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Trauma

Trauma. Orthopeadics Off-Service Resident Teaching William Desloges. ATLS. Primary Survey: A irway maintenance with Cervical spine protection B reathing and Ventilation C irculation and Hemorrhage control D isability: neurological status

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Trauma

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  1. Trauma Orthopeadics Off-Service Resident Teaching William Desloges

  2. ATLS • Primary Survey: • Airway maintenance with Cervical spine protection • Breathing and Ventilation • Circulation and Hemorrhage control • Disability: neurological status • Exposure/Environmental control: Completely undress the patient, but prevent hypothermia • Adjuncts: Monitoring, urinary catheter, NG tube, Blood work, ABG, • X-rays: portable AP chest and pelvis • FAST: Focused Assessment Sonography in Trauma

  3. Secondary Survey • Begins once the primary survey is completed and normalization of vital functions has been demonstrated • Includes reassessment of all vital signs • Head-to-toe evaluation of the trauma patient: • Allergies • Medications currently used • Past illnesses/Pregnancy • Last meal • Events/Environment related to the injury

  4. MSK Exam • Inspect for contusion, swelling and deformity • Palpation of the bones and examination for tenderness and abnormal movement • Pelvis exam • Spine exam • Neurovascular status

  5. Hemorrhage

  6. Hemorrhage • Management of major arterial bleeding: • Application of direct pressure • Pneumatic tourniquet • Aggressive fluid resuscitation • Vascular surgery consult • Unless a superficial bleeding vessel is clearly identified, it is not advisable to use vascular clamps, since risk injuring surrounding structures

  7. Fracture Stabilization • Reduces the risk of: • Neurovascular compromise • Cartilage sparing • Skin necrosis • Decrease blood loss • Reduces pain • Compartment Syndrome • Infection in setting of open fracture • Fat emboli • Acute respiratory distress syndrome and multiple organ failure, probably by calming the systemic inflammatory response

  8. Fracture Stabilization • Splinting • Cast immobilization • Traction: • Skeletal • Skin • External fixation • Definitive fracture fixation: • ORIF • Intramedullary fixation

  9. Open fractures • A fracture is considered to be open when disruption of the skin and underlying soft tissues results in a communication between the fracture and the outside environment

  10. Open fractures • Treatment: • Initial Stabilization and gross debridement and irrigation in the emergency department • Tetanus prophylaxis • Systemic antibiotics: • The administration of antibiotics after an open fracture reduces the risk of infection by 59% • Gustillo Type I and II: 1st generation cephalosporin • Gustillo Type III: add an aminoglycoside • If high risk of anaerobic infection (farm injuries), add penicillin or ampicillin • Prompt formal Irrigation and Debridement with fracture stabilization within 6 hours of injury.

  11. Vascular Injuries • Vessel injury • Direct: laceration or contusion of the artery or vein by fracture fragments or penetrating object • Indirect: by stretching leading to intimal tear • Examination to look for signs of ischemia • Pulses • Expanding hematoma or persistent arterial bleeding • Diminished ankle-brachial index (Normal is > 0.9) • Injury to anatomically related nerves • Abnormal physical exam warrants arteriography (CT angio or conventional angiogram)

  12. Vascular Injuries • Common fractures leading to vascular injuries • Knee dislocation: 7-15% incidence • Supracondylar femur fracture: 2-3% incidence • Proximal tibial fracture • Tibial plafond fracture: 0-5% incidence • Proximal humeral fracture: rare • Pelvic fractures • Treatment: • Fracture Stabilization • Vascular flow should be reestablished within 6 hours • Prophylactic compartmental release to avoid reperfusion compartmental syndrome

  13. Compartment Syndrome • Common signs and symptoms: • Increasing pain greater than expected and out of proportion to stimulus • Palpable tenderness of the compartment • Asymmetry of the muscle compartments • Pain on passive stretch of the affected muscle • Altered sensation • To be covered in more details in another lecture

  14. Pelvic Fractures

  15. Pelvic Fractures • Suspect fracture if visible ecchymosis over the iliac wings, pubis, labia, or scrotum • Assess for blood at meatus/ scrotum/ high prostate, passage of Foley, vaginal tear, perineum/rectum • SI joint tenderness • Pelvis mobility • Rotational instability: assessed by placing hands on ASIS trying to open and close the pelvis • Vertical stability: assessed by axially loading the leg • Repeat exam/manipulation should be avoided • Hemodynamics • In a large series reported by Matta, 35% of the acetabular fractures were associated with an injury involving an extremity, 19% with a head injury, 18% with a chest injury, 13% with a nerve palsy, 8% with an abdominal injury, 6% with a genitourinary injury, and 4% with an injury of the spine

