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© ACS
1
Management
Musculoskeletal
Trauma
© ACS
2
Musculoskeletal Trauma
Common, occasionally life-threatening
Major musculoskeletal injuries often
indicate other injuries
Hemorrhage, compartment syndrome
Crush syndrome, fat embolism are life-
and limb threatening problems
Continued reevaluation !
Trauma is not
rocket science!
ABCDEF
Initial Assessment: Primary
Survey
• A = Airway
• B = Breathing
• C = Circulation
• D = Disability
• E = Exposure
• F = Fracture
• Clear & establish a good airway
– Consider intubation for coma, shock, and thoracic injuries
• C-spine stabilization
Initial Assessment: Airway
Initial Assessment: Breathing
• Chest excursion & breath sounds
– Flail chest
• Pneumothorax
– Open
– Tension
• Massive Hemothorax
Initial Assessment: Circulation
• Perfusion (mental status, skin, pulse)
• Control bleeding with pressure
• Pericardial Tamponade
– Beck’s Triad
• Establish 2 large bore (16G or larger) IV’s
in upper extremity peripheral veins
• Resuscitate with Lactated Ringers
– After 4 L think about resuscitation with blood
Initial Assessment: Disability
• Neurologic status
– Glasgow Coma Scale
• Eye
• Motor-best predictor of long term outcome
• Verbal
– Spinal Cord Injury
Initial Assessment: Exposure
• Remove clothes
• Temperature
– warm blankets
• Finger and tube in every orifice
• Maintain full spine precautions
– Log Roll
Initial Assessment: Fracture
• Stabilize Fractures
• Relocate dislocated joints
• Reassess pulses
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Primary Survey / Resuscitation
Recognize and control hemorrhage
• Direct pressure
• Splint fractures
Aggressive fluid resuscitation
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Primary Survey Resuscitation
Adjuncts : Fracture immobilization
Goals
• Hemorrhage control
• Pain relief
• Prevent further soft-tissue injury
Apply splint early, but avoid delay in
resuscitation
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Primary Survey/ Resuscitation
Adjuncts : x-rays
Determined by patient’s condition
Obtain AP pelvis early if
hemodynamically abnormal and
no obvious source of bleeding
Secondary Survey
• Patient history
• Head to toe physical exam
• Radiography
– Lateral C-spine, C-xray, pelvis
– One cavity above/below entrance/exit wounds
– FAST
• Urinary bladder drainage
• NGT
• Blood sampling/monitoring
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Secondary Survey
History
Mechanism of injury
Environment
AMPLE history
Prehospital care
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Secondary Survey
Physical Examination
Expose / avoid hypothermia
Goal: Identify life- and limb-threatening,
and occult injuries
Examine
• Skin
• Circulation
• Neuromuscular
• Skeletal
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Secondary Survey
Look
• Bleeding deformity, color
• Posteriorly using modified log roll
• Spontaneous movement
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Secondary Survey
Feel
• Temperature, tenderness, crepitus
• Sensation
• Joint stability
• Back and pelvis: Tenderness, gap
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Secondary Survey
Circulatory Evaluation
Color, temperature
Pulse pressure, capillary refill
Paresthesia
Doppler: Ankle / arm ratio
Bruit / thrill
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Secondary Survey
X-ray
Guided by clinical findings
Joint above and below
Obtain 2 views
Delay x-rays if:
• Vascular compromise
• Impending skin breakdown
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Life- Thereatening Injuries
Major pelvic disruption with hemorrhage
Major arterial hemorrhage
Crush syndrome (rhabdomyolysis)
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Major Pelvic Disruption
Posterior pelvic structures disrupted
Pelvis open : vessels, nerves,rectum, skin
Mechanism of injury
• Motorcycle
• Pedestrian
• Crush
• Falls > 12 feet (3.6 meters)
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Major Pelvic Disruption
Assessment and Management
Hemorrhage occurs rapidly, identify
early
Unexplained hypotension
Open wounds, meatal blood, high
prostate, expanding hematoma
Palpable motion of pelvic ring
Hemorrhage control, fluid resuscitation
Management :
stabilization
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Stabilization for transport
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Operative procedures
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Major Arterial Hemorrhage
Penetrating / blunt injury in close
proximity to artery
Hemorrhage, hematoma, hypotension
Ischemic extremity
Stop the bleeding!
