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Pathology of Trauma


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Pathology of trauma, bone fractures and healing. Also included are pathology of bone including common bone tumors.

Published in: Health & Medicine

Pathology of Trauma

  1. 1. <ul><li>if we ignore the &quot;carrot&quot; of our Dreams, then we invite the &quot;stick&quot; of struggle. </li></ul><ul><li>Gill Edwards From &quot;Stepping Into the Magic - A New Approach to Everyday Life&quot; </li></ul>
  2. 2. CPC4.3.4- 19y Karen & Mike, <ul><li>Karen and Mike were returning home from a party in the early hours of Sunday morning. They left the party at about midnight . They were riding Mike’s 500cc motorbike with Mike driving and Karen as passenger. Both had helmets on. </li></ul><ul><li>A passing motorist calls ‘000 ’ at 02h15 asking for an ambulance. He says: ‘…they are both lying on the ground. He is very still . She appears to be in terrible pain and can’t move .’ The location is approximately 20 km from Charters Towers on the Hughenden road. </li></ul><ul><li>The first ambulance arrives about 15 minutes after the 000 call, followed by a police car about 5 minutes later. </li></ul>
  3. 3. CPC4.3.4- At the Scene… <ul><li>ABC assessment </li></ul><ul><ul><li>Mike: airway intact, breathing spontaneously 22 breaths/min, radial Pulse 110 bpm </li></ul></ul><ul><ul><li>Karen-Ann: airway intact, breathing spontaneously respiratory rate 34 breaths/min, radial pulse 140 beats/min </li></ul></ul><ul><li>Detailed examination </li></ul><ul><ul><li>Karen-Ann: bilateral compound femur fractures; ?fractured lower jaw (Left), no chest injury apparent, no abdominal injury apparent </li></ul></ul><ul><ul><li>Mike: L hypochondrial pain, L upper arm pain and loss movement ?fractured L humerus, no chest injury apparent. </li></ul></ul><ul><li>Tutors please introduce/remind students re concept of ‘AMPLE’ history (Allergies, Medications, Past history, Last ate/Tetanus/Events) </li></ul>
  4. 4. CPC4.3.4- At the Scene… <ul><li>Triage decision who needs to be taken to hospital first? </li></ul><ul><li>Tutors please facilitate this discussion based on ‘ABCD’ findings. The finding of a fractured jaw should immediately raise suspicion of cervical spine fracture; L hypochondrial pain should raise possibility of ruptured spleen </li></ul><ul><li>Which hospital Charters Towers : on call GP; TTH : Trauma unit. What are the pros and cons of each? Tutors: remind students re ‘stay and play’/’scoop and run’ debate; concept of ‘The Golden Hour’. </li></ul><ul><li>The ambulance paramedic calls TTH ED and speaks to the on call consultant; the helicopter is dispatched to collect Karen-Ann to take her to TTH; the ambulance will transport Mike by road to TTH. </li></ul>
  5. 5. CPC4.3.4- Core learning Issues… <ul><li>Basic science - Core Learning Issues: </li></ul><ul><ul><li>Over view of tissue injury & Healing . </li></ul></ul><ul><ul><li>Metabolic response to trauma </li></ul></ul><ul><ul><li>Shock - types and Pathophysiology. </li></ul></ul><ul><ul><li>Hypovolaemic shock </li></ul></ul><ul><ul><li>Limb anatomy : upper, lower, femur, humerus and associations (nerves, vessels, muscle attachments etc) </li></ul></ul><ul><li>Clinical Core Learning Issues: </li></ul><ul><ul><li>Assessment of trauma patients </li></ul></ul><ul><ul><li>Assessing patients in shock. </li></ul></ul><ul><ul><li>Assessment of patients with chest injury </li></ul></ul><ul><ul><li>Glasgow coma score </li></ul></ul>
