-drome are (1) pain greater than expected and

that typically increases by passive stretchingof involved muscles, (2) paresthesia in the dis-tribution of the involved peripheral nerve, (3)decreased sensation or functional loss of thenerves that traverse the involved compartment,and (4) tense swelling of the involved region. Apalpable distal pulse usually is often present ina compartment syndrome. Weakness or paralysisof involved muscles and loss of pulses (becausethe compartment pressure exceeds the systolicpressure) in the affected limb are late signs ofcompartment syndrome.


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Remember, changes in distal pulses or capil-lary rell times are not reliable in diagnosinga compartment syndrome. Clinical diagnosis is

based on the history of injury and physical signscoupled with a high index of suspicion. Intra-compartmental pressure measurements may behelpful in diagnosing a suspected compartmentsyndrome. Tissue pressures that are greater than35 to 45 mm Hg suggest decreased capillaryblood ow that results in increased muscle andnerve anoxic damage. Systemic blood pressure isimportant. The lower the systemic pressure, thelower the compartment pressure that causes acompartment syndrome. Pressure measurementis indicated in all patients who have an alteredresponse to pain.

3. Management

All constricting dressings, casts, and splintsapplied over the affected extremity must be re-leased. The patient must be carefully monitoredand reassessed clinically for the next 30 to 60 min-utes. If no signicant changes occur, fasciotomyis required. Compartment syndrome is a time-de-pendent condition. The higher the compartmentpressure and the longer it remains elevated, thegreater the degree of resulting neuromusculardamage and functional decit. Delay in perform-

ing a fasciotomy may result in myoglobinuria,which may cause decreased renal function. Surgi-cal consultation of diagnosed or suspected com-partment syndrome must be obtained early.

D. Neurologic Injury Secondary to FractureDislocation

1. Injury

A fracture or, in particular, a dislocation maycause signicant neurologic injury due to theanatomic relationship or proximity of the nerveto the joint, eg, sciatic nerve compression fromposterior hip dislocation or axillary nerve injuryfrom anterior shoulder dislocation. Optimumfunctional outcome is jeopardized unless thisinjury is recognized and treated early.

2. Assessment

A thorough examination of the neurologic systemis essential in a patient with a musculoskeletalinjury. Determination of neurologic impairmentis important and progressive changes must bedocumented.

Assessment usually demonstrates a deformityof the extremity. Assessment of nerve functionusually requires a cooperative patient. For eachsignicant peripheral nerve, voluntary mo-tor function and sensation must be conrmedsystematically. (See Table 2, Peripheral NerveAssessment of Upper Extremities, and Table 3,page 215, Peripheral Nerve Assessment of LowerExtremities.) Muscle testing must include palpa-tion of the contracting muscle.

Table 2Peripheral Nerve Assessment of Upper Extremities

NERVE MOTOR SENSATION INJURY

Ulnar Index nger abduction Little nger Elbow injury

Median distal Thenar contraction withopposition Index nger Wrist dislocation

Median, anteriorinterosseous

Index tip exion Supracondylar fracture ofhumerus (children)

Musculocutaneous Elbow exion Lateral forearm Anterior shoulder dislocation

Radial Thumb, nger MCPextension

1st dorsal webspace

Distal humeral shaft, anteriorshoulder dislocation

Axillary Deltoid Lateral shoulder Anterior shoulder dislocation,proximal humerus fracture


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Table 3Peripheral Nerve Assessment of Lower Extremities

NERVE MOTOR SENSATION INJURY

Femoral Knee extension Anterior knee Pubic rami fractures

Obturator Hip adduction Medial thigh Obturator ring fractures

Posterior tibial Toe exion Sole of foot Knee dislocation

Supercial peroneal Ankle eversion Lateral dorsumof foot

Fibular neck fracture, kneedislocation

Deep peroneal Ankle/toe dorsiexion Dorsal 1st to2nd web space

Fibular neck fracture,compartment syndrome

Sciatic nerve Plantar dorsiexion Foot Posterior hip dislocation

Superior gluteal Hip abduction Acetabular fracture

Inferior gluteal Gluteus maximus hip

extension

Acetabular fracture

In most multiply injured patients, it is difcult toinitially assess nerve function. However, it mustbe repeated on an ongoing basis, especially afterthe patient is stabilized. Progression is indica-tive of continued nerve compression. The mostimportant aspect of any neurologic assessmentis the documentation of progression. It also is animportant aspect of surgical decision making.

