Amputations

Clearance Cervical Spine

Issue

 

Ventilated trauma patient

- most will have CT scan

- doesn't exclude ligamentous injury

 

Hard collar

- will cause neck ulcers if left on indefinitely (occiput and jaw)

- raises the ICP / issue in head injured patient

 

Options

 

1.  MRI

- sensitive but difficult especially in unwell, ventilated patient

- patients become more unstable being take to MRI

- ICP tend to rise (problem in head injuries)

- may increase time that cervical collar is left on

 

2.  Flexion / extension views of unconscious patient

- under fluroscopy

- is this safe in the ventilated patient?

- has been shown to be very safe

- only very occasionally detects unstable injury missed by CT

- however, difficult to defend if patient wakes up with neurology

 

3.  CT scan alone

- reported incidence of missed unstable C spine injury is 2.5%

 

Evidence

 

Spiteri et al J Trauma Infection and Critical Care 2006

- 839 ventilated trauma patients

- protocol of radiographs, helical CT and dynamic screening

- 87 unstable C spine injuries

- helical CT picked up 85

- dynamic screening picked up 1

- dynamic screening missed one atlanto-occipital dislocation

- a powers ratio on the CT would have detected this

- their conclusion was that helical CT was sufficient

 

Stelfox et al J Trauma Infection and Critical Care 2007

- 140 patients

- cervical collar removed if MRI or helical CT C0 - T1 normal

- policy changed to CT only

- no report of missed injury

- MRI patients waited longer, more likely to get ulcers, were ventilated longer

 

 

 

 

 

 

Compartment Syndrome

Definition

 

Circulation of tissues within a closed osteofascial space are compromised by increased pressure within that space

 

Most common 

- anterior leg compartment

- flexor compartment forearm

- deep posterior leg compartment

 

Aetiology

 

Prerequisite is volume restricting envelope 

- fascia & skin

- POP

- dressings

 

1.  Increased contents

 

Bleeding / edema 

- fracture

- osteotomies 

- crush injuries

- post - ischaemic swelling

 

2.  Decreased size

 

Tight casts & dressings

Tight closure of fascial defects

Fracture reduction 

 

Pathogenesis

 

Increased local tissue pressure increases pressure within intracompartmental veins

- local AV gradient is reduced

- causes decreased local perfusion secondary to Starling Forces

 

Metabolic tissues demands not met

- loss of tissue function & viability

- distal pulses remain as ICP < SBP 

- digit capillary refill remains as venous return extracompartmental 

 

Symptoms

 

1. Pain

- most important sign

- much great than expected 

- masked by coma / neural injury 

- unrelieved by opiates

 

2. Paraesthesia

- often early

- pins & needles or decreased sensation to light touch

- distribution important

- nerve of that compartment will be affected

 

Signs

 

3. Palpation

- swollen, tense compartment

 

4. Passive Stretch

- pain on passive stretch 

- subjective

- complicated by underlying trauma

 

5. Paresis

- may be due to proximal nerve injury or guarding 2° to pain

 

6. Pulses

- pulse & capillary refill are normally present

 

Diagnosis

 

Clinical Diagnosis

 

Tense compartment with pain +++

Pain on passive stretch

 

Intramuscular Pressure Measurement

 

Pressure Measurement

 

Indications

 

1. Unresponsive 

- head injury

- ventilated

2. Uncooperative 

- children, drug abusers

3. Underlying peripheral nerve deficit 

- tibial fracture with CPN nerve deficit

 

Techniques

 

1. Needle - Manometer Method (Whitesides)

- 18G needle is connected via a 3 way stop cock to an air filled 20 ml syringe

- air filled tubing which is connected to a Hg Manometer 

- a small amount of saline sits in tube connected to needle 

- compression of the syringe raises the pressure till saline flows into the compartment

- this is indicated by the meniscus moving

 

2.  Arterial Pressure Transducer

- i.e. devices used in ICU to measure arterial blood pressure and CVP

- no need to inject fluid

- pressure in saline tube equalizes with compartment

- connect to Wick or Slit catheter

- slits have many longitudinal slits to equalize pressure in tube with compartment

 

3.  Stryker Device 

- Variation on 2

 

Interpretation

 

Matsen > 45 mmHg

Mubarek & Rorabeck > 30 mmHg

Whitesides - within 30mmHg of DBP

 

Management

 

Prevention 

 

Remove all tight dressings

- splitting POP decreases pressure by 30%

- bivalving & cutting padding reduces pressure by another 55%

- elevate limb 

 

Avoid hypotension 

 

Ream without tourniquet

 

Early fasciotomy 

 

 

Full-length skin incision

Complete fasciotomy of all compartments

Assessment of muscle (colour / consistancy / contraction / bleeding)

Debridement dead muscle

Delayed DPC / graft 

 

2 Incision Technique Leg

 

Anterolateral compartments

- incision halfway between crest of tibia & fibula

- identify and protect SPN

- expose lateral intermuscular septum (transverse cut)

- release Anterior & Lateral compartments

 

Posterior compartments

- incision 2 cm posterior to posterior margin of tibia

- identify and protect saphenous vein / nerve anteriorly

- identify septum between superficial & deep compartments

- release fascia over Gastro-Soleus (superficial posterior compartment)

- release deep posterior compartment which is located behind the tibia / FDL

 

Perifibular Approach / Single incision Technique

 

Lateral incision beginning just posterior to fibula

- expose & protect CPN

- posteriorly release superficial posterior compartment

- release FHL (deep posterior compartment

- anteriorly expose and release anterolateral compartments after identifying SPN

 

