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Approach to Musculoskeletal
Injuries
Department of Orthopaedic SurgeryDepartment of Orthopaedic SurgeryFatmawati General HospitalFatmawati General Hospital
LUTHFI GATAMORTHOPAEDIC PI!E CO!ULTA!T
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O"ER"IE#
$ i%ni&icant percenta%e o& all
e'er%enc( roo' care ren)ere)*
$ In FGH+ o,er - 'onth perio)+ sur,e(
sho.e) chie& co'plaint o&
'usculoskeletal pro/le' co'prise)appro0* 112 o& all patients 31 in 45*
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Musculoskeletal Injuries
$ ED ph(sician nee)s a coherent+s(ste'atic approach to orthopae)ic
co'plaints*$ e,erit( ran%es &ro' tri,ial sprains toli&e6 or li'/6threatenin% trau'a*
$ O&ten acute trau'a is the cause o& the
presentation*$ Pain an) )ecrease) ROM are the 'ain
s('pto's*
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#hat #e Co''onl( ee
$ Musculoskeletal )isor)ers co''onl(seen in the ED inclu)e78o&t Tissue Injuries 3strains an)
sprains5998Fractures 3open+ close)+ lon% /one+ pel,ic5
8Dislocations
8 In&ections 3so&t6tissue+ /ite .oun)s599
8E&&usions 998Deep ,enous thro'/osis
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Less Co''on :ut;
$ Musculoskeletal )isor)ers less co''onl(
seen in the ED+ /ut un'istaka/l( i'portant7
8pinal Injuries
8Crush Injuries
8Co'part'ent s(n)ro'e
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FRACTURE
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Fractures
$ A partial or co'plete /reak in a /one*
8:one is the tissue in the hu'an /o)( that heals
/( re%eneration .ithout scarrin%*
8For re%eneration to occur the /one 'ust /e
i''o/ili
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Fractures
$ !e. :one For'ation7$ A he'ato'a &or's /et.een reali%ne) F0 &ra%'ents*
$ He'atopoietic cells in the he'ato'a secrete %ro.th
&actors 3GF=s5*$ GF=s sti'ulate &or'ation o& %ranulation tissue at the
F0 en)s+ slo.l( resor/in% the he'ato'a*
$ A pri'ar( callus &or's+ pro%ressin% &ro' a so&t
callus to har) callus*$ Final phase o& healin%7 )urin% re'o)elin% the /one
reassu'es its ori%inal architecture*
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Fractures
$ !o'enclature o& &ractures is essential tosuccess&ul F0 'ana%e'ent in the ED
$ A)e>uate )escription7
8Open or close)?
8#hich /one in,ol,e)?
8Location .ithin the /one?
8Direction o& the 'ain &racture line?8!u'/er o& &ra%'ents?
8Ali%n'ent an) )isplace'ent o& the &ra%'ents?
8Co'plications?
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Close) Fracture
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Open El/o. Fracture
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Open Fractures
$ ORTHOPEDIC EMERGE!C@$ I''e)iate control o& he'orrha%e*
$ plintin% B6 re)uction*$ Copious irri%ation*
$ Earl( a)'inistration o& su&&icient anal%esia+appropriate anti/iotics+ an) tetanus
proph(la0is*
$ E'er%ent consultation .B orthopae)ics &or allT(pe II an) T(pe III open F0=s 3an) so'e T(peI=s5*
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Fractures6Open Classi&ication
I 1c' lon%+ 'ini'al conta'ination+ lo. ener%( &orceA:7 1stBn)Ceph &or )
II 1c' lon%+ 'o)erate conta'ination an) &orce A:71stBn)Ceph plus a'ino%l(c &or )
III Hi%h ener%(+ co''inute) &0+ e0tensi,e tissue )a'a%e+enou%h tissue to co,er .oun)+ e0tensi,e conta'ination+arterial injur(
A:7 1stBn)Ceph plus a'ino%l(c &or )
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PEL"IC FRACTURE
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Pel,ic Fractures
$ Least co''on &racture 325
$ Most are result o& auto6collisions
$ Co''onl( associate) .ith other injuries
$ Pel,is contains 'an( i'portant structures78Iliac ,essels+ uro%enital or%ans+ ner,e ple0i;**
$ Patients can sustain lar%e ,olu'e /loo) loss
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Clinical E,aluation$ An( patient assess'ent /e%ins .ith the A:C=s
3Air.a(+ :reathin%+ Circulation5
$ Co'plete neurolo%ic an) ,ascular e0a'
$ Ha,e hi%h suspicion o& intra6a/)o'inal injuries$ Ph(sical e0a'7
8Ecch('osis or contusion aroun) hips+ perineu'
8Pel,ic insta/ilit( .ith stressin%
8uspect i& si%ns o& urolo%icB%(n &in)in%s7 /loo) aturethral 'eatus+ hi%h6ri)in% prostate
8Hi%h &orce 'echanis's also associate) 3',c+ &e'ur&05
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Pel,ic Fracture6Mana%e'ent
$ 166Control o& /lee)in% ,essels
$ In he'o)(na'icall( unsta/le pts+ consi)er
an%io%raph(
$ 66ur%ical 'ana%e'ent o& the /roken
/one can procee) LATER a&ter li&e6
threatenin% con)itions are controlle)*
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LO!G :O!E FRACTURE
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Lon% :one Fractures
$ Fractures o& the &e'ur+ hu'erus+ ti/iaB&i/ula
$ :lunt an) penetratin% trau'a
$ Re>uires hi%h ener%( to /reak /one+there&ore look &or other injuries*
$ :one has a %enerous /loo) suppl(*$ Does patient ha,e associate) /lee)in%
)isor)er?
