Trauma Principles


Amputations about the Knee

BKA / Below Knee Amputation / Transtibial


Best results

- long posterior musculocutaneous flap 

- well cushioned mobile muscle mass

- full thickness skin

- very anterior scar



- non-ambulator

- get FFD

- better with through knee amputation


Advantages over AKA 


1.  Good Healing 

- > 90% in DM with BKA


2.  Higher prosthesis wearing rates 

- 74% vs 26% for AKA


3.  Reduced energy required for walking

- 74% BKA < 45 year old walk > 1 mile


4.  Reduced mortality 

- 10% vs 30%





- no tourniquet if PVD

- tourniquet in trauma (patients can bleed to death)


Posterior flap

- mark long posterior flap

- avoid suture line over anterior aspect of tibia / problems frequent here


Anterior flap

- short anterior flap at level of tibia cut

- want to extend posterior flap over distal tibia


Anterior Dissection

- find anterior NV bundle between T anterior and EHL

- deep peroneal nerve on interossesous bundle

- divide anterolateral muscles at tibial level to avoid bulbous stump


Tibial resection

- 15cm stump from joint

- no advantage in > 15cm as skinny poor stump

- < 3cm stump worse than through knee

- sharp dissect periosteum 2 cm above

- leave periosteal flap so can suture muscle flap to it

- bevel sharp edges


Fibula resection

- divide fibula 2cm above this

- need to ensure is stable (well connected to tibia via interosseous membrane)

- if not may need to create arthrodesis in young active patient


Fibular arthrodesis / unstabile fibula

- create wedge in tibia

- elevate periosteal sleeve to place over top of graft

- use 1 cm of fibula

- can get pain for 6-9 months as the graft unites


Posterior dissection

- find posterior tibial artery and tibial nerve

- on tibialis posterior between FDL and FHL

- divide deep muscles and allow to retract

- remove soleus leaving only gastrocnemius flap

- ensure vascularity flap


Myodesis gastrocnemius

- through drill holes in tibia and to periosteum of tibia

- fascial repair over muscle bellies



- over drain

- DPC if trauma or infection

- careful pressure dressings with tape to ensure good shaping


Through Knee




1.  Non ambulators

- aids sitting balance

- avoids FFD and subsequent problems


2.  < 3-5 cm tibia


3.  ST tissue loss means BKA not possible


Advantage over AKA

- improved socket suspension

- longer lever arm 

- muscle balanced amputation

- end-bearing potential

- less volume changes



- asymmetrical knee joint

- bulky prosthesis

- overcome by newer prosthetic techniques





- patients can bleed to death



- equal anterior / posterior flaps

- 5cm distal to knee joint

- fish mouth

- can make posterior flap slightly longer



- depends on technique 

- original method is to retain patella

- Mazet & Hennessy excise patella from tendon


Knee dissection

- divide PT off tibial tuberosity

- cruciates and collaterals divided at level of below meniscus

- aim to keep them long

- this preserves the rich proprioceptive function of the capsule


Deep dissection

- divide posterior capsule

- find and ligate popliteal artery and vein

- finding tibial nerve, tension, sharp divide, diathermy



- PT sutured to cruciate stumps

- biceps tendon sutured to PT

- gastrocnemius to anterior capsule


AKA / Transfemoral



- energy expenditure increased by 65%

- residual abduction as A Magnus released from adductor tubercle

- myodesis in 10o adduction maintains abductor strength and prevents abductor lurch

- residual flexion due to quads / hamstring inbalance





- sandbag under buttock

- avoid having leg in flexed position



- if able 

- can bleed to death



- actually want scar slightly posterior, with larger anterior muscle flap

- fish mouth

- larger anterior flap skin and muscle 



- cut quadriceps tendon above patella

- detach sartorius / gracilis / hamstrings 2 cm longer for myodesis

- detach A Magnus



- SFA below vas medialis in Hunter's canal / subsartorial canal

- profunda femoris posterior to femur

- can cut femur first to give access to NV bundles


Femoral transection

- save all possible femoral length

- increasing length increases muscle strength

- minimum 12 cm above knee to fit in prosthetic knee joint

- has to be >18 cm from GT or fixation difficult

- if stump < 5 cm below lesser trochanter then fitted as hip disarticulation


Adductor myodesis

- maintain stump in 10° adduction

- anatomical position

- suture through drill holes in lateral femoral cortex


Anterior musculature

- myodesis of quadriceps to posterior femur avoids FFD

- through anterior drill holes


Posterior musculature

- myoplasty to A Magnus or quads


Soft spica

- suspend dressing from waist

- support medial thigh



- positioning important to prevent contractures

- stump flat on bed

- intermittent prone positioning




Foot and Ankle Amputations



Level not predicated by angiography

- best is appearance of ST at time of surgery as judged by experienced surgeon





- dorsal-plantar or side-to-side flap

- tension free closure

- high reamputation rate in PVD / DM





- stabilise sesamoids in hallux amputation

- leave base of P1 to prevent adjacent toes falling into gap

- this also preserves plantar fascia

- tenodesis of FHB


Second Toe

- beware of HV postoperatively

- can use insert

- may need to fuse 1st MTPJ





- single medial or lateral ray that has an infected ulcer

- multiple resections may excessively narrow foot

- central ray amputations are inferior to Lis Franc amputation



- racquet shaped incision based on involved MT to avoid NV bundles

- most are partial ray resections

- leave base



- Oxford extra-depth shoes with custom insoles





- at TMT

- create long plantar flap

- smooth curve fashioned 



- muscle balance

- Tendo achilles lengthening may be required to avoid later equinus

- muscle reattachment especially Peroneus brevis (try to preserve base fifth MT)