Compartment Release Forearm

 

4 interconnected compartments

- volar superficial

- volar deep (FDP / FPL / pronator quadratus)

- mobile wad (BR, ECRL, ECRB)

- extensor

 

Volar

- incision from medial elbow to carpal tunnel

- must release lacertus fibrosis and carpal tunnel

- divide fascia

- this will release superficial flexor muscles

- ensure release mobile wad

- ensure release FDP

 

Dorsal

- often volar release wil decompress dorsal compartment

- usually ulnar sided incision

- proximal over muscle belly

- distally is mostly tendons

 

Compartment Release Hand

 

Two dorsal incisions

- over MT 2 and MT 4

- release interossei compartments

 

Carpal tunnel incision

- release thenar / hypothenar / adductor

- release carpal tunnel

 

Compartment Release Foot

 

2 dorsal incisions

- over MT 2 and MT 4

- release 4 interossei compartments

 

Medial incision

- release medial / central and lateral compartments

 

Complication

 

Volkmann's contracture

- ischaemic muscles fibrose & contract

- causes deformity & stiffness

- nerves damaged with variable numbness

 

 

 

Compound Fractures

Definition

 

Fracture with break in skin communicating with fracture haematoma or fracture

- contamination with micro-organisms

- coupled with damage to ST and vascular supply

- leads to increased risk in infection and healing problems

 

Gustillo Classification

 

Grade I

- low velocity / wound < 1cm

- minimal contamination & minimal tissue injury

 

Grade II

- wound > 1cm

- moderate contamination / moderate tissue Injury

 

Grade IIIA

 

High velocity injury

- segmental

- comminuted

- suggests extensive injury or loss of soft tissue

- damage to periosteum

 

DPC possible

 

Automatic Grade III

- shotgun wound

- high velocity gunshot wound

- segmental fracture with displacement

- diaphyseal segmental loss

- wound occurring in a farmyard / highly contaminated environment

- crushing force from a fast-moving vehicle

 

Grade IIIB

 

High velocity injury

After debridement needs skin flap / graft

 

Grade IIIC

 

Needed vascular repair to save limb

 

Infection Rate

 

I:      0-2%

II:     2-7%

IIIA:  7%

IIIB:  10-50%

IIIC:  25-50% with 50% or more amputation

 

Management

 

Goals

 

Prevent infection

Manage the wound

Stabilise the fracture

Enable healing

 

Immediate

 

EMST / ATLS Principles

 

Assess Limb

- vascular

- neurology

- skin defect / contamination

- photos

 

Treatment

- irrigate wound

- apply betadine dressing

- stabilise with POP if possible

- appropriate antibiotics / tetanus

- early OT for irrigation / debridement / stabilisation

 

Antibiotics

 

Guidelines

- grade 1: first generation cephalosporin

- grade 2: add gentamicin

- farmyard / heavily contaminate add penicillin (clostridium / gas gangrene)

 

Patzakis JBJS Am 1974

- prospective, randomised controlled trial

- infection with preoperative cephalothin was 2.3% 

- infection 13.9% without antibiotic

 

Swabs

- studies finding of initial swab correlating with infecting organism has been discredited

- no real correlation between road-side organisms & subsequent infection

- subsequent infection are typically hospital acquired

 

Gustilo

- increased rate of gram negative infection in Grade II

- hence add aminoglycoside if Grade II

- add penicillin if soil contamination

- no evidence any other combination is better

 

Timing

- delay > 3 hours increases infection risk

- 48 - 72 hours post injury

- 48 - 72 hours post each procedure

 

Wound Management

 

Irrigation

 

Gustilo JBJSA 1987

- infection higher if < 10L washout

 

Anglen 1984

- pulse lavage 100 x effective than bulb

 

Debridement

 

Must remove all non viable tissue

- remove cortical bone with no ST covering

 

Timing of wound closure

 

Do so when wound is clean

 

No evidence of increased infection with primary closure

- may prevent secondary contamination

- risk of clostridial myonecrosis

 

DPC (delayed primary closure)

- prevent anaerobic conditions in wound

- facilitates drainage

- allows second debridement

- can seal the wound via vacuum dressing

 

Fracture Stabilisation

 

Advantage

- prevent soft tissue from further injury

- facilitates host response to bacteria despite presence of implants

- allows mobilisation and functional rehab

 

Femur

- IMN best for I, II, IIIA and B

- 10% deep infection in type III B

- best to plate in type IIIC before revascularisation

 

Tibia

 

Reamed v unreamed

- no difference in infection rate

 

IMN v External fixator

- reduced risk of revision surgery, malunion and superficial infection with IM nail

- no difference in infection rate or union

 

External fixator

- heavily contaminated wound

- non amenable to nail (i.e. very distal)

- vascular injury

 

Soft Tissue Reconstruction

 

Options

 

Proximal tibia - local pedicle gastrocnemius flap

Middle third - soleus flap

Distal third - free muscle flap (rectus / gracilis / lat dorsi)

 

Timing

 

Gopal et al JBJS Br 2000

- early < 72 hours v late > 72 hours

- 6% v 29% deep infection

- did not use antibiotic beads

 

 

 

 

 

Concussion

Definition

 

Disturbance in brain function caused by direct or indirect injury to head

- no pathology seen on standard neuorological imaging

 

Pathophysiology

 

Disruption of mitachondria

- inability to produce energy

- accounts for symptoms such as lethargy etc

 

