Musculoskeletal
Trauma
Cambridge Trauma weekend 2011
Mr Lee Van Rensburg
www.easytrauma.co.uk
Fatal accident deaths
England and Wales 1988-92 ~ 5 years
 Swimming 191
 Running/jogging 9
 Boating/sailing 69
 Badminton 3
 Motor sports 65
 Cricket 2
 Horse riding 62
 Hockey 2
 Air sports 51
 Rugby 2
 Mountaineering 51
 Golf 1
 Fishing 50
 Gymnastics 1
 Soccer 14
 Tennis 1
Musculoskeletal Trauma
• Life threatening
• Limb threatening
Musculoskeletal Trauma
• Life threatening
• Major pelvic disruption with haemorrhage
• Major arterial haemorrhage
• Crush syndrome (rhabdomyolysis)
• Limb threatening
Musculoskeletal Trauma
• Life threatening
• Limb threatening
•
•
•
•
Open Fractures, joint injuries
Vascular injuries
Compartment syndrome
Neurologic injury
Life Threatening Injuries
• Major pelvic disruption with haemorrhage
• Major arterial haemorrhage
• Crush syndrome (rhabdomyolysis)
Anatomy
Binding of book
Pelvis
Pelvic injury
3 patterns
• Anterior posterior compression (APC)
• Lateral compression
• Vertical shear
APC
Lateral Compression
Vertical shear
3 pelvic injuries
Treatment
• Emergency
• Definitive
Treatment
• Emergency
• Resuscitation ATLS
• Fracture pattern
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–
–
–
Pelvic binder
External fixation - anterior
C Clamp - posterior
Traction
• Angiography - embolisation
• Pelvic packing
• Definitive
Treatment
• Emergency
• Resuscitation ATLS
• Fracture pattern
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–
–
–
Pelvic binder
External fixation - anterior
C Clamp - posterior
Traction
• Angiography - embolisation
• Pelvic packing
Emergency
Pelvic binder
At level of greater trochanters and the symphysis pubis
Splinting Lower Limbs
54 hours
in binder
Emergency
Emergency
Binder and traction limb
C Clamp
C Clamp
Angiography
Angiography
Pelvic packing
Complex/ combination
Complex/ combination
Urethral injury
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•
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•
Blood at meatus
Frank haematuria
Perineal haematoma
Scrotal/ penile haematoma
High riding prostate
Complications
Life Threatening Injuries
• Major pelvic disruption with haemorrhage
• Major arterial haemorrhage
• Crush syndrome (rhabdomyolysis)
Major Arterial Haemorrhage
• Penetrating / blunt injury in close proximity to
artery
• Haemorrhage, haematoma, hypotension
• Ischaemic extremity
• Stop the bleeding!
Crush Syndrome
• Myoglobinuria
• Metabolic acidosis, K+, Ca++ and coagulopathy
• IV fluids, alkalisation of urine
Limb-Threatening Injuries
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•
•
•
Open Fractures, joint injuries
Vascular injuries
Compartment syndrome
Neurologic injury
Open Fractures, Joint Injuries
• Wide spectrum of soft-tissue injury
• Open wound = Open fracture
Open Fractures, Joint Injuries
• Treatment
– Antibiotics?
– Wound swab ????
Co-amoxiclav 1.2g, 8 hrly
– Photograph
Or
Cefuroxime
1.5g, 8 hrly
– Sterile dressings (betadine
or saline)
– Splint – REDUCE YES, DOCUMENT
Penicillin allergy
– Tetanus prophylaxis Clindamycin 600mg, 6 hrly
– Surgical debridement
Vascular Injury, Amputation
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•
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•
•
Variable presentation: Assess pulses
Associated with fractures / dislocations
Realign
Check pulses after splinting
Immediate surgical consult
Keep moist
Keep cool
Don’t freeze
Don’t macerate
Compartment Syndrome
Compartment Syndrome
 Compartment pressure
• Nerve / muscle ischaemia  necrosis
• NO 5 P’s
• Pain, Pain passive stretch
• Elevate (level of heart)
• Release constricting devices (keep splint)
• Suspect tibial, forearm fractures after
revascularisation in unconscious patient
• Early surgical consult
Compartment syndrome
Pitfalls
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•
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•
Simple transverse tibial fracture
Open fractures
Depressed level of consciousness
Pressure 30mmHg
ΔP (Diastolic – compartment) > 30mmHg
Neurologic Injury
• Due to fracture / dislocation
– Anterior shoulder: Axillary nerve
– Posterior hip: Sciatic nerve
• Recognise injury and immobilise
• Early surgical consult
• Careful reduction, if possible,  reassess
and splint
Damage Control Orthopaedics
Beyond ATLS
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•
•
•
ISS 57
SAH, DAI
R Haemothorax
Pelvic ring fracture
SR
21 YO, Male
13/05/06 - 23H50
– (Dissociation R hemipelvis)
• # L Acetabulum
• # L Femur
• Compartment syndrome both lower legs and thighs
Theatre - 1 hr arrival
• Laparotomy
– Pelvis packed, Vac dressing
• C clamp and pelvic ex fix
• Angiogram
• Embolisation
EVD 14/05/06 – 20:45
Theatre 14/05 08h20
• Retrograde femoral nail
• Fasciotomy
• Both thighs both calves
15/05/06
• Angiogram
• IVC filter
• Repeat bleeding
• Laparotomy change of packs
• Bladder repair
• Pubic symphysis ORIF
Theatre 15/05/06
• Angiogram
• IVC filter
• Repeat bleeding
•
•
•
•
Laparotomy change of packs
Bladder repair
Pubic symphysis ORIF
2 hour rewarming on table
Theatre 15/05/06
• Removal of C clamp
• Anterior plating
• R Sacroiliac joint
• Debridement washout
closure C clamp and Ex
fix wounds
Theatre
• Vac dressing change 17/05/06
• Closure of thigh wounds
• Vac dressing change 23/05/06
• Closure of L lower leg wound
• Vac dressing change 28/05/06
• Closure R lower leg wound
Theatre 30/05/06
• Planned ORIF acetabulum
• Wound breakdown
• L iliac crest
• Both thighs
• Washout and vac dressings
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JM
20 YO, Male
27/02/06 – 15:48
#BOS
#Nasal bone
APC pelvic injury
# R Supracondylar femur
# R Tibia shaft (open)
# L Tibial plateau (open)
# Bimalleolar L ankle
Pre hospital
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•
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Intubated through window
Pre hospital arrest
Hr 144, Systolic 60
GCS 3
Pre theatre
• CT brain
• BOS
• Angiogram
• Very small bleeder
embolised
Theatre 27/05/06
• External fixator
• Pelvis
• R leg
• L leg
• Debridement washout,
fasciotomy and vac
dressing
• R thigh
• R lower leg
• L lower leg
• Laparotomy
• EVD
Theatre – 01/03/06
• Plating pubic symphysis
• Intramedullary nail
• R femur retrograde
• R tibia
• Change of Vacs
Theatre 05/03/06
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•
•
•
ORIF L Tibial plateau
ORIF L fibula
Free Flap R tibia
Rotation flap L Tibia
Theatre 23/03/06
• Debridement and SSG L Ankle
• Medial side
Questions
www.easytrauma.co.uk