Immediate surgical consult
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Crush Syndrome
Myoglobinuria
Metabolic acidosis, K , Ca and
coagulopathy
Compartment syndrome
IV fluids, alkalization of urine
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Limb- Threatening Injuries
Open fracture and joint injuries
Vascular injuries
Compartment syndrome
Neurologic injury
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Open Fractures, Joint Injuries
Wide- spectrum of soft-tissue injuries
Open wound = Open fracture
Treatment
• Splint, sterile dressing, tetanus
• Immediate surgical consult
• Tetanus prophylaxis
• Antibiotics?
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Vascular Injury, Amputation
Variable presentation : Assess pulses
Associated with fracture / dislocations
Realign
Check pulses after splinting
Immediate surgical consult
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Compartment Syndrome
Crush Injury with Compartment Syndrome
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Compartment Syndrome
↑ Compartment pressure
Nerve / muscle ischemia → necrosis
Pain, paresthesia, paresis, swelling
Release constricting devices
Suspect in tibial, forearm fracture, after
revascularization, in unconscious patient
Early surgical consult
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Neurologic Injury
Due to fracture / dislocation
• Posterior shoulder : Axillary nerve
• Posterior hip : Sciatic nerve
Recognize injury and immobilize
Early surgical consult
Careful reduction, if possible, → reassess and splint
Traksi
Upaya pengobatan atau rehabilitasi pada
kelainan dan atau cedera sistem
muskuloskeletal dengan menggunakan
traksi (tarikan) padanya secara terus
menerus
Traksi
• Pada Tulang (Traksi Skeletal)
• Pada Kulit (Traksi Kulit)
• Traksi Menetap (Fixed Traction)
• Traksi Berimbang (Balanced Traction)
Tujuan Traksi
• Reposisi (pada fraktur / dislokasi)
• Imobilisasi (setelah reposisi)
• Mengkoreksi deformitas (mis. kontraktur)
• Mengurangi nyeri (Coxitis/Gonitis TB)
• Mencegah deformitas (Coxitis/Gonitis TB,
post poliomielitis)
Prinsip Traksi
• Ada tarikan dan ada kekuatan yang
melawan tarikan (Traksi-Kontra traksi),
kontra traksi yang digunakan biasanya
adalah gravitasi / berat badan pasien
• Traksi-Kontra traksi mengikuti hukum alam
• Traksi-Kontra traksi tidak menimbulkan
komplikasi
Komplikasi Traksi
• Komplikasi akibat tarikannya
– Spasmus pembuluh darah
– Kelumpuhan saraf
– Iskhemi kulit
• Komplikasi akibat perangkat traksi
– Infeksi akibat tusukan kawat/pin
– Alergi plester
Traksi Kulit
Alat : Skin Traction Kit pediatrik, adult
Jenis : plester dengan perekat
foam rubber tanpa perekat
Indikasi : Traksi < 10 lbs ( < 5 Kg )
Kontra indikasi : alergi plester, peny. Kulit
Komplikasi : dermatitis, gangguan
neurologis, gangg. vaskuler
Traksi Kulit
Traksi Tulang
Alat : Skrup/screw
Pin
Wire
Indikasi : traksi waktu lama
beban tarikan besar
Kontra indikasi relatif : anak-anak
Komplikasi : Infeksi, Kerusakan lempeng
pertumbuhan, gangguan neurologis
dan gangguan vaskuler
Traksi Tulang
• Bohler stirrup dg
Steinmann pin
• Denham pin
• Kirschner wire
strainer
Traksi menetap (fixed traction) • Traksi dg bidai Thomas (Thomas splint)
• Keseimbangan bersifat statik
• Digunakan pada transportasi/evakuasi
Arah
tarikan
Bag proksimal
terfiksasi pada paha
Traksi menetap (fixed traction)
Sliding Traction
Traksi Berimbang (balanced traction)
• Ada keseimbangan dinamik antara traksi dengan
kontra traksi
Traksi berimbang dengan bidai Thomas
Traksi berimbang dengan bidai Bohler
Traksi berimbang dengan Traksi Kulit
Bryant Traction
Umur < 2tahun
Berat badan 35-40 lbs
(15,9 – 18,2 Kg)
Komplikasi : gangguan
vaskuler
Traksi berimbang dengan traksi kulit
Buck Extension Traction
Traksi berimbang dengan traksi kulit
Hamilton Russel Traction
Olecranon Traction Dunlop Traction
Spinal Traction
Canvas Head Halter Crutchfield Tongs
Skull Traction
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Pitfalls
Occult injuries
Occult blood loss
Compartment syndrome
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Summary
Primary Survey : Identify life-threatening
injuries
Secondary Survey : Identify limb-
threatening injuries
Mechanism of Injuries : History important
Surgical consult
Early immobilization
Recommended