  16. Pelvic Imaging • Imaging • X-ray: AP, inlet, outlet, obturator oblique and iliac oblique views • CT scan

  17. Pelvic Inlet and Outlet

  18. Columns of the acetabulum

  19. Pelvic AP

  20. Iliac Oblique

  21. Obturator Oblique

  22. Assessment of Pelvic Fractures Anterior disruption: Symphysis pubis (>5mm displacement) Overlapping/locking symphysis pubis Unilateral fracture of both rami Bilateral fracture of all 4 rami

  23. Assessment of Pelvic Fractures Posterior disruption: Ilium # SI joint Sacral fracture

  24. Pelvic Ring Fractures:Young & Burgess Classification • Lateral Compression fractures • Anterior Posterior Compression fractures • Vertical Shear Fractures

  25. Assessment • Radiographic signs of instability: • Sacroiliac displacement of 5mm in any plane • Posterior fracture gap • Avulsion of fifth lumbar transverse process, lateral border of sacrum (sacrotuberous ligament), or ischial spine (sacrospinous ligament)

  26. Tile Classification

  27. Columns of the acetabulum

  28. Acetabular Fracture

  29. Concurrent Femoral Head Fractures

  30. Pelvic Fractures Management • Pelvic Binder: • Most useful for grossly unstable pelvic ring fracture and open book pelvis • Not used for isolated acetabular fracture • reduces pelvic volume, stabilizes raw fracture surfaces, and encourages tamponade • Hemodynamic instability: • Resuscitation • Closed fracture of the acetabulum rarely leads to hypotensive shock. An alternative source of hemorrhage should always be sought • Angiography: Only 5% to 10% of patients with pelvic fractures bleed from arterial sources. Mostly venous bleeding. • Pelvic packing • Open Pelvic fracture: • Sepsis caused by fecal contamination is a major cause of mortality with this injury, and immediate diverting colostomy is indicated in patients with perinealwounds • devastating consequences if timely and appropriate débridement is not performed

  31. Pelvic Binder

  32. Pelvic Ring Fractures Management • Nonoperative treatment • For stable fracture patterns (Tile Type A, B1 and B2) • WBAT for isolated anterior injuries • Protected weight bearing for ipsilateral anterior and posterior ring injuries

  33. Pelvic Ring Fractures Management • Operative treatment indications: • Symphysis diastasis > 2.5cm • Anterior and posterior SI ligament disruption (Sacroiliac displacement of 5mm in any plane) • Vertical instability of posterior hemipelvis • Sacral fracture with displacement > 1cm • External Fixation for definitive management or temporary stabilization • Skeletal traction: for vertically unstable pattern

  34. Acetabulum Fractures Management • General Principle: • Restore articular congruity and hip stability • Nonoperative treatment: • Nondisplaced or minimally displaced fracture (< 1mm step and < 2mm gap) • Roof arc angle > 45 degrees of the AP, inlet and outlet views • On CT, fracture is greater than 10mm from the dome • Posterior wall fracture without instability (< 20% of posterior wall) • Fracture of both column with secondary congruence • Severe comminution in the elderly in whom THA is planned after fracture healing

  35. Case #1 • A 36-year-old female • Unrestrained driver involved in a motor vehicle accident • P105, BP 105/80, RR22, Sat 98%RA • GCS 15 • Primary survey: Ok • Secondary survey: • Right arm: open elbow fracture • Right groin + buttock + hip pain • Large Morrel-Lavallee lesion Rt hip

  36. Case #1 • Both column fracture with a particularly sharp spike of bone from the posterior column protruding through the greater sciatic notch

  37. Angiography revealed a superior gluteal artery injury to be the source of the bleeding, which was successfully treated by embolization

  38. Case #2 • 51 yo Male • Motorcycle crash 80km/hr • GCS 7/15, PERL • P115, BP 80/45, Sat 90% on rebreather mask, RR 22 • Lungs: Bilateral decreased air entry at the bases, subcutaneous emphysema

  39. Case #2 • Airway: intubate • Breathing: Bilateral Chest tube insertion • Circulation: Hemodynamic instability • Type of shock • Abd: no significant distension, soft • Chest tube output if hemopneumothorax • FAST: Focused Assessment with Sonography for Trauma (FAST) is a limited ultrasound examination directed solely at identifying the presence of free intraperitoneal or pericardial fluid. • Scalp Laceration • Check extremities • Pelvis stability

  40. Pelvic Fracture • Pubic diastasis and bilateral pubic rami fractures • Widening of Rigth SI joint • Young and Burgess anterior-posterior type III (AP III) pelvic ring injury • Unstable • Temporary stabilization until fit for definitive management • Needs operative fixation

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