- may initially require AFO

- usually shoe filler eventually





- excellent amputation

- through midfoot leaving only talus and calcaneum


Advantage over Symes

- no problems with heel pad migration

- functional end bearing stump

- no LLD



- original procedure without transfer had problems with late equinus & varus

- reattach to talus neck T. Ant / T Post / EHL / EDL

- Tendo achilles lengthening



- AFO with foot plate & filler

- slipper style prosthesis





- talectomy / forward shift of calcaneum / calcaneotibial arthrodesis


Advantage over Symes

- preserves length & growth centres

- no heel pad migration



- bulky stump

- poorer cosmesis



- dorsal incision from tip LM to 1 inch below MM

- planter incision transversely across sole at level MT bases

- amputate forefoot through Chopart joint

- excise talus

- anterior calcaneal osteotomy transversely across calcaneum at level of peroneal tubercle

- shift calcaneum anteriorly

- excise cartilage of distal tibia / fibula & superior calcaneum

- calcaneo / tibial arthrodesis

- steinman pin through calcaneum and tibia 

- close over drains





- talectomy 

- anterior 1/2 calcaneum excised 

- rotated 90°

- calcaneo-tibial arthrodesis

- used in children to preserve length & growth centres





- through ankle joint

- may allow ambulation with out prosthesis in emergencies 

- end-bearing with stable gait pattern

- can still fit ankle prothesis

- women can be unhappy with cosmesis



- from tip of LM to 1 inch below tip MM across front of ankle

- then continue plantarward under sole between same points / MT bases

- need to preserve large post heel pad

- excise talus & calcaneus

- remove malleoli at level of joint & contour 

- divide arteries / veins / nerves above levels of flaps

- anchor heel pad to anterior tibia via intra-osseous sutures 



- heel pad migration is biggest complication

- don't trim dog ears or can get skin slough







Hip Amputation

Hip Disarticulation / Boyd Technique 


Anterior Racquet shaped incision

- begins just inferior to ASIS

- curves medially to under inguinal ligament

- 5 cm distal to adductor origin


Identify and ligate femoral artery and vein


Posterior incision

- 5 cm beneath ischial tuberosity

- laterally 8 cm below greater trochanter 

- then curve back to ASIS


Superficial Dissection

- detach sartorius & rectus femoris proximal

- divide pectineus 1/2 inch from the pubis

- avoid division of obturator vessels from where exit pelvis


Anterior Deep Dissection

- ER leg

- divide iliopsoas tendon at LT

- detach adductors & gracilis at ischium

- expose and ligate obturator artery / nerve between pectineus & obturator externus at femur


Posterior Deep Dissection

- IR leg

- divide obturator externus / short external rotators at femur

- detach G max & G med from femur

- divide G max in line of skin incision



- disarticulation

- divide capsule & L Teres

- divide hamstrings at ischium


Muscle flaps

- suture gluteal flap to pectineus & adductor muscles 

- approximate skin edges


Hindquarter Amputation



- hemipelvectomy

- trans-iliac /trans-pelvic amputation


Set Up

- two surgeons 

- colostomy & stitch anus closed

- eschmarc to express limb of blood to prevent shock

- cross match 3 L of blood

- prepped from chest to below knees

- tape scrotum to opposite leg

- special frame to hold leg 

- lateral with amputated limb up


3 Part Technique King & Steelquist


Anterior Part

- begin incision at pubic tubercle

- extend along inguinal ligament to ASIS

- extend along crest to PSIS 

- detach abdominal muscles & inguinal ligament from the crest 

- open iliac fossae between peritoneum & iliacus

- at the pubis severe the inguinal ligament & the rectus abdominis & retract the cord medially

- open the space of retzius & retract the bladder into the pelvis

- divide external iliac artery and vein & femoral nerve


Perineal Part

- widely abduct the leg

- extend the incision from the pubic tubercle, along the pubic & ischial rami to the ischial tuberosity

- expose the subcutaneous rami

- elevate the ischiocavernosus & transversus perinei subperiosteally from the rami inferior surfaces