Headache

- ? due to ligament injury at cranio-cervical junction

 

Symptoms

 

Confusion

Tiredness

Lethargy

Inability to concentrate

Headache

Sleep impairment

Slowed reaction times

 

Symptoms worsen with

- concentration

- physical exertion

 

80 - 90% resolve within 1 week

- some patients suffer prolonged post concussion syndrome

 

NHx

 

2 x grade 3 concussions in career

- risk of permanent damage < 10%

- amateur sportsman should cease sports after 2 x Grade 3 concussions

 

3 x grade 3 concussions in career

- risk of permanent damage 60%

 

Adolescent

- studies have shown that after a grade 3 concussion in the next year

- A grade students show little effect to their grades

- average students have significant risk of failing grades

 

Management

 

Generally accepted that concussed athlete should not return to the game

 

Sideline assessment

 

SCAT2 / Sport Concussion Assessment Tool

- assess symptoms and GCS

- also tests memory / concentration / balance / co-ordination

 

Canadian CT Head Rules

 

Stiell et al Lancet 2001

 

1.  GCS < 15 2 hours post injury

2.  2 or more vomiting episodes

3.  Age > 65

4.  Signs basal skull fracture

5.  Signs skull fracture

6.  Dangerous mechanism - > 3 foot or > 5 stairs

7.  Amnesia before event > 30 minutes

 

Zurich Consensus Statement SAJSM 2009

 

Recommends use of SCAT2 and graduated return to play

 

Grading American Academy Neurology 1997

 

Grade 1

 

Definition

- no loss of consciousness

- head injury with confusion < 15 minutes

- full memory of the event

 

Action

- first concusion: return to sport within 15 minutes

- second concussion: 1 week

 

Grade 2

 

Definition

- no loss of consciousness

- confusion > 15 minutes

 

Action

- first concussion: 1 week

- second concussion: 2 weeks

 

Grade 3

 

Definition

- loss of consciousness

- 3A:  few seconds

- 3B:  minutes

 

Action

 

3A

- first concussion: 1 month

- second concussion: 6 months

 

3B

- first concussion: 6 months

- second concussion: 1 year

 

Neuropsychological testing

 

i.e. IMPACT

 

Performed as baseline for all collision athletes

- can then compare scores if concussed

- assess when return to normal / degree impairment

 

Online test availabe

- word remembering

- line drawing recognition

- coloured squares

- X & O

 

Return to sport

 

Stepwise symptom-limited program, with stages of progression

- 24 hours minimum for each step

- return to step 1 if symptoms recur

1. Rest until asymptomatic (physical and mental rest)

- recovery phase
2. Light aerobic exercise (e.g. stationary cycle)

- increase HR
3. Sport-specific exercise

- add movement
4. Non-contact training drills (start light resistance training)

- co-ordination and cognition
5. Full contact training after medical clearance

- functional skills assessed by coach and trainers
6. Return to competition (game play)

 

 

Damage Control Orthopaedics

Definition

 

Approach that contains and stabilises orthopaedic injuries

- so that the patient's overall physiology can improve

 

Aim to avoid second hit of a major orthopaedic procedure

- delay definitive fracture repair until a time when the overall condition of the patient is optimised

 

History

 

Damage control began in general surgery

 

Phase 1

- control bleeding with packs

Phase 2

- resuscitate patient

Phase 3

- definitive surgery

 

Pathogenesis

 

One hit

- initial massive injury and shock

- intense systemic inflammatory syndrome

- macrophages, leucocytes, NK cells, interleukin, complement

- can precipitate multiorgan damage and failure

- i.e. increase endothelial permeability in lungs and predispose to ARDS / MODS

 

Second hit

- restimulates / hyperstimulates inflammatory system

- i.e. prolonged surgical procedures

 

Injury severity markers

 

IL6

- correlates well with degree of injury

- now routine in large trauma centres

 

CRP, TNF, IL 1 and 8

- no correlation to injury severity

 

Genetic predisposition

- DLA-DRII

 

Indications for DCO

 

Unstable patients / patient in extremis

 

Bilateral lung contusions / thoracic trauma 

 

Abdominal / pelvic trauma and hemorrhagic shock

 

Bilateral femur fractures

 

Parameters

1.  Acidotic:  pH < 7.24, lactate > 2.5 mmol/l

2.  Hypothermia:  temperature < 35

3.  Transfusion: > 10 units of blood

4.  Coagulopathy:  platelets < 90 000

4.  Long operative times > 90 minutes

5.  > 65 / geriatric patient

 

Exaggerated inflammatory response

- IL 6 > 800 ug/ml

 

Injury Severity Score / ISS

- > 20 with chest trauma

- > 40

 

Injury Severity Score

 

Based on Injury Scale / AIS

- 9 body regions

- head / face / neck / chest / spine / abdomen / UL / LL / external

- rated in severity 1 - 6

- max of 75

- minor / moderate / serious / severe / critical / untreatable

- a score of 6 in any region indicates futility of medial care

 

ISS

- 6 body regions

- head and neck / face / thorax / abdomen / extremity / external

- top 3 scores in any region are squared

- major trauma > 15

 

Timing of secondary Orthopaedic Procedures

 

Inflammatory response not diminished until day 6

 

Probably once patient stable

 

 

 

 

 

 

EMST / ATLS

Background

 

Trauma is 3rd most common cause death in all age groups

- number one in young adults < 44 years

Death

 

Death occurs in 3 time periods

 

