DIAGNOSIS OF MUSKULOSKLETAL TRAUMA

Dwikora Novembri Utomo

Lab/SMF Orthopaedi & Traumatologi FK Unair-RS dr SutomoS U R A B A Y A

TIU

• PADA AKHIR MODUL PPGD INI,MAHASISWA FK SEMESTER 5 AKAN MAMPU MERENCANAKAN AWAL SECARA MANUAL MAUPUN MENGGUNAKAN ALAT, OBAT PADA KEGAWATDARURATAN TRAUMA MUSKULOSKLETAL SECARA TEPAT,CERMAT ,CEPAT, SEBELUM TINDAKAN DEFINITIF /SPESIALISTIK DILAKSANAKAN.

TIK

• MAMPU MELAKSANAKAN TATACARA PENANGANAN TRAUMA MUSKULOSKLETAL DENGAN CEPAT,CERMAT DAN CEPAT

POKOK BAHASAN

1. DIAGNOSA TRAUMA MUSKULOSKLETAL2. JENIS TRAUMA MUSKULOSKLETAL a. TRAUMA MSK SEDERHANA b. TRAUMA MSK MENGANCAM JIWA c. TRAUMA MSK YG MENGANCAM EKSTREMITAS3. PERTOLONGAN BEDAH AWAL PADA TRAUMA

MSK4. HAL HAL YANG MEMPERBURUK PROGNOSIS5. INDIKASI KONSULTASI

WHAT IS THE DIFFERENCE ?????

Biomechanics of Fractures

E ( Energy Kinetic ) = ½ MV

Vm VM

mM

2

Pelvis

• SOFT TISSUE INJURY : skin, subcutan fat,muscle, artery,venous, nerves etc

• BONE INJURY : broken bones

DefinitionEmergency :

A situation that involves a potential disabling or life threatening condition.

Trauma :A physical wound or injury to living tissue caused by an

extrinsic agent

Fracture : discontinuity of cortex or cartilage

Dislocation : discontinuity of joint

luxation – subluxation

Multitrauma : emergency, life threatening more than one organ requiring immediate treatment intervention

PRIMARY SURVEYThe ABCDEs of muskuloskletal

trauma care identify life threatening condition.

A. Airway maintenance w/ cervical spine protection

B. Breathing and ventilationC. Circulation w/ hemorrhage

controlD. Disability : neurological

statusE. Exposure : completely

undress but prevent hypothermia

life threatening conditions are identified and simultaneous management is instituted

SECONDARY SURVEY

• Done after the patient “stable”

• Head to toe !

• Every orificiums/ every tubes!!

Early Intervention on trauma/multitrauma patient (included MSK trauma problems)

• A Airway and cervical spine protection, protec the cervical : inline imobilisation,collar brace ( head injury,

• C Circulation w/ hemorrhage control (pelvic stabilisation

• D Disability, neurological status(GCS), paraparese or paralysis…..spine fractures suspected…..inline imobilisation!!!

• Exposure : deformity of extremity….imobilisation/splinting!!!

Early Intervention on trauma/multitrauma patient (included MSK trauma problems)

Early Intervention on trauma/multitrauma patient (included MSK trauma problems)

The first step toward cure is to know what the disease is (latin proverb)

Solving the mysteri of a diagnosis is the “detective work of medicine” (Sherlock

Holmes)

How to diagnose the muskuloskletal trauma problems?

• CLINICAL HYSTORY(not for the multitrauma patients)

• PHYSICAL EXAM : LOOK, FEEL, MOVE,MEASUREMENT

• DIAGNOSTIC IMAGING

MUSKULOSKLETAL TRAUMA PROBLEMS

• FRACTURES : Closed, Open

• DISLOCATIONS,FRACTURE-DISLOCATION

• SOFT TISSUE INJURIES :tendon rupture,muscle rupture w/ or w/o neurovascular lesion.

FRACTURES

Close fracture •Open fracture•Compound fracture

FRACTURES

• FRACTURES IS NOT ONLY LESION OF THE BONE

• DOCTORS MUST THINGS : BEYOND THE PICTURES!!!

• THE BONE : LOOKLIKE THE TREE WITH THE ROOT IS THE SOFT TISSUE !!

FRACTURES

FRACTURES

DIAGNOSIS

• CLINICAL HISTORY (Not for multitrauma pts)

*WHEN (time) : golden periode

*HOW ..MOI (Mechanism of injury : Low velocity/High velocity trauma/trivial) !!!

LOOK

• Deformity – Angulation -

Rotation

- DIscrepancy

– Position– Edema– Appearance of the

distal part• Pale• Darken

LOOK

• FEEL

–Crepitation

–Temperature of the distal part

–Pulse

–Sensory

FEEL (neurovasc exam)

MOVE

–Active–Passive–Power–False

movement

MEASUREMENT

• MEASUREMENT- discrepancy– True

length,Anatomical length

– Appearance length

CLINICAL DIAGNOSIS

• “Patognomonis sign/definite sign” of fracture: deformity,false movement,

• From Clinical History,Physical Exam ,the clinical diagnosis of fracture is established,

• Investigation ( X RAY)…important for : “fracture configuration & planning of

definitive treatment” , prognosis.

INVESTIGATION

• X-ray (Immobilization first)– 2 VIEWS (AP-lateral)– 2 JOINTS (proximal & distal)– 2 SIDES (IF Necessary)– Special order

INVESTIGATION (X –RAY)

• Open fracture communication between the fracture and the external environment

• 30% pts with OF are polytrauma patients.