- divide symphysis pubis with osteotome


Posterior Part

- carry incision from PSIS to GT then along gluteal crease to ischial tuberosity 

- expose G max aponeurosis in line with the skin incision 

- elevate G max, forming a large flap of skin, fat & muscle

- expose G medius & short rotators into view 

- sever piriformis & sciatic nerve

- pass gigli saw through greater sciatic notch & bring it out over iliac crest just anterior to SIJ

- divide ilium, sacrotuberous & sacrospinous ligaments

- rotate inominate bone with leg to expose pelvic contents

- divide obturator artery and vein

- divide psoas at SIJ

- divide levator ani off pelvic wall

- hemipelvis now free



- suture G max flap to rectus abdominus / lateral abdominal wall / quadratus lumborum / psoas

- close skin over drains

- firm dressing





LEAP Study

Lower Extremity Assessment Project


Set up


Multicentre Prospective Outcome Study

- 601 patients

- severe, limb threatening lower extremity injuries

- 8 level 1 trauma centres




IIIC / IIIB / selected IIIA

- knee dislocations or closed tibial fractures associated with vascular injuries

- major ST injuries

- severe foot / ankle injuries (open pilon, type IIIB ankle)




GCS < 15 day 21

Third degree burns

Spinal cord deficit


Sensate sole


Bosse et al JBJS Am Dec 2005


3 groups of patients

1.  26 patients with insensate sole at time of admission who underwent amputation

2.  29 patients with insensate sole at time of admission who underwent limb salvage

3.  Case matched group with sensate sole who underwent limb salvage


Assessed at 12 and 24 months

- orthopaedic surgeon

- occupational therapist


- sensation assessed


Sensate v insensate salvage groups

- no difference late amputation

- no functional difference

- similar sensory examinations at 24 months


Insensate salvage v insensate amputation

- amputation more likely to use walking aid

- amputation more likely to have difficulty with stairs



- insensate sole is a poor predictor of eventual function and poor guide to amputation

- a large number have reversible ischaemia or neuropraxia


Outcomes of Reconstruction or Amputation


Bosse et al N Eng J Medicine Dec 2002


Case matched

- functional outcome for amputation or reconstruction the same






Mangled Extremity Severity Score

Mangled Extremity Severity Score  


Johansen et al 1990        

- no score is an absolute predictor of need for amputation

- only acts as a guide

- better to use in conjunction with vascular / soft tissue / bony reconstruction  required


"VISA gives you double frequent flyer points after 6 hours"









Low Energy           1

Medium Energy     2

High Energy          3

Very High Energy   4




Poor pulse                 1

Pulseless & poor CR   2

Totally avascular         3


Score doubled for ischemia > 6/24




Systolic BP > 90 mm Hg 0

Hypotensive transiently     1

Persistent hypotension      2


Age (Years)


< 30 0

30-50    1

> 50     2


Max = 11 or 14 if > 6hrs


>7 = 100% chance of amputation




Helfet Clin Orthop 1990

- objective criteria can predict amputation after lower-extremity trauma

- MESS was prospectively evaluated in 26 lower-extremity open fractures with vascular injury

- 4.00 for the 14 salvaged limbs 

- 8.83 for the 12 amputated limbs p < 0.01

- MESS > 7 100% predictive value for amputation








2/3 PVD 

1/3 Trauma 

5% Tumour

1% Congenital




Dead / Dying / Dangerous / Damn nuisance


Indications for amputation in open tibial fracture


Lange et al J Trauma 1985


Absolute Indications (1 of 2)

1.  Complete tibial nerve disruption

2.  Crush injury with warm ischaemia time > 6 hours


Relative indications (2 of 3)

