ATLS Module 8 - Musculoskeletal Trauma
22 yo female presents after jumping from 3rd story in suicide attempt. She is
hemodynamically normal, but has a GCS score of 13. Both ankles are swollen. Her pulses
are intact. Initial chest and pelvic films are normal. Ankle films reveal bilateral calcaneal
fractures. What additional work up is important to undertake in this patient? -
ANS-radiographic work-up of spine to rule out occult injury
\25 yo male presents after motorcycle crash. vitals: BP 128/70, HR 124, GCS 15. He
complains of right leg pain. On exam, the patient is found to have a significant proximal right
thigh deformity. His distal pulses are intact. What is the best initial management of this
patient's symptoms? - ANS-splint the extremity and administer a small dose of IV narcotic
such as fentanyl
\a properly applied tourniquet must include arterial inflow... What happens if you only occlude
venous systems? - ANS-increase hemorrhage and result in a swollen cyanotic extremity
\compartment syndrome can occur when there is an increase in the compartment content
(bleeding/swelling) or decrease in compartment size (constrictive dressing)... it can occur
wherever muscle is contained within a closed fascial space... what do you have to remember
about the skin? - ANS-skin can act as a restricting layer in certain circumstances
red text
\do all patients with open fractures get IV antibiotics? - ANS-yes.
\for the circulatory evaluation, palpate the distal pulses in each extremity and assess
capillary refill of the digits... what do you do if hypotension limits digital exam of pulse? -
ANS-use doppler probe to detect blood flow
\how are femoral fractures temporarily immobilized? - ANS-traction splints... force is applied
distally at the ankle. Proximally the post is pushed into the gluteal crease to apply pressure
to buttocks, perineum, and groin
\how do you manage a fracture deformity? - ANS-gently pull limb out to length, realigning the
fracture, and splinting into the injured extremity
*this often restores blood flow to an ischemic extremity when the artery is kinked by
shortening and deformity of the fracture site
\how do you manage fractures? - ANS-immobilization including the joint above and below fx
*after splinting, reassess neurologic and vascular status of extremity
\how do you treat all patients with open fractures? - ANS-start IV antibiotics using weight
based dosing ASAP
*first generation cephalosporins
*delay of tx >3 hours is related to increased risk of infectino
\how much blood loss would you expect from a femur fracture and tibial fractures? -
ANS-femur fx = up to 2 L
tibial fx = up to 1.5 L
\How should femur and tibial shaft fractures be stabilized? - ANS-long leg posterior splint
around lower leg to stabilize femur and tibia
\in patients who may be a potential for replantation of amputated extremity, how do you
initially manage the wound? - ANS-thoroughly wash the amputated part with isotonic solution
, (ringers lactate) and wrap it in moist, sterile gauze... then wrap it in moistened steril towel,
place in plastic bag and transport with pt in an insulated cooling chest with crushed ice
*be careful not to freeze it though
\in patients with amputated extremities... who is not a candidate for replantation? - ANS-pt
with multiple injuries who require intensive resuscitation and or emergency surgery for
extremity or other injuries
red text
\in the initial assessment of vascular injuries, why might extremities have adequate flow
initially? - ANS-extremities often have collateral circulation providing adequate flow
\people with bilateral femur fractures vs unilateral femur fractures - ANS-they are at
significantly greater risk for significant blood loss, severe associated injuries, pulmonary
complications, multiple organ failure, and death
\pt has pulsatile bleeding from right leg wound. direct pressure and gause packing applied...
but dressing was quickly saturated with blood. what is the next step in management of
uncontrolled extremity hemorrhage? - ANS-apply manual pressure to artery proximal to the
wound
*if bleeding persists, application of a tourniquet would be appropriate
\the risks of tourniquet use increase over time... if it must remain in place for a prolonged
period to save a life, what choice is made? - ANS-choice of life over limb is made
\what are potentially life threatening extremity injuries? - ANS-major arterial hemorrhage,
bilateral femoral fractures, crush syndrome
\what are the 3 goals when assessing the extremities? - ANS-1. id life threatening injuries
(primary survey)
2. id limb threatening injuries (secondary survey)
3. conduct systematic review to avoid missing other MSK injuries
\what are the common areas for compartment syndrome? - ANS-lower leg, forearm, foot,
hand, gluteal region, thigh
\what are the immobilization guidelines for femoral fractures? - ANS--immobilize temporarily
with traction splints
-avoid excessive traction, which can cause skin damage to the foot, ankle, and perineum
-assess neurovascular status before and after splint application
-do not apply traction for ipsilateral tibia shaft fractures
\what are the immobilization guidelines for tibial fractures? - ANS--immobilization minimizes
pain and soft tissue injury, and decreases risk of compartment syndrome
-if available, use plaster splints to immobilize the lower thigh, knee, and ankle
\what are the risk factors for tetanus? - ANS->6 hours old
contused or abraded
>1cm deep wounds
from high velocity missiles
due to burns or cold
significantly contaminated... particularly wounds with denervated or ischemic tissues
\what are the steps of extremity bleeding control in order? - ANS-1. manual pressure to
wound
2. pressure dressing
3. compression of artery proximal to injury
4. tourniquet application
\What can crush syndrome lead to? - ANS-aka traumatic rhabdomyolysis
22 yo female presents after jumping from 3rd story in suicide attempt. She is
hemodynamically normal, but has a GCS score of 13. Both ankles are swollen. Her pulses
are intact. Initial chest and pelvic films are normal. Ankle films reveal bilateral calcaneal
fractures. What additional work up is important to undertake in this patient? -
ANS-radiographic work-up of spine to rule out occult injury
\25 yo male presents after motorcycle crash. vitals: BP 128/70, HR 124, GCS 15. He
complains of right leg pain. On exam, the patient is found to have a significant proximal right
thigh deformity. His distal pulses are intact. What is the best initial management of this
patient's symptoms? - ANS-splint the extremity and administer a small dose of IV narcotic
such as fentanyl
\a properly applied tourniquet must include arterial inflow... What happens if you only occlude
venous systems? - ANS-increase hemorrhage and result in a swollen cyanotic extremity
\compartment syndrome can occur when there is an increase in the compartment content
(bleeding/swelling) or decrease in compartment size (constrictive dressing)... it can occur
wherever muscle is contained within a closed fascial space... what do you have to remember
about the skin? - ANS-skin can act as a restricting layer in certain circumstances
red text
\do all patients with open fractures get IV antibiotics? - ANS-yes.
