dr. Ahmad Fauzi, Sp.

OT
Dept. Bedah Div. Orthopaedi dan Traumatologi
FK UNILA
2015
Musculoskeletal System
The system of muscles, tendons, ligaments, bones,
joints, nerves, vessels and associated tissues that
provides form, support, stability, and movement to the
body
Musculoskeletal Trauma

Musculoskeletal injuries
High morbidity
Low mortality

Related with Multiple injuries

High morbidity
High mortality
Musculoskeletal trauma

Traffic, factory, domestic, school and

sport
Fractures
Bones, cartilages, epiphyseal plate
Dislocations
joints
Ruptures
Tendon, ligaments, nerve, vessels
Emergency

Emergencies in Musculoskeletal Trauma :

1. Open fracture
2. Fractures with neuro-vascular disturbances
3. Joint dislocations
Extremity injuries

First aids
Life before limb
Life saving ~ ATLS
Limb saving
Realignment
Splint
Neurovaskular !
LIFE SAVING MEASURES

A Airway and cervical spine immobilisation

B Breathing and ventilation
C Circulation (treatment and diagnosis of cause) : w/
hemorrhage control
D Disability (head injury) : neurological status
E Exposure (musculo-skeletal injury) : 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, protect the cervical :

inline imobilisation, collar brace (head injury, cervical injury)
B Breathing w/ Oxygen mask
C Circulation w/hemorrhage control (pelvic stabilisation)
D Disability, neurological status(GCS), paraparese or paralysis
spine fractures suspected inline immobilization
E Exposure : deformity of extremity immobilization/splinting
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)
 Diagnosis of Fractures

History
Fall, twisting injury, direct blow, MVA
Localized pain, aggravated by movement
Crepitus
Physical Examination
General condition associated injuries
Look : deformity, swelling, abN movement
Feel : localized tenderness, muscle spasm,
NVD
Move : ROM
Diagnostic Imaging
Exact nature & extent of fracture
X-ray : min AP & lat (ocassional : oblique)
CT / MRI : spine, pelvis

Salter RB. Textbook of Disorders and Injury of Musculoskeletal System

Diagnosis

History :
Biomechanics ~ Forces
Time of injury
Possibilities or serious injuries
Decrease / lost of functions
Previous management, transportation
Physical examination

General condition :
Vital signs
ABCs

Local condition :
Look
Feel
Move
 Local Condition
Look :
Deformities : angulations, discrepancy, rotation
Bone exposed
Swelling

Feel :
Pain, crepitation, edema

Move :
Functio laesa
NEURO VASCULAR !!
Neuro-vascular
disturbance
Supporting examinations

Laboratory
Imaging
 SPLINT
Straight, strong, flat + padding
Stable
Safe
Immobilization
2 joints
3 dimension
Alignment / anatomic position
Neuro-vascular conditions
Splints
Immobilization
Splinting

Immobilize 2 joints / 2 bones

Neuro-vascular functions

Advantages :
Decreasing pain
Prevent further damages
Decrease or stop the bleeding
Easy transportation
Extrication, stabilization & Transportation
Treatment
1. First do No harm
2. Base treatment on an Accurate Diagnosis and
Prognosis
3. Select Treatment with Specific Aims
4. Cooperate with the Law of Nature
5. Make Treatment Realistic and Practical
6. Select treatment for your patient as an individual
 SPRAIN

A Sprain is an injury to a joint and its ligaments

Sprain RICE
RICE
STRAIN
An injury to a muscle in which the muscle fibers tear as a
result of over stretching
Muscle Strain Symptoms

Swelling, bruising or redness, or open cuts as a consequence

of the injury
Pain at rest
Pain when the specific muscle or the joint in relation to that
muscle is used
Weakness of the muscle or tendons
Inability to use the muscle at all
PRICE

Protection, Rest, Ice, Compression, and Elevation

 Joint Dislocation

Joint contact
Complete / incomplete
Risk of avascular necrosis of the joint cartilage and
bones
Dislocation

Diagnosis / dd :
Dislocation
Fracture
Fracture dislocation
Pain and limitation of movement
Fresh vs neglected dislocations
 Joint Dislocation

Treatment
Reposition ~ instability
Immobilization ~ stable position
Rehabilitation ~ stability, tissue healing

Button hole dislocation

Closed reduction vs open reduction
Dislocation
Fractures

Trauma that produce discontinuity of bone, cartilage or

epiphyseal plate
Related to the SOFT TISSUE INJURIES
SIMPLE MUSKULOSKLETAL TRAUMA
Treatment of Fracture
4R:
Recognition diagnosis, soc ec, religion, etc
Reposition displaced /deformity to anatomic /
acceptable position
Retaining fixation of fragments : external, internal
Rehabilitation early joint ROM, muscle action,
edema, psychological consideration , previous activity
 Closed Fractures Management

Intact skin
Closed reduction + immobilization (cast, traction)
Surgery :
If closed treatment was failed (reduction and
stability)
 Open Fractures

Open wound, relations between bone fragments and

the environment
Infection risk

Gustillo ;
Type I
Type II
Type III A,B and C
OPEN FRACTURES
Type I open fracture
Type II open fracture
Type III A open fracture
Type III B open fracture
Type III C open fracture
 Open Fracture Management

Emergency
Other life threatening injuries
Multiple injuries ?
Antibiotics
Debridement
Fracture fragment Stabilization
Wound coverage
Bone grafting
Rehabilitation
Rehabilitation
LATE COMPLICATION OF FRACTURES

INFECTION IN OPEN FRACTURE

Type I less than 1%

Type II 1-10 %
Type III 10-50%
 Fractures with vascular injuries
Fractures with a high risk of
haemorrhagic shock :
Fracture of pelvis
fracture of femur
Both are an emergency conditions
that needs an immediate
management.
Blood vessels may injured by the bone
fragments, so it always needs a good
examination of the circulation at distal
part of the limb.
Deformity and impairment
Compartment Syndrome

A condition of increasing the closed muscle

compartmental pressure that produce a disturbances
of neuro-vascular function of the extremity
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
No perfusion = Cell Death
Muscle
3-4 hours - reversible
6 hours - variable
8 hours - irreversible

Nerve
2 hours - lose nerve conduction
4 hours - neuropraxia
8 hours - irreversible
 Compartment Syndrome
Clinical Signs :
Classical signs : 5 P (pain,
paresthesia, pallor, paralysis,
pulselessnes).
Bulae
Significant sign : strecth pain and
paresthesia, decompresion
fasciotomy
Measurement of the intra
compartment pressure
fasciotomy
 Progressive elevation of interstitial pressure in a closed
space resulting in impaired perfusion :
Causing functional compromise
Will result in cell death
Consequences when missed
Ischemic contractures
Amputation
Death

Volkmanns Contracture
Management
Remove extrinsic compression
Elevate to at least level of heart
Compartment pressure measurement?
Fasciotomy
INDICATION OF CONSULTATION

ALL FRACTURES & DISLOCATION ARE PATOLOGIC CONDITIONS

IMMOBILISATION/SPLINT FIRST

STRICTLY NO DELAY OF TRANSFERING PATIENTS W/ FRACT +

NEUROVASCULAR INJURY, OPEN FRACTURES, DISLOCATION

DO NOT DO HARM
SUMMARY

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
 Thank you
to cure sometimes, to relieve often, to comfort
always.
- Edward Livingston Trudeau -