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MUSCULOSKELETAL TRAUMA

Dr Moh Adib Khumaidi, SpOT


Introduction
85 % of blunt trauma

Resuscitation priority is like another trauma

Reevaluation
Introduction
Millions of cases annually.
Multiple MOI :
Falls, Automobile collisions, Crashes, Violence, etc
Multi-system trauma

Rarely life threatening


Improperly treated can result permanent
disability.
Anatomy & Physiology of the
Musculoskeletal System
Structures
Skin
Bones
Joints where bones interact
Muscles
Tendons - connect muscle to bone
Ligaments - connect bone to bone
Neurovascular
The Skeleton
Types of Muscles
The Neurovascular
FUNCTION
Protects organs
Allows for efficient movement
Stores salts and other materials needed for
metabolism
Produces RBCis
Scaffolding / Support
Pathophysiology of the
Musculoskeletal System
Injuries to the Musculoskeletal
System
Four basic types of musculoskeletal injuries are:
Strain - An extreme stretching or tearing of MUSCLE & / OR
TENDON.

Sprain - partial or complete tearing of LIGAMENTS and


tissues at the joint.

Dislocation - displacement or separation of a bone


from its normal position at the joint.

Fracture - a break or disruption in bone


closed - the broken bones do not penetrate the skin
open - the skin is pierced by broken bone fragments
Accident Scene..
Life before Limb !!
PRIORITY ?

Life threatening
Limb threatening
Primary Survey & Resuscitation
ABCDE
A irway with cervical spine control
B reathing
C irculation with control of hemorrage
D isability (neurological state)
E xposure (take the patient clothes off)
Primary Survey
Bleeding control direct padding

Splinting bleeding

Fluid resuscitation
Adjunction in Primary Survey

Fracture immobilization
Traction anatomical position
Splint
Be careful in dislocation !
Primary Survey & Resuscitation

Adjuncts : X-Rays
Determinited by patients condition
Obtain AP pelvis early if hemodynamically abnormal and no
obvious source of bleeding
Secondary Survey

Physical Examination
Undress the patient

Component have to be examined :

1. Skin
2. Neuromuscular function
3. Circulatory state
4. Bone & ligament integrity
Dont forget the back!
Secondary Survey

Physical Examination
Look

Feel

Move
Life Threatening Musculoskeletal
Trauma

Pelvic Trauma with Massive Bleeding


Main Arterial Rupture
Crush Syndrome
Life Threatening Musculoskeletal
Trauma

Pelvic Trauma with Massive Bleeding

Examination
- hematoma : pelvic, skrotal,
perianal
- high riding prostate
- meatal bleeding
- leg length discrepancy
Pelvic Trauma with
Massive Bleeding
Life Threatening Musculoskeletal
Trauma

Pelvic Trauma with Massive Bleeding


Management
- Bleeding control & resuscitation
- PSAG
- Traction
- Pelvic sling
- Pelvic Open fracture padding with
tampon
- Pelvic wrapping
Pelvic Wrapping
Pelvic Trauma with Massive Bleeding

Pelvic Wrapping

ADVANTAGES DISADVANTAGES
Easy to use Non anatomical
Rapid stabilization Soft tissue pressure
Risk of visceral
Inexpensive Risk of Sacral root inj.
Pelvic Trauma with Massive Bleeding
PSAG
ADVANTAGES
DISADVANTAGES
Easy to use Decrease vital capacity
Rapid Compartmental synd.
Reusable Exacerbate CHF
PELVIC C-CLAMP
Life Threatening Musculoskeletal
Trauma

Crush Syndrome
Mechanism
- Crush injury & long compression ;
thigh, leg
Examination
- Dark Urine
- Rhabdomiolisis hipovolemic,
metabolic acidosis, hipercalemia,
hipocalsemia & DIC
Management
- Fluid resuscitation & osmotic diuretic
- Alkalinization
Limb Threatening
Musculoskeletal Trauma

Open Fractures

Vascular Trauma & Traumatic Amputation

Compartement Syndrome

Dislocations
Open Fracture grade 1
Open Fracture grade 2
Open Fracture grade 3A
Open Fracture grade 3B
Open Fracture
grade 3C
Life Threatening
Musculoskeletal Trauma
Open Fractures