1.  First few minutes

- death secondary aortic rupture or severe head injury

- 50% die in this period

- only a few survive 

- only if rapid transport 

 

2. Golden Hour 

- major head injury (Haematoma)

- chest injury (Pneumothorax)

- abdominal injuries (Ruptured viscus)

- major fracture (Pelvis, Long bone)

- 35% of deaths

- high salvage rate

 

3. Late death

- days to weeks later 

- brain death / multiorgan failure / sepsis

 

Management priorities

 

1.  Life threatening injuries

2.  Limb threatening injuries

 

Assessment & Management

 

1. Preparation

A Pre-hospital

B In-hospital

2. Triage

3. 1° Survey

4. Resuscitation

5. 2° Survey

6. Continue post resuscitation monitoring & re-evaluation

7. Definitive Care

 

Can occur simultaneously or parallel

 

Preparation

 

A. Pre-hospital

 

Co-ordination between Ambulance & hospital

 

Aims

1. Airway control

2. Stop bleeding

3. Immobilize patient

4. Rapid transport to appropriate facility

5. Obtain history

 

B. In-hospital

 

1. Prepare trauma area

- 1 nurse to take observations on arrival and every 2 minutes

- 1 nurse to record

- cannulas / IDC / chest tube

- suction / intubation

 

2. Notify trauma team

- general surgery / cardiothoracic aware and available

- anaethetist aware and available

 

3. Notify lab

- O negative blood available

- ready to process emergency blood tests / cross match

 

4.  Radiology

- technician to take C spine / CXR / pelvis

 

Triage

 

Sorting of patients based on treatment needs

 

Two scenarios

 

Multiple

- patients don't exceed treatment maximum of hospital 

- treat life threatening pathology first

 

Mass

- patients exceed treatment maximum of hospital

- treat those who will survive if simple intervention

 

Primary survey

 

Life threatening conditions are diagnosed and treated simultaneously

 

A.  Airway Maintenance and Spinal Precautions   

 

A patient who can respond verbally to "How are you?" is conscious and has a clear airway

 

Assume spinal fracture

- hard cervical collar with sand bags and tape

- spinal board

- log roll

 

Monitoring / 2 x large bore 16G cannulas / bloods

- simultaneously attached

- 02 / ECG / blood pressure

- CBC / Renal and liver function / coags / Group and hold / cross match / BHCG

 

Immediate management

- jaw thrust and chin lift

- clear FB / blood etc

- apply oxygen

 

Indications intubation

- GCS < 8

- maxillofacial fractures

- laryngeal trauma / stridor

 

Intubation Adult

- guedel airway / preoxygenate 100% oxygen

- inline traction / protect spine at all times

- rapid sequence induction / cricoid pressure

- xylocaine spray 10%

- fetanyl (1 mcg / kg, 50 - 100 mcg)

- midazolam (0.05 - 0.1 mg / kg, 5 - 10 mg)

- avoid muscle relaxants if possible (succinylcholine 1 mg / kg, usually 100mg)

- avoid propofol if possible / causes hypotension (10mg / ml, give 2.5 mg / kg to maximum 250 mg)

 

Intubation Paediatric Patient

- use Broselow Paediatic Emergency Tape for weight and medications based on heights

- preoxygenate

- atropine 0.02mg / kg or 0.1 to 1 mg given 2 minutes before intubation

- this prevents excessive vagal response and dries secretion

- sedate midazolam 0.1 - 0.3 mg / kg

- cricoid pressure

- paralyse succinylcholine 2mg / kg < 10 or 1 mg / kg > 10

- ETT based on size little finger

- trachea short (5 - 7cm in infant) and very anterior

- set tidal volumes at 6 - 8 ml / kg and RR 40/min infant and 20/min older child

 

Unable to intubate

 

1.  Jet insufflation cricothyroidotomy

- prep / LA

- small incision often required

- insert 12 or 14 G plastic cannula through cricothyroid membrane

- attach to syringe / angle 45^o caudal

- aspirate as insert / stop when aspirate air / advance cannula over needle

- connect to 15 L minute oxygen

- have Y connector or cut side hole in tubing

- intermittitent insufflation 1 second on and 4 seconds off with thumb over hole

- suitable for 30 minutes

 

2.  Surgical cricothyroidotomy

- prep / LA

- horizontal incision between thyroid and cricoid cartilage

- horizontal incision between thyroid and cricoid / don't cut either cartilage

- open with artery forceps

- insert size 5, 6 or ETT, inflate and secure

- not suitable in children under 12 as cricoid is very important

 

Gastric distention / NGT

- can cause hypotension or aspiration

- very common in trauma / children / forced ventilate with bag and mask

- insert NGT as soon as able

- insert through mouth if facial trauma / avoids intracranial penetration

 

B.  Breathing  

 

Immediate management

 

Apply oxygen

- 12 L/min

- check RR (> 20 / minute worrying)

- check oxygen saturations

- apply ECG monitoring

 

Examination

 

Expose chest

- look / feel for flail segment

- symmetrical motion

 

Auscultate

- symmetrical breath sounds

- hear sounds

 

Palpate

- trachea midline

- heart apex

- rib fractures

 

Diagnosis

 

Pneumothorax / haemothorax

- decreased breath sounds

 

 

Tension pneumothorax

- heart apex and trachea displaced

- heart sounds (muffled + distended neck veins = cardiac tamponade)

 

Tension Pneumothorax / Needle thoracostomy

- second intercostal space in midclavicular line

- large gauge needle / 16G

- will hear hiss if tension

- need to place ICC

 

