musculoskeletal injuries

1. Approach to Musculoskeletal
Injuries
Dr. Ashraf Hussein, ER consultant

2. OVERVIEW
• Significant percentage of all emergency
room care rendered.
• In HUP ED, over 6 month period, survey
showed chief complaint of musculoskeletal
problem comprised approx. 11% of all
patients (1 in 9).

3. Musculoskeletal Injuries
• ED physician needs a coherent, systematic
approach to orthopaedic complaints.
• Severity ranges from trivial sprains to life-
or limb-threatening trauma.
• Often acute trauma is the cause of the
presentation.
• Pain and decreased ROM are the main
symptoms.

4. What We Commonly See
• Musculoskeletal disorders commonly seen
in the ED include:
– Soft Tissue Injuries (strains and sprains)**
– Fractures (open, closed, long bone, pelvic, occult)
– Dislocations
– Infections (soft-tissue, bite wounds)**
– Effusions **
– Deep venous thrombosis

5. Less Common But…
• Musculoskeletal disorders less commonly
seen in the ED, but unmistakably important:
– Spinal Injuries
– Crush Injuries
– Compartment syndrome

6. FRACTURES

7. Fractures
• A partial or complete break in a bone.
– Bone is the only tissue in the human body other
than liver that heals by regeneration instead of
by scarring.
– For regeneration to occur the bone must be
immobilized to allow uninterrupted formation
of new bone.

8. Fractures
• New Bone Formation:
• A hematoma forms between realigned Fx fragments.
• Hematopoietic cells in the hematoma secrete growth
factors (GF’s).
• GF’s stimulate formation of granulation tissue at the
Fx ends, slowly resorbing the hematoma.
• A primary callus forms, progressing from a soft
callus to hard callus.
• Final phase of healing: during remodeling the bone
reassumes its original architecture.

9. Fractures
• Nomenclature of fractures is essential to
successful Fx management in the ED
• Adequate description:
– Open or closed?
– Which bone involved?
– Location within the bone?
– Direction of the main fracture line?
– Number of fragments?
– Alignment and displacement of the fragments?
– Complications?

10. Closed Fracture

11. Open Elbow Fracture

12. Open Fractures
• ORTHOPEDIC EMERGENCY
• Immediate control of hemorrhage.
• Splinting +/- reduction.
• Copious irrigation.
• Early administration of sufficient analgesia,
appropriate antibiotics, and tetanus
prophylaxis.
• Emergent consultation w/ orthopaedics for all
Type II and Type III open Fx’s (and some Type
I’s).

13. Fractures-Open Classification
I <1cm long, minimal contamination, low energy force
ABX: 1st/2nd Ceph for 3d
II >1cm long, moderate contamination and force
ABX: 1st/2nd Ceph plus aminoglyc for 3d
III High energy, comminuted fx, extensive tissue
damage, enough tissue to cover wound, extensive
contamination, arterial injury
ABX: 1st/2nd Ceph plus aminoglyc for 5d

14. PELVIC FRACTURES

15. Pelvic Fractures
• Least common fracture (3%)
• Most are result of auto-collisions
• Commonly associated with other injuries
• Pelvis contains many important structures:
– Iliac vessels, urogenital organs, nerve plexi…..
• Patients can sustain large volume blood loss

16. Clinical Evaluation
• Any patient assessment begins with the ABC’s
(Airway, Breathing, Circulation)
• Complete neurologic and vascular exam
• Have high suspicion of intra-abdominal
injuries
• Physical exam:
– Ecchymosis or contusion around hips, perineum
– Pelvic instability with stressing
– Suspect if signs of urologic/gyn findings: blood at
urethral meatus, high-riding prostate
– High force mechanisms also associated (mvc,
femur fx)

19. Pelvic Fracture-Management
• #1--Control of bleeding vessels
• In hemodynamically unstable pts, consider
angiography
• #2--Surgical management of the broken
bone can proceed LATER after life-
threatening conditions are controlled.

20. LONG BONE FRACTURES

21. Long Bone Fractures
• Fractures of the femur, humerus, tibia/fibula
• Blunt and penetrating trauma
• Requires high energy to break bone,
therefore look for other injuries.
• Bone has a generous blood supply.
• Does patient have associated bleeding
disorder?

22. Long Bone Fractures
• Fx’s cause localized bleeding and this can
be substantial resulting in hypovolemic
shock.
– Humerus: 200-500cc
– Unilateral tibia/fibula: 400-800cc
– Femur Fx: 1000-1500cc

23. Long Bone Fracture

24. Management
• ABC’s
• Neurovascular exam (vascular +/- nerve injury)
• Splint involved extremity
– Reduction decreases pain, bleeding
• Orthopedic consultation for definitive
management
• Complications:
– Fat-emboli syndrome
– Blood loss

25. Fracture Complications
• Vascular Injuries
– Most commonly occur in open Fx’s, Fx-dislocations,
or widely displaced Fx’s and at sites where the
vessels lie in close proximity to the bone or @ sites
where the vessels are held in a relatively fixed
position.
• Classic signs: The 5 P’s: Pain, Pallor,
Pulselessness (or diminished pulse),
Paresthesia, and Paralysis.
– Location of Fx and MOI dictate need to assess for
potential vascular injury in asymptomatic patient.

26. Fracture Complications
• Nerve Injuries
– Occur more frequently than vascular injuries in
assoc. w/ Fx.
– Can occur 2/2 blunt trauma, along path of
penetrating trauma, or be caused by the Fx
fragments themselves.
– Nerves are @ increased risk of injury when
they are superficial to the skin, lie close to the
bone, or span a joint, making them susceptible
to stretch injury.