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Lon% :one Fractures
$ F0=s cause locali
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Lon% :one Fracture
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Mana%e'ent
$ A:C=s
$ !euro,ascular e0a' 3,ascular B6 ner,e injur(5
$ plint in,ol,e) e0tre'it(
8Re)uction )ecreases pain+ /lee)in%
$ Orthope)ic consultation &or )e&initi,e 'ana%e'ent
$ Co'plications7
8Fat6e'/oli s(n)ro'e8:loo) loss
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Fracture Co'plications
$ Vascular Injuries8Most co''onl( occur in open F0=s+ F06)islocations+ or
.i)el( )isplace) F0=s andat sites .here the ,essels lie in
close pro0i'it( to the /one or sites .here the ,esselsare hel) in a relati,el( &i0e) position*
$ Classic si%ns7 The P=s7 Pain, Pallor,Pulselessness (or diminished pulse), Paresthesia,
and Paralysis*8Location o& F0 an) MOI )ictate nee) to assess &or
potential ,ascular injur( in as('pto'atic patient*
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Fracture Co'plications
$ Nerve Injuries8Occur 'ore &re>uentl( than ,ascular injuries in
assoc* .B F0*8Can occur B /lunt trau'a+ alon% path o&
penetratin% trau'a+ or /e cause) /( the F0&ra%'ents the'sel,es*
8!er,es are increase) risk o& injur( .hen the(are super&icial to the skin+ lie close to the /one+ orspan a joint+ 'akin% the' suscepti/le to stretchinjur(*
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Fracture Co'plications
$ at !m"oli Syndrome (!S)8Most co''on &or' o& non6thro'/otic
e'/olis'*
8in%le or 'ultiple lon% /one &ractures in (oun%or pel,icBhip &ractures in el)erl( pre)ispose toFE*
8J2 o& patients .B pel,ic or lon% /one&ractures ha,e )etecta/le &at )roplets in their
/loo)*
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Fracture Co'plications
$ Fat E'/oli (n)ro'e 3FE58"ast 'ajorit( re'ain as('pto'atic
8Has characteristic clinical course71* Fracture sustaine)*
* Other than &racture6associate) pain+ patient isas('pto'atic &or 16- hours*
* u))en onset o& li&e6threatenin% s(n)ro'e characteri
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Fracture Co'plications
Deep "enous Thro'/osis
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Deep "enous Thro'/osis
$ Clot &or'in% in one o& the )eep ,eins o& ane0tre'it(7 Le%s Ar's*
$ I& clot propa%ates a/o,e the popliteal &ossa+su/stantial risk o& piece o& clot /reakin% &ree+e'/oli
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Fracture Co'plications
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Fracture Co'plications
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Fracture Co'plications
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CRUH I!UR@
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Crush Injuries
$ First )escriptions &ro' 'ilitar( recor)s+
/o'/in%s in En%lan) an) Europe )urin% .orl)
.ars$ !o. 'ore co''onl( seen in natural )isasters+
/uil)in% collapse+ acts o& terroris'+ a&ter
poisionin%+ a&ter )ru% o,er)oses
$ Injur( results &ro' prolon%e) continuous
pressure on a /o)( part+ t(picall( an e0tre'it(
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Crush Injuries
$ Un)er )irect pressure+ cellular ische'ia incurre)causin% loss cellular inte%rit(
$ Cells leak Q an) '(o%lo/in$ In&lu0 o& ions into the cells causin% irre,ersi/le
cell )eath
$ Can ha,e lar%e &lui) ,olu'e shi&ts
$ Electrol(te a/nor'alities78 H(perkale'ia+ h(perphosphate'ia+ '(o%lo/ine'ia+
h(pocalce'ia+ 'eta/olic aci)osis
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Crush Injuries
$ M(o%lo/in concentrates in
the renal tu/ules
o/structi,e nephropath(
acute renal &ailure
$ #hen ARF occurs+
'ortalit( J6KJ2
$ Arr(th'ias
$ Concern &or sepsis .ith
)e,itali
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Crush Injuries6Treat'ent
$ Earl( consi)eration Breco%nition
$ Flui) resuscitation
8ARF approaches 1JJ2 i& h()ration)ela(e) 1 hours
$ Alkalini
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COMPARTME!T@!DROME
