1. Traumatic Brain Injuries Dr. ArifBaradiaM. Med (Ortho) Supervisor: Professor Mwangombe

2. What is Traumatic Brain Injury?

3. PROCESS not EVENT • PRIMARY and SECONDARY BRAIN INJURY • Penetrating or Non-penetrating

4. Epidemiology • 1.5 m per year MVA 45% Falls 30% Occupational 10% Recreational 10% Assault 5% Role of Alcohol

5. Epidemiology • 40-60% of head injured patients have extremity injury • 32,000-48,000 head injury survivors with orthopaedic injuries annually

6. Pathophysiology of Head Injury • Monroe - Kellie doctrine CSF 10% BLOOD 10% BRAIN 80% Rigid “Box” Aka The Skull

7. Cerebral Blood Flow • 15% C.O • 750ml/min • CPP = MAP – ICP maintain above 70 mmHg

8. Mechanisms of Brain Injury • Brain Contusion • Raised ICP • Diffuse Axonal Injury • Stroke

9. 1.Brain Contusion • cell death + hemorrhage • The contusion often occurs at a site distant from the point of impact

10. 2.Raised ICP

11. Raised ICP Brain Oedema/Swelling Extra-dural Hematoma Sub-Dural Hematoma

12. Brain Oedema

13. Extra-dural Hematoma

14. Subdural Haematoma

15. 3. Diffuse Axonal Injury

16. Secondary Brain Injury Excitatory Neurotransmitters Calcium/Sodium Influx Phospholipases Proteases Arachidonic Acid + water = cytotoxic edema Prostaglandins Thromboxanes Leukotrienes Cell mb integrity Cell function Cell viability

17. Overview • Initial evaluation • Prognosis • Management of Head Injury • Orthopaedic Issues • Operative vs. nonoperative treatment • Timing of surgery • methods • Fracture healing in head injury • Associated injuries • Complications

18. Initial Evaluation Pre-Hospital care Emergency Department ATLS protocol Primary Survey Secondary survey History Physical Exam – GCS < 9, 9 – 12, > 13, xT, xTP Imaging

19. ABCDE • GCS < 9 – intubate • Hyperventilation, 100% Oxy sat • BP > 90mmHg • Pupils • GCS • ICP monitoring

20. Hyperosmolar therapy • Mannitol0.25 – 1 g/kg infusion • Hypertonic saline • Albumin HCT 30 – 33% PaCO2 – 35 +/- 2 mmHg CVP 8 – 14 mmHg Avoid dextrose IV Maintain euthermia or hypothermia

21. Role of Orthopedic Surgeon • Resuscitation • Treatment Methods/Timing • Associated injuries • Complications

22. 1. Damage Control Surgery Goal • Limit ongoing hemorrhage, hypotension, and release of inflammatory factors • Limit stress on injured brain • Initial surgery • <1-2 hrs • limit surgical blood loss

23. Methods • Initial focus on stabilization • External fixation • Limited debridement • Limited or no internal fixation or definitive care • Delayed definitive fixation (5-7 days)

24. 2. Resuscitation: Role of Orthopaedics • Goal: limit ongoing hemorrhage and hypotension • pelvic ring injury-- external fixation reduced mortality from 43% to 7% (Reimer, J Trauma, ‘93) • open injury--limit bleeding • long bone fracture--controversial

25. Long Bone Fracture in the Head Injured Patient • Early fixation (<24 hours) well accepted in the polytrauma patient • In the head injured patient early fixation may be associated with • hypotension – elevated ICP • blood loss/coagulopathy • Hypoxia • Fat embolism • Advocates of early and delayed treatment

26. Early Osteosynthesis Hofman ‘91, Poole ’92, McKee ’97 – either no difference or lower mortality and GOS Bone ‘94, Starr ‘98 – delayed fixation worse mortality and 45X pulm complications

27. Delayed Osteosynthesis • Reynolds ’95, Jaicks ’97, Townsend ‘98 – more hypotension i.e. more fluid resusc needed, lower discharge GCS

28. Fracture Care Decided on a case by case basis but surgery is often optimal • Alignment • Articular congruity • Early rehabilitation • Facilitated nursing care Non-operative fracture care

29. BUT Minimise • Hypotension • Hypoxia • Elevated ICP • Adequate fixation

30. 3. Bone Healing ?enhanced bone healing? • Exuberant callus • Heterotopic ossification Humoralosteogenic factors released by the injured brain - Klein et al ‘99 ?prolactin – Wildburger et al ?Growth Factor – Bidner et al Union rates not significantly affected while malunion rates increased

31. Heterotopic Ossification

32. Formation of lamellar bone inside soft tissue structures where bone does not normally exist • inciting event • signal from the site of injury • supply of mesenchymal cells whose genetic machinery is not fully committed • environment which is conducive to the continued formation of new bone

33. Associated with ventilator dependency Avoid periarticular procedures Use approaches/techniques less associated with H.O. Prophylaxis RT – single dose within 48 hours of surgery Indomethacin – 25 mg tds for 6 weeks Excision

34. Occult Injuries • Fractures, dislocations and peripheral nerve injuries may be “missed” • Up to 11% of orthopaedic injuries may be “missed” • Peripheral nerve injuries are particularly common (as high as 34%) • Occult fractures in children with head injury are also common (37-82%)

35. Occult Injuries • Detailed physical exam with radiographs of any suspect area due to bruising, abrasion, deformity, loss of motion • Consider EMG for unexplained neurologic deficits • Bone scan advocated in children with severe head injury @ 72 hrs

36. Thank You