27. Fracture Complications
• Fat Emboli Syndrome (FES)
– Most common form of non-thrombotic
embolism.
– Single or multiple long bone fractures in young
or pelvic/hip fractures in elderly predispose to
FES.
– 20% of patients w/ pelvic or long bone
fractures have detectable fat droplets in their
blood.

28. • Fat Emboli Syndrome (FES)
– Vast majority remain asymptomatic
– Has characteristic clinical course:
1. Fracture sustained.
2. Other than fracture-associated pain, patient is
asymptomatic for 12-36 hours.
3. Sudden onset of life-threatening syndrome characterized
by rapid cardiopulmonary and neurologic deterioration,
agitation, hallucinations, delirium, coma, hypoxia,
dyspnea, tachypnea, and tachycardia leading to DIC and
ARDS.

29. Deep Venous Thrombosis

30. Deep Venous Thrombosis
• Clot forming in one of the deep veins of an
extremity: Legs > Arms.
• If clot propagates above the popliteal fossa,
substantial risk of piece of clot breaking free,
embolizing to the pulmonary circulation.
• Risk of respiratory distress, hypoxia, pleuritic
chest pain, circulatory compromise, death.
• Doppler ultrasound; CXR; V/Q Scan; spiral CT
• Treatment: anticoagulation

33. CRUSH INJURY

34. Crush Injuries
• First descriptions from military records,
bombings in England and Europe during world
wars
• Now more commonly seen in natural disasters,
building collapse, acts of terrorism, after
poisioning, after drug overdoses
• Injury results from prolonged continuous
pressure on a body part, typically an extremity

35. Crush Injuries
• Under direct pressure, cellular ischemia incurred
causing loss cellular integrity
• Cells leak K+ and myoglobin
• Influx of ions into the cells causing irreversible
cell death
• Can have large fluid volume shifts
• Electrolyte abnormalities:
– Hyperkalemia, hyperphosphatemia, myoglobinemia,
hypocalcemia, metabolic acidosis

36. Crush Injuries
• Myoglobin concentrates in
the renal tubules
obstructive nephropathy
 acute renal failure
• When ARF occurs,
mortality 20-40%
• Arrythmias
• Concern for sepsis with
devitalized tissue

37. Crush Injuries-Treatment
• Early consideration /recognition
• Fluid resuscitation
– ARF approaches 100% if hydration
delayed >12 hours
• Alkalinize the urine –add sodium
bicarbonate to IVF
– prevents myoglobin precipitation and
enhances excretion

38. COMPARTMENT
SYNDROME

39. Compartment Syndrome
• Occurs when pressure w/i soft tissues in a
fixed body compartment increases to level
that exceeds venous pressure,
compromising venous blood flow, and
limiting capillary perfusion.
• Leads to muscle ischemia and necrosis.
• TRUE ORTHOPEDIC EMERGENCY

40. Compartment Syndrome
• Contributing Factors
• External:
– Conditions that reduced size of muscle
compartment (casts/splints); occlusive
dressing; eschar of burns
• Internal:
– Conditions that increase compartment volume:
bleeding, swelling, fluid extravasation into
tissue

42. Hand and Foot
Compartments

43. CS-Recognition
• Suspect with long bone fx, crush injuries
• Presents as pain out of proportion to
physical findings, +/- hypoesthesia,
pulselessness (late).

44. Measure intra-compartmental pressure
when considering compartment
syndrome
Pressures >40mmHg considered dangerous

45. Compartment Syndrome
Compartment syndrome
should be suspected in
long bone Fx’s and Fx’s
associated w/ significant
vascular injuries or
pronounced swelling.
Intra-compartment pressures
must be measured once the
issue of compartment
syndrome is raised.

46. SPINAL INJURY

47. Spinal Injuries
• Devastating injuries
• >80% occur in young males
• Motor vehicle accidents, falls from height,
gunshot wound
• Worrisome presentations:
– pain over spine in setting of trauma
– loss of motor function
– incontinence
– priapism

48. Spinal Injuries
• Additional risk factors for spinal PAIN:
– Metastatic cancer
– Osteoporosis, rheumatic dz, steroid use
(compression fracture)
– IV drug use (epidural abscess)
– Spinal hardware

49. Spinal Injury
• Assessment
– ABCs
– Immobilize neck and back
– GCS, motor/sensory/sphincter tone exam
• Imaging
– Plain c-spine films (lateral only detects >85%
of cervical spine injuries)
– CT/MRI for injuries with neuro deficits and
identifiable spine fractures.

50. • Identifiable spine
fractures require
Orthopedic OR
Neurosurgical
consultation

52. Subluxation and Dislocation

53. Subluxation and Dislocation
• Acute or chronic ligamentous laxity/tearing
can result in subluxation or dislocation of a
joint.
• Classic example: glenohumeral joint:
– Subluxation: 1 bone becomes partially
disarticulated from the other; articular surfaces
remain partially intact.
– Dislocation: bones completely disarticulated;
no parts of articular surfaces are in contact.

54. Dislocations
• Nomenclature is straightforward:
– Most occur @ a joint formed by 2 bones and
the dislocation is named after the affected joint.
– Direction of dislocation refers to the position of
the distal bone in relation to the proximal.

55. • Clinically:
– Pain, deformity, decreased ROM.
– Certain dislocations are associated w/
specific complications, which must be ruled
out in the routine evaluation of the
injury…e.g., the axillary nerve (12%) and
the musculocutaneous nerve (2%) are @
risk in anterior dislocations of the
glenohumeral joint.
– Smooth, timely reduction is mandatory.

57. Bilateral Hip Dislocations

58. More dislocations

60. QUESTIONS ?