Approach to Musculoskeletal

Injuries
Department of Orthopaedic Surgery
Fatmawati General Hospital

LUTHFI GATAM
ORTHOPAEDIC SPINE CONSULTANT

OVERVIEW
Significant percentage of all
emergency room care rendered.
In FGH, over 6 month period, survey
showed chief complaint of
musculoskeletal problem comprised
approx. 11% of all patients (1 in 9).

Musculoskeletal Injuries
ED physician needs a coherent,
systematic approach to orthopaedic
complaints.
Severity ranges from trivial sprains to
life- or limb-threatening trauma.
Often acute trauma is the cause of the
presentation.
Pain and decreased ROM are the main
symptoms.

What We Commonly See

Musculoskeletal disorders commonly
seen in the ED include:
Soft Tissue Injuries (strains and
sprains)**
Fractures (open, closed, long bone, pelvic)
Dislocations
Infections (soft-tissue, bite wounds)**
Effusions **
Deep venous thrombosis

Less Common But

Musculoskeletal disorders less commonly
seen in the ED, but unmistakably important:
Spinal Injuries
Crush Injuries
Compartment syndrome

FRACTURES

Fractures
A partial or complete break in a bone.
Bone is the tissue in the human body that heals
by regeneration without scarring.
For regeneration to occur the bone must be
immobilized to allow uninterrupted formation
of new bone.

Fractures
New Bone Formation:
A hematoma forms between realigned Fx fragments.
Hematopoietic cells in the hematoma secrete growth
factors (GFs).
GFs stimulate formation of granulation tissue at the
Fx ends, slowly resorbing the hematoma.
A primary callus forms, progressing from a soft
callus to hard callus.
Final phase of healing: during remodeling the bone
reassumes its original architecture.

Fractures
Nomenclature of fractures is essential to
successful Fx management in the ED
Adequate description:

Open or closed?
Which bone involved?
Location within the bone?
Direction of the main fracture line?
Number of fragments?
Alignment and displacement of the fragments?
Complications?

Closed Fracture

Open Elbow Fracture

Open Fractures
ORTHOPEDIC EMERGENCY
Immediate control of hemorrhage.
Splinting +/- reduction.
Copious irrigation.
Early administration of sufficient analgesia,
appropriate antibiotics, and tetanus
prophylaxis.
Emergent consultation w/ orthopaedics for all
Type II and Type III open Fxs (and some Type
Is).

Fractures-Open Classification
I <1cm long, minimal contamination, low energy force
ABX: 1st/2nd Ceph for 3d
II >1cm long, moderate contamination and force
1st/2nd Ceph plus aminoglyc for 3d

ABX:

III High energy, comminuted fx, extensive tissue damage,

enough tissue to cover wound, extensive contamination,
arterial injury
ABX: 1st/2nd Ceph plus aminoglyc for 5d

PELVIC FRACTURES

Pelvic Fractures

Least common fracture (3%)

Most are result of auto-collisions
Commonly associated with other injuries
Pelvis contains many important structures:
Iliac vessels, urogenital organs, nerve plexi..

Patients can sustain large volume blood loss

Clinical Evaluation
Any patient assessment begins with the ABCs
(Airway, Breathing, Circulation)
Complete neurologic and vascular exam
Have high suspicion of intra-abdominal injuries
Physical exam:
Ecchymosis or contusion around hips, perineum
Pelvic instability with stressing
Suspect if signs of urologic/gyn findings: blood at
urethral meatus, high-riding prostate
High force mechanisms also associated (mvc, femur
fx)

Pelvic Fracture-Management
#1--Control of bleeding vessels
In hemodynamically unstable pts, consider
angiography
#2--Surgical management of the broken
bone can proceed LATER after lifethreatening conditions are controlled.

LONG BONE FRACTURES

Long Bone Fractures

Fractures of the femur, humerus, tibia/fibula
Blunt and penetrating trauma
Requires high energy to break bone,
therefore look for other injuries.
Bone has a generous blood supply.
Does patient have associated bleeding
disorder?

Long Bone Fractures

Fxs cause localized bleeding and this can
be substantial resulting in hypovolemic
shock.
Humerus: 200-500cc
Unilateral tibia/fibula: 400-800cc
Femur Fx: 1000-1500cc

Long Bone Fracture

Management
ABCs
Neurovascular exam (vascular +/- nerve injury)
Splint involved extremity
Reduction decreases pain, bleeding

Orthopedic consultation for definitive management

Complications:
Fat-emboli syndrome
Blood loss

Fracture Complications
Vascular Injuries
Most commonly occur in open Fxs, Fx-dislocations, or
widely displaced Fxs and at sites where the vessels lie in
close proximity to the bone or @ sites where the vessels
are held in a relatively fixed position.

Classic signs: The 5 Ps: Pain, Pallor,

Pulselessness (or diminished pulse), Paresthesia,
and Paralysis.
Location of Fx and MOI dictate need to assess for
potential vascular injury in asymptomatic patient.

Fracture Complications
Nerve Injuries
Occur more frequently than vascular injuries in
assoc. w/ Fx.
Can occur 2/2 blunt trauma, along path of
penetrating trauma, or be caused by the Fx
fragments themselves.
Nerves are @ increased risk of injury when they
are superficial to the skin, lie close to the bone, or
span a joint, making them susceptible to stretch
injury.

Fracture Complications
Fat Emboli Syndrome (FES)
Most common form of non-thrombotic
embolism.
Single or multiple long bone fractures in young
or pelvic/hip fractures in elderly predispose to
FES.
20% of patients w/ pelvic or long bone
fractures have detectable fat droplets in their
blood.

