Musculoskeletal Trauma

Aka: Musculoskeletal Trauma, Orthopedic Trauma, Musculoskeletal Injury, Soft Tissue Injury, Extremity Injury, Arm Injury, Upper Extremity Injury, Leg Injury, Lower Extremity Injury

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II. Types: Soft Tissue Injury

  1. See Skin Foreign Body
  2. See Burn Injury
  3. Laceration
    1. Consider open Fracture (some Lacerations originate from the inside)
  4. Ligament Sprain
    1. Injury to ligament or capsule
  5. Tendon Strain (Tendinopathy)
    1. Injury translated at musculotendinous junctions
  6. Contusion
    1. Blunt injury disrupts soft tissue (skin, Muscle) capillaries and venules, resulting in Hemorrhage into local interstitial tissue
    2. Associated complications
      1. Compartment Syndrome
      2. Myositis Ossificans
      3. Local Pressure tissue necrosis
      4. Morel-Lavallee Lesion
  7. Apophyseal Injury (children)
    1. Secondary ossification sites for tendon insertions, which may be injured with overuse prior to Growth Plate closure
    2. Examples
      1. Little Leaguer's Elbow
      2. Osgood-Schlatter Disease (knee)
      3. Sever's Disease (heel)

III. Types: Fractures

  1. See Fracture
  2. See Stress Fracture
  3. See Epiphyseal Fracture (children)

IV. Types: Nerve Injuries

  1. General
    1. See Motor Strength (Myotome)
    2. See Sensory Level (Dermatome)
    3. Peripheral Nerve Injury
    4. Compartment Syndrome
  2. Shoulder and Brachial Plexus
    1. Brachial Plexus Injury
    2. Axillary Nerve Injury
    3. Long Thoracic Nerve Injury
    4. Suprascapular Nerve Injury
    5. Spinal Accessory Nerve Injury
  3. Elbow and wrist
    1. Axillary Nerve Injury (e.g. Anterior Shoulder Dislocation, Proximal Humerus Fracture)
      1. Deltoid motor weakness
      2. Lateral Shoulder numbness
    2. Musculocutaneous Nerve Injury (e.g. Anterior Shoulder Dislocation)
      1. Elbow flexion motor weakness
      2. Radial Forearm numbness
    3. Median Nerve Injury
      1. Median Nerve Injury at the Elbow
      2. Median Nerve Injury at the Wrist (Carpal Tunnel)
      3. Distal Median Nerve injury (e.g. wrist Fracture or dislocation)
        1. Thumb and Index opposition (OK sign) motor weakness
        2. Thenar eminence or distal index finger numbness
      4. Anterior Interosseous nerve injury (Median Nerve branch injury, e.g. Humerus supracondylar Fracture in children)
        1. Index finger DIP flexion motor weakness
    4. Radial Nerve Injury (e.g. distal Humerus Shaft Fracture, Anterior Shoulder Dislocation)
      1. Radial Nerve Injury at the Elbow
      2. Radial Nerve Injury at the Wrist
      3. Thumb and finger extension and metacarpophalangeal joint (MCP joint) motor weakness
      4. Dorsal hand first webspace numbness
    5. Ulnar Nerve Injury (e.g. Elbow Injury)
      1. Ulnar Neuropathy at the Elbow (Cubital Tunnel)
      2. Ulnar Nerve Injury at the Wrist (Ulnar Tunnel)
      3. Finger abduction motor weakness
      4. Hypothenar eminence or fifth, small finger numbness
  4. Spine
    1. Spinal Cord Syndrome
    2. Cervical Radiculopathy
    3. Lumbar Radiculopathy
  5. Buttock and legs
    1. Sciatica
    2. Piriformis Syndrome
    3. Meralgia Paresthetica
    4. Tarsal Tunnel
    5. Femoral Nerve Injury (e.g. Public Ramus Fracture)
      1. Knee extension motor weakness
      2. Anterior knee numbness
    6. Obturator Nerve Injury (e.g. Obturator ring Fracture)
      1. Hip adduction motor weakness
      2. Medial thigh numbness
    7. Posterior Tibial Nerve Injury (e.g. posterior Knee Dislocation)
      1. Toe flexion motor weakness
      2. Plantar foot numbness
    8. Superficial peroneal nerve injury (e.g. fibular neck Fracture, posterior Knee Dislocation)
      1. Ankle eversion motor weakness
      2. Lateral foot dorsum numbness
    9. Deep peroneal nerve injury (e.g. fibular neck Fracture, Compartment Syndrome)
      1. Ankle and toe dorsiflexion motor weakness
      2. Dorsal foot first and second web space numbness
    10. Sciatic nerve injury (e.g. posterior Hip Dislocation)
      1. Ankle dorsiflexion (or plantar flexion) motor weakness
      2. Foot numbness
    11. Superior Gluteal Nerve Injury (e.g. Acetabular Fracture)
      1. Hip abduction motor weakness
      2. Upper buttock numbness
    12. Inferior Gluteal Nerve Injury (e.g. Acetabular Fracture)
      1. Hip extension motor weakness (at gluteus maximus)
      2. Lower buttock numbness

