2. MAIN TOPIC
• OPEN FRACTURES
• ACUTE COMPARTMENT
SYNDROME
• CRUSH INJURY and CRUSH
SYNDROME
• DISLOCATION
• UNSTABLE PELVIC
FRACTURES
• MAJOR ARTERIAL
HEMORRHAGE
• SPINAL CORD INJURY
3. OPEN FRACTURES
• Osseous disruption in which a break
in the skin and underlying soft tissue
communicates directly with the
fracture and its hematoma
• Soft tissue injuries :
– Contamination of the wound and
fracture
– Crushing, stripping, and
devascularization soft tissue
– Destruction or loss of the soft
tissue envelope
4. complete assessment of the open fracture
• reviewing the mechanism of injury,
• condition of the soft tissues,
• degree of bacterial contamination,
• characteristics of the fracture
Help to classify the fracture,
determine the treatment regimen,
and establish the prognosis and
potential clinical outcome
5. CLINICAL EVALUATION
• ABCDE
• Initiate resuscitation and address
life-threatening injuries.
• Evaluate injuries to the head,
chest, abdomen, pelvis, and
spine.
• Identify all injuries to the
extremities.
• Assess the neurovascular status
of injured limb(s).
• Assess skin and soft tissue
damage
• Obtain necessary radiographs
6. Type Wound Level of
contamination
Soft tissue injury Bone injury
I <1 cm
long
Clean Minimal Simple, minimal
comminution
II >1cm
long
Moderate Moderate, some muscle damage Moderate
comminution
III
A Usually
>10 cm
long
High Severe with crushing Usually comminuted;
soft tissue coverage of
bone possible
B Usually
>10 cm
long
High Very severe loss of coverage;
usually requires soft tissue
reconstructive surgery
Bone coverage poor;
variable, may be
moderate to severe
comminution
C Usually
>10 cm
long
High Very severe loss of coverage plus
vascular injury requiring repair;
may require soft tissue
reconstructive surgery
Bone coverage poor;
variable, may be
moderate to severe
comminution
CLASSIFICATION : Gustilo and Anderson
7. Type~I of Open Fracture of the Lower Leg
I <1 cm
long
Clean Minimal Simple, minimal
comminution
8. Type~II Open Fracture of the Lower Leg
II >1cm
long
Moderate Moderate, some muscle damage Moderate
comminution
9. Type~II Open Fracture of the forearm
II >1cm
long
Moderate Moderate, some muscle damage Moderate
comminution
10. Type~III Open Fracture of the Fore Arm
III
A Usually
>10 cm
long
High Severe with crushing Usually comminuted;
soft tissue coverage of
bone possible
B Usually
>10 cm
long
High Very severe loss of coverage;
usually requires soft tissue
reconstructive surgery
Bone coverage poor;
variable, may be
moderate to severe
comminution
11. Type~IIIC Open Fracture of Femur
IIIC Usually
>10 cm
long
High Very severe loss of coverage
plus vascular injury requiring
repair; may require soft tissue
reconstructive surgery
Bone coverage poor;
variable, may be
moderate to severe
comminution
12. Principles treatment of open fractures
1. Cleansing the wound
2. Excision of
Devitalized Tissue
(Debridement)
3. Treatment of fracture
4. Closure of the Wound
5. Antibacterial Drugs
6. Prevention of Tetanus
13. EMERGENCY ROOM MANAGEMENT
1. Careful clinical and radiographic
evaluation.
2. Wound hemorrhage direct pressure!
rather than limb tourniquets
3. Initiate parenteral antibiotic(see later).
4. Assess skin and soft tissue damage;
place a saline-soaked sterile dressing on
the wound.
5. Perform provisional reduction of
fracture and place a splint.
6. Operative intervention
14. Antibiotic coverage for open fractures
• Grade I, II : first-generation cephalosporin (Cefacetrile,
cephalexin, cephalotin, cephaloridine, cephapirin, cefatrizine,
cefazedone, cefazolin, cephradine, cefroxadine, ceftezole)
• Grade III: add an aminoglycosides
15. The current dose of toxoid is 0.5
mL; for immune globulin, the
dose is 75 U for patients <5 years
of age, 125 U for those 5 to 10
years old, and 250 U for those >10
years old.