Fracture Complications
Fat Emboli Syndrome (FES)
Vast majority remain asymptomatic
Has characteristic clinical course:
1. Fracture sustained.
2. Other than fracture-associated pain, patient is
asymptomatic for 12-36 hours.
3. Sudden onset of life-threatening syndrome characterized
by rapid cardiopulmonary and neurologic deterioration,
agitation, hallucinations, delirium, coma, hypoxia, dyspnea,
tachypnea, and tachycardia leading to DIC and ARDS.

Fracture Complications

Deep Venous Thrombosis

Deep Venous Thrombosis

Clot forming in one of the deep veins of an
extremity: Legs > Arms.
If clot propagates above the popliteal fossa,
substantial risk of piece of clot breaking free,
embolizing to the pulmonary circulation.
Risk of respiratory distress, hypoxia, pleuritic
chest pain, circulatory compromise, death.
Doppler ultrasound; CXR; V/Q Scan; spiral CT
Treatment: anticoagulation

Fracture Complications

Fracture Complications

Fracture Complications

CRUSH INJURY

Crush Injuries
First descriptions from military records,
bombings in England and Europe during world
wars
Now more commonly seen in natural disasters,
building collapse, acts of terrorism, after
poisioning, after drug overdoses
Injury results from prolonged continuous
pressure on a body part, typically an extremity

Crush Injuries
Under direct pressure, cellular ischemia incurred
causing loss cellular integrity
Cells leak K+ and myoglobin
Influx of ions into the cells causing irreversible
cell death
Can have large fluid volume shifts
Electrolyte abnormalities:
Hyperkalemia, hyperphosphatemia, myoglobinemia,
hypocalcemia, metabolic acidosis

Crush Injuries
Myoglobin concentrates in
the renal tubules
obstructive nephropathy
acute renal failure
When ARF occurs,
mortality 20-40%
Arrythmias
Concern for sepsis with
devitalized tissue

Crush Injuries-Treatment
Early consideration /recognition
Fluid resuscitation
ARF approaches 100% if hydration
delayed >12 hours

Alkalinize the urine add sodium

bicarbonate to IVF
prevents myoglobin precipitation and
enhances excretion

COMPARTMENT
SYNDROME

Compartment Syndrome
Occurs when pressure w/i soft tissues in a
fixed body compartment increases to level
that exceeds venous pressure,
compromising venous blood flow, and
limiting capillary perfusion.
Leads to muscle ischemia and necrosis.
TRUE ORTHOPEDIC EMERGENCY

Compartment Syndrome
Contributing Factors
External:
Conditions that reduced size of muscle
compartment (casts/splints); occlusive
dressing; eschar of burns

Internal:
Conditions that increase compartment volume:
bleeding, swelling, fluid extravasation into
tissue

Hand and Foot

Compartments

CS-Recognition
Suspect with long bone fx, crush injuries
Presents as pain out of proportion to
physical findings, +/- hypoesthesia,
pulselessness (late).

Measure intra-compartmental pressure

when considering compartment
syndrome

Pressures >40mmHg considered dangerous

Compartment Syndrome
Compartment syndrome
should be suspected in
long bone Fxs and Fxs
associated w/ significant
vascular injuries or
pronounced swelling.
Intra-compartment pressures
must be measured once the
issue of compartment
syndrome is raised.

SPINAL INJURY

Spinal Injuries
Devastating injuries
>80% occur in young males
Motor vehicle accidents, falls from height,
gunshot wound
Worrisome presentations:

pain over spine in setting of trauma

loss of motor function
incontinence
priapism

Spinal Injuries
Additional risk factors for spinal PAIN:
Metastatic cancer
Osteoporosis, rheumatic dz, steroid use
(compression fracture)
IV drug use (epidural abscess)
Spinal hardware

Spinal Injury
Assessment
ABCs
Immobilize neck and back
GCS, motor/sensory/sphincter tone exam

Imaging
Plain c-spine films (lateral only detects >85%
of cervical spine injuries)
CT/MRI for injuries with neuro deficits and
identifiable spine fractures.

Classification of Neurologic Injury

Frankel Score
A = Complete loss of motor and
sensory function
B = Only sensory function remains
C = Motor function is present but of
no practical use (i.e., can move legs
but not walk)
D = Motor function impaired
(i.e.can walk but not with normal
gait)
E = No neuro impairment noted

 Identifiable spine
fractures require
Orthopedic OR
Orthopaedic spine
consultation

Case Study:

T12 burst fracture; treated with T12

corpectomy and autograft; posterior fusion and
instrumentation

Subluxation and Dislocation

Subluxation and Dislocation

Acute or chronic ligamentous laxity/tearing
can result in subluxation or dislocation of a
joint.
Classic example: glenohumeral joint:
Subluxation: 1 bone becomes partially
disarticulated from the other; articular surfaces
remain partially intact.
Dislocation: bones completely disarticulated;
no parts of articular surfaces are in contact.

Dislocations
Nomenclature is straightforward:
Most occur @ a joint formed by 2 bones and
the dislocation is named after the affected joint.
Direction of dislocation refers to the position of
the distal bone in relation to the proximal.

 Clinically:
Pain, deformity, decreased ROM.
Certain dislocations are associated w/ specific
complications, which must be ruled out in the
routine evaluation of the injurye.g., the axillary
nerve (12%) and the musculocutaneous nerve
(2%) are @ risk in anterior dislocations of the
glenohumeral joint.
Smooth, timely reduction is mandatory.

Bilateral Hip Dislocations

More dislocations