3. Management

The injured extremity should be immobilizedin the dislocated position and surgical consulta-tion obtained immediately. If indicated and if thetreating doctor is knowledgeable, a careful reduc-tion of the dislocation may be attempted. After re-ducing a dislocation, neurologic function shouldbe reevaluated and the limb splinted.

VII. OTHER EXTREMITY INJURIES

A. Contusions and Lacerations

Simple contusions and/or lacerations should be as-sessed to exclude vascular and/or neurologic injury.In general, lacerations require debridement and clo-sure. If a laceration extends below the fascial level,it requires operative intervention to more formallydebride the wound and assess for damage to under-lying structures.

Contusions usually are recognized by pain in thearea and decreased function of the extremity. Palpa-

tion conrms localized swelling and tenderness. Thepatient usually cannot use the muscle or decreasedfunction occurs from pain in the affected extremity.Contusions are treated by limiting function of theinjured part and applying cold packs, if the patientis seen early.

Beware of small wounds, especially those result-

ing from crush injuries. When a very strong forceis applied very slowly over an extremity, signicantdevascularization and crushing of muscle can occurwith only a small skin wound. Crush and deglovinginjuries can be very subtle and must be suspectedbased on mechanism of injury.

The risk of tetanus is increased with wounds that (1)are more than 6 hours old, (2) are contused and/orabraded, (3) are more than 1 cm in depth, (4) resultfrom high velocity missiles, (5) are due to burn orcold, and (6) have signicant contamination (espe-cially burn wounds and wounds with denervated

or ischemic tissue). (See Appendix 4, Tetanus Im-munization.)

B. Joint Injuries

1. Injury

Joint injuries that are not dislocated (the joint iswithin its normal anatomic conguration but hassustained signicant ligamentous injury) usuallyare not limb threatening. However, such joint in-

juries can decrease the function of the limb.


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CHAPTER 8



2. Assessment

The patient usually relates some form of abnor-mal stress to the joint, eg, impact to the anteriortibia pushing the knee back, an impact to the lat-eral aspect of the leg that results in a valgus strainto the knee, or a fall onto an outstretched arm thatcauses a hyperexion injury to the elbow.

Physical examination reveals tenderness through-out the affected ligament. A hemarthrosis usuallyis present unless the joint capsule is disruptedand the bleeding diffuses into the soft tissues.Passive ligamentous testing of the affected jointreveals instability. X-rays usually demonstrate nosignicant injury. However, some small avulsionfractures from ligamentous insertions or originsmay be present radiographically.

3. Management

Joint injuries should be immobilized. Vascularand neurologic status of the limb, distal to the in-

jury, should be reassessed. Surgical consultationusually is warranted.

C. Fractures

1. Injury

Fractures are dened as a break in the continuityof the bone cortex leading to abnormal motionassociated with crepitus and pain. Fractures usu-ally are associated with some form of soft-tissueinjury, whether the fracture is closed or open.

2. Assessment

Examination of the extremity demonstrates pain,swelling, deformity, tenderness, crepitus, and ab-normal motion at the fracture site. The evaluationfor crepitus and abnormal motion at the fracturesite may occasionally be necessary to make the

diagnosis, but this is painful and potentially canincrease soft-tissue damage. These diagnostictests must not be done routinely or repetitively.Usually the swelling, tenderness, and deformityare sufcient to conrm a fracture. It is importantto periodically reassess the neurovascular statusof a limb, especially if a splint is in place.

X-rays taken at right angles to each other conrmthe history and physical examinations. Depend-ing on the hemodynamic status of the patient,x-rays may have to be delayed until the patient is

stabilized. X-rays through the joint above and be-low the suspected fracture site must be includedto exclude occult dislocation and concomitant

injury.

3. Management

a. Immobilization must include the joint aboveand below the fracture. After splinting, theneurologic and vascular status of the extremitymust be reassessed.

b. Surgical consultation is required for furthertreatment.

VIII. PRINCIPLES OF IMMOBILIZATION

Splinting of extremity injuries, unless associatedwith life-threatening injuries, usually can be left un-til the secondary survey. However, all such injuriesmust be splinted before patient transport. Assess thelimbs neurovascular status after applying splints orrealigning a fracture.

