MUSCULOSKELETAL TRAUMA

Adnan Ali
BS Emergency Care Technology (KMU)
Many patients who sustain blunt trauma also incur injuries to the musculoskeletal
system. These injuries often appear dramatic, but only infrequently cause
immediate threat to life or limb. However, musculoskeletal injuries have the
potential to distract team members from more urgent resuscitation priorities. First,
clinicians need to recognize the presence of life-threatening extremity injuries
during the primary survey and understand their association with severe thoracic
and abdominal injuries. The provider must also be familiar with extremity anatomy
to be able to protect the patient from further disability, and anticipate and prevent
complications.
Major musculoskeletal injuries indicate that the body sustained significant
forces.For example, a patient with long-bone fractures above and below the
diaphragm is at increased risk for associated internal torso injuries. Unstable pelvic
fractures and open femur fractures can be accompanied by brisk bleeding. Severe
crush injuries cause the release of myoglobin from the muscle, which can
precipitate in the renal tubules and result in renal failure. Swelling into an intact
musculofascial space can cause an acute compartment syndrome that, if not
diagnosed and treated, may lead to lasting impairment and loss of the extremity.
Musculoskeletal trauma does not warrant a reordering of the ABCDE priorities of
resuscitation, but its presence does pose a challenge to clinicians. Musculoskeletal
injuries cannot be ignored and treated at a later time; rather, clinicians must treat
the whole patient, including musculoskeletal injuries, to ensure an optimal
outcome. Despite careful assessment, fractures and soft tissue injuries may not be
initially recognized in patients with multiple injuries.
Primary Survey and Resuscitation of Patients with Potentially
Life-Threatening Extremity Injuries
During the primary survey, it is imperative to recognize and control hemorrhage
from musculoskeletal injuries.
Potentially life-threatening extremity injuries include major arterial hemorrhage,
bilateral femoral fractures, and crush syndrome.
Deep soft-tissue lacerations may involve major vessels and lead to exsanguinating
hemorrhage. Hemorrhage control is best achieved with direct pressure.
Hemorrhage from long-bone fractures can be significant, and femoral fractures in
particular often result in significant blood loss into the thigh. Appropriate splinting
of fractures can significantly decrease bleeding by reducing motion and enhancing
the tamponade effect of the muscle and fascia. If the fracture is open, application
of a sterile pressure dressing typically controls hemorrhage. Appropriate fluid
resuscitation is an important supplement to these mechanical measures.
Major Arterial Hemorrhage and Traumatic Amputation
Penetrating extremity wounds can result in major arterial vascular injury. Blunt
trauma resulting in an extremity fracture or joint dislocation in close proximity to
an artery can also disrupt the artery. These injuries may lead to significant
hemorrhage through the open wound or into the soft tissues. Patients with
traumatic amputation are at particularly high risk of lifethreatening hemorrhage
and may require application of a tourniquet.
Assessment
Assess injured extremities for external bleeding, loss of a previously palpable pulse,
and changes in pulse quality, Doppler tone, and ankle/brachial index. The
ankle/brachial index is determined by taking the systolic blood pressure value at
the ankle of the injured leg and dividing it by the systolic blood pressure of the
uninjured arm. A cold, pale, pulseless extremity indicates an interruption in arterial
blood supply. A rapidly expanding hematoma suggests a significant vascular injury.
Management
A stepwise approach to controlling arterial bleeding begins with manual pressure
to the wound. A pressure dressing is then applied, using a stack of gauze held in
place by a circumferential elastic bandage to concentrate pressure over the injury.
If bleeding persists, apply manual pressure to the artery proximal to the injury. If
bleeding continues, consider applying a manual tourniquet or a pneumatic
tourniquet applied directly to the skin
Tighten the tourniquet until bleeding stops. A properly applied tourniquet must
occlude arterial inflow, as occluding only the venous system can increase
hemorrhage and result in a swollen, cyanotic extremity. A pneumatic tourniquet
may require a pressure as high as 250 mm Hg in an upper extremity and 400 mm
Hg in a lower extremity. Ensure that the time of tourniquet application is
documented. In these cases, immediate surgical consultation is essential, and early
transfer to a trauma center should be considered.