Immunization history dT TIG
Incomplete (<3
doses) or not known
+ -
Complete/>10 years
since last dose
+ -
Complete/<10 years
since last dose
- -
Tetanus Prophylaxis
16. Important!!
• Do not irrigate, debride, or probe the
wound in the ER if immediate
operative intervention is
plannedmay further contaminate
the tissues and force debris deeper
into the wound.
• If a surgical delay is anticipated,
performed gentle irrigation with
normal saline.
• Bone fragments should not be
removed in the emergency room, no
matter how seemingly nonviable
they may be.
17. OPERATIVE TREATMENT
• Irrigation, debridement and
remove foreign bodies
• Fracture stabilization
• Soft tissue coverage and bone
grafting
• Limb salvage
18. Principal of irrigation and debridement
• The wound should be extended proximally
and distally to examine the zone of injury.
• Large skin flaps should not be developed
• Tendons, unless severely damaged or
contaminated, should be preserved.
• Pulsatile lavage irrigation, with or without
antibiotic solution, should be performed
• Meticulous hemostasis should be maintained
19. Fracture stabilization
(internal or external fixation)
• provides protection from
additional soft tissue injury,
• maximum access for wound
management,
• maximum limb and patient
mobilization
20.
21.
22. Soft tissue coverage and bone grafting
• Performed once there is no further
evidence of necrosis.
• Bone grafting can be performed when
the wound is clean, closed, and dry.
• The timing of bone grafting after free
flap coverage is controversial.
• Some advocate bone grafting at the time
of coverage; others wait until the flap
has healed (normally 6 weeks).
23. Limb salvage
In Gustilo Gr III, immediate or early
amputation indicated if:
• The limb is nonviable: irreparable
vascular injury, warm ischemia
time >8 hours, or severe crush
with minimal remaining viable
tissue.
• After revascularization the limb
remains so severely damaged
• The patient presents with an injury
severity score (ISS; of >20)
24. ACUTE COMPARTMENT SYNDROME
Increased pressure within a closed fascial spaces of the arm, leg
or other extremity, most often due to injury, exceeds the perfusion
pressure (enough to occlude capillary blood flow) and results in
muscle and nerve ischemia.
25.
26.
27. Etiologies of CS
– Decreased Compartment Size:
• Crush syndrome
• Closure of fascial defect
• Tight dressing or cast
• External pressure(PASG or direct pressure)
– Increased Compartment Content:
• Bleeding
• Edema
• Postischemic swelling
• Exercise
• Trauma
• Burn
• Intra arterial drug
• Orthopaedic surgery or trrauma
• Venous obstruction
29. Injury
Energy is dissipated
into the muscle
intracellular
swelling
Increased pressure,
within the closed
space
circulatory
embarrassment
Ischemia and tissue
damage
30. Clinical picture:
6~P
1. Pain
2. Pallor
3. Puffiness
4. Paresthesia
5. Paralysis
6. Pulselessness
The earliest, most consistent, and most reliable
sign is deep, unrelenting, vague but progressive
PAIN that is out of proportion to the injury and
not responsive to normal doses of pain
medication.
38. • Crush injurycompression of
extremities and body parts that causes
muscle swelling and/or neurological
disturbances in the affected parts of the
body
• Crush syndromelocalized crush
injury with systemic manifestations.
Systemic effects caused by a traumatic
rhabdomyolysis and the release of
toxic muscle cell components and
electrolytes into the circulation
Synonym : Bywaters’ Syndrome
39. Previous experience with earthquakes that
caused major structural damage :
• Incidence of crush syndrome 2-
15%
• Half of those with crush
syndrome developed acute renal
failure
• Half of those with acute renal
failure needed dialysis
• >50% patients with crush
syndrome needed fasciotomy
43. Management of crush injuries
• Apply pressure dressing to gross arterial
bleeding
• Don’t attempt blind clamping of bleeding
vessels.
• Correct gross misalignment of extremities by
gentle application and repositioning of extremity
to better approximate normal anatomy.
• Flood open wounds with sterile saline solution
and cover with antiseptic soaked gauze
dreesings.
