ATCN 2022 Chapter 8 Musculoskeletal Trauma

A patient with long bone fractures above and below the diaphragm is at increased risk
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A patient with long bone fractures above and below the diaphragm is at increased risk
for associated internal torso injuries.
Severe crush injuries cause the release of __________________________ from the muscle, which can precipitate in the renal tubules and result in renal failure.
____________________________, an uncommon but highly lethal complication of long-bone fractures, can lead to pulmonary failure and impaired cerebral function
Severe crush injuries cause the release of myoglobin from the muscle, which can precipitate in the renal tubules and result in renal failure.
Fat embolism, an uncommon but highly lethal complication of long-bone fractures, can lead to pulmonary failure and impaired cerebral function
Appropriate __________________________ fractures can significantly decrease bleeding by reducing motion and enhancing the tamponade effect of the muscle and fascia.
Appropriate splinting of fractures can significantly decrease bleeding by reducing motion and enhancing the tamponade effect of the muscle and fascia.
Assess injured extremities for _________________________________________________________________________________________________
Assess injured extremities for external bleeding, loss of previously palpable pulse, and changes in pulse quality, Doppler tone, and ankle/brachial index.
The ankle/brachial Index is determined by taking
the systolic blood pressure value at the ankle of the injured leg and dividing it by the systolic blood pressure of the uninsured arm.
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
Application of ______________________________________ into bleeding open wounds while the patient is in the ED is not advised, unless a superficial vessel is clearly identified.
Application of vascular clamps into bleeding open wounds while the patient is in the ED is not advised, unless a superficial vessel is clearly identified.
Joint dislocations should be
Joint dislocations should be reduced, if possible; if the joint cannot be reduced, emergency orthopedic intervention may be required.
Patients with bilateral femur fractures are at higher risk for
significant blood loss, severe associated injuries, pulmonary complications, multiple organ failure, and death.
Crush syndrome, or traumatic rhabdomyolysis, refers to the clinical effects of
injured muscle that, if left untreated, can lead to acute renal failure and shock.
The muscle insult is a combination ofdirect muscle injury, muscle ischemia, and cell death with release of myoglobin.Amber-colored urine in the presence of __________________________________________________ or more is indicative of rhabdomyolysis when urine myoglobin levels are not available. Rhabdomyolysis can lead to metabolic acidosis, hyperkalemia, hypocalcemia, and DICAmber-colored urine in the presence of serum creatine kinase of 10,000 U/L or more is indicative of rhabdomyolysis when urine myoglobin levels are not available. Rhabdomyolysis can lead to metabolic acidosis, hyperkalemia, hypocalcemia, and DICMyoglobin -induced renal failure can be prevented with?Myoglobin -induced renal failure can be prevented with intravascular fluid expansion, alkalinization of the urine by intravenous administration of bicarbonate, and osmotic diuresis.Proper application of a splint helps ___________________________, _________________________, and prevents further neurovascular compromise and soft-tissue injury. If an open fracture is present, pull the exposed bone back into the wound, because open fractures require surgical debridement.Proper application of a splint helps control blood loss, reduces pain, and prevents further neurovascular compromise and soft-tissue injury. If an open fracture is present, pull the exposed bone back into the wound, because open fractures require surgical debridement.Key aspects of the patient history aremechanism of injury, environment, preinjury status and predisposing factors, and prehospital observations and care.Primary Blast injuryfrom the force of the blast wave.Secondary Blast Injurymay occur from debris and other objects accelerated by the blast, leading o penetrating wounds, lacerations, and contusions.Tertiary Blast Injurypatient may be violently thrown to the ground or against other objects by the blast effect, leading to blunt musculoskeletal and other injuries.An AMPLE history should be obtained, including information about the patients?exercise tolerance and activity level, emotional problems or illnesses, and previous musculoskeletal injuries.Three goals for assessing the extremities are:1. Identify Life-threatening injuries (primary survey) 2. Identify limb-threatening injuries (secondary survey) 3. Conduct a systemic review to avoid missing and other musculoskeletal injury (continuous reevaluation)Extremity assessment must include the following four components to avoid missing an injury:Skin, which protects the patient from excessive fluid loss and infection Neuromuscular function Circulatory status Skeletal and Ligamentous integrity.Any open wound to a limb with an associated fracture is considered to bean open fracture until proven otherwise by a surgeon.The ability to move all major joints through a full range of motion usually indicatesindicates