Surgery - Musculoskeletal

Musculoskeletal Injuries Contributing to Shock

Several musculoskeletal injuries can result in significant blood loss and contribute to haemorrhagic shock. These include arterial bleeding, pelvic fractures, large vessel puncture, limb amputation, and long bone fractures. Long bone fractures can conceal substantial amounts of blood loss. A humeral fracture may be associated with approximately 0.5–1.5 litres of blood loss, a tibial fracture with approximately 0.5–1.5 litres, and a femoral fracture with approximately 1.0–2.5 litres.

Musculoskeletal Assessment in the Secondary Survey

The primary survey and ABCs should always be addressed first. Once the patient is stable, the musculoskeletal system can be assessed systematically during the secondary survey. This includes taking a focused history and examining the patient using the principles of look, feel, and move.

History

The history should include the position of the patient when first found or on arrival, any obvious or suspected trauma, and the mechanism of injury. In road traffic accidents, important details include seatbelt use, airbag deployment, whether the patient was able to mobilise after the accident, and the direction of impact. It is also useful to determine whether the patient was found close to or away from the accident site.

An AMPLE history should be taken, including allergies, medications, past medical history, last meal, and events surrounding the injury. Previous joint or limb pathology should also be identified. Osteoporosis and osteopenia are especially important because they increase susceptibility to fractures following relatively minor trauma.

Inspection

The patient should be appropriately exposed and both sides of the body compared. Look for open fractures, which may involve exposed bone but are not always immediately obvious. Other important features include swelling, deformity, bruising, wounds, and changes in the colour of the limb distal to the injury.

Palpation

Both sides should be compared while assessing the temperature of the distal limb, the presence of crepitus, joint effusions, haemarthroses, and capillary refill time. In a conscious patient, pain and tenderness should also be assessed. Neurological integrity should be checked by assessing fine touch sensation, motor function, and sweating of the skin, or hidrosis.

Movement

Range of active movement should be assessed in a conscious patient. Passive movement may be considered in an unconscious patient where appropriate. However, an obvious or suspected fracture should not be manipulated before X-ray imaging, as this does not add significantly to the diagnosis and may worsen the injury. Joint dislocations should generally be reduced as soon as clinically appropriate. Weight-bearing may be assessed as tolerated when relevant.

Investigations

Plain X-rays are the standard initial investigation for uncomplicated musculoskeletal trauma. Imaging should be selected according to the suspected site and type of injury.

Rule of Twos

The rule of twos is a useful principle when assessing fractures radiologically. Two joints should be considered, meaning the joint above and the joint below the injury should be assessed where appropriate. Two views, usually an anteroposterior and lateral view, should be obtained to assess displacement and angulation accurately. If doubt remains, the opposite side may occasionally be imaged for comparison, although this is rarely required.