Principles of treatment
4 essentilals are :

1. Wound debridement

2. Antibiotic prophylaxis

3. Stabilization of the fractures

4. Early wound cover


Limb Threatening
Musculoskeletal Trauma
Open Fractures Accident Site

Sterile Dressing

Reduction Splinting
Limb Threatening
Musculoskeletal Trauma
Emergency Room
Open Fractures

Resuscitation !
Limb Threatening Emergency Room...
Musculoskeletal Trauma
Open Fractures

Examination
Clinical examination
Vascular status
Neurolgic status
X-ray diagnostics
Limb Threatening Musculoskeletal Trauma
Vascular Trauma & Traumatic Amputation

History & Examination ?


Time & Initial Management ?
Crush Or Sharp Wound ?
Vascular Trauma &
Traumatic Amputation

Can We Replanted ?
Proper amputee management!

Immediate orthopaedic consult


Limb Threatening
Musculoskeletal Trauma Compartement Syndrome

Increased Pressure Within


Rigid Osteofascial Compartement
Threaten the Circulation To The Enclosed (Intracompartmental)
Muscle, Nerve, And Vascular
Limb Threatening
Musculoskeletal Trauma Compartement Syndrome

Clinical features
Five Ps
Pain
Pallor
Paraestesia
Pulseless
Paralysis

Also Check for :


- Out of proportion Pain !
- Pain on Passive Stretching
Limb Threatening
Musculoskeletal Trauma Compartement Syndrome

Treatment

Decompression by

Open fasciotomy
Joint Dislocations
Displacement of bone from normal joint

Location : hip, shoulder, elbow, finger, patella,


knee, ankle, acromioclavicular

Sign :
loss of normal shape & movement

Always Check For


Neurovascular Injury !
ELBOW DISLOCATION
SHOULDER DISLOCATION
HIP DISLOCATION
Penyembuhan fraktur tergantung
pada :

Integritas Jaringan lunak sekitar fraktur

Suplai darah ke tulang

Derajat kontaminasi bakteri

Konfigurasi fraktur

Usia

STABILITAS ujung-ujung fraktur


PRINSIP PENANGANAN
FRAKTUR

REHABI
RETAIN LI
TATION

REDUC
E

RECOG
NIZE
RECOGNIZE
Tegakkan Diagnosa !

History : Riwayat Trauma ( trivial fall ?? )

Pemeriksaan fisik : tanda fraktur

- Look : bengkak, luka, deformitas

- Feel : Nyeri , NVD

- Move : pastikan gerakan2 pada bagian distal

X Ray : AP, Lat ( 2D)


RECOGNIZE
Gejala yang menyertai :

- Numbness/ weakness

- Skin pallor/ cyanosis

- Blood in urine

- Abdomen pain

- Transient loss of consciousness


REDUCE
Pergeseran fragmen +

Reduce = reposisi

Reposisi tertutup : manipulasi w/o bedah

Reposisi terbuka : manipulasi w/ bedah


RETENTION
Stabilisasi / immobilisasi / fiksasi daerah fraktur

External : bidai , gips, Orthosis , external fixator

Internal : Implant Orthopaedi ;

- extra medular

- intra medular
PRIMARY CARE PHYSICIAN MUST KNOW
Treat common fractures

Refer fracture to specialist /

hospital ( ER )
Emergency
Open Fractures

Dislocation/ Subluxation

Closed Fractures w/ NV problems

Spine fractures
Summary

Primary Survey : Identify life-threatening

Injuries
Secondary Survey : Identify limb-threatening injuries
Proper immobilization
Early Orthopaedic consultation
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CEDERA SPINAL
Trauma Tulang Belakang
Trauma multipel
Cedera vertebra & medula
spinalis
15% cedera diatas
klavikula : cedera servikal
5% cedera kepala : cedera
vertebra
Cedera vertebra :
55% cedera servikal
15% cedera torakal
15% cedera torakolumbal
15% cedera lumbosakral
Pendahuluan
Cedera disingkirkan dengan :
Sadar : neurologis normal & sakit / nyeri tekan (-)
Tidak sadar : pem. radiologis