that the nerve -muscle unit is intact and the joint is stable.Joint stability can be determinedonly by clinical examination.Loss of sensation in stocking or glove distribution is an early signof vascular impairment.Knee dislocations can reduce spontaneously and may present not present with any gross external o radiographic anomalies until aphysical exam of the joint is performed and instability is detected clinicallyAn ankle/brachial index of less than ________________________ indicates abnormal arterial flow secondary to injury or peripheral vascular disease.An ankle/brachial index of less than 0.9 indicates abnormal arterial flow secondary to injury or peripheral vascular disease.The only reason to forgo X-ray examination before treating a dislocation or a fracture isthe presence of vascular compromise or impending skin breakdown. This is commonly seen with fracture -dislocations of the ankle.If a delay in obtaining x-rays is unavoidableimmediately reduce or realign the extremity to reestablish the arterial blood supply and reduce the pressure on the skin.Extremity injuries that are considered potentially limb-threatening includeopen fractures and joint injuries, ischemic vascular injuries, compartment syndrome, and neurological injury secondary to fracture or dislocation.Treat all patients with open fractures as soon as possible withintravenous antibiotics using weight based dosing. First generation cephalosporins are necessary for all patients with open fractures. Delay of antibiotic administration beyond three hours is related to an increase risk of infection.Non-occlusive vascular injury, such as an intimal tear, can causeCoolness and prolonged capillary refill. In the distal part of the extremity, ass well as diminished peripheral pulses and an abnormal ankle/brachial index.Muscle necrosis begins when there is a lack of arterial blood flow for more than6 hours. Nerves may be even more sensitive to an anoxic environment.Compartment syndrome can occur wherever muscle is contained with a closed facial space.. Remember, the skin acts as a restricting layer in certain circumstances.Common areas for compartment syndrome include thethe lower leg, forearm, foot, hand, gluteal region, and thigh.Certain injuries or activities are considered high risk for developing compartment syndrome:Tibia and forearm fractures Injuries immobilized in tight dressings or casts. Severe crush injury to muscle Localized, prolonged external pressure to an extremity Increased capillary permeability secondary to reperfusion of ischemic muscle. Burns Excessive exercise.The absence of a palpable distal pulse is an uncommon oror late finding and is not necessary to diagnose compartment syndrome.______________________________________ are also unreliable for diagnosing compartment syndrome. Weakness or paralysis of the involved muscles in the affected limb is a late sign and indicates nerve or muscle damage. Clinical diagnosis is based on the history of injury and physical signs, coupled with a high index of suspicion.Capillary refill times are also unreliable for diagnosing compartment syndrome. Weakness or paralysis of the involved muscles in the affected limb is a late sign and indicates nerve or muscle damage. Clinical diagnosis is based on the history of injury and physical signs, coupled with a high index of suspicion.Tissue pressures of greater than30 mm hg suggest decreased capillary blood flow, which can result in muscle and nerve damage from anoxia.Compartment syndrome is a clinical diagnosisPressure measurements are only an adjunct to aid in its diagnosis.Signs and symptoms of compartment syndrome:Pain greater than expected and out of proportion to the stimulus or injury Pain on passive stretch of the affected muscle Tense swelling of the affected compartment Paresthesias or altered sensation distal to the affected compartmentSoft-tissue avulsion can shear the skin from the deep fascia, allowing forfor the significant accumulation of blood in the resulting cavity. (Morel-Lavallee lesion)The risk of tetanus is increased with wounds that are more than6 hours old, contused or abraded, more than 1 cm in depth, from high-velocity missiles, due to burns or cold, and significantly contaminated, particularly wounds with denervated or ischemic tissue.Fractures are defined asa break in the continuity of the bone cortex.To exclude occult dislocation and concomitant injury, x-ray films must include thejoints above and below the suspected fracture site.Do not immobilize the knee in complete extension, but with approximately ________________ degrees of flexion to reduce tension on the neurovascular structures.Do not immobilize the knee in complete extension, but with approximately 10 degrees of flexion to reduce tension on the neurovascular structures.Common missed or associated injuries: Posterior Knee DislocationFemoral fracture Posterior hip dislocationCommon missed or associated injuries: Knee Dislocation Displaced Tibial PlateauPopliteal artery and nerve injuries____________________________________ are particularly common in patients with a depressed level of consciousness, and the team leader should ensure timely reevaluation of the limbs to minimize missed injuries.Occult injuries are particularly common in patients with a depressed level of consciousness, and the team leader should ensure timely reevaluation of the limbs to minimize missed injuries.