Specic types of splints can be applied for specicfracture needs. The PASG is not generally recom-mended as a lower extremity splint. However, itmay be temporarily useful for patients with life-threatening hemorrhage from pelvic injuries orsevere lower extremity injuries with soft-tissueinjury. Prolonged ination (>2 hours) of the legcomponents in hypotensive patients may lead tocompartment syndrome.

A long spine board provides a total body splintfor multiply injured patients with possible or con-rmed unstable spine injuries. However, its hard,unpadded surface may cause pressure sores onthe patients occiput, scapulae, sacrum, and heels.Therefore, as soon as possible, the patient should bemoved carefully to an equally supportive paddedsurface, using a scoop-style stretcher or appropriatelogrolling maneuver to facilitate the transfer. The pa-tient should be fully immobilized and an adequatenumber of personnel should be available duringthis transfer. (See Chapter 7, Spine and Spinal CordTrauma Skills Station XI, Spinal Cord Injury Assess-ment and Management, pages 200202, V. Principlesof Spine Immobilization and Logrolling.)

A. Femoral Fractures

Femoral fractures are immobilized temporarily withtraction splints. The traction splints force is applieddistally at the ankle or through the skin. Proximally,


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CHAPTER 8



the splint is pushed into the thigh and hip areas by aring that applies pressure to the buttocks, perineum,and groin. Excessive traction may cause skin damage

to the foot, ankle, or perineum. Neurovascular com-promise may result from stretching the peripheralnerves. Hip fractures can be similarly immobilizedwith a traction splint, but are more suitably immobi-lized with skin traction or a foam boot traction withthe knee in slight exion. A simple method of splint-ing is to bind the injured leg to the opposite leg.

B. Knee Injuries

The use of commercially available knee immobiliz-ers or the application of a long-leg splint of plasteris very helpful in maintaining comfort and stability.

The leg should not be immobilized in complete ex-tension, but should be immobilized with about 10of exion to take pressure off the neurovascularstructures.

C. Tibia Fractures

Tibia fractures are best immobilized with a well-padded cardboard or metal gutter long-leg splint.If readily available, plaster splints immobilizing thelower leg, the knee, and the ankle may be used.

D. Ankle Fractures

Ankle fractures may be immobilized with a pillowsplint or padded cardboard splint, thereby avoidingpressure over bony prominences.

E. Upper Extremity and Hand Injuries

The hand can be temporarily splinted in an ana-tomic, functional position, with the wrist slightlydorsiexed and the ngers gently exed 45 at themetacarpal phalangeal joints. This position usuallycan be achieved by gently immobilizing the handover a large roll of gauze and using a short-armsplint.

The forearm and wrist are immobilized at on pad-ded or pillow splints. The elbow usually is immo-bilized in a exed position, either by using paddedsplints or by direct immobilization to the body witha sling and swath device. The upper arm usually isimmobilized by splinting it to the body or by apply-ing a sling or swath, which can be augmented bya thoracobrachial bandage. Shoulder injuries aremanaged by a sling and swath device or a Velcro-type of dressing.

IX. PAIN CONTROL

Analgesics are generally indicated for a joint injury

or a fracture. However, the administration of painmedications must be tempered by the patientsclinical situation. The appropriate use of splintssignicantly decreases the patients discomfort bycontrolling the amount of motion that occurs at theinjured site.

Patients who do not appear to have signicant painand discomfort from a major fracture may haveother associated injuries, eg, intracranial lesions,hypoxia, or may be under the inuence of alcoholand/or other drugs.

Effective pain relief usually requires administrationof narcotics, which should be given in small dosesintravenously and repeated as needed. Musclerelaxants and sedatives should be administeredcautiously in the patient with an isolated extrem-ity injury, eg, reduction of a dislocation. Wheneveranalgesics, muscle relaxants, or sedatives are admin-istered to an injured patient, the potential exists forrespiratory arrest. Consequently, appropriate resus-citative equipment must be immediately available.

X. ASSOCIATED INJURIES

Certain musculoskeletal injuries, because of theircommon mechanism of injury, are often associatedwith a second injury that is not immediately appar-ent or may be missed. (See Table 4, page 218, As-sociated Injuries.) Steps to ensure recognition andmanagement of these injuries include:

A. Review the injury history, especially the mecha-nism of injury, to determine if another injury may bepresent.

B. Thoroughly reexamine all extremities, placingspecial emphasis on the hands, wrists, feet, and the

joint above and below a fracture or dislocation.C. Visually examine the patients dorsum, includ-ing the spine and pelvis. Open injuries and closedsoft-tissue injuries that may be indicative of an un-stable injury must be documented.