  6. 6. CPC4.3.4- Core learning Issues… <ul><li>Pathology - Core Learning Issues: </li></ul><ul><ul><li>Pathology of fractures, fracture healing * </li></ul></ul><ul><ul><li>Pathology review of trauma, Tissue injury & Wound healing in skin & special tissues. </li></ul></ul><ul><ul><li>Chest injury – lung collapse, surgical emphysema, </li></ul></ul><ul><ul><li>Abdominal Trauma - Splenic rupture. </li></ul></ul><ul><ul><li>Pathology of Head Injury * </li></ul></ul>
  7. 7. &quot;People blame their circumstances for what they are. I don't believe in circumstances. The people who get on in the world are the people who get up and look for the circumstances they want, and if they can't find them, make them ….!&quot; - George Bernard Shaw
  8. 8. Pathology of Bone Fracture & Healing Dr. Venkatesh M. Shashidhar Senior Lecturer & Head of Pathology
  9. 9. Introduction: <ul><li>Bone is a dynamic tissue - </li></ul><ul><li>Osteoblasts - osteoid (type 1 collagen) </li></ul><ul><li>Calcium and phosphate (calcium hydroxyapatite) </li></ul><ul><li>Osteoclasts are multi-nucleated cells which resorb bone (PTH). </li></ul>
  10. 10. Bone Anatomy <ul><li>Diaphysis </li></ul><ul><li>Metaphysis </li></ul><ul><li>Epiphysis – Prox/Dist </li></ul><ul><li>Epiphyseal line </li></ul><ul><li>Periosteum </li></ul><ul><li>Compact cortical bone </li></ul><ul><li>Spongy bone </li></ul><ul><li>Articular Cartilage </li></ul><ul><li>Medullary cavity </li></ul><ul><li>Marrow </li></ul><ul><li>Nutrient artery </li></ul>
  11. 11. Blood Supply to Bone:
  12. 12. Bone tissue: <ul><li>Woven bone – Irregular, immature, fetus / growth plate / fracture. </li></ul><ul><li>Lamellar bone – regular – mature. </li></ul><ul><ul><li>Compact Bone. </li></ul></ul><ul><ul><ul><li>Circumferential </li></ul></ul></ul><ul><ul><ul><li>Concentric </li></ul></ul></ul><ul><ul><ul><li>Interstitial </li></ul></ul></ul><ul><ul><li>Spongy Bone </li></ul></ul><ul><ul><ul><li>Trabecular </li></ul></ul></ul><ul><li>Ossification: Formation of bone. </li></ul><ul><ul><li>Enchondral (long) / Intramembranous (flat) </li></ul></ul><ul><li>Osteoid: – protein mould of future bone. </li></ul>
  13. 13. Lamellar Bone:
  14. 14. Cancellous bone: (Polarization.M) Osteocyte Lamellae
  15. 15. Bone histology: lines of stress: (Black arrows)
  16. 16. Compact Bone: <ul><li>Osteons or Haversian systems. </li></ul><ul><ul><li>blood vessels, lymphatics & nerves. </li></ul></ul><ul><ul><li>osteocytes & in rings of calcified matrix. </li></ul></ul><ul><li>Osteons are aligned to lines of stress. </li></ul><ul><li>In spongy bone: (Trabecular) Lamellae are present but no osteons (& blood vessels). </li></ul>
  17. 17. The matrix of bone : <ul><li>Calcium Hydroxyapatite in collagen framework – RCC* </li></ul><ul><li>Minerals  hardness </li></ul><ul><li>Collagen fibres  Tensile strength. </li></ul><ul><li>Osteoblasts - Calcification - Mineralization </li></ul><ul><li>Collagen & matrix (osteoid) is necessary for Calcification. </li></ul>