• Apply splinting material to immobilize the
injured extremity
• Apply adequate antibiotic and antitetanus
44. Surgical management in crush injuries
• Remember damage control principal
• Wound debridement
• Temporary vascular shunting (for vascular injury)
• External fixation
45. Indication for external fixation in crush injuries
• Unstable pelvic ring injuries not adequately controlled with an
external binder
• Femur fractures with prolonged transport time
• Open extremity frcatures with circumferential wounds needing
dressing changes
• Extremity fractures with associated vascular injuries
• Extremity fractures at risk for compartment syndrome
• Grossly unstable knee/ankle dislocations
47. Clinical manifestations of crush syndrome
• Hypotension acute hypovolemia
• Renal failure rhabdomiolisis releases myoglobin,
potassium, phosporus and creatinine into blood circulation
• Metabolic abnormalities
– calcium flow into muscle cell through leaky membranes
systemic hypocalcemia
– Potassium released from ischemic muscle into systemic
circulationhyperkalemia
– Lactic acid released from ischemic muscle into systemis
circulationmetabolic acidosis
– Imbalance of potassium and calciumcardiac
arrhytmiascardiac arrest
48. Diagnosis criterias of crush
syndrome
1. Crushing injury to a large
mass of skeletal muscle
2. The sensory and motor
disturbances, tense and
swollen
3. Myoglobinuria and/or
hematuria
4. Peak creatine kinase (CK)
> 1000 U/L
49. Management of crush syndrome
• ABC
• Hypotension fluid replacement
• Renal failure
– Prevent renal failure through appropriate hydration
– Maintain diuresis 300cc/hr with IV fluids and mannitol 20%
• Metabolic abnormalities
– IV Sodium bicarbonate 50-100 meq/l until urine pH reach 6,5
– Hyperkalemia/Hypocalcemiaadminister calcium, sodium bicarbonate,
insulin/D5%
– Cardiac arrhytmiasclose monitoring
• Amputation
• Fasciotomy: controversial
• Hyperbaric oxygen therapy
52. Anterior Shoulder Dislocation
• 90% of shoulder dislocations
• MOI :
– indirect trauma shoulder in abduction, extension and external
rotation
– direct: anteriorly directed impact to the posterior shoulder
• Patient presents with the injured shoulder held in slight abduction
and external rotation.
• Squaring of the shoulder
• Careful neurovascular examination is important (axillary nerve and
musculocutaneous nerve integrity)
53.
54.
55. Treatment of anterior shoulder dislocations
• Closed reduction should be
performed after adequate
clinical evaluation and
administration of analgesics
and/or sedation. Described
techniques include:
– Traction-countertraction
58. • Complication
– Tear of rotator cuff
– Avulsion of greater tuberosity
– Brachial plexus or axillary nerve injury
– Instability reccurrence (the most common
complication
59. ELBOW DISLOCATION
• Posterior dislocation is most
common.
• Simple dislocations are those without
fracture.
• Complex dislocations are those that
occur with an associated fracture and
represent just under 50% of elbow
dislocations.
• Highest incidence in the 10- to 20-
year old age group associated with
sports injuries
60. MOI
• Most commonly, injury is
caused by a fall onto an
outstretched hand or elbow,
• Posterior dislocation: This
is a combination of elbow
hyperextension, valgus
stress, arm abduction, and
forearm supination
61. • Patients guard the injured
upper extremity
• A careful neurovascular
examination should be
performed before
radiography or
manipulation.
• Following manipulation or
reduction, repeat
neurovascular examination
should be performed.
62. TREATMENT of Simple Elbow dislocation
Conservative
• For posterior dislocations, reduction should be performed with
the elbow flexed while providing distal traction.
• Neurovascular status should be reassessed, followed by
evaluation of stable range of elbow motion.
• Postreduction management should consist of a posterior splint
at 90 degrees and elevation.
• Early, gentle, active range of elbow motion is associated with
better long-term results
• Recovery of motion and strength may require 3 to 6 months.
63.
64. Operative, indications:
• The elbow cannot be held in a
concentrically reduced position,
• Redislocates before postreduction
radiography,
• Dislocates later in spite of splint
immobilization,
• Dislocation is deemed unstable
three general approaches to this
problem:
(1) open reduction and repair of soft
tissues back to the distal humerus,
(2) hinged external fixation,
(3) cross-pinning of the joint.