If time to operative intervention is longer than 1 hour, a single attempt to deflate
the tourniquet may be considered in an otherwise stable patient. The risks of
tourniquet use increase with time; if a tourniquet must remain in place for a
prolonged period to save a life, the choice of life over limb must be made.
The use of arteriography and other diagnostic tools is indicated only in resuscitated
patients who have no hemodynamic abnormalities; other patients with clear
vascular injuries require urgent operation. If a major arterial injury exists or is
suspected, immediately consult a surgeon skilled in vascular and extremity trauma.
Application of vascular clamps into bleeding open wounds while the patient is in the ED is not
advised, unless a superficial vessel is clearly identified. If a fracture is associated with an open
hemorrhaging wound, realign and splint it while a second person applies direct pressure to the
open wound. Joint dislocations should be reduced, if possible; if the joint cannot be reduced,
emergency orthopedic intervention may be required.
Amputation, a severe form of open fracture that results in loss of an extremity, is a traumatic
event for the patient, both physically and emotionally. Patients with traumatic amputation may
benefit from tourniquet application. They require consultation with and intervention by a
surgeon. Certain mangled extremity injuries with prolonged ischemia, nerve injury, and muscle
damage may require amputation. Amputation can be lifesaving in a patient with hemodynamic
abnormalities resulting from the injured extremity.
Although the potential for replantation should be considered in an upper extremity, it must be
considered in conjunction with the patient’s other injuries. A patient with multiple injuries who
requires intensive resuscitation and/or emergency surgery for extremity or other injuries is not a
candidate for replantation. Replantation is usually performed on patients with an isolated
extremity injury. For the required decision making and management, transport patients with
traumatic amputation of an upper extremity to an appropriate surgical team skilled in
replantation procedures.
In such cases, thoroughly wash the amputated part in isotonic solution (e.g.,
Ringer’s lactate) and wrap it in moist sterile gauze. Then wrap the part in a similarly
moistened sterile towel, place in a plastic bag, and transport with the patient in an
insulated cooling chest with crushed ice. Be careful not to freeze the amputated
part.
Bilateral Femur Fractures
Patients who have sustained bilateral femur fractures are at significantly greater
risk of complications and death. Such fractures indicate the patient has been
subjected to significant force and should alert clinicians to the possibility of
associated injuries. Compared with patients with unilateral femur fractures,
patients with bilateral femur fractures are at higher risk for significant blood loss,
severe associated injuries, pulmonary complications, multiple organ failure, and
death. These patients should be assessed and managed in the same way as those
with unilateral femur fractures. Consider early transfer to a trauma center.
Crush Syndrome
Crush syndrome, or traumatic rhabdomyolysis, refers to the clinical effects of injured muscle
that, if left untreated, can lead to acute renal failure and shock. This condition is seen in
individuals who have sustained a compression injury to significant muscle mass, most often to a
thigh or calf. The muscular insult is a combination of direct muscle injury, muscle ischemia, and
cell death with release of myoglobin.
Assessment
Myoglobin produces dark amber urine that tests positive for hemoglobin. A myoglobin assay may
be requested to confirm its presence. Amber-colored urine in the presence of serum creatine
kinase of 10,000 U/L or more is indicative of rhabdomyolysis when urine myoglobin levels are not
available. Rhabdomyolysis can lead to metabolic acidosis, hyperkalemia, hypocalcemia, and
disseminated intravascular coagulation.
Management
Initiating early and aggressive intravenous fluid therapy during resuscitation is critical to
protecting the kidneys and preventing renal failure in patients with rhabdomyolysis. Myoglobin-
induced renal failure can be prevented with intravascular fluid expansion, alkalinization of the
urine by intravenous administration of bicarbonate, and osmotic diuresis.
Adjuncts to the Primary Survey
Adjuncts to the primary survey of patients with musculoskeletal trauma include fracture
immobilization and x-ray examination, when fracture is suspected as a cause of shock.
Fracture Immobilization
The goal of initial fracture immobilization is to realign the injured extremity in as close to
anatomic position as possible and prevent excessive motion at the fracture site. This is
accomplished by applying inline traction to realign the extremity and maintaining traction with
an immobilization device .Proper application of a splint helps control blood loss, reduces pain,
and prevents further neurovascular compromise and soft-tissue injury. If an open fracture is
present, pull the exposed bone back into the wound, because open fractures require surgical
debridement. Remove gross contamination and particulate matter from the wound, and
administer weight-based dosing of antibiotics as early as possible in patients with open fractures.
