Musculoskeletal Trauma

1. MusculoskeletalTrauma Silvia De La Guardia RN, BSN, CEN Tenet Health Systems Emergency Department

2. Learning Objectives • List three signs or symptoms of joint dislocations. • Identify how much blood can accumulate in the femur compartment. • Explain why prompt reduction of joint injuries is important. • Identify signs of a femur and pelvic fracture. • Identify injuries or complications associated with pelvic fractures. • Discuss emergent management of compartment syndrome.

3. Musculoskeletal Trauma • Musculoskeletal injuries often appear dramatic, rarely cause immediate threat to life or limb • Major injuries, especially to long bones, indicate significant forces applied to body • Imperative to recognize and control hemorrhage from musculoskeletal injures in primary survey • Suspect neurovascular injury with any injury to the bones of an extremity. • Splinting significantly decreases bleeding • Reducing motion • Tamponade effect

4. Mechanism of Injury • Motor Vehicle Crash • Patella injury • Fractured femur • Hip fracture/dislocation • Assault • Fall • Calcaneus fracture • Compressed vertebral bodies • Sports • Recreational and home activities

5. Assessment Inspection • Appearance of Extremity • Normal vs. abnormal • Difference between injured and non-injured • Integrity of injured area • Deformity - Burns • Contusions - Tenderness • Abrasions - Lacerations • Punctures - Swelling • Bleeding - Protrusion of bone

6. Assessment Palpation • Six P’s • Pulse • Pain • Pallor • Paresthesias • Paralysis • Pressure • Palpate for stability and crepitus Circulation Pulse Cap refill Temp/color Swelling Motor Paralysis Sensation Pain Paresthesia

7. Pathophysiologic Changes BLOOD LOSS • Large blood loss is due to damage to arteries or veins close to bones • Edema can cause compression of structures. • Physiological changes activated to minimize damage: • Clotting system activation to decrease bleeding • Cell membrane restoration to enhance fluid reabsorption • Increased collateral blood flow to promote healing

8. Pathophysiologic Changes • Bone/joint displacement can compress surrounding vessels and nerves • As arterial blood is obstructed, tissue oxygenation ceases. Ischemia/tissue death. • In this process: • Pain increases - Pale limb • Weak pulses - Skin cyanotic • Cool skin - Increased capillary refill

9. Pathophysiologic Changes NEUROLOGIC CHANGES • Nerves can be compressed or lacerated • Nerve injury results in • Diminished pain • Partial or complete loss of motor • Partial or complete loss of sensation

10. Pathophysiologic Changes FRACTURES • Open - Closed • Complete - Incomplete • Comminuted - Greenstick • Impacted - Displaced • Fissure - Spiral

11. TYPES OF INJURIES

12. TYPES OF INJURIES Blunt injures • Acceleration/deceleration mechanism • Falls, MVC, work/home injuries • Assaults, sport injuries • Include • Fractures, dislocations, • Strains: Injury to muscle or tendon • Sprains: Injury to ligament • Ligamentous tears Penetrating Injuries • Penetrating objects • Open fractures

13. Joint Injuries • Considered limb-threatening injuries • Joint dislocations • Normal range of motion is exceeded • Complicated by neurovascular compromise • Associated fractures • Avascular necrosis • Complication of joint injuries • Caused by delay reduction • Knee dislocations require immediate reduction to prevent complications • Peroneal nerve injury • Popliteal artery disruption

14. Joint Injuries Signs and Symptoms • Inability to move the affected area • Neurovascular compromise • Abnormal range of motion • Pain • Deformity of joint • Edema

15. Femur Fractures • Result from major trauma • Common mechanism of injury • Falls • MVC • penetrating wounds (GSW) • Femoral neck fractures common • Femur fractures may not be obvious • Result in significant blood loss

16. Femur Fractures Signs and Symptoms • Pain • Inability to bear weight • Shortened extremity • Internal or external rotation • Edema or deformity • Hypovolemic shock

17. Pelvic Fractures Classification • Stable: • Pelvic ring fracture in one place • Stable to palpation • Can withstand normal physiologic forces • Without abnormal deformation • Unstable • Pelvic ring fractured in more than one place • Bony instability with palpation

18. Pelvic Fractures • Can be classified by type of force • External rotation (anteroposterior) • Lateral compression • External rotation (abduction) • Shear • These can be life-threatening and often have large blood loss and genitourinary injuries. • Bleeding significant enough to cause hypovolemic shock

19. Pelvic Fractures • Injuries to pelvis can be: • Open: associated with injuries to perineum, rectum, genitourinary system. Have higher mortality rate. • Closed.

