MUSCULO-SKELETAL

INJURIES
Principles of Management

JOSELITO T. DYCHIOCO, M.D.

Orthopaedic Surgeon
 LEARNING OBJECTIVES:
At the end of the lecture, the
students should be able to:

• Describe the definition, signs and

symptoms of: fractures, subluxation,
dislocation, sprain & strain

• Differentiate the different types of

fractures
• Evaluate & Administer emergency care
for musculoskeletal injuries
• Understand the different methods of
definitive treatment of musculoskeletal
injuries
• Identify the 4 stages of fracture healing,
factors affecting fracture healing and
complications of fractures
 Fracture

- break in the continuity

of a bone associated with
soft tissue injury
 Subluxation

- joint disruption with

remaining contact
between the bone ends

  Normal   Subluxation  
 Dislocation

- joint disruption
with no contact
remaining
between the bone
ends

Dislocation 
 Types of Fractures
• Open / compound
– skin is broken or
damaged
• Closed / simple
– skin intact, no wound
exists
 Types of Fractures
• Transverse: cuts across bone at right angles
• Greenstick: incomplete (children)
• Spiral : sharp ends
• Oblique: slant
• Impacted: ends of bone jammed together
• Comminuted: splintered or crushed
Pathologic Fractures
• Fracture that occurs in a bone that
already has an abnormality or lesion (
tumor, infection, etc.)
• Results usually from an injury that is
trivial
Pathologic Fracture
 Stress Fractures
• Increased pain post activity
• Overuse
• X-ray may not show fracture
• May develop into full fracture
• Tibia and bones in feet (common
sites)
Stress Fracture
 Fracture
Displacement
 Fracture
Displacement
 Fracture
Displacement
Emergency Care
of
Fractures
 Look For:
• DOTS and CSM
– Deformity, open wounds, tenderness,
swelling
– Circulation, sensation, movement
• Point tenderness
• Loss of use - (child’s leg)
• Crepitus: grating sensation
• History of the injury
Fractures: What To Do

• Most are not life threatening

– Pelvis, spinal breaks are exceptions
• Treat for shock
• Look and feel (remove clothing
around injury)
– Pain, location ,numbness, tingling
• Check for DOTS
Fractures: What To Do
#2
• Check CSM
-No circulation? Emergency!
• Gently manipulate to restore blood flow
• Bone could depress vessels or nerves
• Capillary refill test
– Sensation - Squeeze fingers and toes
– Movement - Wiggle fingers and toes
Assessment
Fractures: What To Do
#3

• Control bleeding
• Cover wounds before splinting
• Splint
• RICE
 Splinting

• Splint all fractures before

moving unless life is threatened

• “Splint them where they lie”

Splinting
 Reasons For
Splinting
• Reduces pain
• Prevents further damage
• Prevents development of an
open fracture
• Reduces bleeding and
swelling
• If in doubt, splint
 What Is A Splint?
• Device used to stabilize a fracture or dislocation
• Three types:
– Rigid
• Board (padded)
• Cardboard etc.
– Soft (air splint)
• self splint (use body parts)
– Traction
• Used on femur, EMS only
What Is A Splint?
– Soft (air splint)
 Splint Application
• Splint joints above and below the
break / splint on both sides if possible
• Rule of thirds
• Check CMS after splinting
• RICE (unless pulse is absent)
 Should I Ever Try To
Reduce A Fracture?
• Only if :
– In remote area and > 1 hour away /
Deformed and angulated ???
– Absence of CSM
• Splint in deformed position
Emergency Care
of
Dislocations
 Dislocations

• Joint is pulled apart

• Bones are not aligned properly

POSTERIOR HIP DISLOCATION
KNEE DISLOCATION
• More than half of
all knee
dislocations are
anterior or
posterior, and both
of these have a
high incidence of
popliteal artery
injury.
Dislocations: What To
Do
• Check CSM
• Splint (do not reduce)
• Medical attention
– Sometimes you may try to reduce an
anterior shoulder, kneecap or finger
(wilderness)
• Never reduce: spine, elbow, wrist, knee,
hip
 Additional Extremity
Injuries
• Sprains
• Strains
• Contusions
• Tendonitis/Tendinitis
– Treat all with RICE
 Sprain