D. Review the x-rays obtained in the secondary sur-vey to identify subtle injuries that may be associatedwith more obvious trauma.


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Table 4Associated Injuries

INJURY MISSED/ASSOCIATED INJURY

Clavicular fractureScapular fractureFracture and/or dislocation of shoulder

Major thoracic injury, especially pulmonarycontusion and rib fractures

Displaced thoracic spine fracture Thoracic aortic rupture

Spine fracture Intraabdominal injury

Fracture/dislocation of elbow Brachial artery injuryMedian, ulnar, and radial nerve injury

Major pelvic disruption (motor vehicleoccupant)

Abdominal, thoracic, or head injury

Major pelvic disruption (motorcyclistor pedestrian)

Pelvic vascular hemorrhage

Femur fracture Femoral neck fracturePosterior hip dislocation

Posterior knee dislocation Femoral fracturePosterior hip dislocation

Knee dislocation or displaced tibialplateau fracture

Popliteal artery and nerve injuries

Calcaneal fracture Spine injury or fractureFracture-dislocation of hind footTibial plateau fracture

Open fracture 70% incidence of associated nonskeletal injury

XI. OCCULT SKELETAL INJURIES

Remember, not all injuries can be diagnosed dur-ing the initial assessment and management of thepatient. Joints or bones that are covered or wellpadded within muscular areas may contain occultinjuries. It may be difcult to identify nondisplacedfractures or joint ligamentous injuries, especially ifthe patient is unresponsive or there are other severeinjuries. It is important to recognize that injuries arecommonly discovered days after the injury incident,eg, when the patient is being mobilized. Therefore,is it important to reassess the patient routinely andto relate this possibility to other members of thetrauma team and the patients family.

XII. PITFALLS

A. Musculoskeletal injuries are a potential source ofoccult blood loss in the hemodynamically abnormalpatient. Occult sites of hemorrhage are the retroperi-toneum from unstable pelvic ring injuries, the thigh

from femoral fractures, and any open fracture withmajor soft-tissue involvement where blood loss maybe serious and occur before the patient reaches thehospital.

B. A compartment syndrome is limb-threatening.Clinical ndings must be recognized and surgicalconsultation obtained early. These may be normal inpatients with hypotension.

C. Despite a thorough examination, occult associ-

ated injuries may not be appreciated during theinitial evaluation of the patient. It is imperative torepeatedly reevaluate the patient to assess for theseinjuries.

XIII. SUMMARY

The goal of initial assessment and management ofmusculoskeletal trauma is to identify injuries thatpose a threat to life and/or limb. Although uncom-mon, life-threatening musculoskeletal injuries mustbe properly assessed and managed. Most extrem-


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ity injuries are appropriately diagnosed and man-aged during the secondary survey. It is essentialto recognize and manage in a timely manner pelvic

fractures, arterial injuries, compartment syndrome,open fractures, crush injuries, and fracture-disloca-tions. Knowledge of the mechanism of injury andhistory of the injury-producing event enables thedoctor to be aware of what associated conditionspotentially exist with the injured extremity. Earlysplinting of fractures and dislocations can preventserious complications and late sequelae. Addition-ally, an awareness of the patients tetanus immuni-zation status, particularly in cases of open fracturesor signicantly contaminated wounds, can preventserious complications. Armed with the properknowledge and skills, as outlined in this chapter, the

doctor can satisfactorily provide the initial manage-ment for most musculoskeletal trauma.

BIBLIOGRAPHY

1. American Academy of Orthopaedic Surgeons:Emergency Care and Transportation of theSick and Injured, 8th Edition. Sudbury, MA,

Jones and Bartlett Publishers, 2002.

2. Bone LB, Johnson KD, Weigelt J, et al: Early ver-sus delayed stabilization of femoral fractures:A prospective, randomized study. Journal ofBone and Joint Surgery 1989; 71A:336340.

3. Browner BD (ed): Controversies and perils.Techniques in Orthopedics 1994; 9(4):258.

4. Browner BD, Jupiter JB, Levine AM, et al (eds):Skeletal Trauma. Philadelphia, WB Saunders,1991.

5. Carter PR: Common hand injuries and infec-tions. In: A Practical Approach to Early Treat-ment. Philadelphia, WB Saunders, 1983.

