MSK Trauma

Question 1

What is the best way to achieve hemorrhage control of an actively bleeding extremity injury?

Answer 1

Direct pressure!
-can also appropriately splint the fractures to significantly decrease bleeding - this reduces motion and enhances the tamponade effect of muscle and fascia

Question 2

How do you measure an ABI?

Answer 2

Ankle-Brachial Index:
-Ankle SBP of injured leg/Brachial SBP of uninjured arm = if ABI < 0.9, this is concerning for an ischemic/vascular injury, need to get imaging

Question 3

What is the stepwise approach to controlling arterial bleeding? (4)

Answer 3

1. Manual pressure to the wound
2. Apply a pressure dressing using a stack of gauze held in place by a circumferential elastic bandage to concentrate pressure over the injury
3. If bleeding persists, apply manual pressure to the artery proximal to the injury
4. If bleeding continues, apply a manual tourniquet or a pneumatic tourniquet directly to the skin. Tighten the tourniquet until the bleeding stops (a properly applied tourniquet MUST occlude arterial inflow since occluding only the venous system can increase hemorrhage and result in a swollen, cyanotic extremity

***Be sure to document the time the tourniquet was applied. In these cases immediate surgical consultation is essential and transfer ASAP to trauma center

Question 4

What is the maximum length of time a tourniquet can stay on for before you risk losing the limb?

Answer 4

Approximately 1 hour - if time to operative intervention is longer than 1 hour, a single attempt to deflate the tourniquet MAY be considered in an otherwise stable patient.
-the risks of tourniquet use increases with time so if a tourniquet must remain in place for a prolonged period to save a life, the choice of life over limb must be made

Question 5

True or false: Application of vascular clamps into bleeding, open wounds in the ED is not advised.

Answer 5

True!

-can consider this ONLY if a superficial vessel is clearly identified

Question 6

When would replantation of a limb be considered in cases of traumatic amputation?
-if replantation is possible, how should you transport the amputated limb?

Answer 6

Would only be considered for UPPER extremity injuries and the patient has to be stable with no other injuries (ie. has an isolated upper extremity injury)
-if this is possible, wash the amputated part in isotonic solution and wrap it in moist sterile gauze. Then place the part in a similarly moistened sterile towel, place in a plastic bag, and transport with the patient in an insulated cooling chest with crushed ice

Question 7

True or false: Bilateral femur fractures result in a significantly increased risk of complications and death (significant blood loss, severe associated injuries, pulmonary complications, multiple organ failure, etc).

Answer 7

True!

Question 8

What is the management for rhabdomyolysis secondary to crush injury?

Answer 8

1. Aggressive IV fluid therapy to protect the kidneys and prevent renal failure from ATN

Question 9

What is your management for open fractures?

Answer 9

1. Provide inline traction, gently pulling the exposed bone back into the wound by straightening the extremity (pull the limb out to length), and apply immobilization
2. Remove gross contamination and particulate matter from the wound and cover with a moist sterile dressing
3. Administer weight based dosing of antibiotics as early as possible (Ancef)
4. Surgical consultation ASAP
5. Give Tetanus booster

***Overall: do NOT forget Ancef and Tetanus

Question 10

In vascular injuries to an extremity, after what time frame does muscular necrosis begin if there is no arterial blood flow?
-what is your management if you suspect a fracture deformity that is impeding arterial flow to an extremity?

Answer 10

6 hours

Management:

1. Gently pull the limb out to length
2. Realign the fracture
3. Splint the injured extremity

-this maneuver often restores blood flow to an ischemic extremity when the artery is kinked by shortening and deformity at the fracture site

Question 11

What tests may be required for vascular injuries to extremities?

Answer 11

CT angiograms

Question 12

In a patient with an anaphylactic penicillin allergy, what antibiotic can you use for an open fracture instead of ancef?

Answer 12

Clindamycin

Question 13

What antibiotics should you use for open fractures of the following circumstances:

• severe soft tissue damage and substantial contamination with associated vascular injury?
• farmyard/soil or standing water

Answer 13

• severe soft tissue damage/substantial contamination with associated vascular injury: Ancef + Gentamicin
• farmyard/soil or standing water: Pip-Tazo for pseudomonas coverage

Question 14

What is compartment syndrome?

Answer 14

Develops when increased pressure within a musculofascial compartment causes ischemia and subsequent necrosis
-can occur wherever muscle is contained within a closed fascial space

Question 15

What type of injuries are at high risk for compartment syndrome?

Answer 15

1. Tibia and forearm fractures
2. Injuries immobilized in tight dressings or casts
3. Severe crush injury to muscle
4. Localized, prolonged external pressure to an extremity
5. Increased capillary permeability secondary to reperfusion of ischemic muscle resulting in edema
6. Burns
7. Excessive exercise

Question 16

What are the signs and symptoms of compartment syndrome?

Answer 16

1. Pain out of proportion to the stimulus/injury
2. Pain with passive strength of the affected muscle
3. Paresthesias or altered sensation distal to the affected compartment
4. Tense swelling of the affected compartment

***Can also consider pallor, paralysis and pulselessness but these are very late findings and are not reliable/necessary to diagnose compartment syndrome

Question 17

True or false: Compartment syndrome is a clinical diagnosis. Pressure measurements are only an adjunct to aid in its diagnosis.

Answer 17

TRUE :)

Question 18

What is the management for compartment syndrome?

Answer 18

1. Immediately release all constrictive dressings/casts/splits
2. Immediately obtain a surgical consultation

The only treatment for compartment syndrome is fasciotomy ASAP

Question 19

What wounds are at higher risk of tetanus?

Answer 19

1. Wounds > 6 hours old
2. Contused or abraded
3. More than 1 cm in depth
4. High-velocity missile wounds
5. Burns or hypothermic wound injury
6. Significantly contaminated, particularly wounds with denervated or ischemic tissue

Question 20

Should you use a traction splint for a patient with both a femur fracture and tibia/fibular fracture in the same extremity?

Answer 20

NO! If you do this, this can result in a neurovascular injury
-instead use a long-leg posterior splint with an additional sugar-tong splint for the lower leg

Question 21

What associated injury can you see with knee dislocation?

Answer 21

Popliteal artery and nerve injuries

Question 22

What associated injuries can you see with elbow fracture/dislocation?

Answer 22

Brachial artery injury, median/ulnar/radial nerve injury