65. HIP DISLOCATIONS
• Anterior dislocations
constitute 10% to
15% of traumatic
dislocations of the
hip, with posterior
dislocations
accounting for the
remainder.
• Sciatic nerve injury is
present in 10% to
20% of posterior
dislocations
66. MOI
• Almost always result from high-
energy trauma, such as motor
vehicle accident, fall from a
height, or industrial accident.
• Force transmission to the hip joint
occurs with application to one of
three common sources:
– The anterior surface of the
flexed knee striking an object
– The sole of the foot, with the
ipsilateral knee extended
– The greater trochanter
67. Anterior Dislocations
• Comprise 10% to 15% of
traumatic hip dislocations.
• Result from external
rotation and abduction of
the hip.
68. Posterior Dislocations
• Much more frequent than
anterior hip dislocations.
• Result from trauma to the
flexed knee (e.g.,
dashboard injury) with the
hip in varying degrees of
flexion
69. TREATMENT
Closed Reduction
Allis Method
• Patient supine with the surgeon
standing above the patient on the
stretcher
• Surgeon applies in-line traction while
the assistant applies countertraction by
stabilizing the patients pelvis.
• Surgeon should slowly increase the
degree of flexion to approximately 70
degrees.
• Gentle rotational motions of the hip as
well as slight adduction
• A lateral force to the proximal thigh
may assist in reduction.
70.
71. STIMSON GRAVITY TECHNIQUE
• Patient is placed prone on the
stretcher with the affected leg
hanging off the side of the stretcher.
• This brings the extremity into a
position of hip flexion and knee
flexion of 90 degrees each.
• In this position, the assistant
immobilizes the pelvis, and the
surgeon applies an anteriorly
directed force on the proximal calf.
• Gentle rotation of the limb may
assist in reduction
72. OPEN REDUCTION
Indications for open reduction of a dislocated hip include:
– Dislocation irreducible by closed means.
– Nonconcentric reduction.
– Fracture of the acetabulum or femoral head requiring
excision or open reduction and internal fixation.
– Ipsilateral femoral neck fracture.
73. COMPLICATIONS
• Osteonecrosis: observed in 5% to 40% of injuries
• Posttraumatic osteoarthritis: the most frequent long-term
complication of hip dislocations
• Recurrent dislocation: rare (<2%)
• Neurovascular injury
74. KNEE DISLOCATIONS
• High-energy: A motor vehicle
accident with a dashboard•
injury
involves axial loading to a flexed
knee.
• Low-energy: This includes athletic
injuries and falls.
• Hyperextension with or without
varus/valgus leads to anterior
dislocation.
• Flexion plus posterior force leads to
posterior dislocation (dashboard
injury).
76. Clinical Evaluation
• Gross knee distortion
• Extent of ligamentous injury is related to
the degree of displacement, gross
instability may be realized after
reduction
• Ligament examination is important
• A careful neurovascular examination is
critical, both before and after reduction
• Vascular injury : popliteal artery
disruption (20% to 60%)
• Neurologic injury : peroneal nerve (10%
to 35%). Commonly associated with
posterolateral dislocations
77. TREATMENT
• The posterolateral
dislocation is irreducible•
owing to buttonholing of
the medial femoral
condyle through the
medial capsuledimple
sign over the medial
aspect of the limb
requires open reduction
• The knee should be
splinted at 20 to 30
degrees of flexion
78. Operative
• Indications :
– Unsuccessful closed reduction.
– Residual soft issue interposition.
– Open injuries.
– Vascular injuries.
• Vascular and ligamentous injuries
should be repaired.
79. COMPLICATIONS
• Limited range of motion: most common
• Ligamentous laxity and instability: uncommon
• Vascular compromise: result in atrophic skin
changes, hyperalgesia, claudication, and muscle
contracture.
• Nerve traction injury
81. • Initial survival depend on prevention of
death from hemorrhage
adequate replacement for blood
lost, and control ongoing bleeding
• Disruption of the posterior osseus-
ligamentous (sacroiliac, sacrospinous,
sacrotuberous)
• Unstable injury characterized by the type
of displacement as:
– Rotationally unstable
– Vertically unstable
82. Classification
Tile classification
(based on a continuum of stability)
– Type A fractures :
• Stable
• posterior ligamentous arch intact.