  18. 18. Bone is dynamic  cont. remodeling <ul><li>5-10% / year </li></ul><ul><li>Vitamin D </li></ul><ul><li>Nutrition </li></ul><ul><li>Physical activity </li></ul><ul><li>Age, hormones </li></ul><ul><li>PTH, PHRP </li></ul><ul><li>IL1, TNF,TGF- β </li></ul>
  19. 19. Osteoblasts & Osteocytes in Osteoid: Osteocyte Osteoblasts Osteoid
  20. 20. Osteoclast in lacuna; Osteoclast Lacuna
  21. 21. Growth plate: Mature bone Immature bone
  22. 22. Osteoblasts & Osteoid: Osteocyte Osteoblasts Osteoid
  23. 23. Bone Review: <ul><li>Bone Function: </li></ul><ul><ul><li>Anatomy </li></ul></ul><ul><ul><li>Mineral homeostasis. </li></ul></ul><ul><ul><li>Hemopoiesis. </li></ul></ul><ul><li>Ossification/Calcification </li></ul><ul><ul><li>Intramembranous </li></ul></ul><ul><ul><li>Endochondral </li></ul></ul>Key Words: Mineralization Calcification Ossification Osteoid Tensile strength Volkmann’s canal Haversian canal Lacunae Osteon Compact bone Trabecular bone
  24. 24. Obstacles cannot crush me. Every obstacle yields to stern resolve. -Leonardo da Vinci
  25. 25. Pathology of Bone Fracture & Healing Dr. Venkatesh M. Shashidhar Senior Lecturer & Head of Pathology
  26. 26. Fractures: <ul><li>Discontinuity in the bone. </li></ul><ul><li>Simple / Compound. </li></ul><ul><li>Horizontal, oblique, spiral, </li></ul><ul><li>Comminuted – multiple. </li></ul><ul><li>Greenstick – partial, usually in children. </li></ul><ul><li>Torus – compression of cortex – children. </li></ul><ul><li>Colle's fracture ? </li></ul>
  27. 27. An individual at prolonged bed rest quickly begins to lose bone mineral density (BMD). Conversely, physical activity increases BMD . Use it or Loose it….!
  28. 28. Fracture Types: Transverse Spiral Oblique Linear
  29. 29. Fracture Types: Pott’s Incomplete Impacted Green stick
  30. 30. Fracture Types: Comminuted Colle’s Compound
  31. 31. Simple / Compound Fracture
  32. 32. Fracture Healing: 1 day 1-3 Week (Soft) 6 Weeks (Hard) >8 Weeks
  33. 33. Stages of fracture healing: <ul><li>1Day - Hematoma </li></ul><ul><ul><li>Blood clot, fibrin mesh – provide frame support. </li></ul></ul><ul><li>3Day-1wk - Inflammation </li></ul><ul><ul><li>Inflammatory cells infiltrate the wound. PDGF, IL, TGF etc.. Factors promote proliferation of stroma. </li></ul></ul><ul><li>1-3 Week - Soft callus. </li></ul><ul><ul><li>granulation tissue- Fibroblasts & endothelial cell proliferation with osteoid deposition. </li></ul></ul><ul><li>3-6 Week – Hard Callus </li></ul><ul><ul><li>– Mineralization of osteoid, ca+, woven bone forms. </li></ul></ul><ul><li>8Week+ - Re-modeling </li></ul><ul><ul><li>resorption/deposition along lines of stress. Lamellation & osteon formation. </li></ul></ul>
  34. 34. Bone healing - Callus Fracture Fibula 6 weeks later Callus Fracture
  35. 35. Bone healing - Callus
  36. 36. <ul><li>Irregular osteoid trabeculae </li></ul><ul><li>Lack of lamellae. </li></ul><ul><li>Prominent lining by osteoblasts. </li></ul><ul><li>Irregularly arranged osteocytes. </li></ul>Callus – Woven bone
  37. 37. Fracture with Callus <ul><li>Fractured bone ends. </li></ul><ul><li>Osteoid (note surrounding plump osteoblasts) </li></ul><ul><li>Granulation tissue </li></ul>
  38. 38. Fracture with Callus <ul><li>Fractured bone ends. </li></ul><ul><li>Granulation tissue </li></ul><ul><li>Woven bone (callus) </li></ul>