•Ligament damage
•Ligaments connect bone
to bone
•Primary stabilizer of
 Strains
• Pulled muscle
• Occurs when:
–Muscle extended beyond its normal
range of motion
• muscle is not warmed up (stretched)
 Tendonitis
Inflammation of a Tendon

• Musculotendinous unit
–Tendon connects muscle to bone
• Tennis elbow
• Golfers elbow
• Treatment: RICE
 Muscle Contusions
(Bruises)
• Swelling
• Pain
• Tenderness
• Discoloration
–Treatment: RICE
 Muscle Cramps:
What To Do
• Stretch the muscle or apply pressure
• Consume fluid with electrolytes
– Gatorade / sports drinks / lightly salted water
• Pinch upper lip, hard??
– Acupuncture technique
• DO NOT MASSAGE
 RICE

• Rest
• Ice
• Compression
• Elevation
 RICE

• RICE will eliminate or reduce swelling =

faster recovery
• NEVER use HEAT initially for
sprains, strains, fractures,
bruises etc.
 Rest
• Speeds up healing
• Reduces blood flow to the area
• Reduces swelling
–Using body part increases blood
flow to the area
 Ice
• Vasoconstriction
• Apply 20-30 minutes every 2-3
hours (variable)
• Apply for the first 48-72 hours
–(variable –24-48 hours)
–Severe injury? 72 hrs.
recommended
 Icing Methods
• Commercial hot/cold packs
• Ice bags (1part alcohol, 3 parts water)
• Ice cups
• Frozen vegetables
• Cold, wet towels from the freezer
• Snow
• Contrast baths (l min. cold, 4 min. warm:
variable)
 Caution With Ice
• Frostbite
• Do not ice posterior knee (nerve
damage)
• Raynaud’s syndrome
 Compression
• Fill hollow areas with padding
• Wrap towards the heart
–Loosen at night
 Elevation

• Controls swelling and pain

• Elevate first 72 hours
 Using Heat for
Injuries
• 48-72 hours after injury
(variable)
• Vasodilation
 Other Injuries
• Ring Removal
• Blood under the nail
– Heat pointed metal object, burn through nail
– Drill through the nail???
• Nail Avulsion
• Splinter
– V-notch
• Treat as minor wounds
 Definitive
• Traction
Treatment
• Closed reduction
• Open reduction
• External fixation
 4 STAGES OF FRACTURE
HEALING:
• INFLAMMATORY OR CELLULAR
CALLUS
• MINERALIZED CALLUS
• BONY CALLUS
• REMODELING
Fracture Healing
Fracture Healing
Fracture Healing
Fracture Healing
Factors Influencing
Healing
Delays Healing
• Corticosteroids & NSAID
• Diabetes mellitus
• Deficiency of sex hormones
• Poor oxygenation
• Deficiency of vitamin D
• Excessive bone gap & motion
• Impaired bone nutrition or vitality
• Pathologic conditions (infection, malignancy)
• Presence of synovial fluid
• Deficiency or abnormality of bone substance
• Slow bone growth (advancing age)
Factors Influencing
Healing
Promotes Healing
• Growth hormone
• Thyroid hormone & calcitonin
• Insulin
• Anabolic hormones
• Normal absorption of nutrients
• Electrical stimulation of bone
• Vitamin C & D
• Exercise & weight bearing
• Rapid bone growth (youth)
Complicatio
ns of
Fractures
 Complications of
Fractures

Vascular compromise

Neurologic complication
Complicatio
ns of
Fractures
Complicatio
ns of
Fractures
Complicatio
ns of
Fractures
Complicatio
ns of
Fractures
Complicatio
ns of
Fractures
Complication
s of
Fractures
Managemen
t of
Nonunion
Management of
Nonunion
Management of
Nonunion
Classification of Open
Fractures
(Gustilo & Anderson)
 Treatment of Open
Fractures

• Treat as an emergency
• Culture & sensitivity
• Anti-tetanus
prophylaxis
• IV antibiotics
 Treatment of Open
Fractures

• Debridement in the
OR
 Treatment of Open
Fractures

• After debridement
 Treatment of Open
Fractures

• Decide on kind of bone

stabilization
• Early wound coverage
• Early bone grafting
 Treatment of Open
Fractures

• If the bone gets

infected
• Do an adequate
debridement
• Use antibiotic beads
 Treatment of Open
Fractures

• Rehabilitation
of the limb &
the patient
Thank You