6. Dalal SA, Burgess AR, Seigel JH, et al: Pelvicfracture in multiple trauma: Classication by

mechanism is key to pattern of organ injury, re-suscitative requirements, and outcome.Journalof Trauma 1989; 29(7):9811000.

7. Gustilo RB, Anderson JT: Prevention of infectionin the treatment of 1025 open fractures of longbones.Journal of Bone and Joint Surgery 1976;58A:453.

8. Gustilo RB, Mendoza RM, Williams DN: Prob-lems in the management of type III (severe)open fractures: A new classication of type IIIopen fractures.Journal of Trauma 1985; 24:742.

9. Hansen ST, Swiontkowski MF: OrthopedicTrauma Protocols. New York, Raven Press,1993.

10. Heppenstall RB, Sapega AA, Scott R, et al: Thecompartment syndrome: An experimental andclinical study of muscular energy metabolismusing phosphorus nuclear magnetic resonancespectroscopy. Clinical Orthopedics 1988; 226:138155.

11. Hoppenfeld S: Physical Examination of theSpine and Extremities. New York, Appleton,

1976.

12. Koury HI, Peschiera JL, Welling RE: Selectiveuse of pelvic roentgenograms in blunt traumapatients.Journal of Trauma 1993; 34:236.

13. Maull KI, Capenhart JE, Cardea JA, et al: Limbloss following MAST application. Journal ofTrauma 1981; 21:6062.

14. Moore EE, Ducker TB, Edlich RF, et al (eds):Early Care of the Injured Patient, 4th Edition.Philadelphia, BC Decker, 1990, chapters 1924.

15. Ododeh M: The role of reperfusion-induced in-jury in the pathogenesis of the crush syndrome.New England Journal of Medicine 1991; 324:14171421.

16. Rockwood CA, Green DP, Bucholtz R (eds):Fractures, 3rd Edition. Philadelphia, JP Lippin-cott Co, 1991.

17. Trafton PG: Orthopaedic emergencies. In: HoMT, Saunders CE (eds): Current EmergencyDiagnosis and Treatment, 3rd Edition. EastNorwalk, CT, Appleton & Lange, 1990.

18. Tscherne H, Gotzen L: Fractures with Soft-Tis-

sue Injuries. Berlin, Springer Verlag, 1984.


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SKILLS STATION XII

XIIMusculoskeletal TraumaAssessment and ManagementSKILLS STATION

OBJECTIVES:

Performance at this station will allow the participant to:

1. Perform a rapid assessment of the essential components of the musculoskeletal system.

2. Recognize life- and limb-threatening injuries of the musculoskeletal system, and institute initial man-agement of these problems.

3. Identify the patient at risk for compartment syndrome.

4. Recognize the indications and the value of appropriate splinting of musculoskeletal injuries.

5. Apply standard splints to the extremities, including a traction splint.

6. Recognize the complications associated with the use of splints.

7. Identify pelvic instability associated with pelvic fracture.

8. Recognize the value of the AP pelvic x-ray to identify the potential for massive blood loss and the ma-neuvers that may be used to reduce pelvic volume and control bleeding.

PROCEDURES:

1. Perform a physical examination of the musculoskeletal system.

2. Apply a leg traction splint.

3. Review and discuss a series of x-rays and identify injuries.


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SKILLS STATION XII


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CHAPTER 8SKILLS STATION XII

Musculoskeletal Trauma Assessment and Management MUSCULOSKELETAL TRAUMA


INTERACTIVE SKILLS PROCEDURES

Musculoskeletal TraumaAssessment and Management

Note: Standard precautions are required whenever caring for the trauma patient.

Note: A series of x-rays with related scenarios is provided at the conclusion of this section for use during thisstation in making evaluation and management decisions based on the ndings.

Goal of Splinting: To prevent further soft-tissue injury and control bleeding and pain. Consider the immo-bilization of fractured extremities with the use of splints as secondary resuscitation devices that aid in the

control of bleeding.

I. PHYSICAL EXAMINATION

A. Look, General Overview

External hemorrhage is identied by obvious external bleeding from an extremity, pooling of blood on thestretcher or oor, blood-soaked dressings, and bleeding that occurs during transport to the hospital. The ex-aminer needs to ask about characteristics of the injury incident and prehospital care.