  39. 39. Factors affecting Bone Healing: <ul><li>Local factors </li></ul><ul><li>Immobilization * </li></ul><ul><li>Improper reduction – abnormal position </li></ul><ul><li>Infection. Debris, dead tissue in wound </li></ul><ul><li>Joint involvement </li></ul><ul><li>Damage to nerves / blood vessels. </li></ul><ul><li>Bone pathology – tumors, osteoporosis, etc. </li></ul><ul><li>Systemic Factors </li></ul><ul><li>Age* </li></ul><ul><li>Nutrition – vitamin /mineral deficiency. </li></ul><ul><li>Immune status. </li></ul><ul><li>Systemic Diseases </li></ul><ul><ul><li>Chronic disease </li></ul></ul><ul><ul><li>Diabetes* </li></ul></ul><ul><li>Drugs – steroids. </li></ul><ul><li>Genetic disorders </li></ul><ul><ul><li>Haemophilia etc.. </li></ul></ul>
  40. 40. Immobilization
  41. 41. Complications: <ul><li>Short Term: </li></ul><ul><li>Haemorrhage, Vascular injury* </li></ul><ul><li>Nerve / Visceral Injury* </li></ul><ul><li>Crush Syndrome* </li></ul><ul><li>Fat embolism </li></ul><ul><li>Renal failure </li></ul><ul><li>Shock, DIC. </li></ul><ul><li>Thromboembolism </li></ul><ul><li>Infection – Septicemia </li></ul><ul><li>Tetanus, Gas Gangrene </li></ul><ul><li>Long Term: </li></ul><ul><li>Delayed union </li></ul><ul><li>Non-union </li></ul><ul><li>Mal-union – deformity. </li></ul><ul><li>Growth disturbances </li></ul><ul><li>Contractures </li></ul><ul><li>Avascular Necrosis. </li></ul><ul><li>Osteomyelitis </li></ul><ul><li>Pseudoarthrosis </li></ul><ul><li>Osteoarthritis. </li></ul>
  42. 42. Crush Syndrome: <ul><li>Increase in osteofascial compartments pressure leading to Muscle ischemia / necrosis – may lead to limb amputation </li></ul><ul><li>Signs: </li></ul><ul><ul><li>Pain, Swelling, Inflammation, mottling (necrosis) and blisters. </li></ul></ul><ul><li>Complications: </li></ul><ul><ul><li>Acute Renal failure (Low-output uraemia with acidosis) </li></ul></ul><ul><ul><li>DIC </li></ul></ul><ul><ul><li>Rhabdomyolysis </li></ul></ul>
  43. 43. Osteomyelitis – excess Callus
  44. 44. Complications of # <ul><li>This is a photograph of the left calf showing 30° equinus deformity and severe scarring to the back of the lower leg. This was due to a severe soft tissue injury with ischaemia of the calf muscles and infection. Note the split skin grafting of the lesion. </li></ul>
  45. 45. Pseudoarthrosis <ul><li>Established non union of the mid shaft of the humerus of several years duration. </li></ul><ul><li>It was forming a mobile painless pseudarthrosis which he was using as an effective elbow joint. His actual elbow joint was completely stiff. No treatment was indicated. </li></ul>
  46. 46. Cubitus valgus deformity: <ul><li>Cubitus valgus deformity due to a fracture of the lower humerus 3 years previously. </li></ul><ul><li>Gradually increasing due to damaged lateral & continued growth of medial epiphysis. </li></ul><ul><li>Also note late or tardy ulnar nerve palsy. </li></ul>
  47. 47. Bone necrosis, Sequestrum - involucrum Sequestrum - Involucrum Sequestrum
  48. 48. Large sequestrum:
  49. 49. Disorders of Bone Paget’s Disease
  50. 50. Paget’s Disease