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Co'part'ent (n)ro'e
$ Occurs .hen pressure .Bi so&t tissues in a&i0e) /o)( co'part'ent increases to le,elthat e0cee)s venouspressure+co'pro'isin% ,enous /loo) &lo.+ an)li'itin% capillar( per&usion*
$ Lea)s to 'uscle ische'ia an) necrosis*
$ #$%! O$#&OP!DI' !!$!N'*
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Co'part'ent (n)ro'e
$ Contri/utin% Factors
$ E0ternal7
8Con)itions that re)uce) si
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Han) an) Foot
Co'part'ents
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C6Reco%nition
$ uspect .ith lon% /one &0+ crush injuries
$ Presents as pain out o& proportion to
ph(sical &in)in%s+ B6 h(poesthesia+
pulselessness 3late5*
M i t t t l
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Measure intra6co'part'ental pressure
.hen consi)erin% co'part'ent
s(n)ro'e
Pressures +-mm&g considered dangerous
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Co'part'ent (n)ro'e
Co'part'ent s(n)ro'e
shoul) /e suspecte) in
lon% /one F0=s an) F0=s
associate) .B si%ni&icant
,ascular injuries or
pronounce) s.ellin%*
Intra6co'part'ent pressures
'ust /e 'easure) once the
issue o& co'part'ent
s(n)ro'e is raise)*
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PI!AL I!UR@
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pinal Injuries
$ De,astatin% injuries
$ J2 occur in (oun% 'ales
$ Motor ,ehicle acci)ents+ &alls &ro' hei%ht+%unshot .oun)
$ #orriso'e presentations78pain o,er spine in settin% o& trau'a
8 loss o& 'otor &unction8 incontinence
8priapis'
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pinal Injuries
$ A))itional risk &actors &or spinal PAI!7
8Metastatic cancer
8Osteoporosis+ rheu'atic )
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pinal Injur(
$ Assess'ent
8A:Cs
8I''o/ili
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Classi&ication o& !eurolo%ic Injur(
$ Frankel core
$ A Co'plete loss o& 'otor an)
sensor( &unction
$ : Onl( sensor( &unction re'ains
$ C Motor &unction is present /ut o&no practical use 3i*e*+ can 'o,e le%s
/ut not .alk5
$ D Motor &unction i'paire)
3i*e*can .alk /ut not .ith nor'al
%ait5
$ E !o neuro i'pair'ent note)
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$ I)enti&ia/le spine
&ractures re>uireOrthope)ic OROrthopae)ic spineconsultation
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Case Study: T12 burst fracture; treated with T12corpectomy and autograft; posterior fusion and
instrumentation
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u/lu0ation an) Dislocation
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u/lu0ation an) Dislocation
$ Acute or chronic li%a'entous la0it(Btearin%
can result in su/lu0ation or )islocation o& a
joint*
$ Classic e0a'ple7 %lenohu'eral joint7
8u/lu0ation7 1 /one /eco'es partiall(
)isarticulate) &ro' the otherN articular sur&aces
re'ain partiall( intact*
8Dislocation7 /ones co'pletel( )isarticulate)N
no parts o& articular sur&aces are in contact*
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Dislocations
$ !o'enclature is strai%ht&or.ar)7
8Most occur a joint &or'e) /( /ones an)
the )islocation is na'e) a&ter the a&&ecte) joint*
8Direction o& )islocation re&ers to the position o&
the )istal /one in relation to the pro0i'al*
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$ Clinicall(7
8Pain+ )e&or'it(+ )ecrease) ROM*
8Certain )islocations are associate) .B speci&ic
co'plications+ .hich 'ust /e rule) out in theroutine e,aluation o& the injur(;e*%*+ the a0illar(
ner,e 3125 an) the 'usculocutaneous ner,e
325 are risk in anterior )islocations o& the
%lenohu'eral joint*
8'ooth+ ti'el( re)uction is 'an)ator(*
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:ilateral Hip Dislocations
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More )islocations
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