ORTHOPAEDIC EMERGENCY

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ORTHOPAEDICEMERGENCY

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Objective

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Background

• Musculoskeletal injury very common in major
  trauma
• Incidence of significant orthopaedic injury in
  severe injured patient is 78
• Permanent disability after major trauma from
  musculoskeletal or CNS injury

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Background

• Orthopaedic injury occurs as part of
• Multiple orthopaedic injuries only
• Multisystem trauma, with multiple orthopaedic
  injuries
• Multisystem injury with minor (not
  life-threatening) orthopaedic injury

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Resuscitation

• Orthopaedic haemorrhage control (C part of
  primary survey)
• Secondary survey
• Injury recognition high energy limb injuries
• Timing of surgery
• Orthopaedic intervention

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Orthopaedic surgical priorities

• Ischaemia correction
• Wound care
• Long bone stabilization
• Other fractures
• Reaming for femoral shaft fracture reaming and
  pulmonary failure
• Principle of external fixation
• Compartment syndrome
• Limb salvage versus amputation

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Orthopaedic haemorrhage control

• Address and control sources of catastrophic
  haemorrhage
• Direct pressure controls (most peripheral
  bleeding)
• Broken bones bleed
• Femur 1000 cm3
• Tibia 750 cm3
• Plevic fracture 2000 cm3

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Orthopaedic haemorrhage control

• Splinting reduces blood loss (pre-hospital)
• Continued hypotension is unlikely in isolated
  long bone fracture
• Look elsewhere
• Pelvic bleeding kills
• Unstable pelvic fractures need to be stabilized
  quickly

20-25 of all major trauma deaths have a pelvic
fracture
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Secondary survey Orthopaedic injuries usually
identified during the secondary survey

• History mechanism of injury
• Detailed history
• Patterns of orthopaedic injury exists
• Falls from height calcaneal fractures, tibial
  fractures and spinal fractures
• Examination
• Major long bone fractures usually obvious
• Limb deformed/short
• Up to 10 of lesser fracture may be missed (use
  Tertiary Survey)

All fractures are important to the patient
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Secondary survey

• Assess major joints for active and passive ROM
  and stability
• Careful palpate long bones for
• pain, crepitus, and abnormal movement
• Look carefully for open fractures
• Orthopaedic emergency (must not be missed)
• May only be a puncture wound
• Bleed local pressure
• Cover loosely by appropriate sterile dressing
• OR (debridement) within 6 h
• Broad spectrum antibiotic
• Tetanus toxoid/immunoglubulin

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Secondary survey

• Dont forget to logroll assess for all spine
• Splint the injury site
• Reduces pain and further damage to local
  structure
• Reduces blood loss
• Splint the joint above and below the fracture
  site
• Check distal neurological status and circulation
  before and after applying splint
• Femoral fractures are placed in a traction splint
  (Thomas), other limb fractures use plaster of
  Paris

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Secondary survey

• Radiological imaging
• Low threshold for obtaining radiographs of area
  of concern
• Radiographs need to be repeated (if poor quality)
  Do not forgotten about it
• Appropriate timing of assessment
• Specialized imaging
• CT, MRI

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Injury recognition high energy limb injuries

• The surgical fracture and soft tissue management
  is complex the prognosis and outcome is
  corresponding worse
• History
• Any road traffic accident
• Fall from a height
• General or localized crushing
• Missile wounds
• Contamination
• History of entrapment in any period
• History of limb ischemia

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Injury recognition high energy limb injuries

• Examination
• Large or multiple wounds
• Imprints or contamination
• Crush or burst wounds
• Skin degloving
• Ipsilateral fracture
• Evidence of associated compartment syndrome,
  vascular injuries, and nerve injuries

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Injury recognition high energy limb injuries

• Plain radiography
• Segmental fracture
• Highly comminutes fractures
• Wide displacement of bone fragments
• Evidence of air in the soft tissues

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Timing of surgery

• An injury results in an inflammatory reaction
  which is promote healing and repair, but if
  prolonged or exaggerated leading to systemic
  inflammatory response syndrome, acute respiratory
  distress syndrome (ARDS)
• Aim to control inflammatory response and restore
  normal physiology and homeostasis ASAP

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Timing of surgery

• Reducing the overall inflammatory response
• Remove necrotic/devitalized tissue by
  debridement/fasciotomy
• Reduce blood loss and pain by splinting/stabilizin
  g fractures
• Reduce ischemia by joint relocation/fasciotomy/sta
  bilizing fracture
• Inflammatory response increases in excessive
  surgery blood loss/hypothermia