\for the circulatory evaluation, palpate the distal pulses in each extremity and assess
capillary refill of the digits... what do you do if hypotension limits digital exam of pulse? -
ANS-use doppler probe to detect blood flow
\how are femoral fractures temporarily immobilized? - ANS-traction splints... force is applied
distally at the ankle. Proximally the post is pushed into the gluteal crease to apply pressure
to buttocks, perineum, and groin
\how do you manage a fracture deformity? - ANS-gently pull limb out to length, realigning the
fracture, and splinting into the injured extremity
*this often restores blood flow to an ischemic extremity when the artery is kinked by
shortening and deformity of the fracture site
\how do you manage fractures? - ANS-immobilization including the joint above and below fx
*after splinting, reassess neurologic and vascular status of extremity
\how do you treat all patients with open fractures? - ANS-start IV antibiotics using weight
based dosing ASAP
*first generation cephalosporins
*delay of tx >3 hours is related to increased risk of infectino
\how much blood loss would you expect from a femur fracture and tibial fractures? -
ANS-femur fx = up to 2 L
tibial fx = up to 1.5 L
\How should femur and tibial shaft fractures be stabilized? - ANS-long leg posterior splint
around lower leg to stabilize femur and tibia
\in patients who may be a potential for replantation of amputated extremity, how do you
initially manage the wound? - ANS-thoroughly wash the amputated part with isotonic solution
, (ringers lactate) and wrap it in moist, sterile gauze... then wrap it in moistened steril towel,
place in plastic bag and transport with pt in an insulated cooling chest with crushed ice
*be careful not to freeze it though
\in patients with amputated extremities... who is not a candidate for replantation? - ANS-pt
with multiple injuries who require intensive resuscitation and or emergency surgery for
extremity or other injuries
red text
\in the initial assessment of vascular injuries, why might extremities have adequate flow
initially? - ANS-extremities often have collateral circulation providing adequate flow
\people with bilateral femur fractures vs unilateral femur fractures - ANS-they are at
significantly greater risk for significant blood loss, severe associated injuries, pulmonary
complications, multiple organ failure, and death
\pt has pulsatile bleeding from right leg wound. direct pressure and gause packing applied...
but dressing was quickly saturated with blood. what is the next step in management of
uncontrolled extremity hemorrhage? - ANS-apply manual pressure to artery proximal to the
wound
*if bleeding persists, application of a tourniquet would be appropriate
\the risks of tourniquet use increase over time... if it must remain in place for a prolonged
period to save a life, what choice is made? - ANS-choice of life over limb is made
\what are potentially life threatening extremity injuries? - ANS-major arterial hemorrhage,
bilateral femoral fractures, crush syndrome
\what are the 3 goals when assessing the extremities? - ANS-1. id life threatening injuries
(primary survey)
2. id limb threatening injuries (secondary survey)
3. conduct systematic review to avoid missing other MSK injuries
\what are the common areas for compartment syndrome? - ANS-lower leg, forearm, foot,
hand, gluteal region, thigh
\what are the immobilization guidelines for femoral fractures? - ANS--immobilize temporarily
with traction splints
-avoid excessive traction, which can cause skin damage to the foot, ankle, and perineum
-assess neurovascular status before and after splint application
-do not apply traction for ipsilateral tibia shaft fractures
\what are the immobilization guidelines for tibial fractures? - ANS--immobilization minimizes
pain and soft tissue injury, and decreases risk of compartment syndrome
-if available, use plaster splints to immobilize the lower thigh, knee, and ankle
\what are the risk factors for tetanus? - ANS->6 hours old
contused or abraded
>1cm deep wounds
from high velocity missiles
due to burns or cold
significantly contaminated... particularly wounds with denervated or ischemic tissues
\what are the steps of extremity bleeding control in order? - ANS-1. manual pressure to
wound
2. pressure dressing
3. compression of artery proximal to injury
4. tourniquet application
\What can crush syndrome lead to? - ANS-aka traumatic rhabdomyolysis
