Trauma approach
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management priorities in high energy trauma Define the terms of fracture, dislocation and Subluxation Identify the clinical and radiological pictures of fractures Classify the different types of fractures general principles of fracture management Principles of open fracture management
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Trauma approach
- 1. Trauma Approach Done by: Dr. Fahad Albedaiwi My supervisor : Dr. Shaima Alsofi
- 2. Objectives • management priorities in high energy trauma • Define the terms of fracture, dislocation and Subluxation • Identify the clinical and radiological pictures of fractures • Classify the different types of fractures • general principles of fracture management • Principles of open fracture management
- 3. Trauma Epidemiology – Leading cause of death in the first 4 decades . – 150,000 deaths annually in the US. – Permanent disability 3 times than mortality rate. – Trauma related costs exceed $400 billion annually in US .
- 4. Cont. • In Saudi Arabia (SA): • injuries are the second leading cause of death. • traffic-related injuries were the most common cause of trauma . • 9% of all patients died either before or after being treated at the hospital. • teenagers (more likely to be male) in traffic-related injuries. Ann Saudi Med. 2014 Jul-Aug;34(4):291-6. doi: 10.5144/0256-4947.2014.291
- 5. ATLS PROTOCOL • Preparation &triage • Primary survey • Resuscitation • Adjunct to primary surveyand resuscitation • Secondary survey • Adjunct to secondary survey • Post resuscitationmonitoring • Reevaluation • Definitive care • Tertiarysurvey
- 6. 1st priority is to save patient’s life • Always start withthe “ABCDE” approach
- 7. Primary Survey • ABCDEs of trauma care A airway and c-spine protection B breathing and ventilation C circulation with hemorrhage control D disability/Neurologic status E exposure Environmental control • Adjunct to primary survey and resuscitation
- 8. Secondary Survey • AMPLE history Allergies, Medications, PMH, Last meal, Events • Physical exam from head to toe, including rectalexam • Frequent reassessment of vitals • Diagnostic studies at this time simultaneously – X-rays, lab work, CT orders if indicated – FAST exam
- 9. Special Groups Pediatric • Same priorities with different amount of fluid and different size of equipment Pregnant women • Anatomic and physiologic changes Two patient “treat the mother totreat the fetus”
- 10. Elderly • Comorbidities: heart disease , DM, lung disease • Multiple medication use • Increased risk of death
- 11. fractures • A disruption or break in the continuity of the structure of bone
- 13. Where can FracturesOccur? • Just about every bone in the body has been broken • The most commonly broken bones are: – Wrist – Ankle – Hip- This happens more frequently in the elderly • Fingers and toes are broken frequently too due to sport injuries
- 14. Description • 5 things are taken into account whenfractures are described. • The name of the bone • The location on the bone • The type of fracture (open or closed) • The shape (Like a spiral fracture) • The degree of displacement
- 15. Types of Fractures • transverse • Spiral • Oblique • Comminuted • Displaced • Greenstick • Impacted • Intraarticular • Pathological • Stress • Avulsion fracture
- 17. Diagnosis • Clinical picture – Completehistory – Physicalexamination • Radiography
- 18. Mechanism of Injury Classification • Direct trauma • Indirect Trauma
- 19. Direct trauma • Tapping fractures • Crushing fractures • Penetrating fractures – High velocity missiles > 2500f/s – Low velocity missiles < 2500 f/s
- 20. Indirect Trauma : • Traction or tension fract. • Angulation fract. • Rotational fract. • Compression fract.
- 21. common causes of fractures • car accidents • Fall from a height • Direct blow • Repetitive forces • Pathology
- 22. Clinical Manifestations – Immediate localized pain – Decrease Function – Inability to bear weight or use affected part – Swelling – Bruising – May or may not see obvious bone deformity
- 23. Orthopedic Emergencies Resulting from Soft Tissue Trauma • Compartment syndrome • Vascular injury "complete vspartial”
- 24. Radiological evaluation X-ray Rules of 2 • Two views • Two joints • Two sides • Special views • CT scan
- 25. Fracture management Aims • A) safe life • B) Safe the limb • c) Safe the function
- 26. First Aids • Efficient First Aid: This relieves the pain and preventscomplications. • Safe transport: • This help to minimize complications of injures to the spine, fracture of the lower limbs, ribs etc all fractures should beimmobilized immediately • Backslab • traction • collar and cuff sling
- 27. Definitive fracture treatment • Conservative – Closed, undisplaced – Closed, reducible • Operative
- 28. conservative •Close Reduction : if displaced>under G.A or conscious sedation or L.A: traction and counter traction, manual realignment, reverse mechanism of injury. •Immobilization : POP cast , slab , Functional braces traction (fixed or balanced).
