Lecture №24 General trauma (cor)

8/8/2019 Lecture 24 General trauma (cor)

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G E N E R A L T R A U M A

Leading causes of injury death by manner of death in the USA

1995. Data from Fingerhut & Warner 1997.5

Initial management of the acutely injured patients.

Priorities.a) the patient may have more than one injury;

b) the obvious injury is not necessarily the most important one.

Categories of injury:

1. Exigent.These are the most life-threatening conditions,requiring instantaneous intervention (complete airway

obstruction).2. Emergency.Those conditions requiring immediate interventionover a period of few minutes.

. rgent. ose con t ons requ

r

ng ntervent on w t

n t e rst

hour.4. Deferrable.Those conditions that may or may not immediatelyapparent but will subsequently require treatment (urethraldisruption).

Steps in initial resuscitation (ABC).

Airway

- removal of debris and the "chin lift" or "jaw thrust"maneuvers ull the ton ue forward to clean the airwa of lessseverely injured patients.

Jaw-thrust maneuver. Two hands are placed on the mandibular ramiand pushed anteriorly, so opening the airway.

Chin-lift maneuver. The tips of the fingers are placed beneath thepatient's chin and the jaw is lifted anteriorly while the mouth is

opened by drawing down on the lower lip with the thumb of thesame hand.

Endotracheal intubation is required at patients with severe

head injury, profound shock.


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Endotracheal and nasotracheal intubation

Cervical spine injury is always a possibility (ovoid movement of the neck). Before

intubation the spine should be stabilized until an injury has been excluded.

Potential spinal injuries. The patient is completely immobilized on a long

backboard. A rigid cervical collar and paracervical rolls are placed to protect the

cervical spine.

Consider spine injuryConsider spine injury

In some situations a surgical airway may be required. Surgical cricothyroidotomy

may be preceded by needle cricothyroidotomy with jet insufflation to improve

oxygenation.

Surgical airway

Cricothyroidotomy is a preferable emergency procedure.

Technique for cricothyroidotomy. Side view demonstrates that the cricothyroid

membrane is more superficial than the trachea which makes performance of a

cricothyroidotomy technically easier than a tracheostomy.

Technique for tracheostomy.


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Breathing (ventilation)

If there is a decreasedes irator dr ive or an

unstable chest wall, anassisted ventilation isnecessary.

Assisted ventilation may be done using Ambu bag or with a

help of mechanical ventilator.

Most common reasons for ineffective ventilation after intubation

malposition of endotracheal tube, pneumothorax, and hemothorax(palpation, auscultation, X-ray to exclude).

In some circumstances (tension pneumothorax) decompression ofthe chest by needle catheter placement is appropriate prior to theradiograph.

Circulation (perfusion)

When possible control of the bleeding precedes placement of the i.v. lines.

(compressive dressing, tourniquet, or placement of pneumatic antishock

garment (pelvic injuries) may be required. Minimum two i.v. lines should be

placed percutaneously, or with venous cut-down, or internal jugular

(subclavian) vein cannulation. Fluid resuscitation begins with a 1000 ml bolus of

LR. Response to therapy is monitored by skin perfusion, UO, or CVP.

Newly placed central venous catheter via the subclavian access route.

-

(, , .)

Eye opening:

1 oint - ever

Best verbal response

1 point - no response

A brief examination is done to determine a) level of consciousness (GCS), b)

pupillary condition c) movement of extremities(paralysis).

Neurologic assessment

2 points - to pain

3 points - to verbal stimuli

4 points - spontaneously

2 points - incomprehensible sounds

3 points - inappropriate words

4 points - disoriented and converses

5 points - oriented and converses

Best motor response:

1 oint - o res onse Total score = 3 - 15;

Less than 10 ointsa at ient

2 points - extension (decerebral rigidity)

3 points - flexion abnormal (decortical rigidity)

4 points - flexion withdrawal

5 points - localized pain

6 points - obey

is serious injury.

15 points - clear consciousness;

13-14 points - stupor;

9-12 points - sopor;

4-8 points - coma;

3 points - death;


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Examination is done in aead-toe manner

Exposure to complete examination

Reexamine the patientcompletely but expeditiously(diagnosing other injuries).Examination is done in a head-toe manner, o ta n ng ancollecting data from laboratoryand radiologic tests. This timeis also for placement ofadditional lines, catheters (NG,Foley, etc.) and monitoringdevices.

When the patient is

oxygenating, ventilating, andperfusing adequately a priorityplane should be established forsubsequent treatment.

Lateral radiograph demonstrating

an L1 burst fracture (arrow).

a priority plane should be established forsubsequent treatment.

TYPES OF TRAUMATIC INJURIES

Ganglion?Ganglia are cystic, round, usually nontender or painfulswellings located along tendon sheaths or joint capsules. Thedorsum of the hand and wrist is a frequent site of involvement.Flexion of the wrist makes ganglia more prominent; extensionendsto obscure them. Gan lia ma alsodevelo elsewhere onthe

hands, wrists, ankles, and feet.

The origin is unclear (overexertion, hereditaryThe origin is unclear (overexertion, hereditary

predisposition). It grows from a joint and filled withpredisposition). It grows from a joint and filled withsynovial fluid like a shellsynovial fluid like a shell


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Ganglion cyst

Diagnosis is clinical, but XDiagnosis is clinical, but X--ray is always necessaryray is always necessaryTreatment

is only indicated if ganglion causes severe pain or

limits activity

TreatmentTreatment is only indicated if ganglionis only indicated if ganglioncauses severe pain or limits activitycauses severe pain or limits activity

Massage (recurrence)Massage (recurrence)

Aspiration (recurrence)Aspiration (recurrence)

Surgical removal of all theSurgical removal of all the

cyst by orthopedistcyst by orthopedist

Bursitis. Swelling and inflammation of the olecranon (or any other)bursa may result from trauma. The swelling is superficial to the

olecranon process. Bony landmarks of the joint may be attenuateddue to fluid. Also bursitis may affect any other joints.

Contusion of soft tissuesis characterized by pain, edema, andbruising as a result of laceration of small vessels of the skin and

subcutaneous tissue. Trauma to underlying structures must bepresumed requiring further investigation.

Sprain. Some fibres are torn but the whole ligament is mechanicallyintact. Pain is provoked by movements in the joint, localized

tenderness. Bone percussion is painless. Local swelling and bruisingare common.Treatment:first 24-48 hours ice or chemical cold pack, elevation,elastic bandage, after two days heat may be used, NSAID, no weightbearing, removable splint or light cast, progressive active exercises

after healing

Bivalved cast.The two halves are rejoined


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Ligament rapture.The ligament is broken in two. Clinical picture

is the same but accompanied by joint's instability found duringlocal examination.Medical therapy is the same, immobilization is necessary. Suture

is done only at some types of rapture (arthroscopic suture of thecruciate ligament of the knee)

Tendon and muscle rapture. Retraction of ends (muscle contraction).

Because of the gap the healing does not occur leading to impairedfunction. The active movements are lost, passive movements may bepainful. Localized tenderness.Rapture of the insertion of the quadriceps muscle into the patella

Local swelling and bruising. The gap is visible or palpable. Lossof active movements may not be obvious if other muscles take

over the function of the tendon.Rapture of the tendon of the long head of the left biceps muscle.

When the muscle contracts the long head bunches near the

elbow.

Tendon rapture. Treatment: suturing followed by immobilization with externalsplintage for 3-6 weeks. Medical treatment is the same.

Velpeaus bandage can be used.


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Dislocation and sublaxation

Clicking sound when the dislocation has occurred. Pain andtenderness, edema and bruising, hemarthrosis, loss of normaljoint shape. The joint area looks like hollow. The extremity may

be shortened and loses its normal axis.

Subcoracoid dislocation of the left shoulder

The extremity may beshortened and loses

its normal axis

dislocation of theright shoulder

dislocation of thean e

Treatment of dislocation

Closed joint reduction.

Commonly reduction is done under i.v. sedation. Local anesthesia (ifused) is done into joints cavity (20 ml 1% lidocaine). Always assess

neurovascular status.

Ankle dislocation.Assistant helps to stabilize the leg. The foot istwisted toward the side to which the tallus is dislocated.

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Closed joint reduction.

Shoulder joint dislocation. Matsons methodis shown using two wrappedsheets. Traction and contratraction are applied over a period of several minutes,

which should reduce the dislocation with a click. After reduction a shoulder

immobilizer is necessary at position of internal rotation and adduction.

X-ray confirms reduction.

The arm hangs free off the table with appropriate weights (approximately

5kg) attached at the wrist (Stimsons method). Usually it takes 20-30

minutes to achieve reduction. Dzhanelidzes methoduses force produced

by doctors weight.

Motais (left) and Kochers methods of shoulder reduction

Kochers method of reduction of dislocated hip. An assistant stands

on the side and steadies the pelvis. Traction is applied in the line ofthe femur. Reduction is achieved with a clunk and is confirmed byradiology.

Closed reduction of a radial head.The physician holds the

patient injured hand in a hand-shake position.Immobilization after reduction of dislocation

Positioning used to immobilize a body part

Ankle/foot: 90 0 angle between foot and leg. Neutraleversion/inversion

Knee: 15-200 flexion

Shoulder: resting at the side of the body Elbow: 900 angle between forearm and arm. Neutral

pronation/suppination

Wrist: Neutral pronation/suppination, 20-300wristextension

0. ,

300 flexion

Metacarpals, MCP joint, proximal phalanges: wrist positionas above, MCP joint in 900 flexion, DIP and PIP joints in afull extension

IP joints middle/distal phalanx: full extension at IP joints.

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Immobilization after reduction of dislocation

Splint padding is done to entire area to be splinted. Evenly, circular fashion, at

least two layers with extra over bony prominences.Fiberglass (prefabricated splints can be measured and cut)/plaster (10-15 layers):

generally immobilize one joint above and one joint below injury.

The splint is applied to the soft roll (after water deepening). Hold the bandage in

desired position until splint hardens (5-10min with fiberglass, 10-15 min with

aster

Posterior elbow splint(above) and sugar tong forearm splint(below) are used for

forearm and wrist injuries. Note: the splint reaches the level of MCP joints

Commercial sling. The elbow is fixed at 900 angle. With the

arm resting across the chest the wrist is elevated higher whenthe elbow with the thumb pointing upward.

Ulnar gutter splintis used for 4th -5th metacarpal or phalanx injuries

(above). Radial gutter splint is used for 2nd -3rd metacarpal or fingers

injuries (below).

Thumb spica splintLong leg splintis used for knee and tibia injuries (it consists

of two splints for additional stability)

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Ankle splintis used at isolated ankle injuries (it consists of two

splints).

Complications of casts:burns, cast sores, joint contracture

Complications of dislocation:ischemia (vascular compression), neurologic,

infectious, joint stiffness, instability, recurrent dislocation.

Range-of-motion exercises for the affected

joint after period of healing and immobilization

Compression of

the popliteal artery

Fractureis a structural break in the normal continuity of the bone.

bone fracture:

- direct force and indirect

force

Mechanism of cancellous

bone fracture:

- compression and traction

injuries (avulsion).

A) Formation of hematoma; B) after 1 week osteoblasts start to form as the clotretracts; C) after 3 weeks a procallus begins to form and stabilize the fracture; D)from 6 to 12 weeks a callus forms with bone cells; E) in 3 to 4 months osteoclastsbegin to remodel the fracture site; F) with normal apposition the bone will becompletely remodeled in 12 months.

Fracture healing (union) Clinical signs

Relative signs:local tenderness, swelling and bruising, deviationof extremity's axis, disturbance of function of extremity.

Absolute signs (pathognomonic)to fractures: exposure of the bonefragments or obvious protrusion of bone fragments under theintact skin, pathologic mobility, bone crepitation, and radiologics gns o e rac ure.

Fracture of extremity. Peripheral blood circulation and nervous

function must be examined (physical examination or usingadditional tools).

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Obvious

deformity ofthe limb

Obvious deformity of the limb

Radiologic confirmation of fracture is absolutely necessary. It is

done at two planes (AP and lateral view).

Unstable burst fracture of L1 (arrow)

(result of a motor vehicle accident).

Pelvic disruption (arrow).

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Description according to fracture line Description according to displacement ofbone fragments Treatment of fractures

General management

ABC approach Correction of blood loss and shock (pelvic fracture may

lead to approximately 2 L blood loss)

Pain: splintage and analgesics Coexisting injuries are treated according to priority plane Tetanus toxoid and AB for o en fractures

Splintageis done at the scene of injury (to reduce pain andadditional trauma due to displacement of bone fragments)

Bucks traction may be used for hip

fractures until surgery is performed.

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Local management

Scheme for fracture management

Define fracture

Detect complications

Does the fracture need reduction?

Is the fracture stable or unstable?

How can the fracture be stabilized?

Does the fracture need immobilization and for how long?

How can the patient best be rehabilitated?

Possible methods of fracture treatment

protection alone

immobilize with external splint without reduction

closed reduction (manipulation or traction) followed byimmobilization with external splint or traction;

open reduction and external fixation;

excision of fractured fragment and prosthetic replacement

Treatment of open fractureThe aim of surgery is to convert open fracture to closed one. Tetanus toxoid

and AB are considered.

Wound irrigation. An open fracture of the tibia at initial operation.

Dissection and excision of tissue as well as lavage with copious quantities of

fluid (by a jet lavage system). Surgery is finished by closure of the wound.

Distal superficial femoral artery traumatized at the site of a fracture of the distal

third of the femur. Blood supply is restored parallel to open reduction of fracture

Restoration of bone integrity (methods of fracture reduction)

Gravity methods: collar and cuff, hanging cast

Closed manipulations Traction (fixed or sliding)

Operation

Gravity reduction U-slabwith collar and cuff sling.

Closed manipulations

Fracture reduction using:

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Fracture reduction using skeletal and skin traction (fixed or sliding)

The principal elements of sliding

traction: traction and countertractionRussel traction, a form of skin traction, may

be used for fractures of the hip and femur.

Methods of stabilisation of fractures (immobilization of the fracture)

External splint: a) plaster of Paris or plastic cast; b) external fixation;

Internal splint (screws, plate, nail)

Continuous traction a) hanging cast; b) fixed or sliding traction (skin or

skeletal)

Stabilisation of fractures using Plaster cast

Volkmanns contracture following

fracture of the humerus.A split plaster of Paris cast.

Stabilisation of fractures using external fixation

External fixator applied to a severe lower limb injury, which was associated with

extensive soft tissue damage with blistering and skin loss. The fixator provided

early stability and allowed for care of the soft tissues.

Intramedullary nail.The nail stabilizes

a femoral fracture and both proximal

and distal locking help maintain

length, rotation and alignment.

Lumbar fracture-dislocation treated by

posterior spinal instrumentation and

fusion from L2 to L5.

Stabilisation of fractures using internal splints At elderly patients a surgery should be considered over closed stabilizationespecially sustained to fracture of the femoral neck.

Extracapsular fracture of neck of femur fixed by internal fixation with a

sliding compression screw and six-hole plate

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Stabilization of fracture usingcontinuous traction

Compound fractures

Severe initial injury

Causes of delayed and nonunion of fractures

Soft tissue interposition

Distraction Infection

Poor blood supply

Inadequate immobilization

Patholo ical fracture

Osteoporosis

Nutritional disorders (malnutrition, vit. D deficit) Metabolic disorders (uremia, hyperparathyroidism)

Drugs (steroids, cytotoxic drugs)

General rules of bone healing (duration of immobilization)

Fracture of low limb heals twice longer

Fracture in adults heals twice longer

Transverse heals longer then spiral and oblique

Compound and comminuted are particularly slow to unite

No fracture unites in less then 3 weeks

Surgical treatment with open reduction of bone fragments is

indicated at the following situations:

Compound fractures

Reduction of fracture (failure of other types of reduction) Stabilisation of fracture (failure of other types of reduction)

Management of complications (vascular or head injury)

Soft tissue management

Complications of fractures

Local(nerve, arterial injury followed by acute arterial ischemia, acute

compartment syndrome (edema of muscle compartments).

Early:skin necrosis, gas gangrene, infection, DVT, embolism;

Late:joint stiffness, osteomyelitis, pseudoarthrosis, deformed union.

Crash-syndromeis a condition caused by prolonged compressionand crashing of soft tissues (mainly muscles) resulting incharacteristic local and general pathologic changes in the body

developing during and after release of compression

Pathology of the crash-syndromecompression acute arterial ischemia (compression of arteries, pain is followed

by angiospasm, hypovolemia)

release of compression reperfusion injury (edema of muscle compartments,

compartment syndrome, and ischemic muscle necrosis)

resorption of toxins from necrotic tissues endotoxicosis multiple organ

failure

Most common complication of the syndrome are:

- MODS (ARF and AHF) and purulent septic complications

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Clinical picture

General:early period signs of traumatic shockwith characteristic hemodinamic

changes.

Local:Initially the skin is warm, PS on arteries is present. Further an edema

increases, skin necroses appear, and signs of compartment syndrome develop

(acute arterial ischemia)

Second period is characterized by signs of ARF and poliorganic failurewith

characteristic clinical and laboratory picture with progress of fluid-electrolyte

disorders and intoxication.Local changes are less important and characterized by edema and local septic

complications.

Late periodis accompanied by necrosis and sequestration of dead muscles,

urulent complications, muscle and joint contractures

At the early period it is very difficult to determine how much tissues are

devitelized. So an extend of surgery is difficult to measure.

Treatment

- elastic bandaging (to decrease postischemic edema)

- cooling and splinting of the extremity

- aggressive antishock and detoxication therapy

- , , y , .

Early surgery is indicated at case of steadily progressing edema and development oflife-threatening ARF

Without aforementioned indications a surgical procedure is done only after

demarcation of necrotized tissues.

Early surgery fasciotomy, is done to decompress compartment pressure

Formely used subcutaneous fasciotomy

is currently less popular

Open fasciotomy with or without

necrectomy is a method of choice

A postoperative wound is managed according to commonrules of untidy wound care preventing cumulation of necrotic

tissues, etc.external fixation is useful if a patient has coexisting fracture.

Documents

Lecture №24 General trauma (cor)