  51. 51. CPC4.3.4- Core learning Issues… <ul><li>Pathology - Core Learning Issues: </li></ul><ul><ul><li>Pathology of fractures, fracture healing * </li></ul></ul><ul><ul><li>Pathology – review of trauma, Tissue injury & Wound healing in special tissues. </li></ul></ul><ul><ul><li>Pathology of chest injury – lung collapse, surgical emphysema, </li></ul></ul><ul><ul><li>Pathology of splenic rupture. </li></ul></ul>
  52. 52. Summary & Further Reading: <ul><li>Bone types, histology, formation, </li></ul><ul><li>Osteons, HS, lacunae, lamellae </li></ul><ul><li>Calcium, PO 4 ,Vit D, PTH & Calcitonin, </li></ul><ul><li>Healing - stages, factors (local/systemic) , complications (short/long term) </li></ul><ul><li>Pseudoarthrosis, involucrum, osteomyelitis. </li></ul><ul><li>Systemic Bone Diseases: </li></ul><ul><li>Osteoporosis, Osteomalacia & Rickets </li></ul>
  53. 53. He who is fixed to a star does not change his mind because of rough road. -Leonardo da Vinci
  54. 54. CPC-3.4– MSS - Trauma <ul><li>Pathology - Core Learning Issues: </li></ul><ul><ul><li>Pathology of trauma, Tissue injury & Wound healing </li></ul></ul><ul><ul><li>Fractures, fracture healing </li></ul></ul><ul><ul><li>Pathology of chest injury. </li></ul></ul><ul><ul><li>Pathology of splenic rupture </li></ul></ul><ul><li>Basic science - Core Learning Issues: </li></ul><ul><ul><li>Over view of tissue injury & Healing. </li></ul></ul><ul><ul><li>Metabolic response to trauma </li></ul></ul><ul><ul><li>Shock types and Pathophysiology. </li></ul></ul><ul><ul><li>Hypovolaemic shock </li></ul></ul><ul><ul><li>Limb anatomy : nerves, vessels & muscle functions. </li></ul></ul>
  55. 55. What Nerve Injury? <ul><li>Radial </li></ul><ul><li>Median </li></ul><ul><li>Brachial </li></ul><ul><li>Axial </li></ul><ul><li>Ulnar </li></ul>
  56. 56. What Nerve Injury? <ul><li>Radial </li></ul><ul><li>Median </li></ul><ul><li>Brachial </li></ul><ul><li>Axial </li></ul><ul><li>Ulnar </li></ul>
  57. 57. What Nerve Injury? <ul><li>Radial </li></ul><ul><li>Median </li></ul><ul><li>Brachial </li></ul><ul><li>Axial </li></ul><ul><li>Ulnar </li></ul>
  58. 58. Fracture ? <ul><li>Scaphoid & radius </li></ul><ul><li>Radius & metacarpel </li></ul><ul><li>Ulna & Metacarpel </li></ul><ul><li>Colle’s & metacarpel </li></ul><ul><li>Ulna & metacarpel </li></ul>
  59. 59. 16y Boy, fracture. ? Diagnosis <ul><li>Mature spongy bone. </li></ul><ul><li>Woven bone. </li></ul><ul><li>Granulation tissue. </li></ul><ul><li>Osteomyelitis. </li></ul><ul><li>Osteosarcoma. </li></ul>A B
  60. 60. 16y Boy, bone, Identify structure A: <ul><li>Endosteum. </li></ul><ul><li>Central canal. </li></ul><ul><li>Bone marrow. </li></ul><ul><li>Osteocytes. </li></ul><ul><li>Lamellae. </li></ul>A B C B
  61. 61. What Nerve Injury? <ul><li>Radial </li></ul><ul><li>Median </li></ul><ul><li>Brachial </li></ul><ul><li>Axial </li></ul><ul><li>Ulnar </li></ul>
  62. 62. Which nerve injury is most likely? <ul><li>Radial </li></ul><ul><li>Median </li></ul><ul><li>Brachial </li></ul><ul><li>Axial </li></ul><ul><li>Ulnar </li></ul>
  63. 63. 28y man, increasing back pain & hat size! <ul><li>Soft callus fracture. </li></ul><ul><li>Hard callus fracture. </li></ul><ul><li>Osteoporosis. </li></ul><ul><li>Paget’s disease. </li></ul><ul><li>Osteosarcoma. </li></ul>
