Musculoskeletal Trauma in Polytrauma Victims

1. Musculoskeletal Traumain Polytrauma Victims Kris Arnold, MD, MPH

2. Musculoskeletal Traumain Multitrauma Patients • 85% of multi trauma patients have musculoskeletal trauma • Rare immediate threat to life or extremity viability • Indicator of risk for torso injury • Common cause of prolonged or permanent disability if not treated properly

3. Musculoskeletal Injury Issues During Primary Survey ABC… • Bleeding from open fractures • Bleeding from closed long bone fractures • Humerus 1-2 units blood • Femur 3-4 units blood • Bleeding from pelvic fracture • May be exsanguinating • Vascular & Neurologic injury from dislocations

4. Pelvic Fractures • Pelvis fracture severity based on breaking ring structure Image Source: http://basicxray.blogspot.com/2009/08/normal-pelvic-anatomy.html

5. Pelvic Fractures • Type A – No instability of ring • Avulsion of single bone – low risk • Rehabilitation – progressive weight-bearing • Late surgical intervention Image source: Michael E. Stadnick, M.D http://www.radsource.us/clinic/0806

6. Pelvic Fractures • Type B • Disruption anteriorly and posteriorly with intact posterior ligaments • Problems • Rotational instability • Increased risk of bleeding • Associated injuries • Urethra • Pelvic organs • Abdominal organs Open Book

7. Pelvic Fractures • Type C • Anterior and posterior disruption with disruption of posterior sacro-iliac complex • Rotational and vertical instability • High risk of bleeding • High risk associated injuries • Urethral • Pelvic organs • Abdominal organs

8. Emergency Pelvic Fracture Stabilization Binding force at level of trochanters Image source: Michael T. Archdeacon, MD http://www.aaos.org/news/aaosnow/jul09/clinical8.asp

9. Pelvic Fracture Stabilization C-clamp

10. Pelvic Fracture Management • Rule out urethra injury • Retrograde urethrogram (RUG)

11. Musculoskeletal Injury Management During Secondary Survey History • Mechanism of extremity injury • Direct blunt force • Crush • Fall • Initial extremity positioning

12. Extremity Injury Assessment • Look • Undress completely • Deformity • Swelling • Listen • Pain • Crepitance • Feel • Crepitance • Abnormal mobility

13. Initial Fracture Management • Angulated – realign & stabilize • Prevent further soft tissue injury • Reduce pain • Potentially decrease bleeding Photo source: Bush LA, Chew FS. Subtrochanteric femoral insufficiency fracture in woman on bisphosphonate therapy for glucocorticoid-induced osteoporosis. Radiology Case Reports. [Online] 2009;4:261.

14. Angulated Fracture Management during Prehospital Management Extremity Vascular Injury Evaluation Evaluate Distal Perfusion Compromised “Normal” Realign Immobilize Compromised “Normal” Reevaluate Distal Perfusion

15. Extremity Fracture Assessment • Imaging • Plain x-rays • Two views • Anterior-posterior • Lateral • Must be correctly aligned • Image one joint above and below • Maissoneuve

16. Open Fractures • Realign and splint as for closed

17. Upper Extremity Nerve Injury

18. Lower Extremity Nerve Injuries

19. Crush Injury • Compartment syndrome • Rhabdomyolysis

20. Compartment Syndrome • Lower Extermity • Lower leg • Thigh • Gluteal • Foot • Upper Extremity • Forearm • Hand

21. Compartments Lower Leg

22. Compartment Syndrome Clinical Evaluation • Pain out of proportion to injury or worsening • Pain with stretching involved muscles • Pain with using involved muscles • Possible decrease in sensation or paresthesias over or distal to involved compartment • Late or inconsistent • Loss of peripheral pulse • Loss of normal color – pale • Paralysis of involved muscles • Tissue pressure >35-40cm H2O w/ normal systemic BP –lower w/ hypotension (normal <10cm H2O)

23. Fasciotomy

24. Rhabdomyolsysis Trauma Fractures and Crush Injurues Electrocution/ Thermal Burns Burned Muscle “Tea colored” urine Heme + urinalysis dip No red blood cells on microscopic

25. Small but Important

26. Posterior Knee Dislocation

27. Posterior Hip Dislocation

28. Reduction Posterior Hip Dislocation

29. Anterior Hip Dislocation

30. Thank You

31. Questions??