Nanthini S ThyeCheeKeong Lynette Lee NurNadiatulAsyikin NursheilaIzrin Oon Li Keat HurulAini CPC OrthopaedicsWITH PROF. RAZIF ALI
25 year old motorcyclist
Thrown off in a collision with a lorry
Brought to A&E unit in a hospital
On examination No head and spinal injury Stabilized Vital signs stable Initial assessment: closed fracture of his left femur closed distal extraarticular fracture of his right radius soft tissue injury of his right shoulder Decision was made for: internal fixation of his left femur closed reduction and POP of his right radial fracture as a semi emergency.
Question 1: In the Accident & Emergency Room while waiting to be admitted to the ward, describe FIVE (5) other procedures / actions you would do as part of treatment or investigation not mentioned above? (10 marks)
Continuation of the primary survey Disability (D) of the central nervous system Basic neurologic assessment with AVPU score: A – Alert V – Responds to verbal stimuli P – Responding to painful stimuli U – Unconscious Pupil size, inequality and reactivity to light GCS score
Continuation of the primary survey Exposure/Environmental control/X-Rays (E) Full exposure of the patient Assess from head to toe for injuries not recognized and managed Keep patient warm
X-rays: Cervical spine: lateral view of C1-T1 Chest : Anteroposterior view Pelvis : Anteroposterior view Focused abdominal sonography for trauma (FAST) scan on ‘5Ps’: Perihepatic – liver lacerations Perisplenic – splenic lacerations and rupture Pelvic – free fluid e.g. haematoma Pleural – haemothorax, pneumothorax Pericardial – pericardial effusion
Abdomen and pelvis External injuries Abdominal distension by gas or fluid Tenderness and guarding Bleeding from urethral meatus Presence of palpable bladder PR exam: blood, high-riding prostate, anal tone
Limbs Check the neurovascular status of each limb Analgesia – orthopaedic injuries are extremely painful Correct obvious deformity by temporary splinting
Name of procedure and Purpose
Skeletal traction of left proximal tibia Purpose:
To reduce a fracture or dislocation
To prevent or reduce muscle spasm
To immobilize a joint or part of the body
To treat joint pathology
PRIOR TO APPLICATION
Ensure adequate analgesia / sedation
Place patient in supine position
Record baseline neurovascular observations:
Skin colour and temperature
Capillary refill time
Movement of joints
Swelling and sensation
Observe affected limb for any:
Soft tissue damage
Principles of Skeletal Traction Align the distal to the proximal fragment Remain constant Allow for adequate exercise and diversion Allow for optimum nursing care
LOCAL ANAESTHESIA Inject local anaesthetic into the skin, subcutaneous tissue, and periosteum of both sides, making sure it goes under the periosteum.
Cord/ Rope is then attached to the pin’s holder and passed over a pulley, and fixed to a weight. The weight may pull the patient out of the bed, thus need to exert countertraction by raising the foot off his bed.
Due to procedure itself
Infection of the pin tract
Injury to common peroneal
Due to prolonged bed rest
9) The problem you suspected in QXN (8), describe 4 other symptoms and/or signs would you look for ? 6 “P”s? use them as criteria is Not reliable Only pain & paraesthesia useful The rest are uncommon or late signs Eg. Paralysis or even muscle weakness indicate irreversible muscle damage
Symptoms Pain out of proportion to apparent injury (early and common finding) Persistent deep ache or burning pain Paresthesias (onset within approximately 30 minutes to 2 hours of ACS; suggests ischemic nerve dysfunction)
Signs Pain with passive stretch of muscles in the affected compartment (early finding) Tense compartment with a firm "wood-like" feeling Diminished sensation (two point discrimination found to be earliest)
Late signs Pallor from vascular insufficiency (uncommon) Muscle weakness (onset within approximately two to four hours of ACS) Paralysis (late finding)
10) What first aid in the ward can you immediately give after you suspect the problem in QXN 8? relieving all external pressure on the compartment. Any dressing, splint, cast, or other restrictive covering should be removed Maintain perfusion: Hypotension reduces perfusion, exacerbating tissue injury, and should be treated with intravenous isotonic saline. The limb should not be elevated. Elevation can diminish arterial inflow and exacerbate ischemia . Analgesics should be given and supplementary oxygen provided. Further research
Capillary blood flow becomes compromised at 20 mmHg. • Pain develops at pressures between 20 and 30 mmHg. • Ischemia occurs at pressures above 30 mmHg. Traditional recommendations for decompression include absolute pressure readings above 30 mmHg , or above 45 mmHg .