20. Pelvic Fractures Signs and Symptoms • Intra-abdominal or genitourinary injury • Look for blood in meatus • Higher mortality rate • Shortening and abnormal rotation of the affected leg • Pain to pelvic area, back, thighs • Hypovolemic shock

21. Interventions • Stabilize pelvic fractures • PASG • Wrap pelvis in sheet • External fixator • Assist with additional diagnostic studies • Radiographs • CT scan • Cystogram • Angiogram • Embolization

22. Open Fractures • Considered Limb-threatening injuries • Consider contaminated avoid retracting bone back into tissue • Higher risk of infection • Poor wound healing • Osteomyelitis • Sepsis

23. Open Fractures Signs and Symptoms • Skin disruption • Protrusion of bone • Pain • Bleeding can be minimal or severe • Neurovascular compromise • Do not move fracture: minimize more damage • Call orthopedic consult early • Realign to restore blood flow and nerve integrity • Operative debridement

24. Emergent Interventions • Obtain wound culture • Irrigate the wound with sterile saline • Cover open wounds with dry sterile dressing • Administer medications • Tetanus • Antibiotics • Inspect dressings frequently

25. Avascular Injury • Acutely avascular extremity must be recognized promptly and treated emergently • Assess temperature, color, capillary refill, pulses • Early operative revascularization is critical • Muscles and nerves do not tolerate lack or arterial blood flow for longer than 6 hours • Use of tourniquets is controversial • Indicated for ongoing hemorrhage uncontrolled by direct pressure • Use of tourniquets is a “Life over limb” decision • Risk of tourniquet increase with time

26. Amputation • Traumatic event for patient: • Physically and emotionally • Amputations may benefit from a tourniquet • Replantation • Injury of an isolated extremity • Clean sharp amputations • Fingers • Distal extremity, below the knee or elbow • Wrist, forearm • Pediatric patient

27. Amputation Signs and Symptoms • Obvious tissue loss • Pain • Evidence of hypovolemic shock • Bleeding (minimal to severe) • Complete: less bleedingthan partial because of retraction of arteries. • Avulsive type complete amputation can result in severe bleeding.

28. Emergent Interventions • Control active bleeding • Remove gross debris • Elevate and splint the stump • Place amputated part on ice bath: do not freeze • Wrap in saline soaked gauze • Place in plastic bag then • Place bag on ice or ice water mixture • Prepare patient for admission or transfer • Administer medications: pain meds, antibiotics.

29. Crush Injuries • Life-threatening and difficult to treat • Cellular destruction • Damage to vessels • Result from • prolonged entrapment • Crushing blow • Sequelae • Hemorrhage and fluid loss • Destruction of muscle • Infection • Compartment syndrome • Rhabdomyolysis

30. Crush Injuries Sign and Symptoms • Massively crushed pelvis or extremities • Soft tissue swelling • Pain • Hypovolemic shock • Compartment syndrome • Loss of neurovascular function distal to injury

31. Emergent Interventions • Administer intravenous fluids to increase urinary output and excrete myoglobin • Elevate the injured extremity • Cleanse open wounds • Reassess urinary output • Motor and sensory function • Prepare for surgical debridement

32. Compartment Syndrome • Pressure increases inside fascial compartment Decreased perfusion and cellular ischemia. • Nerves, vessels, muscles can be compressed. • Prolonged ischemia results in • Pain • Necrosis • Loss of function • Amputation • Degree of damage • Amount of pressure • Time

33. Compartment Syndrome • Internal sources: • Bleeding • Tissue edema • Crush injuries • External sources • Tight dressings • Cast, excessive traction • More frequently seen • Lower leg • Forearm

34. Compartment Syndrome Signs and Symptoms • Pulses • Loss of pulse uncommon • Late unreliable sign • Pain • Disproportionate to injury • With passive movement • Pallor: Poor color, cool temperature • Paresthesia: Numbness, tingling, • Paralysis: motor dysfunction, injury to nerves, weak. • Pressure: compartment will feel tense, swollen

35. Emergent Interventions • Remove dressings, cast and splints • Elevate limb to level of the heart • Assist with measurement of compartment pressures • Reassess neurovascular status • Surgical consultation: Fasciotomy (may prevent muscle/neurovascular damage and loss of limb)

36. Diagnostics • X-Rays • Different views (anterior, posterior, lateral) • Film should include joints above/below. • Angiography • Indicated to identify tears or compressions in arteries/veins of extremity.

37. Interventions • Control bleeding • Splint and immobilize affected extremity • Apply ice • Elevate extremity: compartment syndrome keep at level of heart • Administer medication: antibiotics, tetanus, pain • Prepare for definitive stabilization • Provide psychosocial support • Prepare for operation, admission, or transfer, discharge

38. Evaluation • Monitor breathing effectiveness and rate of respiration. • Tachypnea, rales, and wheezes may be indicators of fat embolus syndrome. • Reassess and document 5 P’s.

39. Learning Objectives • List three signs or symptoms of joint dislocations. • Identify how much blood can accumulate in the femur compartment. • Explain why prompt reduction of joint injuries is important. • Identify signs of a femur and pelvic fracture. • Identify injuries or complications associated with pelvic fractures. • Discuss emergent management of compartment syndrome.

40. References • ATLS, advanced trauma life support for doctors (8th ed.). (2008). Chicago, IL: American College of Surgeons. • Beers, M. H. (2006). The Merck manual of diagnosis and therapy (18th ed.). Whitehouse Station, N.J.: Merck Research Laboratories. • Coven, D. L., & Yang, E. H. (n.d.). Medscape.com. Retrieved September 1, 2010, from emedicine.medscape.com/article/1910735-overview • Howard, P. K., Steinmann, R. A., & Sheehy, S. B. (2010). Sheehy's emergency nursing: principles and practice. (6th ed.). St. Louis, Mo.: Mosby Elsevier. • Tintinalli, J. E., & Stapczynski, J. S. (2011). Tintinalli's emergency medicine: a comprehensive study guide (7th ed.). New York: McGraw-Hill. • TNCC: trauma nursing core course (5th ed.). (2000). Park Ridge, Ill.: Emergency Nurses Association.