• Require emergency treatment

• Significant morbidity

OPEN FRACTURES

OPEN FRACTURES

Grade I open fracture

Grade II open fracture

Grade III A open fracture

GRADE IIIb open fract

Grade III C open fracture

AO Principles of Fracture Management, 2000, pp 671

Gustilo, Burgess, Tscherne, the AO-ASIF group, recommended the following steps for open injuries: – Treat OF as emergencies – Initial evaluation to diagnose life & limb-threatening

injuries – Appropriate antibiotic tx in the emergency OR and

continue treatment for 2 to 3 days only – Immediately debride the wound of contaminated and

devitalized tissue, copiously irrigate, repeat debridement within 24 to 72 hours

– Stabilize the fracture with the method determined at initial evaluation

– Leave the wound open – Rehabilitate the involved extremity aggressively

Principles of Management

• Prevention of infection• Soft tissue healing and bone

union• Restoration of anatomy• Functional recovery

AO Principles of Fracture Management, 2000,

• Prevention of infection• Soft tissue healing and bone union• Restoration of anatomy• Functional recovery

• Golden 6 hours - Bacterial colonization and subsequent wound infection

• Once the skin barrier is disrupted, bacteria enter from the local environment and attempt to attach and grow

• Assess contamination - appropriate antibiotics• Radical Debridement - dead tissue is culture

media( can’t be replaced /prolonged GP by anykind of AB)

• Copious lavage > 10 litres - decrease bacterial load

ORTHOPAEDIC INFECTION:Diagnosis and treatment,1989 pp8

Debridement

• Radical• Wound extended

adequately for visual• Decompress tight

compartments• Copious lavage

• Avoid further soft tissue damage reduce and splint fractures

• Zones of Injury - Repeated Debridement

• Gentle handling• Bony stability• Early coverage < 1 week• Delay closure

• Prevention of infection• Soft tissue healing and bone union• Restoration of anatomy• Functional recovery

• Prevention of infection• Soft tissue healing and bone union• Restoration of anatomy• Functional recovery

• Prevention of infection• Soft tissue healing and bone union• Restoration of anatomy• Functional recovery

FRACTURES OF THE SPINEFRACTURES OF THE SPINE

Cervical Dislocation Thorax Dislocation

Lumbar Fracture

How to decide the level of injury? (based on clinical exam)

SENSORY

MOTOR

REFLEX (PHYSIOLOGIC)

REFLEX (PATOLOGIC)

DISLOCATIONS

• All joint s are surrounded by a joint capsule and ligaments, a dislocation to occur, at least a part of capsule and its ligaments must be torn

DISLOCATION

COMPLICATION OF MUSKULOSKLETAL TRAUMA

1.DAMAGED OF NERVE OR SPINAL CORD

2. DAMAGED OF THE VASCULAR

COMPLICATION OF MUSKULOSKLETAL TRAUMA

COMPARTEMENT SYNDROME

• Compression of nerve & bloodvessels

• Within enclosed anatomic space (osteofacial)

• Leading to impaired bloodflow

Pathophysiology

2 main pathways*

– Increasing fluid content within the

compartment (ex : haemorrhage,

oedema)

– Decreasing the compartment size

(ex : external compression)

* Whitesides, Acute compartment syndr, J Am Acad Orthop Surg 1996;4

How to Diagnosed ?

• Mainly by clinical examination!!!

Sign & Symptoms

Classic signs 5 P

– Pain

Severe extremity pain out of proportion to

injury

Early sign, worse with passively stretching

involved muscle

– Paresthesia or anesthesia to light touch

– Paralysis

– Pulselessness

Not present in early cases

• Pallor

LATE COMPLICATION OF FRACTURES

INFECTION IN OPEN FRACT

• Grade I less than 1%

• Grade II 1-10 %

• Grade III 10-50%

SIMPLE MUSKULOSKLETAL TRAUMA

LIFE THREATENING MUSKULOSKLETAL TRAUMA

LIMB THREATENING MUSKULOSKLETAL TRAUMA

FACTORS THAT MAKE THE PROGNOSIS BECOME WORSE

• Bad pre hospital management

* no imobilisation/splint

* improper transfer of patients (ex : to transfer spine fract w/o inline imobilisation)

*delayed transfer (over golden periode,under diagnosis of vascular injury)

Pre Hospital

– Control :

Airway

Circulation

Immobilization

Transportation

INDICATION OF CONSULTATION

• ALL FRACTURES & DISLOCATION ARE PATOLOGIC CONDITION.

• IMOBILISATION /SPLINT FIRST

• STRICTLY NO DELAY OF TRANSFERING PATIENTS W/ FRACT + NEUROVASCULAR INJURY, OPEN FRACTURES , DISLOCATION.

• DO NOT DO HARM

SUMMARY

• 30% of OF ARE POLYTRAUMA PATIENTS.• FRACTURES IS NOT ONLY LESION ON THE

BONE.• EARLY INTERVENTION OF MSK TRAUMA

SHOULD BE DONE PROPERLY, FOR BETTER PROGNOSIS.

• TO KNOW THE BASIC KNOWLEDGE FOR MAKING DIAGNOSIS OF MSK TRAUMA IS MANDATORY BEFORE TREATING PATIENTS.

• DO NOT DO HARM

REFERENCE