MUSCULOSKELETAL AND
SOFT TISSUE TRAUMA
DARA Pichvirackboth
General and Digestive Surgeon
Khmer Soviet Friendship Hospital
• Examination of traumatized patient
• Investigation of fracture
• Management of fracture
• Complication of fracture
• Injuries to soft tissues: fat, skin, muscle, ligaments , tendons and nerves
MUSCULOSKELETAL TRAUMA
CONTENT
• Introduction
• History taking after trauma
• Clinical examination
• Investigation of fractures
• Management of fracture
• Complication of fracture
• Dislocation
• Common fracture and joints injuries
INTRODUCTION
• Fractures are a common medical problem.
• Bone: inert things but a dynamic living tissues with rich blood and nerve supply.
• Consequences: blood loss and pain.
• Pain: splints and analgesics.
• Blood loss: hypovolemic shock (major pelvic fracture 6+, femur 2-3+and tibia 1+)
• Death: not the broken bone, but associated injuries to the head, the chest and the
abdomen.
HISTORY TAKING AFTER TRAUMA(1)
• 2 reasons to do : clinical and medicolegal.
• Clinical history: simple domestic accidents, high velocity transport accident or battle
injuries.
• The questions to be asked:
What happened?
How did it happen?
Where and when did it happen?
What was the patient like before it happened ?
Who is the person?
HISTORY TAKING AFTER TRAUMA(2)
• Medicolegal aspects: all sorts of consequences that affect the patient and the
patient’s family.
• Insurance claim and litigation.
• Meticulous notes for one month, one year, ten years later (giving an account to an
accident).
CLINICAL EXAMINATION
• Vital areas (airway protection and cardiorespiratory viability)
A Airway
B Breathing
C Cardiovascular system
D Neurological Defects
E Exposure to detect all injuries
• Injured areas
• Other areas at risk
• Do a general examination
INJURED AREA
• Signs of fracture:
Deformity
Tenderness
Swelling
Discoloration of bruising
Loss of function and crepitus
• Immediate vicinity of fracture:
Skin: open or close fracture
Subcutaneous tissues: reddening of the skin with firmness and tenderness / infection ?
Surrounding muscles: compartment syndrome.
Major vessels: supracondylar of elbow fracture or knee dislocation (distal palses)
Nerve injuries: complete or incomplete division, stretching (neuropraxia)
OTHERS AREAS OF RISK
• Head and neck injuries.
• Rib fractures and pneumothorax.
• Femoral and pelvic injuries.
• Small injuries with big injuries.
INVESTIGATION OF A FRACTURE
• Fracture architecture: spiroid fracture (low energy) vs oblique and transverse
fractures (high energy and tissues damages+++)
• Plan radiography (X-ray) of the injured area:
• X-ray of the others areas:
• CT Scan (computed tomography)
• MRI (Magnetic resonance imaging)
• Other imaging: ultrasound
FRACTURE ARCHITECTURE
HOW TO DESCRIBE A FRACTURE
• Which bone and which side?
• Open or closed fracture?
• Where on the bone? (intraarticular, mid shaft, proximal or lower third)
• What shape? (Spiral, oblique, or transverse)
• How many fragments? (simple, butterfly, comminuted)
• Position of the distal fragment?
Displacement: anterior-posterior, medial-lateral
Angulation: anterior-posterior, varus-valgus
Rotation: internal-external
MANAGEMENT OF THE FRACTURE (1)
• Immediate management: Pain relief
Systemic pain relief: pain killers (Paracetamol, tramadol, NSAID, Morphine's)
Local anesthetic nerve block
Splintage
PAIN KILLER
NERF BLOCK
SPLINTAGE (ATTELLE)
MANAGEMENT OF THE FRACTURE (2)
• Definitive management
Reduction: closed and open reductions
Holding: casting, functional bracing, internal fixation, external fixation , traction
Rehabilitation
CASTING AND FUNCTIONAL BRACING
INTERNAL ET EXTERNAL FIXATION
TRACTION
COMPLICATIONS OF FRACTURE
• Infection: open fracture or surgical complication
• Fat embolism: respiratory distress (tachypnoea and mile confusion)
• Renal failure: myoglobin (crush’s syndrome)
• Compartment syndrome: fasciotomy and skin graft
• Immobility
• Delayed union and non-union
• Malunion
• Growth arrest: growth plate (children)
COMPARTMENT SYNDROME
DISLOCATION
• Shoulder
• Elbow
• Hip
• Knee
• Ankle
TO SUM UP
• General clinical examination (Urgent situation, ABCDE)
• Other areas at risk (Head, spine, thorax, abdomen)
• Injured areas (fracture)
• Immobilization (splintage)
• Pain control, wound protection (open fracture)
SOFT TISSUES TRAUMA
• Injuries: ligaments, tendons, muscles and nerves.
• Even low velocity, broken bone but damage cells and tearing tissues (inflammatory
reaction).
• Inflammation: swelling, hyperemia, and pain.
• First aide to reduce the acute inflammation and pain: RICE (reduce swelling++)
R: Rest
I: Ice (avoid thermal injury)
C: compression ( avoid hindering the circulation)
E: Elevation (above the heart level)
INJURIES TO SPECIFIC SOFT TISSUES(1)
• Fat and skin: bruising (ecchymosis) and blisters.
Fat necrosis: intense red reaction just like infection or cellulitis (patient is well and
apyrexial). No Antibiotics!
Hematomata: can be aspirated
• Muscle: dead cells cannot regenerate and healing by fibrosis with compensatory of
surrounding muscles.
Stiffness: rehabilitation.
INJURIES TO SPECIFIC SOFT TISSUES(2)
• Ligament: incomplete (sprains) and complete (tears or ruptures).
Sprains: no instability whiles rupture with instability.
Rupture: less severe pain than sprains (nerf damage) and surgical intervention is
seldomly required (healing spontaneously with splintage ).
• Tendons: generally from penetrating trauma.
INJURIES TO SPECIFIC SOFT TISSUES(3)
• Nerves: stretching, cutting ,and crushing.
• Attention: evaluation before treatment.
• Types:
Neurotmesis: complete anatomical division of a nerve with Wallerian degeneration.
Axonotmesis: a nerve injury that results in division of the axons but the connective
tissues survive.
Neuropraxia: a minimal nerve lesion producing paralysis without Wallerian
degeneration.
SPECIFIC NERVE INJURIES
• Footdrop: common peroneal nerve.
• Wrist drop: radial nerve.
• Sciatic nerve injuries: penetrating trauma (injection) or posterior dislocation of the
hip.
Thanks for your attention!
