Initial Assessment and Management

Loma Linda Medical Center

Musculoskeletal Trauma

Case Scenario

● A wall collapses on a 44-year-old male worker

● BP: 130/75; Pulse: 110; RR: 22

● GCS score: 15

● Painful, bruised, deformed right leg

What are your priorities?Is this life- or limb-threatening?

Objectives

● Describe the principles for assessing patients with musculoskeletal injuries.

● Identify treatment priorities.

● Explain the importance of musculoskeletal injuries in multiply injured patients.

Primary Survey

How do musculoskeletal injuries impact on the primary survey?

Primary Survey

●External bleeding

●Occult blood loss

● Pelvic fractures

● Long bone fractures

How do musculoskeletal injuries impact on the primary survey?

A B D EC

Primary Survey

What are my priorities and management principles?

Primary Survey

●Stop the bleeding! (pressure /

tourniquet)

●Splint the extremity

●Stabilize the pelvis

During the Primary Survey – The 3 S’s

What are my priorities and management principles?

Primary Survey

●Prevents further blood loss and injury

●Can restore or maintain perfusion

●Relieves pain

● Important during evaluation

●Do not delay

Rationale for Splinting

Primary Survey

Stabilization

Secondary Survey

●Look

●Listen

●Feel

Secondary Survey

Look

●Deformity

●Pain

●Tenderness

●Wound(s)

Rationale for Splinting

Listen

●Doppler signals

●Bruit

Feel

●Crepitus

●Skin flaps

●Neurologic deficit

●Pulses

Secondary Survey

●Preinjury status and predisposing factors

●Mechanism of injury

●Time of injury

●Associated factors (eg, environment)

●Prehospital observations and care

Key Information

Secondary Survey

●Vascular compromise

●Open fractures

Early Concerns

Secondary Survey

●Reduce fracture(s)

●Splint fracture(s)

●Assess by Doppler

●Obtain surgical consult Time is critical!

●Consider angiography

Assess and Manage Vascular Compromise

Secondary Survey

●Apply appropriate splint

●Cleanse / debride (now or later)

●Consider time factor

●Obtain orthopedic consult

●Antibiotic / tetanus status

Managing Open Fractures

Secondary Survey

●What x-rays do I need?

●Any suspected area

●One joint above and below

●When do I obtain them?

●Patient is hemodynamically normal

X-Ray Studies

Secondary Survey

●When should I delay getting x-rays?

● If life-threatening injuries take priority

● If patient transfer will be delayed

X-Ray Studies

Compartment Syndrome

What injuries can cause compartment syndrome?

Compartment Syndrome

What injuries can cause compartment syndrome?●Tibia and forearm

fractures

●Vascular and bony injuries

●Injuries immobilized in tight dressings or casts

●Severe crush injuries to muscle

●Burns

Compartment Syndrome

How do I recognize compartment syndrome?

Compartment Syndrome

●Pain

●Disproportionate

●Passive stretch

●Tense compartments

●Asymmetry

●Paresthesia

●Tissue pressures > 35 to 45 mm Hg

How do I recognize compartment syndrome?

● Altered sensation

● Compartment syndrome

● Vascular injury

● Crush injuries / myoglobinuria

● Occult fractures / soft tissue injuries

● Coagulation disorders

Pitfalls

Pitfalls

Summary

●Manage life-threatening injuries first

●Stop the bleeding!

●Reduce and immobilize fractures and dislocations

●Recognize vascular compromise

●Consider compartment syndrome

Thank you everyone!