Kesalahan penanganan dapat memperburuk


kerusakan neurologis dan prognosa.
Curiga cedera :
Imobilisasi adekuat
Long spine board : transportasi, dilepas secepatnya
Log rolling / 2 jam : mencegah dekubitus.
Anatomi Vertebra
Kolumna
Vertebralis :
7 vertebra servikal,
12 torakal,
5 lumbal,
sakrum &
koksigeus.
Anatomi Vertebra
Bagian :
Anterior : korpus,
diskus
intervertebralis,
ligamentum
longitudinal anterior
dan posterior.
Posterior : pedikel,
lamina, sendi faset,
ligamentum
interspinosus dan
muskulus
paraspinalis.
Pemeriksaan
Sensibilitas
C5 : area diatas deltoid
C6 : jempol
C7 : jari tengah
C8 : jari kelingking
T4 : papila mamae
T8 : xifosternum
T10 : umbilikus
T12 : simfisis
L4 : medial betis
L5 : web jari kaki I - II
S1 : lateral pedis
S3 : tuberositas iskhii
S4 & S5 : perianal
Pemeriksaan
Motoris
C5 : Abduksi bahu

C6 : Ekstensi wrist

C7 : Ekstensi siku
C8 : Fleksi jari tangan
T1 : Abduksi kelingking
L2 : Fleksi panggul
L3 : Ekstensi lutut
L4 : Dorsifleksi ankle
L5 : Ekstensi jari kaki I
S1 : Fleksi ankle
(+) Otot sfinger ani eksterna
(colok dubur)
Gradasi kekuatan Otot

0 : Kelumpuhan total

1 : Teraba kontraksi

2 : Gerakan tanpa menahan gaya berat

3 : Gerakan melawan gaya berat

4 : Gerakan melawan gaya berat dengan

tahanan kurang dari normal


5 : Kekuatan normal
Syok Neurogenik dan Syok
Spinal
Syok neurogenik
Akibat kerusakan jalur Syok spinal
simpatis Terjadi setelah cedera
Vasodilatasi viseral dan medula spinalis
ekstermitas bawah :
flasid dan arefleksia
hipotensi
Atoni simpatis jantung : Lama berlangsungnya
bradikardia bervariasi
Responsif thd resusitasi Efek terhadap organ lain :
cairan (-) Hipoventilasi ; paralisis
Vasopresor : otot interkostal
mempertahankan perfusi Paralisis otot diafragma
jaringan (cedera C3-C5)
Atropin : mengatasi Anestesia ; dapat
bradikardia menutupi cedera lain
Pengelolaan Umum
Imobilisasi
Sejak fase pra rumah sakit.
Meliputi bagian atas & bawah dari lokasi cedera
Dipertahankan s/d cedera disingkirkan.
Posisi netral : terlentang tanpa rotasi / fleksi-ekstensi
Bila tdp deformitas, jangan direduksi.
Kolar semirigid tidak menjamin stabilisasi, perlu
penyangga tambahan pada long spine board.
Bila dilakukan intubasi : pada posisi netral.
Gelisah / agitasi : sedativa / pelumpuh otot.
Pengelolaan Umum
Cairan intravena
Dibatasi untuk maintenance, kecuali pada syok.
Syok neurogenik : vasopresor
Kateter schwann ganz : monitor cairan.
Kateter urine : monitor urin.

Pipa nasogastrik
Mengosongkan lambung & mencegah aspirasi.
Pengelolaan Umum
Obat-obatan
Metilprednisolon, pd 8 jam pertama, dosis :
30 mg/kgBB dalam 15 menit pertama.
5,4 mg/kgBB/jam untuk 23 jam berikutnya.

Transfer
Dilakukan setelah KU stabil
Telah difiksasi : bidai / backboard / kolar
Bila pernafasan tidak adekuat : intubasi
Thoracolumbosacral orthosis (TLSO) fabricated from a body
cast mold:
Anterior (A), lateral (B), and posterior (C) views of a patient
fit with a custom. Note the contouring over the iliac crests.
PEDICLE SCREW SUBLAMINARY
WIRING
PEDICLE SCREW PLATING
SYNTHES SYSTEM
Cervical Plate
Thank You