Pneumothorax / Hemothorax / Intercostal Catheter

- 5th intercostal space just anterior to midaxillary line

- need to avoid spleen / liver

- level with nipple

- use larger tube if for haemothorax

- gown and glove, prep, LA down to pleura

- scapel incision, artery forcep down through pleura

- blunt dissection

- insert 32 F gauge tube without stylet aiming posteriorly and superiorly

- connect to underwater suction drain at -20 cm H2O

- suture and tape in (no 1 suture purse string, standard dressing, sleek)

- ensure drain is swinging

 

 

Open chest wound

- taped on 3 side flutter dressing intially

- allows air out with expiration

- convert to occlusive dressing only after insertion of ICC

- ICC in 5th intercostal space

- otherwise risk tension pneumothorax

 

Cardiac Tamponade / Pericardiocentesis

- 20 ml syringe and 18G spinal needle

- aseptic technique

- insertion point between xiphisternum and left sternocostal margin

- can fill with some saline and inject 1ml periodically to prevent blockage of tip

- angle 45^o to abdominal wall, 45^o to sagittal plane

- aim for tip of left scapula

- insert up to 5 cm watching for ECG changes, aspirating as advance

- if patient truly has cardiac tamponage, insert drainage catheter using seldinger technique

- best done under echo guidance if possible

 

Hemothorax / Indications for thoracotomy

- > 1500 mls blood

- > 250 mls per hour for 4 hours

 

Flail chest

- no specific management required

- management of underlying lung injury

- may require mechanical ventilation / epidural

 

C. Circulation

 

Stages of Shock

 

	Stage I	Stage II	Stage III	Stage III
Blood loss	< 750	750 - 2000	1500  - 2000	> 2000
% blood volume	15%	30%	40%	> 40%
PR	< 100	> 100	> 120	> 140
BP	Normal	Decreased	< 90	< 70
Pulse Pressure	Normal	Decreased
RR	Normal		30 - 40	> 35
Urine output	> 30	Slightly reduced		Negligible
GCS	Anxious	Anxious	Confused	Lethargic

 

Immediate Management

 

Stop external bleeding / pressure

IV cannulas x2 16G         

Send off FBC / ELFT / glucose / Toxicology / Xmatch / pregnancy test

 

Resuscitate with isotonic crystalloid

- 2 litres then

- blood (O negative / type specific / cross matched)

 

Children 20 mls / kg bolus

- repeat x 3 then consider blood

- blood 10mls / kg type specific or O negative

- any hypotension in child indicates severe blood loss / > 45%

- can provide via intraosseous tibial infusion in < 6 hours

- anteromedial tibia below tibial tubercule / aim away from knee

- maintenance 4 / 2 / 1 rule per hour

 

Burns

- rule of 9's to calculate % BSA

- 2 - 4 mls RL per kg per % BSA first 24 hours

- half in first 8 hours, remainder in last 16 hours

 

Pelvic immobiliser / strap / sheet if any signs pelvic injury

 

ECG

- premature ventricular contractures

- lidocaine 1 mg / kg

 

Causes

 

Lung - tension pneumothorax / hemothorax

Heart - cardiac tamponade / aortic dissection

Abdomen - intra-abdominal bleeding

Pelvis - pelvic fractures

Long bone fracture

Spinal injury

External bleeding

Corticosteroid deficiency

 

Examine

- signs chest trauma / reduced breath sounds

- muffled heart sounds / distended neck veins

- abdomen exam - tenderness / rigidity

- pelvis - tender / mobile

- femoral deformity / long bone fracture

- external bleeding / scalp laceration

 

Investigations

- abdomen (Fast scan / DPL / CT scan) 

- pelvis (Xray)

- CXR (hemothorax / widened mediastinum)

- echo / CT chest

 

DPL

 

Technique

- LA

- decompress bladder with IDC

- decompress stomach with NGT

- incision supraumbilical if pelvic fracture / infraumbilical otherwise

- dissect down to peritoneum

- insert peritoneal dialysis catheter and aspirate

- if aspirate negative, infuse 1L crystalloid

- lavage , then aspirate 250 mls

- send to lab for analysis

 

Results

1.  Initial aspiration

- > 10 mls frank blood or obvious bowel contents

2.  Post lavage

- labs analysis: > 100 000 RBCs or > 500 WBC / ml, or positive gram stain

 

Hypotensive / Bradycardia

- suspect spinal injury

- trial 2L fluid

- atropine: 0.5 - 1 mg IV as push / maximum 3 mg

- noradrenalin: 0.1 - 2 mcg / kg / min up to maximum 30 mcg/min

- dopamine: 10 mcg / kg / min

 

IDC
- as soon as patient stable enough

- enables monitoring of resuscitation

- adults 0.5 mls / kg / hour

- paeds 1 ml / kg / hr (2mls if < 1 year)

 

D.  Disability 

 

GCS / Pupils

 

GCS = MVE

Severe HI <9

Moderate HI 9-12

Minor 13-15

 

Best eye response (E)

1. No eye opening 

2. Eye opening in response to pain

3. Eye opening to speech

4. Eyes opening spontaneously 

 

Best verbal response (V)

1. No verbal response 

2. Incomprehensible sounds

3. Inappropriate words

4. Confused

5. Oriented

 

Best motor response (M)

1. No motor response 

2. Extension to pain

3. Abnormal / decorticate flexion to pain

4. Normal flexion / Withdrawal to pain

5. Localizes to pain

6. Obeys commands

 

Head Injury < 9

 