Qualified clinicians may attempt reduction of joint dislocations. If a closed reduction successfully
relocates the joint, immobilize it in the anatomic position with prefabricated splints, pillows, or
plaster to maintain the extremity in its reduced position.
If reduction is unsuccessful, splint the joint in the position in which it was found. Apply splints as
soon as possible, because they can control hemorrhage and pain.
However, resuscitation efforts must take priority over splint application. Assess the neurovascular
status of the extremity before and after manipulation and splinting.
X-ray Examination
Although x-ray examination of most skeletal injuries is appropriate during the secondary survey,
it may be undertaken during the primary survey when fracture is suspected as a cause of shock.
The decisions regarding which x-ray films to obtain and when to obtain them are based on the
patient’s initial and obvious clinical findings, the patient’s hemodynamic status, and the
mechanism of injury.
Secondary Survey
Important elements of the secondary survey of patients with musculoskeletal
injuries are the history and physical examination.
History
Key aspects of the patient history are mechanism of injury, environment, preinjury
status and predisposing factors, and prehospital observations and care
Mechanism of Injury
Information obtained from the patient, relatives, prehospital and transport
personnel, and bystanders at the scene of the injury should be documented and
included as a part of the patient’s history. It is particularly important to determine
the mechanism of injury, which can help identify injuries that may not be
immediately apparent
The clinician should mentally reconstruct the injury scene, consider other potential
injuries the patient may have sustained, and determine as much of the following
information as possible:
1. Where was the patient located before the crash? In a motor vehicle crash, the
patient’s precrash location can suggest the type of fracture—for example, a lateral
compression fracture of the pelvis may result from a side impact collision.
2. Where was the patient located after the crash— inside the vehicle or ejected?
Was a seat belt or airbag in use? This information may indicate certain patterns of
injury. If the patient was ejected, determine the distance the patient was thrown,
as well as the landing conditions. Ejection generally results in unpredictable
patterns of injury and more severe injuries.
3. Was the vehicle’s exterior damaged, such as having its front end deformed by a
head-on collision? This information raises the suspicion of a hip dislocation.
4. Was the vehicle’s interior damaged, such as a deformed dashboard? This finding
indicates a greater likelihood of lower-extremity injuries.
5. Did the patient fall? If so, what was the distance of the fall, and how did the
patient land? This information helps identify the spectrum of injuries.
6. Was the patient crushed by an object? If so, identify the weight of the crushing
object, the site of the injury, and duration of weight applied to the site. Depending
on whether a subcutaneous bony surface or a muscular area was crushed, different
degrees of soft-tissue damage may occur, ranging from a simple contusion to a
severe degloving extremity injury with compartment syndrome and tissue loss.
7. Did an explosion occur? If so, what was the magnitude of the blast, and what
was the patient’s distance from the blast? An individual close to the explosion may
sustain primary blast injury from the force of the blast wave. A secondary blast
injury may occur from debris and other objects accelerated by the blast (e.g.,
fragments), leading to penetrating wounds, lacerations, and contusions. The
patient may also be violently thrown to the ground or against other objects by the
blast effect, leading to blunt musculoskeletal and other injuries (i.e., a tertiary blast
injury).
8. Was the patient involved in a vehicle-pedestrian collision? Musculoskeletal
injuries follow predictable patterns based on the patient’s size and age
Environment
When applicable, ask prehospital care personnel for the following information
about the postcrash environment:
1. Did the patient sustain an open fracture in a contaminated environment? 2. Was
the patient exposed to temperature extremes? 3. Were broken glass fragments,
which can also injure the examiner, at the scene? 4. Were there any sources of
bacterial contamination, such as dirt, animal feces, and fresh or salt water? This
information can help the clinician anticipate potential problems and determine the
initial antibiotic treatment.
Preinjury Status and Predisposing Factors
When possible, determine the patient’s baseline condition before injury. This
information can enhance understanding of the patient’s condition, help determine
treatment regimen, and affect outcome. An AMPLE history should be obtained,
including information about the patient’s exercise tolerance and activity level,
ingestion of alcohol and/or other drugs, emotional problems or illnesses, and
previous musculoskeletal injuries.