V. Types: Regions

  1. Spine and proximal nerves
    1. Spinal Cord Syndrome
    2. Cervical Spine Injury
    3. Lumbar Spine Injury
    4. Brachial Plexus Burner
    5. Thoracic Outlet Syndrome
  2. Upper extremity
    1. Shoulder Injury
    2. Rotator Cuff Injury
    3. Elbow Pain
    4. Hand Injury
    5. Wrist Injury
  3. Lower extremity
    1. Hip Pain
    2. Knee Injury
    3. Leg Pain
    4. Ankle Fracture
    5. Foot Pain

VI. Types: Mechanism

  1. High velocity injury
    1. Motor Vehicle Accident
  2. Falls
    1. Fall on Outstretched Hand
    2. Fall on Shoulder
  3. Work and chores
    1. Occupational Injury
    2. Lawn Mower Injury
  4. Sports
    1. Bicycling
    2. Cross Country Skiing
    3. Golf Injuries
    4. Running Injury
    5. In-line Skating
    6. Scuba Diving
    7. Surfing
  5. Skin and Soft Tissue Injury
    1. Penetrating Trauma (e.g. Gunshot Wound, Stab Wound)
    2. Blast Injury
    3. Laceration
    4. Puncture Wound
    5. BIte Wound
    6. Burn Injury

VII. History

  1. See Trauma History (SAMPLE History)
  2. Background
    1. Hand dominance (for upper extremity injuries)
    2. Profession or sports
  3. History of Present Illness
    1. Mechanism of injury
    2. Protective equipment
    3. Regions of injury
  4. Past medical history
  5. Last Tetanus Vaccination (if skin penetration)

VIII. Exam

  1. See Brief Musculoskeletal Exam
  2. See Neurologic Exam
  3. See Trauma Secondary Survey
  4. See Hand Neurovascular Exam
  5. Approach: Every Extremity Injury
    1. Mnemonic: "joint above, joint below, circulation, motor and Sensation, skin and compartments"
    2. Include examination of joint above and below the involved joint
    3. Include Sensory Exam, Motor Exam, Reflex Exam and vascular exam (pulses, Capillary Refill)
    4. Include skin and compartment exam
    5. Mallon (2013) Shoulder Disorders, EM Bootcamp, Las Vegas
  6. Upper extremity
    1. Shoulder Exam
    2. Elbow Exam
    3. Hand Exam
    4. Wrist Exam
  7. Lower extremity
    1. Hip Exam
    2. Knee Exam
    3. Ankle Exam
  8. Spine
    1. Spinal Cord Syndrome
    2. Neck Exam
    3. Low Back Exam
    4. Mnemonic
      1. C3-4-5 keeps the diaphragm alive (Spontaneous Breathing)
      2. S2-3-4 keeps the stool off the floor (Reflex Defecation Center)

IX. Precautions: Assess for Fracture (Especially in children)

  1. Ligaments and Tendons are stronger than Growth Plate
  2. Bone Fractures less often after Growth Plate fusion

X. Complications: Pitfalls

  1. Injuries with risk of vascular compromise (consider angiography)
    1. Posterior Knee Dislocation
    2. Supracondylar Femoral Fracture
    3. Suprecondylar Humeral Fracture
  2. Compartment Syndrome
    1. Consider Compartment Pressures
  3. Epiphyseal Fracture (children)
    1. Ligaments and Tendons are stronger than Growth Plate
    2. Bone Fractures less often after Growth Plate fusion

XI. Management

  1. See Musculoskeletal Injury Management

XII. References

  1. (2018) ATLS, ACS, Chicago, p. 161

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