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Orthopaedic intervention

• Life-saving condition should taken first
• Stable/suitable condition ? limb salvage
  procedures
• Communication and coordination with other
  specialty
• The initial goal is patient survival
  (life?limb?function)

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Orthopaedic intervention

• Physiologic assessment at each stage
• Danger signs
• Hypoxia
• Hypothermia
• Abnormal clotting
• Acidosis
• Increase intracranial pressure

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Orthopaedic surgical priorities

• Ischaemia correction
• Wound care
• Long bone stabilization
• Other fractures
• Reaming for femoral shaft fracture reaming and
  pulmonary failure
• Principle of external fixation
• Compartment syndrome
• Limb salvage versus amputation

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Ischaemia correction

• Identify and correct the source of haemorrhagic
  shock
• Reduce dislocated joints
• Splint limbs in anatomical position
• Stabilized fractures if associated vascular
  repair is required
• Fasciotomy for compartment syndrome
• Avoid hypothermia

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Wound care

• Open fracture need to be debrided and stabilized
  within 6 h
• Tourniquet (not necessary)
• Remove contaminants
• Excise necrotic or devitalized tissue and skin
  margins
• Copious irrigation
• Minimum 6 liter saline
• Pressurized and pulsatile lavage
• Viability of muscle 4 C colour,
  contractility, consistency, capacity to bleed
• After debridement Do not close wound primarily

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Wound care

• Close joint capsule
• Cover bone end by viable soft tissue
• Re-inspect the wound within 48 h
• Definite wound closure should be within 5 days of
  injury
• Antibiotic until definite wound closure is
  controversial

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Wound care

• Fracture stabilization after wound care
• Choice depends on
• Fracture configuratrion
• Fracture grade
• Extent of soft tissue damage/contamination
• Surgical experience

Gustilo and Anderson open fracture classification
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Long bone stabilization

• Femoral shaft fractures and pelvic stabilization
  should within 24 h
• Reduce overall patient morbidity and mortality
• Excellent pain control
• Avoids traction and associated difficulty sitting
  and moving
• Femoral shaft fractures are the next priority
  after pelvic stabilization
• Closed IM nailing treatment of choice
• Temporary EF

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Other fractures

• Femoral neck fracture and talar neck fracture are
  the next priority (risk of avascular necrosis)
• Followed by
• Metaphyseal distal femoral fracture
• Proximal and distal metaphyseal tibial fractures
• Ankle fractures
• Foot fractures
• Wrist/elbow fractures

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Other fractures

• Factors
• Patients general condition
• Requirement for specialized imaging
• Soft tissue swelling (foot and ankle fractures
  may be delay for 2 weeks)
• Ipsilateral limb (upper and lower extremities)
• Surgical and nursing expertise
• Implant avialability
• Fatigue of theatre staff

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Reaming for femoral shaft fracture reaming and
pulmonary failure

• Reamed femoral intramedullary nail should be
  avoid in blunt chest trauma patient (ARDS)

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Principle of external fixation

• Suitable for many different injury patterns
• Provisional stabilization
• Quick and easy
• Bloodless
• Easily adjustable
• Bridged fracture (complex articular fracture)
• Alternative to IM nailing
• Convert to IM nail within 2 weeks

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Compartment syndrome

• Results in fibrosis and nerve damage
• Most common lower leg, forearm, foot and in
  patient with major trauma
• Easy to miss if patient being resuscitated,
  paralysed or intoxicated
• Signs
• Pain-more than expected
• Pain-unrelieved by immobilization
• Never assume pain is from the bone
• Pain on passive stretching of the affected
  compartment
• A tense, swollen limb

Pulselessness, pallor, paresthesia and paralysis
are late signs after damage has occured
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Compartment syndrome

• Normal compartment pressure is 0 mmHg
• Isolated compartment pressure gt 40 mmHg
• Differential pressure (DBP) lt 30 mmHg
• Treatment
• Fasciotomy
• Release all dressings and splints down to the skin

Compartment syndrome can occur in open fracture
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Limb salvage versus amputation

• Difficult to decision
• Need to discuss options with patient
• Photographic evidence useful
• MESS score for decision making but not absolute
• Factors involved decision making
• Extent of bony injury
• Nerve supply (esp. posterior tibial nerve)
• Crush injuries
• Physiologic reserve
• Smoking
• Economic, psychological and social factors
• Mass casualty situation

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Common Musculoskeletal Injuries

• Multiple trauma head, thoraco-abdominal
  injuries, long bone fracture and open joint
  injury
• Crushed limb / blast injury / high fall
• Traumatic amputation of limb or part of limb
• Fx pelvis, severe, unstable with bleeding
• Fx-dislocation long bone with vascular
  complication
• Open (compound) Fx / joint injury
• Gunfire / shotgun / high velocity missile injury

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Common Musculoskeletal Injuries

• Fx-dislocation / spinal cord / brachial plexus
  injury
• Fx-dislocation of major bone and joint
• Compartment syndrome / ischemic limb
• Ligamentous injury (rupture) of knee / ankle
• Ruptured muscle / tendon
• Bone and joint infection, hematogenous
• Acute bursitis / tendinitis

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Serious Causes of Death in Orthopaedic Emergency

1. High (upper) cervical spine injury
2. Severe fracture of pelvis with unstable and
   massive bleeding
3. Multiple crushed limb and trunk injury

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Estimated Blood Loss from Fracture

• Pelvis 100-4,000 cc
• Femur 400-2,700 cc
• Tibia 250-1,800 cc
• Humerus 200 800 cc

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Assessment

• Glasgow coma scale (GCS)
• Musculoskeletal abbreviated injury score (AIS) ?
  ISS
• Revised trauma score
• Trauma injury severity score (TRISS)

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Glasgow Coma Scale (GCS) Glasgow Coma Scale (GCS)
Parameter Score
Eye opening Eye opening
Spontaneous 4
To voice 3
To pain 2
None 1
Verbal response Verbal response
Oriented 5
Confused 4
Inappropriate words 3
Incomprehensible sounds 2
None 1
Motor response
Obeys command 6
Localized pain 5
Withdraws to pain 4
Flexible to pain 3
Extension to pain 2
None 1
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Musculoskeletal Abbreviated Injury Score (AIS) Musculoskeletal Abbreviated Injury Score (AIS)
Injury Score
Contusions / sprains 1
Interphalangeal dislocation 1
Digital fracture 1
Hip dislocation 2
Closed humerus fracture 2
Clavicle fracture 2
Open humeral fracture 3
Crushed elbow or shoulder 3
Femoral fracture 3
Open tibial fracture 3
Above knee amputation 4
Severe pelvic fracture with blood loss lt 20 by volume 4
Severe pelvic fracture with blood loss gt 20 by volume 5
Unsurvivable 6
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Revised Trauma Score (RTS) Revised Trauma Score (RTS)
Result Score
Respiratory rate (breaths/min) Respiratory rate (breaths/min)
10-29 4
gt29 3
6-9 2
1-5 1
0 0
Systolic blood pressure (mm/Hg) Systolic blood pressure (mm/Hg)
gt89 4
76-89 3
50-75 2
1-49 1
0 0
GCS GCS
13-15 4
9-12 3
6-8 2
4-5 1
3 0
RTS 0.9368 GCS 0.7326 SBP 0.2908 RR
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TRISS score ? to predict the probability of
survival
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Resuscitation

• Resuscitation / treatment protocol based on ATLS
  guidelines

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Resuscitation/Treatment Protocol Based on ATLS Guidelines
1. Primary survey and resuscitation (patient stabilization) A Airway and cervical spine B Breathing and oxygenation C Circulation and hemorrhage D Dysfunction of the CNS E Exposure and environmental
2. Consider transfer to more appropriate hospital if indicated
3. Secondary survey A Allergies M Medicines P Previous medical history/pregnancy L Last meal E Events leading to trauma
4. Definitive care Early total care Damage control surgery
5. Tertiary survey Missed injuries
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Steps

• 1. The important initial steps are to check that
  the airway is clear and maintained.
• 2. Breathing and oxygenation are maintained by
  examining for and treating a blocked airway,
  pneumothorax, tension pneumothorax, hemothorax,
  flail chest, or pericardial tamponade

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Steps

• 3. Control hemorrhage and maintain circulation
• bilateral femoral fractures and
• pelvic fracture
• Associated with significant occult blood loss
• 4. Fluid resuscitation (2 large-bore venous
  cannulas)
• 5. Immediate cross match

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Steps

• 6. A thorough examination of the abdomen ,
  pelvis, and limb ? looking for signs of abdominal
  and pelvic bleeding, pelvic instability, and
  hemorrhage and limb damage, particularly open
  fractures

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Steps

• 7. Complete CNS examination ? patients
  responsiveness and GCS including neurological
  examination of the limb
• 8. Radiographical examination of the chest and
  pelvis (head, neck and spine if clinically
  required)

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Steps

• 9. Adequate stabilization
• 10. Secondary survey and appropriate
  investigation
• 11. Management plan for definitive treatment ?
  life-threatening injuries should be treated first
  
• 12. Tertiary survey within 24 hours

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9Rs

• 1. Recognition
• 2. Recussitation if required
• 3. Respective system evaluation
• 4. Respective system treatment
• 5. Retention (retainment) I temporary
  splinting, wound coverage, etc.
• 6. Reduction
• 7. Retention (retainment) II definitive
  immobilization
• 8. Rehabilitation
• 9. Reconstruction

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Resuscitation/Treatment Protocol Based on ATLS Guidelines
1. Primary survey and resuscitation (patient stabilization) A Airway and cervical spine B Breathing and oxygenation C Circulation and hemorrhage D Dysfunction of the CNS E Exposure and environmental
2. Consider transfer to more appropriate hospital if indicated
3. Secondary survey A Allergies M Medicines P Previous medical history/pregnancy L Last meal E Events leading to trauma
4. Definitive care (Fracture treatment) Early total care Damage control surgery
5. Tertiary survey Missed injuries
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Early Total Care

• Early femoral fracture fixation was associated
  with decreased pulmonary complications and
  reduced hospital stay
• Long bones are more benefited

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Damage Control Surgery

• Early reamed femoral nailing or external
  fixation followed by secondary nailing
• The second one is associated with less blood
  loss, shorter operating times and lower incidence
  of multiple organ failure (MOF) and ARDS

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Damage Control Surgery

• Which patients are suitable?

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Parameters Associated with Adverse Outcome in Multiple Injured Patient
1. Unstable condition or difficult resuscitation 2. Coagulopathy (platelet count lt 90,000) 3. Hypothermia (lt32 c) 4. Shock and gt 25 units of blood replacement 5. Bilateral lung contusions on initial radiographs 6. Multiple long bones plus truncal injury AIS gt 2 7. Probable operating time gt 6 hr 8. Arterial injury and hemodynamic instability (BPlt 90) 9. Exaggerated inflammatory response (IL-6 gt 800 pg/ml)
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Conditions in Which Damage Control Surgery Should Be Considered
1. Polytrauma ISS gt 20 and thoracic trauma (AIS gt2) 2. Polytrauma with severe abdominal/pelvic trauma and hemodynamic shock (BP lt90 mm Hg) 3. ISS gt 40 4. Bilateral lung contusions 5. Initial mean pulmonary arterial pressure gt 24 mmHg 6. Pulmonary artery pressure increase gt6 mmHg during long bone intramedullary nailing
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Tertiary Survey (Common missed injuries)

• Facial bone fracture
• Base of skull fracture
• C spine injury C1 fracture, C1-2
  subluxation/dislocation, C 2 dens fracture.
• Posterior dislocation of shoulder glenohumeral
  joint
• Scaphoid fracture, lunate / peri-lunate
  dislocation

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Tertiary Survey (Common missed injuries)

• Radial head fracture
• Pelvic fracture body of sacrum
• Seat-belt fracture T/L compression
• Fracture and dislocation of the hip with femoral
  shaft fracture
• Ligamentous injuries of the knee
• Fracture tibial platea
• Fracture talus

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Open Fracture

• Some important factors
• Golden period - 8 hr
• 12 hr. potentially infected
• Environment / atmosphere
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• Types Gustilo - I, II, III A,B,C
• Foreign body in wound
• Associated injury

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Gustilo Classification of Open Fractures
Type Definition
I Open fracture with a clean wound lt 1 cm in length
II Open fracture with a laceration of gt 1 cm long and without extensive soft tissue damage, flaps, or avulsions
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Gustilo Classification of Open Fractures
Type Definition
III Either an open fracture with extensive soft-tissue laceration, damage, or loss an open segmental fracture or a traumatic amputation. Also High-velocity gunshot injuries Farm injuries Open fracture requiring vascular repair Open fracture older than 8 hr
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Gustilo Classification of Open Fractures
Type Definition
IIIa Adequate periosteal cover of a fractured bone despite extensive soft tissue laceration or damage High-energy trauma irrespective of size of wound
IIIb Extensive soft-tissue loss with significant periosteal stripping and bone damage Usually associated with massive contamination
IIIc Association with arterial injury requiring repair, irrespective of degree of soft-tissue injury
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Management

• Outline of treatment in emergency unit
• 1. Temporary dressing
• 2. Splinting
• 3. Initial c/s ( anarobic)
• 4. Stop bleeding
• 5. Check associated injuries
• 6. X-Ray, etc.
• 7. Prophylactic Antibiotics
• 8. Tetanus Toxoid, Antitoxin

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