The delta pressure is found by subtracting the compartment pressure from the diastolic pressure. Many clinicians use a delta pressure of 30 mmHg to determine the need for fasciotomy. Others use a difference of 20 mmHg .
11) Describe the pathophysiology of the problem you suspected in QXN 8?
Compartment Syndrome Anatomy
Muscle groups -including the nerves and blood vessels that flow through them- are covered by
a tough membrane (fascia) that does not readily expand-this area is called a “compartment”
PATHOPHYSIOLOGY complex pathophysiology the final common pathway is cellular anoxia  prerequisite for the development of increased compartment pressure is a fascial structure (prevents adequate expansion ) widely believed hypothesis : arteriovenous pressure gradient theory   Elliott, KG, Johnstone, AJ. Diagnosing acute compartment syndrome. J Bone Joint Surg Br 2003; 85:625. Olson, SA, Glasgow, RR. Acute compartment syndrome in lower extremity musculoskeletal trauma. J Am Acad Orthop Surg 2005; 13:436.
PATHOPHYSIOLOGY ↑ Compartmental volume (↑ fluid content) ↓ Compartment volume (constriction of the compartment) ↑ INTRACOMPARTMENTAL PRESSURE Due to inelasticity of fascia venous outflow is reduced (obstruction) oedema Inadequate venous drainage But early-Lymphatic Drainage compensate Vascular congestion Muscle and nerve ischaemia,necrosis Further ↑ intracompartmentalpressure (venous pressure ) ( arteriovenous pressure gradient) ↓ capillary perfusion Compromise arterial circulation (late)
Compartment Syndrome:Sequela After Initial Injury Tissue damage- irreversible tissue death within 4-12 hours permanent disabilities can develop from undiagnosed compartment syndrome Amputation- sometimes tissue beyond repair and only measure to prevent gangrene and death is amputation
Muscle infarcted Replaced by inelastic fibrous tissue ( Volkmann’s ischaemic contracture) Necrosis of the nerve and muscle within the compartment Vicious circle that Ends after ~12 hours Nerve -capable to regenerate
12) If the problem still continues despite first aid in QXN 10, elaborate what would you do?
Fasciotomy Fasciotomy -definitive and only treatment for acute compartment syndrome (ACS) If intra-compartment pressure > 40mmHg Immediate open fasciotomy Morbidity from delay is significant, so the operation should be performed immediately. The wound should not be stitched until a post-surgical assessment has been done at 48 hours. subsequent skin grafts may be needed for successful healing
Cross section of a forearm.Palm up.
the thick, fibrous bands that line the muscles are filleted open, allowing the muscles to swell and relieve the pressure within the compartment Depending upon the amount of swelling (edema), a second operation may be required later to close the skin after the swelling has resolved. If muscle necrosis, do debridement
Hyperbaric oxygen -considered as an adjunct treatment after surgery to promote healing and reducing repetitive surgery Treatment will also be directed to the underlying cause of the compartment syndrome try to prevent other associated complications including kidney failure due to rhabdomyolysis
13) You did a secondary survey, he complained of pain in left hip; you found he was tender in the left iliac region.What investigation will you order ? ( 1 mark ) ANTEROPOSTERIOR RADIOGRAPH OF PELVIS VITAL SIGNS
Anatomy of the pelvic bone
14) What did the investigation in Figure 2 show ? ( 1 mark ) ISOLATED FRACTURE OF LEFT ILIUM WITH INTACT PELVIC RING
15) IN THE SAME NIGHT after admission to A&E ( 10 HOURS after admission ), his pulse rate became 140 beats a minute and blood pressure became 70 / 40 mm Hg. He looked pale, there is pallor of conjunctivae and sweaty palms and forearms but he is still conscious. Explain briefly what pathophysiology may be happening here.(2 marks) Tachycardia Hypotensive Anaemic Sweaty palms * HYPOVOLAEMIC SHOCK(CLASS III) PELVIC FRACTUREBLOOD VESSEL INJURYBLEEDINGHYPO VOLAEMIC SHOCK
16) Name 3 investigations / actions / procedures you would do to stabilize the above situation.( 3 marks) Resuscitation: a)Vascular access:Insert TWO large bore cannula,Arterial line? b)Blood investigation c)Fluid therapy,oxygen Stabilization of the fracture: -pelvic binder/external fixator Repeat FAST scan Refer to orthopaedic team for further management of the fracture