1. Open wounds may not bleed, but may be indicative of nerve injury or an open fracture.

2. A deformed extremity is indicative of a fracture or joint injury. This type of injury should be splinted

before patient transport or as soon as is safely possible.3. The color of the extremity is important to assess. The presence of bruising indicates muscle injury orsignicant soft-tissue injury over bones or joints. These changes may be associated with swelling or hema-tomas. Vascular impairment may be rst identied by a pale, distal extremity.

4. Position of the extremity may be helpful in determining certain injury patterns. Certain nerve decitslead to specic positions of the extremity. For example, injury to the radial nerve results in wrist drop, andinjury to the peroneal nerve results in foot drop.

5. Observation of spontaneous activity helps determine the severity of injury. Observing whether thepatient spontaneously moves an extremity may suggest to the examiner other obvious or occult injuries.An example is the brain-injured patient who does not follow commands and has no spontaneous lowerextremity movement. This patient could have a thoracic or lumbar fracture.

6. Gender and age are important clues to potential injuries. Children may sustain growth plate injuriesand fractures that may not manifest themselves (eg, buckle fracture). A woman is less likely to have a ure-thral injury than a vaginal injury with a pelvic fracture.

7. Drainage from the urinary catheter should be observed. If the urine is bloody or if catheter insertion isdifcult, the patient may have a pelvic fracture and a urologic injury.

B. Feel

Life- and limb-threatening injuries are excluded rst.


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MUSCULOSKELETAL TRAUMA Musculoskeletal Trauma Assessment and Management


1. The pelvis is palpated anteriorly and posteriorly to assess for deformity, motion, and/or a gap that in-dicates a potentially unstable pelvis. The compression-distraction test as well as the push-pull test shouldbe done only once. These tests are dangerous because they may dislodge clots and cause rebleeding.

2. Pulses in all extremities should be palpated and the ndings documented. Any perceived abnormalityor difference must be explained. Normal capillary rell (


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g. Muscle power is graded in the standard form. The motor examination is specic to a variety of vol-untary movements of each extremity. (See Chapter 7, Spine and Spinal Cord Trauma, Table 1, page 181,Muscle Strength Grading.)

7. The deep tendon reexes also are assessed.

8. Remember, assess the patients back!

II. PRINCIPLES OF EXTREMITY IMMOBILIZATION

A. Assess the ABCDEs and treat life-threatening situations rst.

B. Remove all clothing and completely expose the patient including the extremities. Remove watches, rings,bracelets, and other potentially constricting devices. Remember, prevent the development of hypothermia.

C. Assess the neurovascular status of the extremity before applying the splint. Assess for pulses, externalhemorrhage, which must be controlled, and perform a motor and sensory examination of the extremity.

D. Cover any open wounds with sterile dressings.

E. Select the appropriate size and type of splint for the injured extremity. The device should immobilize thejoint above and the joint below the injury site.

F. Apply padding over bony prominences that will be covered by the splint.

G. Splint the extremity in the position in which it is found if distal pulses in the injured extremity are pres-ent. If distal pulses are absent, one attempt to realign the extremity should be tried. Gentle traction should bemaintained until the splinting device is secured.

H. The extremity is placed in a splint if normally aligned. If malaligned, the extremity needs to be realignedand then splinted.

I. Do not force realignment of a deformed extremity. If it is not easily realigned, splint the extremity in theposition in which it is found.

J. Obtain orthopaedic consultation.

K. Document the neurovascular status of the extremity before and after every manipulation or splint appli-cation.

L. Administer appropriate tetanus prophylaxis. (See Appendix 4, Tetanus Immunization.)

III. REALIGNING A DEFORMED EXTREMITY

Physical examination determines if the deformity is from a fracture or dislocation. The principle of realign-ing an extremity fracture is to restore length by applying gentle longitudinal traction to correct the residualangulation and then rotational deformities. While maintaining realignment with manual traction, a splint isapplied and secured to the extremity by an assistant.

A. Upper Extremity

1. Humerus

Grasp the elbow and manually apply distal traction. After alignment is obtained, a plaster splint is appliedand the arm secured to the chest wall with a sling and swath.


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2. Forearm

Manually apply distal traction through the wrist while holding the elbow and applying countertraction. Asplint is then secured to the forearm and the injured extremity is elevated.

B. Lower Extremity

1. Femur

Realign the femur by manually applying traction through the ankle if the tibia and bula are not fractured.As the muscle spasm is overcome, the leg will straighten and the rotational deformity can be corrected.This maneuver may take several minutes, depending on the size of the patient.