  64. 64. Fracture ? Type of tissue <ul><li>Soft callus </li></ul><ul><li>Trabecular bone </li></ul><ul><li>Woven bone </li></ul><ul><li>Spongy bone </li></ul><ul><li>Osteoid matrix </li></ul>
  65. 65. 28y man, Leg fracture. Identify ‘B’ <ul><li>Mature spongy bone </li></ul><ul><li>Woven bone </li></ul><ul><li>Granulation tissue </li></ul><ul><li>Osteoblasts </li></ul><ul><li>Osteoclast </li></ul>A B C D E
  66. 66. Fracture ? Identify structure B <ul><li>Mature bone </li></ul><ul><li>Granulation tissue </li></ul><ul><li>Osteoid tissue </li></ul><ul><li>Macrophages </li></ul><ul><li>Osteoblasts. </li></ul>
  67. 67. Fracture ? Expected complications <ul><li>Fat embolism </li></ul><ul><li>Mal union </li></ul><ul><li>Bone Necrosis </li></ul><ul><li>Radial nerve injury </li></ul><ul><li>All of the above </li></ul>
  68. 68. Pathology CLI: <ul><li>Pathology Major CLI: </li></ul><ul><ul><li>Pathology of Trauma – Fractures types, complications & bone healing. </li></ul></ul><ul><ul><li>Head injury – Pathology, Pathogenesis & clinical features. </li></ul></ul><ul><ul><li>Over view of Tumors of connective tissue – Osteosarcoma. (Web CPC 8) </li></ul></ul><ul><li>Pathology Minor CLI: </li></ul><ul><ul><li>Burns – Pathophysiology. </li></ul></ul><ul><ul><li>Blunt abdominal injury, spleen rupture. </li></ul></ul><ul><ul><li>Blunt and penetrating Chest injury, surgical emphysema, </li></ul></ul><ul><ul><li>Forensic Pathology – Gun shot, knife, electric, drowning. </li></ul></ul>
  69. 69. CPC-3.4– KFP Questions/theme: <ul><li>Types of fractures. </li></ul><ul><li>Stages of Fracture healing – gross & Micro. </li></ul><ul><li>Factors affecting fracture healing – Local / systemic. </li></ul><ul><li>Complications of fractures. </li></ul><ul><li>Clinical & Pathology of specific organ trauma: Spine, chest, abdomen, spleen </li></ul><ul><li>Pathology of Crush syndrome. </li></ul><ul><li>Head injury: (covered separately) </li></ul>
  70. 70. &quot;I learned that good judgment comes from experience and that experience grows out of mistakes .&quot; – Omar Bradley
  71. 71. Fracture Cases Self Assessment Questions.
  72. 72. ? Fracture - ? complications. <ul><li>Injury to Posterior tibial vessels and nerves. </li></ul><ul><li>Ischaemia / Infarction. </li></ul><ul><li>Paralysis of the foot. </li></ul><ul><li>Acute blood loss – shock </li></ul><ul><li>Crush syndrome </li></ul><ul><li>Renal Failure </li></ul><ul><li>Fat embolism. </li></ul><ul><li>Long term compl…? </li></ul>
  73. 73. What Nerve Injury? <ul><li>Radial </li></ul><ul><li>Median </li></ul><ul><li>Brachial </li></ul><ul><li>Axial </li></ul><ul><li>Ulnar </li></ul>A median nerve palsy due to a wound on the palmar aspect of the wrist. This is causing wasting and paralysis of the thenar muscles.
  74. 74. What Nerve Injury? <ul><li>Radial </li></ul><ul><li>Median </li></ul><ul><li>Brachial </li></ul><ul><li>Axial </li></ul><ul><li>Ulnar </li></ul>Median nerve injuries lead to loss of wrist flexion strength, ulnar deviation of the wrist, loss of thumb opposition, and loss of finger flexion of the thumb, index and long finger interphalangeal joints.  When making a fist, the ring and small fingers flex while the long and index tend to stay straight.  In low median nerve injuries the fingers are still able to flex, but thumb opposition is often lost.  