17) Name 3 investigations / monitoring procedures to help you know that you really stabilized the above problem adequately.( 3 marks) a)Vital signs,Pulseoxymetry and CVP monitoring if available b)ABG C)CBD-urine output monitoring
The intended operation on the femur was delayed… On DAY 3 after the accident, the patient was noted to have ↓ level of consciousness in the ward round
Name 1 diagnosis you suspect & what other 4 symptoms and/or signs would you look for
Fat Embolism Presence of fat globules obstructing arteries in the lung parenchyma & peripheral circulation after long bone or other major trauma More frequent in closed than in open # Incidence ↑ with no. of # involved Can occur in relation to other trauma Pathogenesis: mechanical & biochemical theory
GURD’s Criteria for Diagnosis Major Axillary or subconjunctivalpetechiae Hypoxaemia PaO2 <60mmHg CNS depression disproportionate to hypoxaemia Minor Tachycardia >110bpm Pyrexia >38.5 Retinal emboli on fundoscopy Fat globules in urine and sputum Increased ESR, decreased haematocrit and platelet For diagnosis, at least 1 MAJOR and 4 MINOR criteria must be present
4 Symptoms and/or Signs Respiratory distress: SOB CNS abnormalities: Confusion, restlessness, coma Changes in V/S: ↑ temperature, ↑ PR Petechiae: neck, chest, axilla, subconjunctiva
Chest radiograph: may be normal / snow-storm appearance / diffuse, ground glass appearance Head CT-evidence of microvascular injury Spiral CT Others: -ECG, TEE -D-dimers -ventilation/perfusion scan
What further treatment would this patient receive?
Supportive Mx Maintenance of adequate oxygenation & ventilation Maintain stable hemodynamics Fluids & blood products as clinically indicated Prophylaxis of DVT & stress-related GI bleeding Nutrition
The right shoulder When En. M recovered from the operation and ICU, he began to ambulate. He complained of a right shoulder problem when examined as shown in Figure 3A and 3B
Figure 3A Figure 3B
Question 21 Name ONE clinical test which describe the method of examination shown in the figures Shoulder impingement test
Question 22 Name TWO diagnoses possible for the above problem 1. Rotator cuff impingement 2. Rotator cuff tear
The rotator cuff muscles
Rotator cuff impingement “Mechanical impingement of rotator cuff tendon beneath the anteroinferior portion of the acromion, especially when the shoulder is placed in the forward-flex and internally rotated position.” NeerCS 2nd. Anterior acromioplasty for the chronic impingement syndrome in the shoulder: a preliminary report. J Bone Joint Surg Am. Jan 1972;54(1):41-50.
Neer’s classification Stage I: oedema and haemorrhage Stage II: fibrosis and tendinopathy Stage III: partial or complete tear
Clinical features Pain Gradual onset In the anterolateral part of shoulder On overhead movement Worse at night Associated with weakness and stiffness Clicking or creaking sounds during movement Joint instability Positive Impingement test Normal range of movement and strength
Rotator cuff tear Partial tears frequently occur with supraspinatus tendinitis Complete tear may result from sudden shoulder strain or as complication of tendinitis or partial rupture
Clinical features History of trauma to the shoulder Pain Sudden onset In anterolateral part of shoulder Associated with gross weakness of abduction Joint instability Persistent painful arc of abduction Decreased strength on involved muscle group Decreased range of movement
Conservative Treatment NSAIDS Rest, activity modification (avoid irritating activities) Ice on affected area Physical therapy for stretching/ ROM Rotator cuff strengthening and scapular stabilization
Physical therapy Strengthening the rotator cuff tendons Stretching and regaining lost motion caused by pain and inflammation Allowing the humerus to be better positioned under the acromion, thus reducing compression of the bursa
Examples of physical therapy Cross arm push External rotation on elastic resistance cord
Surgical treatment Arthroscopic subacromial decompression to expand the space between acromion and rotator cuff tendons Rotator cuff repair in rotator cuff tears