• avulsion fractures, iliac wing fractures, and transverse
fractures of sacrum.
– Type B fractures
• rotationally unstable but vertically stable.
• includes open-book and lateral compression (LC) injuries.
– Type C fractures
• vertically and rotationally unstable,
83. Young and Burgess classification based on Tile's classification.
4 subtypes
• anterior-posterior compression (APC),
• lateral compression,
• vertical shear (VS),
• combined mechanisms (CM)
84. Presentation
• ABCs (airway, breathing, circulation)
• MOI.
• Destot sign, superficial hematoma above
the inguinal ligament, in the scrotum, or
in the thigh
• Look for a rotational deformity of the
pelvis or lower extremities.
• LLD may also present with pelvic
fractures.
• Lower extremities must undergo a
thorough neurovascular examination
85. • Unexplained hypotension may be the only indication of
major pelvic disruption
• Physical signs: progressive flank, scrotal, perianal swelling
and bruising
• Mechanical instability, is test by manual manipulation
(should be performed only once!)
• Sign of instability:
– leg length discrepancy or rotational deformity usually external
– Open wound in flank, perinium, rectum
86. Imaging
Plain radiography
• Unstable fractures characterized by
– Hemipelvic cephalad
displacement that exceeds 0.5
cm SI diastasis that exceeds 0.5
cm.
– Findings suggestive of pelvic
instability include cephalad
hemipelvic displacement less
than 1 cm and/or a diastatic
fracture of the sacrum or ilium
less than 0.5 cm.
87. • All trauma patients in whom the spine cannot be clinically
cleared must receive full cervicothoracolumbosacral (CTLS)
spine series.
• Initial evaluation chest radiography.
Evaluate pathology includes pneumothorax, pulmonary
contusion, and acute respiratory distress syndrome (ARDS).
88. Treatment
• Hemodynamically unstable aggressive resuscitation and
prevention of further hemorrhage.
• External fixation is indicated in a hemodynamically
unstable patient with an unstable pelvic fracture.
• Operative indications
– diastases of pubic symphysis greater than 2.5 cm,
– sacroiliac joint dislocations,
– displaced sacral fractures,
– crescent fractures,
– posterior or vertical displacement of the hemipelvis (>1 cm),
– rotationally unstable pelvic ring injuries,
– sacral fractures in patients with unstable pelvic ring injuries that
require mobilization,
– and displaced sacral fractures with neurologic injury
89. Management
– Hemorrhage control
and rapid fluid
resuscitation
– Pelvic C-clamp
– Longitudinal skin or
skeletal traction
– Pelvic sling
– PASG
– Open pelvic
fracturepacking
the open wound
92. Contraindications
• ORIF is contraindicated for patients who are unstable
and critically ill or who have severe open fractures
with inadequate wound debridement, crushing
injuries
93. Major Arterial Hemorrhage
• Injury:
– Penetrating wound
– Blunt trauma
• Assesment:
– Loss of palpable pulse/changes in pulse quality
– Change in Doppler quality
– Cold, pale, pulseless
– Rapidly expanding hematoma
94. Management
– Application of direct pressures
to the open wound
– Aggressive fluid resuscitation
– Pneumatic torniquet
– Vascular clamp is not
recommended unless superficial
vessel is clearly identified
– If a fracture is associated with
an open hemorrhaging wound,
fracture should be realignment
and splinting
95. Spinal Cord Injury
• Insult to the spinal cord that partially or
completely interrupts the three main function of
the cord-motor, sensory, and reflexes activities
• Classification : ASIA impairment scale A-E
complete or incomplete
– Anal sphincter + /BCR + incomplete
96. Incomplete SCI
1. Central cord syndome prog. good
2. Anterior cord syndrome prog. worst
3. Posterior cord syndrome rare
4. Brown sequard syndrome most promising
5. Conus medullaris loss of bowel & bladder
function
6. Cauda equina syndromeneed urgent surgery
98. Management in SCI
Clearing the cervical spine
Tx of complicationts
Steroid : high dose methylprednisolon
Surgery
rehabilitation : physical, occupational, social workers, psycologist