2. Tibia

Manually apply distal traction at the ankle and countertraction just above the knee, provided that thefemur is intact.

C. Vascular and Neurologic Decits

Fractures associated with neurovascular decit require prompt realignment. Immediate consultation with asurgeon is necessary. If the vascular or neurologic status worsens after realignment and splinting, the splintshould be removed and the extremity returned to the position in which blood ow and neurologic status aremaximized. The extremity is then immobilized in that position.

IV. APPLICATION OF THE TRACTION SPLINT

A. Application of this device requires 2 people1 person to handle the injured extremity, the other to applythe splint.

B. Remove all clothing, including footwear, to expose the extremity. Apply sterile dressings to open wounds,and assess the neurovascular status of the extremity.

C. Cleanse any exposed bone and muscle of dirt and debris before applying traction. Document that theexposed bone fragments were reduced into the soft tissues.

D. Determine the length of the splint by measuring the uninjured leg. The upper cushioned ring should beplaced under the buttocks and adjacent to the ischial tuberosity. The distal end of the splint should extendbeyond the ankle by approximately 6 inches (15 cm). The straps on the splint should be positioned to supportthe thigh and calf.

E. The femur is aligned by manually applying traction through the ankle. After realignment is achieved,gently elevate the leg to allow the assistant to slide the splint under the extremity so that the padded portion

of the splint rests against the ischial tuberosity. Reassess the neurovascular status of the distal injured extrem-ity after applying traction.

F. The ankle hitch is positioned around the patients ankle and foot while the assistant maintains manualtraction on the leg. The bottom strap should be slightly shorter than, or at least the same length as, the 2 uppercrossing straps.

G. Attach the ankle hitch to the traction hook while the assistant maintains manual traction and support.Apply traction in increments using the windlass knob until the extremity appears stable, or until pain andmuscular spasm are relieved.

H. Reassess the neurovascular status of the injured extremity. If perfusion of the extremity distal to the injuryappears worse after applying traction, gradually release the traction.


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I. Secure the remaining straps.

J. Frequently reevaluate the neurovascular status of the extremity. Document the neurovascular status after

every manipulation of the extremity.K. Administer tetanus prophylaxis, as indicated. (See Appendix 4, Tetanus Immunization.)

V. COMPARTMENT SYNDROMEASSESSMENT AND MANAGEMENT

A. Important Considerations

1. Compartment syndrome may develop insidiously.

2. Compartment syndrome may develop in an extremity from compression or crushing forces and with-out obvious external injury or fracture.

3. Frequent reevaluation of the injured extremity is essential.

4. The patient who has been hypotensive or is unconscious is at increased risk for developing compart-ment syndrome.

5. The unconscious or intubated patient cannot communicate the early signs of extremity ischemia.

6. Pain is the earliest symptom that heralds the onset of compartment ischemia, especially pain on passivestretch of the involved muscles of the extremity.

7. Loss of pulses and other classic ndings of ischemia occur late, after irreversible damage has oc-curred.

B. Palpate the muscular compartments of the extremities, comparing the compartment tension in the injuredextremity with that in the noninjured extremity.

1. Asymmetry is a signicant nding.

2. Frequent examination for tense muscular compartments is essential.

3. Measurement of compartment pressures is helpful.

4. If compartment syndrome is suspected, obtain surgical consultation.

C. Obtain orthopaedic or general surgical consultation early.

VI. IDENTIFICATION AND MANAGEMENT OF PELVIC FRACTURES

A. Identify the mechanism of injury, which can suggest the possibility of a pelvic fracture, eg, ejection froma motor vehicle, crushing injury, pedestrian struck by moving vehicle, or motorcycle collision.

B. Inspect the pelvic area for ecchymosis, perineal or scrotal hematoma, or blood at the urethral meatus.

C. Inspect the legs for differences in length or asymmetry in rotation of the hips.

D. Perform a rectal examination, noting the position and mobility of the prostate gland, any palpable frac-ture, or the presence of gross or occult blood in the stool.

E. Perform a vaginal examination, noting palpable fractures, the size and consistency of the uterus, or thepresence of blood. Remember, females of childbearing age may be pregnant.


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F. If steps B. through E. are abnormal, or if the mechanism of injury suggests a pelvic fracture, obtain an APx-ray of the patients pelvis. (Note: The mechanism of injury may suggest the type of fracture.)

G.If steps B. through E. are normal, palpate the bony pelvis to identify painful areas.