- serious associated polytrauma

- severe ipsilateral foot trauma

- projected long course to full recovery


MESS (Mangled Extremity Severity Score) guide only

- involve patient in decision





- maximum function

- minimum complication rate



- most distal level that will achieve healing & provide functional stump



- improve sitting balance, transfers & nursing care

- through knee best in non ambulatory

- balanced amputation

- no FFD of knee, which limits impinging on bed and development of sores


Principles of Good Outcome


1.  Reconstructive approach 

- not considered as a failure

2.  Team approach

- early involvement of rehab / prosthetist

3.  Pre-op assessment & planning

4.  Patient explanation & involvement

5.  Good surgical technique

- optimal limb length

- good residual joint

- excellent ST (non adherent and durable) with muscle cushioning

6.  Early prosthetic fitting

7.  Amputee rehabilitation

8.  Appropriate prosthesis prescription


Energy Cost of Level


O2 Consumption inversely proportional to

- length of residual limb

- number of joints preserved


Increase over baseline

- long BKA 10%

- medium BKA 20%

- short BKA 40%

- medium AKA 60%

- hindquarter 100% +

- wheelchair ~ 0%


Maximum walking speeds

- normal = 82 m /min

- BKA = 50-70 m /min

- AKA = 40-55 m /min


Geriatric with PVD & AKA is virtually at maximum energy expenditure


End Bearing Vs Non- End Bearing


End Bearing / disarticulation 


Weight taken through end of stump

- scar non-terminal

- bone end metaphyseal, not hollow diaphyseal

- usually joint disarticulation

- end bearing prosthesis used


Non End Bearing / transosseous



- intimate fit needed to distribute load over as wide a load as possible

- load transfer usually over the entire residual limb

- scar can be terminal

- usually trans-osseous amputations where end bearing would be too painful






Maximise length & joints


Skin cover




Skin Flaps

- careful planning

- Atraumatic ST handling

- keep skin flaps thick

- avoid unnecessary dissection between tissue planes

- Non-terminal if end bearing

- Terminal if °End bearing

- Full thickness skin 

- Avoid SSG



- leave long

- Bevelled bone end

- Min Periosteal strip in adults

- strip 0.5 cm in kids to prevent terminal overgrowth





- Mobile non-adherent muscle mass


Stabilisation of distal ends

- provides padding over bone

- prevents atrophy

- avoids FFD by balancing deforming forces

- improves lever arm length i.e. avoid trendelenberg in AKA



- suture at functional length

- Myodesis - suture to bone

- Myoplasty - suture to muscle or ST



- Sharp division of nerve under gentle non-crushing retraction

- Allows cut end to retract into ST

- inevitable neuroma cushioned by muscle

- Clamping increases CRPS II

- Ligature / Diathermy has no effect



- Excellent haemostasis

- Delayed closure as needed




Immediate Post surgical Prosthesis Limb Fitting IPSF

- Rapid application of limb < 5/7

- Early Weight bearing

- Suitable for traumatic amputee's 

- Increased wound complications due to rapid stump shrinkage in first 2weeks


Early Post surgical Prosthesis Limb Fitting

- Better as most rapid stump shrinkage has occurred 

- 14-21 days

- Less wound complications






1. Phantom Sensation

- Sensation that limb still present

- Occurs in most patients

- Usually diminishes over time


2. Phantom Pain


Burning pain in Phantom limb

- Occurs in ~10% of pts

- usually settles 4- 6 weeks



- Increase prosthetic use

- Physio



3.  Causalgia / RSD 


Pain in stum - Burning / throbbing etc


Non-op Treatment

- Massage, Compression, TENS

- Varied success


Operative Treatment

- Limited success



- Effective

- Peri-op Epidural

- Post-op intraneural anaesthesia


4. Mechanical Causes 

- Sharp bone end

- Poor ST envelope

- Unstable skin 

- Ill fitting prosthesis


5. Other Causes

- Radicular pain

- Proximal OA

- Ischaemic pain

- Neuroma not uncommon cause consider LA injection for Dx





- Minimise with rigid dressings

- If soft dressings used, stump wrapping important


Excessive proximal tightness results in

- Proximal narrowing

- Increased distal oedema

- Dumb Bell stump




Usually occur between amputation & prosthetic fitting


Hip In AKA




- abduction


Minimised by

- Adductor Magnus / Hamstring stabilisation 

- Quads myodesis to posterior femur

- Avoidance of stump on pillow

- Early active & passive exercises

- Prone lying


Knee in BKA





Minimised by

- LL rigid dressings


- Quads strengthening

- HS stretching

- Difficult to treat once established because of short lever arm




Breakdown not uncommon

- Especially in PVD & DM




Numerous problems

- Epidermoid cysts

- Contact dermatitis

- Superficial skin infections







No ambulation potential

Severe cardiac disease 

Poor vision

Poor motivation or compliance

Poor stump - infected, ulceration, poor skin

FFD knee or hip




Young traumatic or neoplastic amputee

Motivated PVD / neuropathy amputee with cardiac reserves




Best to fit prothesis ~ day 14 

- allows most stump shrinkage to occur

- IPOP tends to cause high complication rate especially with PVD


Elements of a Prosthesis


1. Socket

- transmits forces between the stump & the prosthesis in all planes 

- may be proximal, distal or total bearing 


2. Means of Suspension

- suction socket 

- suspension belts 

- neoprene sleeve 

- elastic stocking 

- silicone sleeve 


3. Joint mechanism (knee)


A.  Stance phase control 



- aligns the prosthesis so the ground reaction force passes in front of the knee 

- locks in hyperextension; 2 drums lock at 0-15o

- for elderly 


Mechanical stabilisers 

- braking mechanism activated by the weight bearing load or hydraulics


B.  Swing phase control 

- pneumatic cylinder 

- hydraulic cylinder 

- intelligent prosthesis - computer adjusts rate of swing to cadence (steps/min) 


4. Terminal device / Foot 



- Solid Ankle Cushioned Heel

- wood keel / heel cushion / rubber foot

- use for BKA


B.  Single axis

- some DF/ PF possible

- makes knee stable

- use if knee stiff ie AKA or through knee


C.   Multi - Axis Foot

- hindfoot eversion / inversion + DF / PF

- better for active patient


D.   Dynamic Response

- "Ryan's Superfoot"