Prehospital Observations and Care
All prehospital observations and care must be reported and documented. Findings
at the incident site that may help to identify potential injuries include • The time of
injury, especially if there is ongoing bleeding, an open fracture, and a delay in
reaching the hospital • Position in which the patient was found • Bleeding or
pooling of blood at the scene, including the estimated amount • Bone or fracture
ends that may have been exposed • Open wounds in proximity to obvious or
suspected fractures • Obvious deformity or dislocation • Any crushing mechanism
that can result in a crush syndrome • Presence or absence of motor and/or sensory
function in each extremity • Any delays in extrication procedures or transport •
Changes in limb function, perfusion, or neurologic state, especially after
immobilization or during transfer to the hospital • Reduction of fractures or
dislocations during extrication or splinting at the scene • Dressings and splints
applied, with special attention to excessive pressure over bony prominences that
can result in peripheral nerve compression or compartment syndrome • Time of
tourniquet placement, if applicable
Physical Examination
For a complete examination, completely undress the patient, taking care to prevent
hypothermia. Obvious extremity injuries are often splinted before the patient
arrives at the ED. The three goals for assessing the extremities are:
1. Identify life-threatening injuries (primary survey). 2. Identify limb-threatening
injuries (secondary survey). 3. Conduct a systematic review to avoid missing any
other musculoskeletal injury (i.e., continuous reevaluation). Assessment of
musculoskeletal trauma includes looking at and talking to the patient, palpating the
patient’s extremities, and performing a logical, systematic review of each extremity.
Extremity assessment must include the following four components to avoid missing
an injury: skin, which protects the patient from excessive fluid loss and infection;
neuromuscular function; circulatory status; and skeletal and ligamentus integrity.
Look and Ask
Visually assess the extremities for color and perfusion, wounds, deformity (e.g.,
angulation or shortening), swelling, and bruising.
A rapid visual inspection of the entire patient will help identify sites of major
external bleeding. A pale or white distal extremity is indicative of a lack of arterial
inflow. Extremities that are swollen in the region of major muscle groups may
indicate a crush injury with an impending compartment syndrome. Swelling or
ecchymosis in or around a joint and/or over the subcutaneous surface of a bone is
a sign of a musculoskeletal injury. Extremity deformity is an obvious sign of major
extremity injury
Inspect the patient’s entire body for lacerations and abrasions. Open wounds may
not be obvious on the dorsum of the body; therefore, carefully logroll patients to
assess for possible hidden injuries. (See Logroll video on MyATLS mobile app.) Any
open wound to a limb with an associated fracture is considered to be an open
fracture until proven otherwise by a surgeon.
Observe the patient’s spontaneous extremity motor function to help identify any neurologic
and/or muscular impairment. If the patient is unconscious, absent spontaneous extremity
movement may be the only sign of impaired function. With a cooperativepatient, trauma team
members can assess active voluntary muscle and peripheral nerve function by asking the patient
to contract major muscle groups. The ability to move all major joints through a full range of
motion usually indicates that the nerve-muscle unit is intact and the joint is stable.
Feel
Palpate the extremities to determine sensation to the skin (i.e., neurologic function) and identify
areas of tenderness, which may indicate fracture. Loss of sensation to pain and touch
demonstrates the presence of a spinal or peripheral nerve injury. Areas of tenderness or pain
over muscles may indicate a muscle contusion or fracture. If pain, tenderness, and swelling are
associated with deformity or abnormal motion through the bone, fracture should be
suspectedDo not attempt to elicit crepitus or demonstrate abnormal motion.
Joint stability can be determined only by clinical examination. Abnormal motion
through a joint segment is indicative of a tendon or ligamentous rupture. Palpate
the joint to identify any swelling and tenderness of the ligaments as well as
intraarticular fluid. Following this, cautious stressing of the specific ligaments can
be performed. Excessive pain can mask abnormal ligament motion due to guarding
of the joint by muscular contraction or spasm; this condition may need to be
reassessed later.