- 29. • Application of pulling force to attain realignment – Skin traction short- term: 48 - 72 hrs – Skeletal traction "longer periods"
- 30. Conservative treatment • Undiplaced or minimally displaced fractures • Fractures that can be immobilized and reduced non operatively • Patients who are not medically fit • Fracture of tarsal or metatarsal bone with less displacement • Fractures of the metacarpal bones lessdisplaced
- 31. Duration of immobilization: upper limb lowerlimb • Child : 4-3 weeks 8-6 weeks • Adult : 8-6 weeks 12-10weeks
- 32. Operative ORIF "open reduction internal fixat." - Pin & wire fixat. - Screw fixat. - Plate & screws fixat. - Intra-medullary fixat. Percutaneous pinning External fixation
- 33. Indications of internal fixation of the fractures • Displaced fractures longbone fractures • Intra-articular fractures • Unstablefractures • Fractures with vascularinjuries • Fracture neck of femur inadults • Fractures with multiple fragments • Multiple fractures
- 34. Rehabilitation Physiotherapy • It essentially consist of muscle Re-education exercise and instructions regarding mobilization of the limb and gait training
- 36. At time of injury ”Immediate" – Haemorrhage – Damage to important internal structures "brain ,heart" – Skin loss,Shock,Nerve damage – COMPARTMENT SYNDROME Fracture - Complications
- 37. Local General Tissue necrosis Deep VeinThrombosis, Local woundInfection Pulmonary embolism Loss ofalignment Osteoarthritis Delayed andmalunion Joint stiffness LATE COMPLICATION Fracture - Complications
- 38. Dislocation & Subluxation PIPJ Subluxation Elbow joint Dislocation. Subluxation :Is an incompletedisplacement. Joint dislocations require promptand effective care in the Emergency Department
- 40. Elbow dislocation injury inup to 8% Brachial artery
- 42. Hip dislocation Traumatic mechanism Typical appearance •19 % lead to sciatic nerve injury. •90 % Posterior dislocation .
- 44. Knee dislocation • swelling/hematoma • Ant. Most common • Complications – Popliteal artery ( 10- 30%) – Common peroneal nerve(20-30%)
- 45. Open fracture • Break in the skin and underlyingsoft tissue near the site of broken bone .
- 47. Type 1 Open Fractures • Wound less than 1 cm, • without contamination • minimal soft tissue injury • Inside-out injury
- 48. Type 2 Open Fractures • Wound between 1 and 10 cm, • mild contamination, • moderate soft tissue damage
- 49. • Wound larger than 10 cm • sever soft tissue damage – Subtypes 3A, 3B,3C – 3A: Adequate soft tissue coverage – 3B: Inadequate soft tissue coverage – 3C: Arterial injury requiring repair Type 3 Open Fractures
- 50. Open Fracture Classification Gustilo and Anderson • Type I Infection rate 0-2% – Clean wound <1 cm in length – # is simple, transverse or oblique with little comminution • Type II Infection rate 2-7% – Laceration >1cm without extensive soft tissue damage, flaps or avulsions • Type III Infection rate 10-25% – Extensive soft tissue damage, crushing or a traumatic amputation
- 51. Common bacteria encountered with open fractures Blunt Trauma, Low EnergyGSW Staph, Strept Farm Wounds Clostridia Fresh Water Pseudomonas, Aeromonas Sea Water Aeromonas, Vibrios War Wounds, High Energy GSW Gram Negative
- 52. What systemic antibiotic? 1st GenCeph Gent PCN Type 1 Type 2 +/- type3 +/- Farm/War Wounds
- 53. Initial assessment & management in ER • ABC’s • Assess entire patient • Careful PE,neurovasc S.T.A.N.D •Sterilecompressive dressings& Splinting • Tetanus tox. • Antibiotics • Narcotic med (Paincontrol( • Debridement & Localirrigation
- 54. OR management • Aggressive debridement and irrigation –Debridement to prevent deep infection –Remove any foreign body –Excise margins –Resects to healthy tissue. –Debridement preformed every 24-48hrs if needed . • Remove bony fragments w/o soft tissue attachments . • Fracture stabilization . • Early soft tissue coverage .
- 55. Open fracture stabilization • Splint – Good option if operative fixation not required • Internal fixation – Wound is clean and soft tissue coverage available • External fixation – Dirty wounds or extensive soft tissue injury