H. Determine pelvic stability by gently applying anterior-posterior compression and lateral-to-medial com-pression over the anterosuperior iliac crests. Testing for axial mobility by gently pushing and pulling on thelegs will determine stability in a cranial-caudal direction.

I. Cautiously insert a urinary catheter, if not contraindicated, or perform a retrograde urethrogram if a ure-thral injury is suspected.

J. Interpret the pelvic x-ray, giving special consideration to those fractures that are frequently associatedwith signicant blood loss, eg, fractures that increase the pelvic volume.

1. Conrm the patients identication on the lm.

2.Systematically evaluate the lm for:a. Width of the symphysis pubisgreater than 1 cm separation signies signicant posterior pelvicinjury.

b. The integrity of the superior and inferior pubic rami bilaterally.

c. The integrity of the acetabula, as well as femoral heads and necks.

d. Symmetry of the ilium and width of the sacroiliac joints.

e. Symmetry of the sacral foramina by evaluating the arcuate lines.

f. Fracture(s) of the transverse processes of L5.

3. Remember, the bony pelvis is a ring that rarely sustains an injury in only 1 location. Displacement ofringed structures implies 2 fracture sites.

4. Remember, fractures that increase the pelvic volume, eg, vertical shear and open-book fractures, areoften associated with massive blood loss.

K. Techniques to Reduce Blood Loss from Pelvic Fractures

1. Avoid excessive and repeated manipulation of the pelvis.

2. Internally rotate the lower legs to close an open-book type fracture. Pad bony prominences and tie therotated legs together. This maneuver may reduce a displaced symphysis, decrease the pelvic volume, andbe used as a temporary measure until denitive treatment can be provided.

3. Apply and inate the PASG. This device also is useful when transporting the patient.

4. Apply a pelvic external xation device (early orthopaedic consultation).

5. Apply skeletal limb traction (early orthopaedic consultation).

6. Embolize pelvic vessels via angiography.

7. Obtain early surgical and orthopaedic consultation to determine priorities.

8. Place sandbags under each buttock if there is no indication of spinal injury and other techniques toclose the pelvis are not available.

9. Apply a pelvic binder.


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10. Arrange for transfer to a denitive care facility if local resources are not available to manage this in-jury.

VII. IDENTIFICATION OF ARTERIAL INJURY

A. Recognize that ischemia is a limb-threatening and potentially life-threatening condition.

B. Palpate peripheral pulses bilaterally (dorsalis pedis, anterior tibial, femoral, radial, and brachial) for qual-ity and symmetry.

C. Document and evaluate any evidence of asymmetry in peripheral pulses.

D. Reevaluate peripheral pulses frequently, especially if asymmetry is identied.

E. Early surgical consultation is required.

VIII. PRINCIPLES OF EXTREMITY EXAMINATION AND IMMOBILIZATION

A. Scenario #1

A 28-year-old man is involved in a head-on motorcycle collision with a car. At the scene, he was combative,his systolic blood pressure was 80 mm Hg, heart rate was 120 beats/minute, and his respiratory rate was20 breaths/minute. In the emergency department, his vital signs have returned to normal and the patient iscomplaining of pain in his right upper extremity and both lower extremities. His right thigh and left lowerextremity are deformed. Prehospital personnel report a large laceration to the left leg, to which they applieda dressing.

B. Scenario #2

Scenario A: A 20-year-old woman is found trapped in her automobile. Several hours are required to extricateher because her leg was trapped and twisted beneath the dashboard. In the hospital, she is hemodynamicallynormal and alert. She complains of severe pain in her left leg, which is splinted.

Scenario B: A 34-year-old man is shot in the right leg while cleaning his handgun. He is unable to walk be-cause of knee pain and states his lower extremity is painful, weak, and numb.

C. Scenario #3

A 16-year-old boy is thrown approximately 100 feet (33 meters) from the back of a pickup truck. In the emer-gency department his skin is cool and he is lethargic and unresponsive. His systolic blood pressure is 75 mmHg, his heart rate is 145 beats/minute, and his respirations are rapid and shallow. Breath sounds are equaland clear to auscultation. Two large-caliber IVs are initiated, and 2500 mL of warmed crystalloid solution isinfused. However, the patients hemodynamic status does not improve signicantly. His blood pressure nowis 84/58 mm Hg and his heart rate is 135 beats/minute.


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Musculosceletal Trauma