Circulatory Evaluation
Palpate the distal pulses in each extremity, and assess capillary refill of the digits. If
hypotension limits digital examination of the pulse, the use of a Doppler probe may
detect blood flow to an extremity. The Doppler signal must have a triphasic quality
to ensure no proximal lesion. Loss of sensation in a stocking or glove distribution is
an early sign of vascular impairment.
In patients with normal blood pressure, an arterial injury can be indicated by pulse discrepancies,
coolness, pallor, paresthesia, and even motor function abnormalities. Open wounds and
fractures close to arteries can be clues to an arterial injury. Knee dislocations can reduce
spontaneously and may not present with any gross external or radiographic anomalies until a
physical exam of the joint is performed and instability is detected clinically. An ankle/brachial
index of less than 0.9 indicates abnormal arterial flow secondary to injury or peripheral vascular
disease. Expanding hematomas and pulsatile hemorrhage from an open wound also indicate
arterial injury.
X-ray Examination
The clinical examination of patients with musculoskeletal injuries often suggests the need for x-
ray examination. Tenderness with associated bony deformity likely represents a fracture. Obtain
x-ray films in patients who are hemodynamically normal. Joint effusion, abnormal joint
tenderness, and joint deformity indicate a joint injury or dislocation that must also be x-rayed.
The only reason to forgo x-ray examination before treating a dislocation or a fracture is the
presence of vascular compromise or impending skin breakdown. This condition is commonly
seen with fracture-dislocations of the ankle
If a delay in obtaining x-rays is unavoidable, immediately reduce or realign the
extremity to reestablishthe arterial blood supply and reduce the pressure on the
skin. Alignment can be maintained by appropriate immobilization techniques.
Limb-Threatening Injuries
Extremity injuries that are considered potentially limb-threatening include open
fractures and joint injuries, ischemic vascular injuries, compartment syndrome, and
neurologic injury secondary to fracture or dislocation.
Open Fractures and Open Joint Injuries
Open fractures and open joint injuries result from communication between the
external environment and the bone or joint . Muscle and skin must be injured for
this to occur, and the degree of soft-tissue injury is proportional to the energy
applied. This damage, along with bacterial contamination, makes open fractures
and joint injuries prone to problems with infection, healing, and function.
Assessment
The presence of an open fracture or an open joint injury should be promptly
determined. The diagnosis of an open fracture is based on a physical examination
of the extremity that demonstrates an open wound onthe same limb segment as
an associated fracture. At no time should the wound be probed.
Documentation of the open wound begins during the prehospital phase with the
initial description of the injury and any treatment rendered at the scene. If an open
wound exists over or near a joint, it should be assumed that the injury connects
with or enters the joint. The presence of an open joint injury may be identified
using CT. The presence of intraarticular gas on a CT of the affected extremity is
highly sensitive and specific for identifying open joint injury. If CT is not available,
consider insertion of saline or dye into the joint to determine whether the joint
cavity communicates with the wound. If an open joint is suspected, request
consultation by an orthopedic surgeon, as surgical exploration and debridement
may be indicated.
Management
Management decisions should be based on a complete history of the incident and
assessment of the injury. Treat all patients with open fractures as soon as possible
with intravenous antibiotics using weight-based dosing. First-generation
cephalosporins are necessary for all patients with open fractures .Delay of antibiotic
administration beyond three hours is related to an increased risk of infection.
Remove gross contamination and particulates from the wound as soon as possible,
and cover it with a moist sterile dressing. Apply appropriate immobilization after
accurately describing the wound and determining any associated soft-tissue,
circulatory, and neurologic involvement. Prompt surgical consultation isnecessary. The
patient should be adequately resuscitated and, if possible, hemodynamically normal.
Wounds may then be operatively debrided, fractures stabilized, and distal pulses
confirmed. Tetanus prophylaxis should be administered.
Vascular Injuries
In patients who manifest vascular insufficiency associated with a history of blunt, crushing, twisting,
or penetrating injury or dislocation to an extremity, clinicians should strongly suspect a vascular
injury.
Assessment
The limb may initially appear viable because extremities often have some collateral
circulation that provides adequate flow. Non-occlusive vascular injury, such as an
intimal tear, can cause coolness and prolonged capillary refill in the distal part of
the extremity, as well as diminished peripheral pulses and an abnormal
ankle/brachial index. Alternatively, the distal extremity may have complete
disruption of flow and be cold, pale, and pulseless.