Intubate

CT Head

Neurosurgery consult

Oxygenate

Avoid hypotension

Maintain low ICP

 

Low ICP

 

Maintain BP

- avoid glucose containing fluids

- Ringer's lactate or N/S

 

Hyperventilation

- low CO2 can cuase cerebral ischaemia

- keep CO2 at 35 mmHg

- can lower CO2 to 30 mmHg in acute deterioration

 

20% Mannitol

- indicated for acute neurological deterioration in patient without hypotension

- 1g / kg IV as bolus over 5 minutes

 

Seizures

 

Diazepam 0.2 mg / kg at rate 5 mg / minute

- so maximum dose 20 mg in 100 kg man

 

Phenytoin

- loading dose 1g IV at 50mg / minute

- maintenance dose then 100 mg / 8 hours

- titrate based on serum levels

 

E.  Exposure   

 

Suitably undress

Avoid hypothermia / keep warm

 

Do not proceed to Secondary Survey until stable

 

Early monitoring 

- PR / BP

- O2 sats

- arterial line

- NGT / IDC - if no CI

 

Trauma Series    

- lateral C spine / CXR / AP pelvis

 

Blood at meatus / high riding prostate / suspected urethral disruption

- urethrogram / 15 mls contrast via IDC in urethral meatus with balloon minimally inflated

- if urethra intact on xray / advance into bladder

- inflate with 1500mls contrast / saline and leave balloon inflated

- looking for bladder injury

- extraperitoneal - IDC left in situ draining

- intraperitoneal - requires surgery

- if urethra not intact requires urology intervention / surgery

 

Secondary survey

 

Meticulous examination from head to toe encompassing all systems looking for occult injury

 

History

 

Get ancillary history        

- ambulance officers / police / Family / Patient / Witnesses

 

Allergies

Medications

Past medical history

Last ate

Events related to accident         

- MOI / Restraint / Ejection

 

Head to toe

 

Scalp - lacerations / open fractures

Eyes  - pupils

Face - fractures

Mouth

C spine    

- tender

- step / gap / boggy swelling

- ROM if conscious and co-operative / no distracting injuries

 

Neck 

- subcutaneous emphysema

- lacerations

- tracheal deviation

- oesophageal injury

- vessel injury

 

Chest

- breath Sounds

- heart Sounds

- subcutaneous emphysema

- ribs / sternum / clavicle fracture

 

Abdomen 

- distension

- tenderness

 

Pelvis     

- spring test

- push / pull test

- tenderness / ecchymosis

- blood meatus / scrotal ecchymosis / open injuries (rectum / vagina) / high riding prostate

 

UL   

- shoulder girdle and clavicle / SC jts

- long bones

- dislocations

- neurovascular

- compartments

 

LL   

- long bones

- dislocations

- neurovascular

- compartments

 

Spine logroll

- step / gap / boggy swelling / tender / ecchymosis

- PR -  tone / power / sensation / BCR / anal wink reflex

 

 

Fat Embolism

Definition

 

Embolic marrow fat macroglobules damage small vessel perfusion

- leading to endothelia damage in pulmonary capillaries

- leads to respiratory failure and ARDS like picture

 

Epidemiology

 

Fat embolism

- 90% of traumas

 

Fat Embolism Syndrome

- 3 - 4 % 

- 10% mortality

 

Aetiology

 

Long bone or pelvic trauma

Femoral fracture + head injury

Nonoperative femoral treatment

Reamed femoral nails

Bilateral femoral fractures

 

Orthopaedic procedures including THA

 

Liposuction

IV lipids

 

Pathology

 

1.  Mechanical

- blockage

- likely minimal part 

 

2.  Biochemical

- damage to endothelium

- via fatty acids liberated by lipoprotein lipase

- leads to increased endothelial permeability

 

Diagnosis / Gurd's criteria 

 

One major and 4 minor criteria, plus fat microglobulinaemia must be present

 

Major

- respiratory symptoms / pulmonary oedema

- cerebral signs / altered mental status

- petechial rash (only 20 - 50%, over upper body especially axilla)

 

Minor

- PR > 110

- fever > 38.5

- retinal petechiae / fat globules

- jaundice

- elevated ESR

- renal dysfunction

- acute drop in Hb / platelets

- fat globules in urine or sputum

 

Management

 

Supportive

- maintain BP, UO

- mechanical ventilation

 

Prevention

- stabilisation of long bone fractures

- both reamed and unreamed nails cause increase fat embolism

 

 

 

Gunshot Wounds

Concept

 

Treat the wound, not the gun velocity

 

Management based on gun velocity old fashioned because

1.  Only 1/3 guns are known 

2.  High velocity guns can produce low energy transfer wounds

 

Wound Ballistics

 

Kinetic Energy = 1/2mv²

- important factor is tissue interaction

- energy transfer

 

Two mechanisms of tissue injury

 

1. Permanent cavity

- tissue actually hit by the bullet

- increases with distance travelled through tissue

 

2. Temporary cavity

- tissue stretched by the bullet passage

- as vacuum created, microbes can be sucked in at exit or entry

- increased with distance travelled through tissue

 

Microbes

 

Bullets are not sterile

- suck microbes in as well

- clothing fabric gets pulled in too

- wadding also gets into wound

 

Pathology

 

Amount of tissue damage depends on

 

1. Bullet type 

- partially jacketed fall apart

- Dum Dum - soft nosed bullets deform and start to spin earlier

 

2. Target tissue

- inelastic brain worse than elastic muscle

- bone fragments can produce their own injury

 

