Traumatic Brain InjuriesDr. Arif Baradia M. Med (Ortho)Supervisor: Professor Mwangombe

What is Traumatic Brain Injury?

• PROCESS not EVENT

• PRIMARY and SECONDARY BRAIN INJURY

• Penetrating or Non-penetrating

Epidemiology

• 1.5 m per year

MVA 45%Falls 30%Occupational 10%Recreational 10%Assault 5%

Role of Alcohol

Epidemiology

• 40-60% of head injured patients have extremity injury

• 32,000-48,000 head injury survivors with orthopaedic injuries annually

Pathophysiology of Head Injury

• Monroe - Kellie doctrine

CSF 10%

BRAIN 80%

BLOOD 10%

Rigid “Box”Aka The Skull

Cerebral Blood Flow

• 15% C.O

• 750ml/min

• CPP = MAP – ICP maintain above 70 mmHg

Mechanisms of Brain Injury

1.Brain Contusion2.Raised ICP3.Diffuse Axonal Injury4.Stroke

1.Brain Contusion

• cell death + hemorrhage

• The contusion often occurs at a site distant from the point of impact

2.Raised ICP

Raised ICP

Brain Oedema/SwellingExtra-dural HematomaSub-Dural Hematoma

Brain Oedema

Extra-dural Hematoma

Subdural Haematoma

3. Diffuse Axonal Injury

Secondary Brain InjuryExcitatory Neurotransmitters

Calcium/Sodium Influx

PhospholipasesProteases

Cell mb integrityCell functionCell viability

+ water = cytotoxic edema

Arachidonic Acid

ProstaglandinsThromboxanesLeukotrienes

Overview

• Initial evaluation• Prognosis• Management of Head Injury• Orthopaedic Issues– Operative vs. nonoperative treatment

• Timing of surgery• methods

– Fracture healing in head injury– Associated injuries– Complications

Initial Evaluation

Pre-Hospital careEmergency Department

ATLS protocolPrimary SurveySecondary survey

HistoryPhysical Exam – GCS < 9, 9 – 12, > 13, xT, xTPImaging

ABCDE

• GCS < 9 – intubate• Hyperventilation, 100% Oxy sat• BP > 90mmHg• Pupils• GCS• ICP monitoring

Hyperosmolar therapy– Mannitol 0.25 – 1 g/kg infusion– Hypertonic saline– Albumin

HCT 30 – 33%PaCO2 – 35 +/- 2 mmHgCVP 8 – 14 mmHgAvoid dextrose IVMaintain euthermia or hypothermia

Role of Orthopedic Surgeon

• Resuscitation• Treatment Methods/Timing• Associated injuries• Complications

1. Damage Control Surgery

Goal– Limit ongoing hemorrhage, hypotension, and

release of inflammatory factors– Limit stress on injured brain– Initial surgery • <1-2 hrs• limit surgical blood loss

Methods– Initial focus on stabilization• External fixation• Limited debridement• Limited or no internal fixation or definitive care

– Delayed definitive fixation (5-7 days)

2. Resuscitation: Role of Orthopaedics

• Goal: limit ongoing hemorrhage and hypotension– pelvic ring injury-- external fixation reduced mortality from 43% to 7% (Reimer, J Trauma, ‘93)– open injury--limit bleeding– long bone fracture--controversial

Long Bone Fracture in the Head Injured Patient

• Early fixation (<24 hours) well accepted in the polytrauma patient

• In the head injured patient early fixation may be associated with – hypotension – elevated ICP– blood loss/coagulopathy– Hypoxia– Fat embolism

• Advocates of early and delayed treatment

Early Osteosynthesis

Hofman ‘91, Poole ’92, McKee ’97 – either no difference or lower mortality and GOS

Bone ‘94, Starr ‘98 – delayed fixation worse mortality and 45X pulm complications

Delayed Osteosynthesis

• Reynolds ’95, Jaicks ’97, Townsend ‘98 – more hypotension i.e. more fluid resusc needed, lower discharge GCS

Fracture Care

Decided on a case by case basis but surgery is often optimal–Alignment–Articular congruity–Early rehabilitation–Facilitated nursing care

Non-operative fracture care

BUT

Minimise–Hypotension–Hypoxia–Elevated ICP–Adequate fixation

3. Bone Healing

?enhanced bone healing?– Exuberant callus – Heterotopic ossification

Humoral osteogenic factors released by the injured brain - Klein et al ‘99

?prolactin – Wildburger et al?Growth Factor – Bidner et al

Union rates not significantly affected while malunion rates increased

Heterotopic Ossification

Formation of lamellar bone inside soft tissue structures where bone does not normally exist

1) inciting event2) signal from the site of injury 3) supply of mesenchymal cells whose genetic

machinery is not fully committed4) environment which is conducive to the

continued formation of new bone

Associated with ventilator dependencyAvoid periarticular proceduresUse approaches/techniques less associated

with H.O.Prophylaxis

RT – single dose within 48 hours of surgeryIndomethacin – 25 mg tds for 6 weeks

Excision

Occult Injuries

• Fractures, dislocations and peripheral nerve injuries may be “missed”– Up to 11% of orthopaedic injuries may be

“missed”– Peripheral nerve injuries are particularly common

(as high as 34%)– Occult fractures in children with head injury are

also common (37-82%)

Occult Injuries

• Detailed physical exam with radiographs of any suspect area due to bruising, abrasion, deformity, loss of motion

• Consider EMG for unexplained neurologic deficits

• Bone scan advocated in children with severe head injury @ 72 hrs

Thank You