Musculoskeletal trauma Flashcards
Order of steps in aim of extremity bleeding control
Pressure to wound
Pressure dressing
Compression of artery proximal to injury
Tourniquet
Potentially life threatening extremity injuries
Major arterial haemorrhage
Bilateral femur fractures
Crush syndrome
Pelvic disruption
Management of life threatening extremity injuries
Traction splint fractures
Fluid resuscitation
Direct pressure to open wounds
Reduce joint dislocations when possible
Aim of splinting fractured extremities
Prevent bone movement which:
- Decreases blood loss
- Decreases pain
- Helps preserve distal perfusion
Management of open fractures
Reduce the fracture
(pull bone ends back into wound if needed)
Clean wound
Sterile saline soaked pressure dressing over wound
Abx
Indication for tourniquet
Traumatic amputations - high risk with major arterial haemorrhage
Sign of interrupted arterial blood supply
Cold, pale pulseless extremity
Sign of significant vascular injury
Rapidly expanding haematoma
Indication for arteriography and other diagnostic tools
Patients with no haemodynamic compromise only
Indication for urgent surgery for extremity injuries
Clear vascular injuries
When to consider trial of deflating tourniquet
If time to surgery is > 1 hour
One attempt only - life over limb
Another name for crush syndrome
Traumatic rhabdomyolysis
Crush syndrome
Direct muscle injury
Muscle ischaemia
Cell death and release of myoglobin
Acute renal failure and death
When is crush syndrome and highest risk
Compression injury to significant muscle mass
Eg thigh or calf
Assessment if suspected crush syndrome
Myoglobin assay
OR
Amber coloured urine with Creatinine Kinase > 10,000
Management of crush syndrome
Aggressive fluid therapy
Intravascular fluid expansion
When to check neurovascular status of a limb
Before and after manipulation / splint
Management of joint dislocations
Reduce and immobilise in anatomical position
If unable to reduce, splint in position it was found to control bleeding and pain
Deformities seen with anterior shoulder dislocation
Squared off
Deformities seen with posterior shoulder dislocation
Locked in internal rotation
Deformities seen with posterior elbow dislocation
Olecranon prominent posteriorly
Deformities seen with anterior hip dislocation
Extended, abducted and externally rotated
Deformities seen with posterior hip dislocation
Flexed, adducted and internally rotated
Deformities seen with anteroposterior knee dislocation
Loss of normal contour
Extended
May spontaneously reduce prior to evaluation
Deformities seen with lateral ankle dislocation
Externally rotated
Prominent medial malleolus
Lateral dislocation most common
Deformities seen with lateral subtalar joint dislocation
Laterally displaced os calcis (calcaneous)
Lateral dislocation most common
Deformities seen with lateral subtalar joint dislocation
Laterally displaced os calcis (calcaneus)
Lateral dislocation most common
When to treat an injury to the extremity prior to X ray
Presence of vascular compromise
Impending skin breakdown
Open fracture definition
Open wound on same limb segment as associated fracture
Open joint injury definition
Open wound over / near joint
Confirm with CT or saline / dye injection
Needs Orthopaedic consult
Antibiotics used for open fractures
First generation cephalosporins IV (Eg cefazolin)
Clindamycin if anaphylactic penicillin allergy
Weight based dosing
Management of vascular injury to extremity
Operative revascularisation
Within 6 hours
Compartment syndrome definition
Increased pressure within musculofascial compartment
Results in ischaemia and necrosis
Causes of compartment syndrome
Increase in compartment contents - Eg bleeding
Decrease in compartment size - Eg restrictive dressing
Common areas of compartment syndrome occurrence
Lower leg
Forearm
Signs of compartment syndrome
Disproportionate pain
Pain in passive stretch of affected muscle
Tense compartment swelling
Paraesthesia / altered sensation distal to affected compartment
Management of compartment syndrome
Release all restrictive dressings / casts / splints
Fasciotomy
Method for splint application
Inline traction
Immobilise joint above and below the fracture
Assess neurovascular status before and after
Management of lacerations
Debride and close
Consider tetanus immunisation
Management of contusions to extremities
Limit extremity function
Cold packs
Management of crushing or degloving injuries
Suspect based on mechanism if injury
Palpate component involved
Consider surgical consult for drainage / debridement
When to splint fractures when transferring patients
Prior to transfer
Immobilisation guidelines for femoral fractures
Traction splint
Do NOT apply traction when have ipsilateral tibial shaft fractures as can cause neurovascular damage
Immobilisation guidelines for femoral fractures + tibial shaft fractures
Use long leg posterior splint for the lower leg
Immobilisation guidelines for knee injuries
Immobilise knee with 10 degree flexion
Commercial knee immobiliser
OR
Posterior long leg plaster splint
Immobilisation guidelines for tibial fractures
Plaster splints
Immobilisation guidelines for ankle fractures
Well padded plaster splint
Immobilisation guidelines for forearm / wrist fractures
Padded or pillow splint
Splint wrist and fingers in functional position where possible
Immobilisation guidelines for elbow injuries
Partially flexed position
Padded splints
Immobilisation guidelines for upper arm injuries
Sling and swath device
+/- thoracobrachial bandage
Immobilisation guidelines for shoulder injuries
Sling and swathe device
Immobilisation guidelines for hand injuries
Short arm splint
Hand position for immobilisation of hand injuries
Slight dorsiflexion
Fingers flexed 45 degrees at metacarpophalangeal joints
Injuries associated with calcaneus fractures
Spinal injuries / fractures