  75. 75. ? Fracture ? complications <ul><li>Median, Ulnar, Radial neuropathy. </li></ul><ul><li>Radiocarpal arthrosis. </li></ul><ul><li>Mal position, Mal union </li></ul><ul><li>Tendon Ruptures </li></ul><ul><li>Finger stiffness. </li></ul><ul><li>Volkmann’s ischemia </li></ul><ul><li>Shoulder-hand syndrome* </li></ul>
  76. 76. <ul><li>May damage radial nerve </li></ul><ul><li>If there is any doubt as to whether the nerve will recover, one should await for evidence of possible recovery of the nearest muscle supplied below the lesion. This is the brachioradialis with radial nerve injuries in the mid shaft of the humerus. The rate of possible regeneration of the nerve is assessed at 1mm a day or 3 cm (1 inch) a month plus an extra month. </li></ul>? Fracture ? complications
  77. 77. ? Trauma ? findings <ul><li>The Chest X-ray showed rupture of the left hemi-diaphragm with associated collapse of the left lung. The Chest X-ray showed rupture of the left hemi-diaphragm with associated collapse of the left lung. </li></ul>
  78. 78. Todays Summary: <ul><li>Trauma – Basic Science, Pathology & Clinical & EPP& RR issues. </li></ul><ul><li>Anatomy </li></ul><ul><li>Circulation, shock, ischemia, infarction. </li></ul><ul><li>Tissue injury – Healing. </li></ul><ul><li>Bone Fractures – Bone Healing. </li></ul><ul><li>Stages, Factors affecting & Complications. </li></ul><ul><li>Abdominal, Thoracic Trauma. </li></ul><ul><li>Head injury – later.. </li></ul>
  79. 79. Spiritual Wisdom All your suffering start with your desires. Stop desiring and you won't suffer. Jalaluddin Rumi
  80. 80. 22 Female Motorcycle accident
  81. 82. 22 Female Motorcycle accident internal fixation was used after the fracture was reduced, and a Rush nail was inserted up the fibula to maintain alignment. Debridement and split skin grafting done. Surprisingly recovery… as no major vascular or nerve damage.
  82. 83. Spleen Rupture: <ul><li>Most common abdominal solid organ injury </li></ul><ul><li>Preexisting disease  markedly increase the risks & severity of splenic injury. </li></ul><ul><li>Preexisting infections or Splenomegaly  fragile, large with thin capsule  rupture. </li></ul><ul><li>Minor impact in patients with splenomegaly reportedly results in major injury and the need for splenectomy. </li></ul>
  83. 84. Blunt Trauma: <ul><li>two-thirds of the stomach and the spleen had herniated through a 10cm diaphragm laceration into the chest. The stomach and spleen were reduced into the abdomen by extending the laceration laterally. </li></ul>
  84. 85. ?Trauma: ? findings <ul><li>A CT scan showed the stomach in the left thoracic cavity, and the rib fractures responsible for the diaphragmatic laceration: </li></ul>
  85. 86. ? Fracture ? complications  What is this shadow?
  86. 87. <ul><li>The collar cuff is supporting a fracture of the shaft of the humerus. The only absolute indication for a collar cuff sling in upper limb injuries is in humeral shaft fractures. This is because the weight of the arm help reduce the fracture and helps hold the fracture in alignment. </li></ul>? Fracture ? complications
  87. 88. <ul><li>You tell me now, </li></ul><ul><li>I don’t know…!!! </li></ul>? Fracture ? complications
  88. 89. <ul><li>???? </li></ul>? Fracture ? complications
  89. 90. <ul><li>What level UMN ? </li></ul><ul><li>What level LMN ? </li></ul><ul><li>Urinary symptoms? </li></ul>? Fracture ? complications
  90. 91. ? Fracture ? complications <ul><li>Compound Mid Shaft # Femur. </li></ul><ul><li>List complications shown in the image? </li></ul><ul><li>List Short term & Long term complications? </li></ul>
  91. 92. ? Fracture ? complications
  92. 93. ? Fracture ? complications Cervical spine - C1 post ring fracture right side. C2 fracture body with listhesis.
  93. 94. Spinal Injuries <ul><li>3 major types - Cervical, Thoracic and lumbar spine. </li></ul><ul><li>Cervical & lumbar region – Loose  less paralysis. </li></ul><ul><li>Stability of spine is due to supra & interspinous ligaments. </li></ul><ul><li>Thoracic region – Tight fit of cord – damage  paraplegia. </li></ul><ul><li>Injuries of cervical and thoracic cord  spastic paraplegia after the first 1 to 3 weeks of spinal shock have worn off. </li></ul><ul><li>Injuries to thoraco lumbar region  combined upper and lower motor type of paralysis. </li></ul><ul><li>Injuries of the cauda equina will cause a lower motor neurone paralysis as well as autonomic nerve damage. </li></ul>
  94. 95. Ignite the spark within your soul , for it will reveal that which is your truth . Ellie Crystal
  95. 96. Fracture healing: