Principle Management of Wound and Fracture in Emergency Department
dr. Tedjo Rukmoyo, SpOT (K) Spine
Presented in Clinical Update Seminar January 15th 2011
Initial ManagementATLS Procedure
A : airwayB : breathingC : circulationD : disabilitiesE : exposure
Compressive dressings for hemorrhageCheck
Cervical ChestAbdoment
X ray
HeadPelvisNeurovascular
Wound Inspection & Palpation
Concentrate onHemorrhage LocationSizeBorder Wound typeExudateInfectionDressed or undressed
Wound managementEvaluate the woundNeuroVasc statusJoint MovementX-RAY !Sterile saline dressingIrrigate with NS
1 or 2 litresTetanus status immunity IV antibioticsPrepare minor set
NeedleSuture materialinstruments
Wound irrigation
Irrigate with NaCl 0,9 % 1 – 2 litreBrush, evacuate foreign bodyUse :
Povidon iodineSavlonPerhidrol (hidrogen peroxide)
Irrigate with NaCl to cleanse
Debridement
Excision:Wound EdgeSkin Abrasion Dead TissueDirty Bone
Evacuate:Foreign body
Re-Irrigation / Spoel Irrigation Temporary
Dressing Types and Assistive Devices
Dry Dressings dry wound
Wet-to-Dry Dressings wet wound
Packing deep wound
Vacuum Assisted Closure
Compression Elastic Bandage
Principle Wound and Skin coverage
Without skin lossPrimary clossure
Contraindication :
1. Contamination
2. NV injury
3. Tension
Principle Wound and Skin coverage
With skin loss :Secondary intention
Release / counter incision
STSG, FTSG
Flap fasciocutaneus,
rotational
Fracture Classification
Close (simple)Open
Gustillo Anderson○ Grade I○ Grade II○ Grade III a○ Grade IIIb ○ Grade IIIc
> Grade III B
Vascular disruptionArteriographyIf can be repaired? Possible Limb salvage Failed? amputation?
Debridement and Irrigation
As soon as possible Scrub and brush wound dirtSuperficial debridement:
Identify and explore -> extend woundExcised non viable tissue
Debridement and Irrigation
Deep debridement :When in doubt take it outCheck muscle : 4 c
ColorCapacity to bleedContractilityConsistency
Cover by tissue or moist dressingRemove Foreign body
Irrigation
Use NS, high volume low pressure lavageFor grade II-III :
6 – 10 lUse antiseptics, perhidrol, antibiotic, etc
Skeletal Stabilisation
Evaluate vascular status, limb salvage, debridement and irrigationStabilize the bone :
Restore lengthAngular alignmentRotation
Will promote healingDecrease pain and further damage
Method Skeletal stabilisation
Cast : splint, circular cast
Traction : skin, skeletal
External fixation : steinman or K wire
Internal Fixation
Plate and screwAccurate anatomicalMantain /w plateVarious types
IM nailsRestore alignmentCallus healingMinimize soft tissue damage
Rehabilitation
Early Range of MotionIsometric, isotonic, isokinetic excerciseMotor Power excerciseNon weight bearingPartial weight bearingFull weight bearingReturn to normal activity