Trauma of the Musculoskeletal System Flashcards
Musculoskeletal trauma affects both…?
Skeletal/joints and the soft tissues
Advanced Trauma Life Support (ATLS) - what makes up the primary survey? (5)
Airway & C-spine Control Breathing & Ventilation Circulation & Haemorrhage Control Disability & AVPU (level of consciousness) Exposure & Environment Control
What makes up the secondary survey? (3)
Head to toe examination
Detailed history
Special tests (x-rays, blood labs)
What is the key message of advanced life support?
Treat life threatening injuries FIRST e.g. apply pressure to haemorrhage from an open wound / reduce a pelvic fracture if haemodynamically unstable, etc
THEN prevent long term complications once the patient is stable.
What imaging is done for musculoskeletal trauma?
X-ray Computerised tomography Magnetic resonance imaging Ultrasound Bone scan
What is polytrauma?
Trauma to several body areas or organ systems
One or more may be life threatening
Our upper limb or lower limb fractures/dislocations more disabling?
Which is associated with more severe injuries?
Upper limb more disabling
Lower limb associated with more severe injuries
What is the possible blood loss within the first 2 hours of a tibia/fibula haemorrhage?
500 ml
What is the possible blood loss within the first 2 hours of a femur haemorrhage?
500ml
What is the possible blood loss within the first 2 hours of a pelvis haemorrhage?
2000ml
Why are pelvic fractures a problem? (3)
Haemorrhage
10-20% mortality
Persistent pain in 25-35%
What are the biggest causes of trauma/haemorrhage?
Car accident (48.5%), work accident (27.3%), motorcycle accident (18.2%) and then crushing and tractors (make up 0.6% together)
Are pelvic bleeds usually venous or arterial?
85% are venous (they are thin walled vessels). The pre-sacral venous plexus overlies the sacroiliac joint, the fracture disrupts the joint and tears veins causing bleeding. There is also bleeding from cancellous bone surfaces.
Mainly from the internal iliac vein.
Stabilising a pelvic fracture - how is this done? What happens if it is not done?
External fixation (frame) left for 8 weeks if possible Mal-union
What are some potential skin soft tissue traumas? (3)
Open fractures
Degloving injuries
Ischemic necrosis
What are some potential muscles soft tissue traumas? (2)
Crush and compartment syndromes
What are some potential blood vessel soft tissue traumas? (2)
Vasospasm (can lead to clot formation) and arterial laceration
What are some potential nerve soft tissue traumas? (3)
Neurapraxias, axonotmesis, neurotmesis
What are some potential ligament soft tissue traumas? (2)
Joint instability and dislocation
What does neurapraxia mean?
Nerve is compressed, but no axonal damage after it has been decompressed.
What does axonotmesis mean?
There is axoplasmic damage, but the endoneural sheath intact (can reform, about 3mm a day).
What does neurotmesis mean?
Axon disrupted, loss of tubules, support cells destroyed.
As it regrows, it can form a tangle of nerve axons.
All severe soft tissue injuries require urgent treatment. Why?
Because of potential complications – for example, a severe soft tissue injury will delay fracture healing
What is reduction?
What fractures require reduction?
Putting the bone back into alignment
If displaced
Fractures that aren’t displaced - how are they treated?
Simple splintage (e.g. clavicle, ribs, MT’s carpals and stress or impacted fractures)
What is closed reduction?
What is open reduction internal fixation (ORIF)?
Closed reduction is the manipulation of the bone fragments without surgical exposure of the fragments -
alignment without angulation. Done with anaesthesia.
Open reduction is where the fracture fragments are exposed surgically by dissecting the tissues - anatomic
When is open reduction done?
When you need accurate reduction/when internal fixation is needed, i.e. close to a joint
What are the downfalls of ORIF?
Risk of infection
Can slow healing if too rigid
When is traction used?
Fractures or dislocation requiring slow reduction
How are we going to hold the reduction?
Semi-rigid (Plaster) or Rigid (Internal fixation)
How is internal fixation done?
Use K wires or intramedullary nails to hold everything in place
What can internal fixation lead to?
Bone is too rigid and may develop osteoporosis – bone isn’t turning over quick enough and so gets removed
Treating the fracture operatively – what are the benefits? (3)
Quick rehabilitation
Low risk of joint stiffness
Low risk of mal-union
What are the benefits of treating a fracture non-operatively? (2)
Rapid healing
Low risk of infection
What are the disadvantages of treating a fracture operatively? (3)
How have these been rectified?
Risk of non-union - improved implants
Slow healing
Risk of infection - antibiotic prophylaxis
(ALSO Development of minimally invasive methods)
What are the disadvantages of treating a fracture non-
operatively? (4)
Risk of non-union
Risk of mal-union
Risk of joint stiffness
Slow rehabilitation
What are the current absolute indications for operative treatment? (5)
Displaced intra-articular fractures Open fractures Fractures with vascular injury or compartment syndrome Pathological fractures Non-unions
What are the current relative indications?
Loss of position with closed method
Poor functional result with non-anatomical reduction
Displaced fractures with poor blood supply
Economic and medical indications
What factors affect healing time? (2)
Local factors
Systemic factors
What is meant by ‘Clinical Union’?
Bone moves as one
Can be tender when stressed
What is meant by ‘Radiological Union’?
At least 3 out of 4 cortices healed on 2 views
Bridging callus formation
Fracture line often still present
Remodelling
Is fracture union is equal to fracture consolidation?
No
How long does it take for an upper limb fracture to heal in an adult?
What about lower limb?
6-8 weeks, 12-16 weeks
How long does it take for an upper limb fracture to heal in a child?
What about lower limb?
3-4 weeks, 6-8 weeks
What are the potential general early complications? (4)
Other injuries, pulmonary embolism, fat embolism, acute respiratory distress syndrome
What are the potential early bone complications? (1)
Infection
What are the potential early soft tissue complications? (4)
Plaster sores
Wound infection
Neurovascular injury
Compartment syndrome
What are the potential general late complications? (3)
Chest infection
UTI
Bed sores
What are the potential late bone complications? (3)
Non-union
Mal-union
Avascular necrosis
What are the potential late soft tissue complications? (3)
Tendon rupture Nerve compression Volkmann contracture (death of muscle)
How does a patient with a fat embolism present? (3)
Mild hypoxaemia
Multiple hyperintense punctate lesions throughout cerebral white matter
Petechie (rash) over chest and upper arm
If the pressure within an anatomical compartment exceeds the perfusion pressure of that compartment then…?
Causes collapse of the venous and capillaries close
What are the six “P”s of musculoskeletal assessment?
Paraesthesia Pallor Polar Paralysis Pain Pulselessness
Capillary blood flow within the compartment may be compromised at pressures of…?
> 20 mmHg
How is compartment syndrome diagnosed?
Clinical presentation or pressure monitoring
How is compartment syndrome treated?
Fasciotomy