3. Tissue width 

- bullets really cause damage after they spin 180°

- occurs when hit tissue

- has to be > 12cm tissue thickness for this to start

- hence calf may have low energy transfer wound

- thigh / abdomen have high energy transfer

- energy transfer can increase as travel along wound

 

4. High velocity bullets

- have more kinetic energy to transfer

- much worse if start to spin / > 12 cm tissue

- better outcome if already exited prior to spin or fragmentation

 

Management

 

Initial

 

ATLS

- secondary survey

- entry wound / exit wound

- NV injury

- history gun type & range

- cover wound

- ADT & antibiotics

- splint 

 

Abdomen

- all GSW that pass through the abdomen become infected without 2/52 antibiotic treatment

 

Lumbar spine

- all bullets retained in the lumbar spine should be removed acutely

- the cauda equina involves multiple levels & LMN have a better chance of recovery

- better if < 48/24 or > 2/52 to avoid oedema

 

Operative Management

 

 

First OT

- scrub

- large incisions to explore wound

- excise all devitalised tissue 

- washout +++

- skeletal stabilisation

- always leave wound open

 

Remove bullet if

- easy to do so

- danger of later migration causing injury

- likely to cause later pain (i.e. hand / foot)

 

Second OT

- 48 hours

- DPC if wound clean

- SSG / muscle flaps as needed

 

Non-Operative Management

 

In USA good success with non-op management of low energy transfer wounds 

 

 

Principles of External Fixation

Indications

 

Acute / damage control

- compound injures

- periarticular injuries

- high energy injuries / let soft tissues settle

- multi-trauma (avoid second hit)

 

Chronic / definitive management

- mal /non union

- infection

- deformity

- LLD

 

Problems

 

Pin site infections

Malunion

Non union

 

Construction

 

Pins

 

Diameter

- < 1/3 diameter of bone

- 3, 4, 5 mm

 

Materials

- stainless steels

- titanium

- HA coated

 

Bars

 

Increased diameter

- increased strength and rigidity

 

Clamps

 

Modular, multidirectional

- pin to bar

- bar to bar

 

Frame types

- uniplanar

- biplanar

- circular

- hybrid (combination of planar + circular)

- joint spanning (non or articulated)

 

Increasing strength / stiffness

 

Increase pin diameter

Increase number of pins

Increase pin spread on same side of fracture

- near / far / near / far

 

Decrease distance of bar to bone

Increase number of bars

 

Note:  Increasing stiffness can lead to non union

- to increase union rates

- reduce stiffness

- i.e. reduce above factors

 

MRI issues

 

Non compatible

- local heating

- production of current

- costly disruption of MRI machine

- interference with pictures

 

Healing

 

1.  Rigid inter-fragmentary fixation

- intramembranous ossification

 

If a frame is too rigid

- osteopenic nonunion

- need to reduce rigidity

- may need bone graft

 

2.  Micro-motion / strain

- collagen formation and endochondral ossification

 

If a frame is too loose

- excessive callous

- hypertrophic non union

 

Types

 

Ankle External Fixation

 

 

 

 

 

 

Principles of Internal Fixation

Indications

 

Irreducible fractures

- fractures that cannot be reduced except by operation

 

Unstable fractures

- fractures that are inherently unstable and prone to re-displacement after reduction

 

Fractures that unite poorly

- i.e. fractures of the femoral neck

 

Pathological fractures

- fractures in which bone disease may prevent healing

 

Multiple fractures

- where fixation of one fracture facilitates treatment of the others

 

Fractures in patients who present nursing difficulties 

- i.e. paraplegics, multiply injured patients, elderly

 

Principles of Internal Fixation

 

Aim 

- produce stable fracture fixation

- minimum of devascularisation

- early motion and partial loading

 

Stable fixation 

- fixation that prevents motion of the fragments

- stable fixation is best represented by a simple fracture with a rigid plate applied across the fracture in compression

- the introduction of compression introduced stability

- stable fixation restores the load bearing capacity

 

Compression

- produces preloading, maintaining close contact of the fragment surfaces

- produces friction which resists transverse displacement and torque about the long axis

- allows the transfer of force from fragment to fragment rather than via the implant

 

Strain 

- relative deformation of a tissue

- displacement of fragments divided by the width of the fracture gap

- represents the degree of instability

- at very low levels of strain the bone heals by primary healing

- at intermediate levels healing is by callus 

- at high levels non-union occurs

 

Instability is best tolerated by multi-fragmentary fractures 

- the displacement is distributed over several interfaces 

- the individual strain is low

 

Strain is very high for bone fragments separated by a single narrow gap

- these fractures are very intolerant of even minute displacement

 

Types of Internal Fixation

 

1. Lag screws

2. Plates

3. Intramedullary Nails

4. Tension Band Wiring

 

Lag Screws

 

Stability is achieved by compression and bone contact

- load transfer occurs directly from fragment to fragment and not via the implant

- should be placed perpendicular to the fracture line

- can apply 2000-4000N

- 1 screw is never strong enough to achieve stable fixation and 2 or 3 screws are required

- provide excellent stability but their strength is usually inadequate to resist displacement under functional loads

- are therefore usually combined with a neutralisation plate

 

 

Plates

 

1. Neutralisation plate

2. Buttress plate

3. Tension Band plate

4. Bridging Plate

 

Neutralisation plate

- used to protect lag screws

- conduct part or all of the force from one fragment to another

- protect the fracture fixation from bending, shear, and rotation

- e.g. lateral malleolus fractures - lag then apply a derotation plate

 

 

Buttress plate / Antiglide Plate

- physically protect underlying thin cortex

- often used with metaphyseal fixation

- buttress is intra-articular (tibial plateau)

- antiglide is metaphyseal - diaphyseal

 

 

Compression plate (DCP - dynamic compression Plate)

- compression generated either by a tension device or by the dynamics of the plate itself (DCP)

- plate should be applied to the tension side of eccentrically loaded long bones

- produces fracture compression and resists tension forces

- DCP plate can produce about 600N (lag screw 2000-4000N)

- underlying bone loss due to interruption of blood supply / periosteum injury

- limited by decreasing the surface contact of the plate i.e. LCDCP (limited contact DCP)

- plate should be over bent to produce compression of the far as well as near cortex

- inner screws should be applied first

 

 

Bridging Plate

- used in the treatment of some multifragmentary fractures i.e. femur

- instead of individually fixing each fragment

- minimal disruption to blood supply

- reduction is performed indirectly

- compression is only sometimes possible

 

Concept

- 6 holes over each fragment if possible

- only fill 50% in intermediate fragments

- i.e. 3 bicortical screws sufficient

- near far near far concept

 

Intramedullary Nails

 

Indication

- for fixation of the diaphysis of long bones

- reamed vs unreamed

- initial nails relied on interference fit on either side of the fracture and hence could only be successfully applied to midshaft fractures

- interlocked nails have expanded indications to distal and proximal 1/3 shaft fractures

 

 

Tension Band Wiring

 

Concept

- relies upon compression by the dynamic component of the functional load

- allows some load induced movement

- really only suitable for metaphyseal regions

- eg. patella and olecranon

 

 

Screws

 

Cortical screws

- greatest SA of thread for any given length

 

Cancellous screw

- smaller core diameter

- larger thread diameter

- threads further apart (increased pitch)

 

Splints

 

Plaster 

 

Roll of Muslin stiffened by dextrose or starch

- impregnated with hemihydrate of calcium sulfate i.e. dehydrated gypsum

- when H20 is added, the calcium sulfate takes up its water of crystallization

- exothermic

 

Fiberglass

- knitted fiberglass

- 45% polyurethane resin

- 55% fiberglass

- prepolymer is methylene bisphenyl di-isocyanate (MDI), which converts to a nontoxic polymeric urea substance

- MDI molecules have isocyanate end-groups that react with any molecule containing an active hydrogen

- exothermic reaction 

 

 

 

 

 

Rib Fractures and Flail Chest

Incidence

 

10% of all multitraumas

 

Issues

 

Alters mechanics of ventilation / causes respiratory compromise

- significant morbidity 33%

- significant mortality 12%

 

Surgical Fixation

 

 

Swart et al J Orthop Trauma 2017

- meta-analysis of surgical fixation

- decreased mortality

- decrease mechanical ventilation times

- decreased ICU and hospital sty

- decreased rates of pneumonia and tracheostomy

 

Traction

Indications

 

Relieve pain

Reduce deformity

Hold fracture reduced

Allow movement while relieving pain

 

Types

 

Skin

Skeletal

Fixed

 

Reduction Principles

 

1. Apply traction in the long axis of the limb

2. Reverse the mechanism that produced the fracture

3. Align the fragment that can be controlled with the one that cannot

 

Skin Traction

 

Applied over large area of skin - spreads load

 

Never more than 10lb (4.5 kg)

 

Contraindications

- circulatory impairment

- lacerations or abrasions on skin 

- marked bony shortening - requiring greater reduction force

 

Skeletal traction

 

Indications

- lower limb fractures 

- cervical spine

   

Sites

 

Distal femur

- entry medial to prevent injury femoral artery on exit

- just proximal to adductor tubercle

- above intercondylar notch

- below Hunter's canal

- perpendicular to distal femur

- flex knee, insert knife, turn 90^o so there is a transverse nick in ITB so knee can flex if needed

 

Proximal tibia

- 2 cm posterior to crest and 2 cm inferior to tibial tuberosity

- insert laterally to avoid injury to CPN on exit

 

Distal tibia

- 5cm proximal to ankle joint in middle of tibia on lateral

 

Calcaneus

- 2 cm below and behind tip of lateral malleolus

 

Skull tongs

- 1.5 to 2 cm above superior tip of pinna

 

HTB

- roll patient and put on back piece

- apply front piece and attach

- apply halo pins x 4

- outer edge of eyebrows

- close eyes tightly to prevent inability to closure

- above and posterior to ears

- 8 pound / sq inch

- ensure below equator of head

- attach to thoracic brace

 

Fixed traction

 

Definition

 

Force applied against fixed point of body

- i.e. ischial tuberosity

 

Thomas splint (1876)

- counter traction

- up against ischial tuberosity

- need 2 cm clearance about thigh

- needs to be 15 cm longer than leg

- need slings to support leg and bandage over top

 

Balanced traction

- attach Thomas splint

- leg sits on padded slings on splint

- skin traction on calf

- tie to distal aspect of Thomas splint

- this is tensioned by winding about paddle pop stick

- weight hung off end of Thomas splint over pulley on edge of bed to pull away from ischium

- rope tied to Thomas splint and hung from top pulley with weight attached, this pulls the Thomas splint off the bed

- need safety rope attached to weight

- needs daily pressure care and regular oiling

 

Hamilton Russell traction

- also known as Australian traction

- first described by Dr Hamilton Russell of Melbourne in the 1920's