Musculoskeletal Trauma Flashcards
Do injuries to the musculoskeletal system present in blunt trauma or penetrating trauma?
Blunt trauma
What are you assessing when assessing the limb that has a musculoskeletal trauma?
Colour and perfusion
Wound
Deformity
Swelling
Discolouration
Bruising
What does swelling over the region of a major muscle group suggest?
Crush injury with impending compartment syndrome
What does a pale or white distal extremity suggest?
A lack of arterial inflow
What does swelling or ecchymosis in or around a joint and/or over the subcutaneous surface of a bone suggest?
Musculoskeletal injury
What do wound over a bony prominence suggest?
Open fracture
Why is palpation of the extremity important when assessing limbs?
It helps determine sensation and to identify areas of tenderness
What does a loss of sensation to touch or pain to a limb indicate?
A spinal or peripheral nerve injury
What does pain, swelling and deformity over a boney prominence indicate?
A possible underlying fracture
What is indicative of a ligamentous rupture?
Abnormal motion of the joint
What is extremely important following musculoskeletal trauma?
Palpation of distal pulses and assessment of capillary refil
What can be used if hypotension limits the assessment of distal pulses?
A Doppler
What might penetrating extremity trauma result in?
Arterial vascular injury
Apart from penetrating extremity injury, what else could disrupt arterial blood flow?
Blunt trauma resulting in an extremity fracture or joint dislocation in close proximity to arterial vasculature
What is the best way to manage a haemorrhage to a limb?
Direct pressure and the use of a tourniquet
If a fracture is associated with arterial bleeding, what is advisable?
Realignment of the boney structure with concurrent application of pressure - where possible joint dislocation should be relocated
What does crush syndrome refer to?
The clinical sequela of injured muscle
What happens if crush injuries are left untreated?
Lead to acute renal failure
What is the muscular injury seen in crush injury a combination of?
Direct muscle injury, muscle ischaemia and cell death
What is muscular trauma often associated with?
Rhabdomyolysis - which can range from an asymptomatic illness with elevated creatinine kinase to life threatening associated with acute renal failure and disseminated intravascular coagulation (DIC)
What is the initial management and goal for crush syndrome?
Aggressive fluid resuscitation in order to protect the kidneys and avoid acute renal failure
What helps to prevent myoglobin-induced renal failure?
Intravascular expansion and osmotic diuresis to maintain a high tubular volume and urine flow
Why do open fractures require timely multidisciplinary management?
The consequence of infection following open fractures can be significant and lead to life long disability
What are the BOAST-4 guidelines?
Guidelines that focus specifically on the management of open fractures
Where should patients be taken if they have an open fracture to the long bones, hind or mid foot?
Taken directly or transferred to a specialist centre that has the ability to provide orthoplastic care
When should antibiotics be given for an open fracture?
Within 1 hour of injury
For an open fracture that should the documentation of the examined limb contain?
Assessment of neurological and vascular status
Should an open fracture limb be realigned and splinted?
Yes
Prior to formal debridement of an open fracture, how should the wound be handled?
Only to remove gross contamination and allow for photographs to be taken. The wound should be dressed in saline soaked gauze and occlusive dressing
When should debridement be undertaken using fasciotomy tones for wound extension?
- immediately for heavily contaminated wounds (agricultural, aquatic or sewage) or associated vascular compromise
- within 12 hours of injury for other solitary high energy open fractures
- within 24 hours for all other low energy open fractures
What is acute compartment syndrome of a limb caused by?
Raises pressure within a closed fascial compartment causing local tissue ischemia and hypoxia
In clinical practice when is acute compartment syndrome of a limb commonly seen?
After tibial and forearm fractures
High energy wrist fractures
Crush injuries
Restrictive dressings or casts
Prolonged immobilisation
Reperfusion of ischemic limb
What should be part of routine evaluation of patients presenting with significant limb injuries?
Assessment for compartment syndrome
What should you be documenting for a patient with suspected compartment syndrome?
Time and mechanism of injury
Time of evaluations
Level of pain
Level of consciousness
Response to analgesia
Whether regional anaesthesia has been given
What are the clinical key finding for a patient with compartment syndrome?
Pain out of proportion to the associated injury
Pain on passive movement of the muscle of the involved compartments
What should patients who are at risk of compartment syndrome have?
Hourly documented nursing assessment of the injured limb
Patient with symptoms or clinical signs of compartment syndrome and are wearing a dressing should have what done to them?
All circumferential dressing to the skin releases and the limb elevated to heart level
What should all hospital that treat patients with significant limb injuries have?
The ability to measure inter compartmental pressures
Is compartment syndrome a surgical emergency?
Yes, surgery should occur within 1 hour of the decision to operate
For patient shaving compartment pressures measured, what else should be monitors and what would be the sign that the patient has an increased risk of compartment syndrome?
Diastolic blood pressure should be monitored. A difference between the diastolic pressure and the compartment pressure of 30mmHg suggests risk of compartment syndrome
If absolute compartment pressure is greater than 40 mmHg and the patient has clinical symptoms of compartment syndrome, what should be done?
Urgent decompression should be considered - immediate open fascial decompression of all involved compartments