Management
It is crucial to promptly recognize and emergently treat an acutely avascular
extremity.
Early operative revascularization is required to restore arterial flow to an ischemic
extremity. Muscle necrosis begins when there is a lack of arterial blood flow for
more than 6 hours. Nerves may be even more sensitive to an anoxic environment.
If there is an associated fracture deformity, correct it by gently pulling the limb out
to length, realigning the fracture, and splinting the injured extremity.
This maneuver often restores blood flow to an ischemic extremity when the artery
is kinked by shortening and deformity at the fracture site.
When an arterial injury is associated with dislocation of a joint, a clinician may
attempt gentle reduction maneuvers. Otherwise, the clinician must splint the
dislocated joint and obtain emergency surgical consultation. CT angiography may
be used to evaluate extremity vascular injuries, but it must not delay reestablishing
arterial blood flow and is indicated only after consultation with a surgeon.
When an arterial injury is associated with dislocation of a joint, a clinician may
attempt gentle reduction maneuvers. Otherwise, the clinician must splint the
dislocated joint and obtain emergency surgical consultation. CT angiography may
be used to evaluate extremity vascular injuries, but it must not delay reestablishing
arterial blood flow and is indicated only after consultation with a surgeon
casts can also have vascular compromise Promptly release splints, casts, and any
other circumferential dressings upon any sign of vascular compromise, and then
reassess vascular supply.
Compartment Syndrome
Compartment syndrome develops when increased pressure within a musculofascial
compartment causes ischemia and subsequent necrosis. This increased pressure may
be caused by an increase in compartment content (e.g., bleeding into the
compartment or swelling after revascularization of an ischemic extremity) or a
decrease in the compartment size (e.g., a constrictive dressing). Compartment
syndrome can occur wherever muscle is contained within a closed fascial space.
Remember, the skin acts as a restricting layer in certain circumstances. Common areas
for compartment syndrome include the lower leg, forearm, foot, hand, gluteal region,
and thigh
Delayed recognition and treatment of compartment syndrome is catastrophic and can
result in neurologic deficit, muscle necrosis, ischemic contracture, infection, delayed
healing of fractures, and possible amputation.
Assessment
Any injury to an extremity can cause compartment syndrome. However, certain
injuries or activities are considered high risk, including.
• Injuries immobilized in tight dressings or casts • Severe crush injury to muscle •
Localized, prolonged external pressure to an extremity • Increased capillary
permeability secondary to reperfusion of ischemic muscle • Burns • Excessive
exercise
. Early diagnosis is the key to successful treatment of acute compartment
syndrome. A high degree of awareness is important, especially if the patient has an
altered sensorium and is unable to respond appropriately to pain. The absence of a
palpable distal pulse is an uncommon or late finding and is not necessary to
diagnose compartment syndrome. Capillary refill times are also unreliable for
diagnosing compartment syndrome. Weakness or paralysis of the involved muscles
in the affected limb is a late sign and indicates nerve or muscle damage. Clinical
diagnosis is based on the history of injury and physical signs, coupled with a high
index of suspicion. If pulse abnormalities are present, the possibility of a proximal
vascular injury must be considered.
Measurement of intra compartmental pressure can be helpful in diagnosing
suspected compartment syndrome. Tissue pressures of greater than 30 mm Hg
suggest decreased capillary blood flow, which can result in muscle and nerve
damage from anoxia. Blood pressure is also important: The lower the systemic
pressure, the lower the compartment pressure that causes compartment
syndrome.
Management
Compartment syndrome is a time- and pressure-dependent condition. The higher
the compartment pressure and the longer it remains elevated, the greater the
degree of resulting neuromuscular damage and resulting functional deficit. If
compartment syndrome is suspected, promptly release all constrictive dressings,
casts, and splints applied over the affected extremity and immediately obtain a
surgical consultation. The only treatment for a compartment syndrome is a
fasciotomy. A delay in performing a fasciotomy may result in myoglobinuria, which
may cause decreased renal function. Immediately obtain surgical consultation for
suspected or diagnosed compartment syndrome.
Thanks