- flexible keel allows smoother roll over

- store energy via carbon fibre foot plate

- Aid toe off / more natural gait / save energy

- expensive

- not used in children as turnover too high


BKA Prosthesis




Usually firm PTB design

- can add liner for increased comfort

- definitive socket fitted 1 year (size stabilised by then)

- load patella tendon & medial / lateral flares

- most weight actually borne on medial tibial flare

- extend flares higher if unstable knee




Suprapatellar cuff

- simplest & most common

- dacron & leather

- grips condyles

- advantage is transfers all force to residual leg below knee


Supracondylar mould

- grips above femoral condyles

- young patient or < 5cm residual tibia


Neoprene 5mm liner

- rolled over distal thigh

- frictional fit ± suction

- negative pressures in swing


AKA Prosthesis 





- lack of bony contours

- not truly end bearing

- usually ischial bearing



1. Suction with valve hole

2. Waist or hip belts - if femur too short



- surface tension

- negative pressure

- active muscles

- stable body weight / socket fits




1. Quadrilateral

- traditional socket with narrow AP diameter

- weight bear on ischium / not in socket

- difficult for the femur to sit in adduction


2. CAT - CAM

- narrow medial - lateral diameter

- femur sits in adduction 

- more ovoid

- incorporate ischium into socket via flare

- more comfortable

- better femoral stability in socket


Knee Design Options


1. Single axis

- simple hinge


2.  Polycentric axis 

- 4 bar linkage device

- more natural

- expensive and heavy


3. Friction

- limits knee flexion


A.  Constant

- cheaper

- limited to one walking speed


B.  Variable friction, including with extension

- hydraulic controlled

- resist flexion in extended knee

- easy flexion in flexed knee

- allows different speeds 


4.  Safety knees / Stance control knee

- lock when weight applied 

- good for elderly



- Single Axis Safety Knee


Most expensive & heaviest

- Polycentric Hydraulic Controlled Knee


Through Knee Prosthesis



- endbearing socket



- via femoral condyle flares or strap

- 4 bar linkage knee overcomes previous problems with through knee

- folds away when sitting

- knees at same level



Upper Limb Amputations

General Principles


All possible length should be preserved consistent with clinical judgement

- function of amputated stumps decrease progressively with each higher level of amputation 

- prosthetic rejection by patient increases with the more proximal amputations

- most ADL'S can be performed adequately with one limb, so don't use prosthesis

- all nerves are drawn distally into wound & sectioned so they retract well proximally to bone level of amputation





- can preserve flexion / extension of radiocarpal joint which transmitted partly to prosthesis



- fashion long palmar, short dorsal flaps in ratio (2:1)

- divide tendons under tension

- divide nerves well proximal to amputation

- divide vessels just proximal to amputation bony level

- divide bones and smooth / round edges

- anchor wrist flexor and extensor tendons to remaining carpal bones in line of pull to allow wrist flexion/extension


Wrist disarticulation



- fashion long palmar, short dorsal flaps (2:1)

- skin apices 1cm distal to ulnar and radial styloids

- divide vessels, nerves, tendons and open radiocarpal joint

- resect radial / ulnar styloid processes & smoothen bony processes to form a smooth rounded contour

- protect distal radioulnar joint including triangular ligament to preserve supination/ pronation

- insert suction drain and skin closure 




Forearm amputationForearm amputation



- preserve as much length as possible (forearm rotation and strength proportional to length retained)

- if circulation compromised, amputation through distal 1/3 forearm are less likely to heal

- distally skin is thin and subcutaneous tissue scant

- junction mid and distal thirds good compromise for amputation level

- short 'below elbow stump' (up to 3.8-5cm long) preferable to through or above elbow

- important to preserve elbow joint



- skin incision apices at level of bone cut

- ligate radial / ulnar arteries and divide nerves under tension then transverse bone cuts and rasp edges

- fashion FDS flap long enough to be carried around bone ends 

- section rest of muscles at level of bone

- suture FDS flap over dorsal fascia


Proximal third

- fashion equal volar and dorsal flaps ideally

- divide muscle bellies distal to bone cuts to allow for retraction

- transverse bone cuts and rasp edges

- if stump is proximal to bicipital radial tuberosity, then resect distal 2.5cm of biceps tendon

- this lengthens stump functionally and enhances prosthetic fitting

- leaves brachialis as principle elbow flexor


Krukenburg's Amputation

- performed as a secondary procedure in 'below elbow' amputation

- converts forearm amputation into radial and ulnar pincers

- need at least 10 cm from olecranon tip & elbow flexion contracture <70o

- classically used in blind bilateral below elbow amputee


Elbow disarticulation



- good level for amputation due to easy fitting of prosthesis to distal humeral flare

- allows transmission of humeral rotation to the prosthesis (preferable to a more proximal humeral amputation)

- due to modern prosthesis techniques, disarticulation is preferred to proximal humeral amputation



- equal anterior and posterior flaps with apices at level  of humeral epicondyles

- posterior flap extents 2.5cm. distal to olecranon tip

- anterior flap extends just distal to biceps tendon insertion

- divide lacertus fibrosis

- reflect distally flexor origin off medial epicondyle

- expose neurovascular bundle on medial side of biceps tendon

- divide brachial artery, median and ulnar nerves proximal to elbow joint

- free the insertions of biceps and brachialis from radius / ulna

- divide radial nerve as lies between brachialis and BR

- divide transversely extensor mass 6 cm distal to joint line

- divide posterior fascia and triceps tendon near tip of olecranon

- divide anterior joint capsule to complete the disarticulation & remove the forearm

- leave intact articular cartilage of humerus 

- suture triceps tendon anteriorly to biceps and brachialis

- suture extensor muscle mass medially to flexor origin muscle stump


Can add distal humeral osteotomy

- create anterior angulation 45o

- aids prosthesis fitting / reduces need for shoulder harness


Above Elbow



- most important to preserve limb length


Above elbow prosthesis

- elbow-lock mechanism stabilises joint in full extension, flexion or in a position between

- lock mechanism extends 3.8 cm distally from the end of the prosthetic socket

- therefore most distal bone section should be 3.8cm from end of humerus to allow room for this mechanism


Supracondylar level

- equal anterior and posterior flaps at length 1/2 diameter of arm at that level

- artery and nerve divided proximal to level of resection

- divide anterior compartment muscle flaps 1.3cm distal to bone section level so they retract to this level

- free triceps insertion off olecranon & preserve as a long flap

- transverse bone cut 3.8 cm proximal to humerus end and rasp edges

- suture long flap of triceps anteriorly to the fascia over anterior muscles


Proximal to supracondylar level

- equal anterior and posterior flaps

- divide anterior compartment muscles 1cm distal to bone cut to allow retraction

- divide triceps 3.8-5cm distal to bone cut

- suture triceps anteriorly over bone end to anterior muscle fascia


Shoulder amputations



- shoulder amputation levels require fitting as if for joint disarticulation

- Prosthetic function is severely impaired at shoulder level 

- prostheses are used primarily as a holding device when performing activities with both hands


Through surgical neck



- patient supine with sandbag beneath shoulder (patient's back 45 degrees to table)


Anterior incision

- incision from coracoid process, along anterior deltoid border to its insertion


Posterior incision

- along posterior deltoid border to posterior axillary fold

- connect the two limbs of incision by a second incision that passes through axilla then incise anteriorly through axilla


Superficial dissection

- ligate cephalic vein, separate deltoid and pectoralis major in deltopectoral groove

- reflect deltoid laterally

- divide pectoralis tendon at its insertion and reflect medially


Expose neurovascular bundle

- develop plane between pectoralis minor and coracobrachialis to expose neurovascular bundle

- divide axillary artery and vein inferior to pectoralis minor

- divide nerves on stretch so they retract proximal to pectoralis minor


Deep dissection

- divide deltoid insertion and reflect deltoid / lateral skin flap superiorly

- divide teres major and latissimus dorsi at bicipital groove

- divide short and long heads of biceps, triceps and coracobrachialis 2 cm distal to bone cut

- section bone at surgical NOH



- suture long head triceps, both heads biceps and coracobrachialis over end of humerus

- suture pectoralis major tendon to bone end

- bevel deltoid to allow skin closure


Shoulder disarticulation


Position and incision

- as above


Superficial dissection

- ligate cephalic vein

- separate deltoid and pectoralis major

- retract deltoid laterally and divide insertion

- divide pectoralis major tendon at insertion and reflect medially


Neurovascular bundle

- divide conjoint tendon and P minor on coracoid

- expose neurovascular bundle

- ligate axillary artery and vein and thoracoacromial artery

- divide nerves on stretch so they retract proximal to pectoralis minor


Deep dissection

- reflect deltoid insertion superiorly to expose shoulder joint capsule

- divide teres major and latissimus dorsi at insertions

- after internally rotating arm divide posterior rotator muscles at insertion & posterior capsule 

- place arm in extreme external rotation & divide subscapularis anterior joint capsule

- divide triceps at infraglenoid tubercle insertion & divide inferior capsule to severe the limb



- suture all muscles across glenoid to fill the hollow out (deltoid to inferior glenoid)

- may need to trim prominent anterior acromion to produce smoothly rounded contour

- drain deep to deltoid





- shoulder girdle amputation

- consists of removal entire shoulder girdle / upper limb in interval between scapula and thoracic wall

- indicated for malignant tumour involving upper humerus or shoulder joint

- atypical skin flaps often used, may require axillary skin grafts


Anterior Approach




Upper limb of incision

- begins at lateral border sternocleidomastoid

- extends laterally along anterior aspect clavicle

- back across AC joint

- over superior aspect shoulder to scapular spine

- inferiorly along vertebral border of scapula to inferior angle


Lower limb

- starts at mid 1/3 clavicle

- runs inferiorly in deltopectoral groove 

- runs posteriorly through axilla to join upper limb incision at inferior scapular angle


Superficial Dissection

- subperiosteally dissect out clavicle 

- cut at lateral border sternocleidomastoid and through AC joint

- external jugular divided or retracted


Deep Dissection

- release pectoralis major off humerus and pectoralis minor off coracoid to expose neurovascular structures

- ligate subclavian artery and vein, divide brachial plexus under stretch

- release Lat dorsi & remaining soft tissues that bind shoulder girdle to anterior chest wall and allow limb to fall posteriorly and down 

- while holding arm across the chest divide posterior rotator cuff

- divide anterior and posterior muscles holding scapula to thoracic wall 

- trapezius / omohyoid / L scapulae / rhomboids / serratus anterior 

- suture pectoralis major and trapezius over lateral chest wall

- trim flaps and primary suture


Posterior Approach



- lateral decubitus position near edge of operation table





- make posterior incision first

- begin at medial end of clavicle, extending laterally along clavicle over acromion process to posterior axillary fold

- along axillary border of scapula to a point inferior to scapular angle

- curve incision medially to end 5cm from midline of the back

- same incision as for anterior approach except posterior limb runs along axillary border of scapula



- as above

- starts at mid 1/3 clavicle and runs inferiorly just lateral and parallel to deltopectoral groove

- then runs posteriorly through axilla to join posterior axillary incision at lower 1/3 of axillary border of scapula


Superficial Dissection

- elevate full-thickness skin flaps and subcutaneous tissue to medial border of scapula

- trapezius / lat dorsi divided parallel to medial border of scapula

- divide Levator scap / rhomboids / serratus anterior / omohyoid from scapula

- ligate vessels especially transverse Cervical artery and Transverse scapular artery

- free clavicle and divide at medial end with subclavius

- shoulder falls anteriorly


Deep dissection

- subclavian artery & vein / brachial plexus on stretch (divided close to spine)

- divide P major and minor & remove limb



Clearance Cervical Spine



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




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%




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



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




Prerequisite is volume restricting envelope 

- fascia & skin


- 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 




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 




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




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




Clinical Diagnosis


Tense compartment with pain +++

Pain on passive stretch


Intramuscular Pressure Measurement


Pressure Measurement




1. Unresponsive 

- head injury

- ventilated

2. Uncooperative 

- children, drug abusers

3. Underlying peripheral nerve deficit 

- tibial fracture with CPN nerve deficit




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




Matsen > 45 mmHg

Mubarek & Rorabeck > 30 mmHg

Whitesides - within 30mmHg of DBP






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 


Compartment Release


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



- 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



- 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




Volkmann's contracture

- ischaemic muscles fibrose & contract

- causes deformity & stiffness

- nerves damaged with variable numbness




Compound Fractures



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






Prevent infection

Manage the wound

Stabilise the fracture

Enable healing




EMST / ATLS Principles


Assess Limb

- vascular

- neurology

- skin defect / contamination

- photos



- irrigate wound

- apply betadine dressing

- stabilise with POP if possible

- appropriate antibiotics / tetanus

- early OT for irrigation / debridement / stabilisation





- 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



- 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



- 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



- delay > 3 hours increases infection risk

- 48 - 72 hours post injury

- 48 - 72 hours post each procedure


Wound Management




Gustilo JBJSA 1987

- infection higher if < 10L washout


Anglen 1984

- pulse lavage 100 x effective than bulb




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



- prevent soft tissue from further injury

- facilitates host response to bacteria despite presence of implants

- allows mobilisation and functional rehab



- IMN best for I, II, IIIA and B

- 10% deep infection in type III B

- best to plate in type IIIC before revascularisation




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




Proximal tibia - local pedicle gastrocnemius flap

Middle third - soleus flap

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




Gopal et al JBJS Br 2000

- early < 72 hours v late > 72 hours

- 6% v 29% deep infection

- did not use antibiotic beads









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

- no pathology seen on standard neuorological imaging




Disruption of mitachondria

- inability to produce energy

- accounts for symptoms such as lethargy etc



- ? due to ligament injury at cranio-cervical junction







Inability to concentrate


Sleep impairment

Slowed reaction times


Symptoms worsen with

- concentration

- physical exertion


80 - 90% resolve within 1 week

- some patients suffer prolonged post concussion syndrome




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%



- 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




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



- no loss of consciousness

- head injury with confusion < 15 minutes

- full memory of the event



- first concusion: return to sport within 15 minutes

- second concussion: 1 week


Grade 2



- no loss of consciousness

- confusion > 15 minutes



- first concussion: 1 week

- second concussion: 2 weeks


Grade 3



- loss of consciousness

- 3A:  few seconds

- 3B:  minutes





- first concussion: 1 month

- second concussion: 6 months



- first concussion: 6 months

- second concussion: 1 year


Neuropsychological testing




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



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




Damage control began in general surgery


Phase 1

- control bleeding with packs

Phase 2

- resuscitate patient

Phase 3

- definitive surgery




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



- 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



Indications for DCO


Unstable patients / patient in extremis


Bilateral lung contusions / thoracic trauma 


Abdominal / pelvic trauma and hemorrhagic shock


Bilateral femur fractures



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



- 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










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

- number one in young adults < 44 years



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




A. Pre-hospital


Co-ordination between Ambulance & hospital



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




Sorting of patients based on treatment needs


Two scenarios



- patients don't exceed treatment maximum of hospital 

- treat life threatening pathology first



- 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 45o 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




Expose chest

- look / feel for flail segment

- symmetrical motion



- symmetrical breath sounds

- hear sounds



- trachea midline

- heart apex

- rib fractures




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


PneumothoraxPneumothorax Post ICC


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 45o to abdominal wall, 45o 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



- 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



- premature ventricular contractures

- lidocaine 1 mg / kg




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



- 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



- abdomen (Fast scan / DPL / CT scan) 

- pelvis (Xray)

- CXR (hemothorax / widened mediastinum)

- echo / CT chest





- 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



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


- 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



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



CT Head

Neurosurgery consult


Avoid hypotension

Maintain low ICP




Maintain BP

- avoid glucose containing fluids

- Ringer's lactate or N/S



- 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




Diazepam 0.2 mg / kg at rate 5 mg / minute

- so maximum dose 20 mg in 100 kg man



- 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




Get ancillary history        

- ambulance officers / police / Family / Patient / Witnesses




Past medical history

Last ate

Events related to accident         

- MOI / Restraint / Ejection


Head to toe


Scalp - lacerations / open fractures

Eyes  - pupils

Face - fractures


C spine    

- tender

- step / gap / boggy swelling

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



- subcutaneous emphysema

- lacerations

- tracheal deviation

- oesophageal injury

- vessel injury



- breath Sounds

- heart Sounds

- subcutaneous emphysema

- ribs / sternum / clavicle fracture



- distension

- tenderness



- spring test

- push / pull test

- tenderness / ecchymosis

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



- shoulder girdle and clavicle / SC jts

- long bones

- dislocations

- neurovascular

- compartments



- long bones

- dislocations

- neurovascular

- compartments


Spine logroll

- step / gap / boggy swelling / tender / ecchymosis

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



Fat Embolism



Embolic marrow fat macroglobules damage small vessel perfusion

- leading to endothelia damage in pulmonary capillaries

- leads to respiratory failure and ARDS like picture




Fat embolism

- 90% of traumas


Fat Embolism Syndrome

- 3 - 4 % 

- 10% mortality




Long bone or pelvic trauma

Femoral fracture + head injury

Nonoperative femoral treatment

Reamed femoral nails

Bilateral femoral fractures


Orthopaedic procedures including THA



IV lipids




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



- respiratory symptoms / pulmonary oedema

- cerebral signs / altered mental status

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



- 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





- maintain BP, UO

- mechanical ventilation



- stabilisation of long bone fractures

- both reamed and unreamed nails cause increase fat embolism




Gunshot Wounds



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




Bullets are not sterile

- suck microbes in as well

- clothing fabric gets pulled in too

- wadding also gets into wound




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







- secondary survey

- entry wound / exit wound

- NV injury

- history gun type & range

- cover wound

- ADT & antibiotics

- splint 



- 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


Gunshot Wound Compound Pelvic Fracture


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 


Gunshot wound elbowGunshot wound elbow 2


Principles of External Fixation



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





Pin site infections


Non union







- < 1/3 diameter of bone

- 3, 4, 5 mm



- stainless steels

- titanium

- HA coated




Increased diameter

- increased strength and rigidity




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




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




Ankle External Fixation


Fracture blisters 1Fracture blisters 2


Ankle Ext Fix 1Ankle Ext Fix 2Ankle Ext Fix 3





Principles of Internal Fixation



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



- 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



- 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



- 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


Lag ScrewLag Screw 2




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


Derotation PlateNeutralisation 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


Antiglide PlageButtress PlateTibial Plateau ORIF


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


Forearm Fracture PlateCompression Plates


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



- 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



- 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


Humeral Nail APFemoral NailTibial IMN


Tension Band Wiring



- 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


Patella TBW




Cortical screws

- greatest SA of thread for any given length


Cancellous screw

- smaller core diameter

- larger thread diameter

- threads further apart (increased pitch)






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



- 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


Rib fractures Flail Chest


10% of all multitraumas




Alters mechanics of ventilation / causes respiratory compromise

- significant morbidity 33%

- significant mortality 12%


Surgical Fixation


Rib Fracture Plates


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





Relieve pain

Reduce deformity

Hold fracture reduced

Allow movement while relieving pain








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)



- circulatory impairment

- lacerations or abrasions on skin 

- marked bony shortening - requiring greater reduction force


Skeletal traction



- lower limb fractures 

- cervical spine




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 90o 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



- 2 cm below and behind tip of lateral malleolus


Skull tongs

- 1.5 to 2 cm above superior tip of pinna



- 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




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