Download - Limb injuries
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Emergency day:
Critical period of
limb injuries
Pariyut Chiarapattanakom, M.D.
Institute of OrthopaedicsLerdsin General Hospital
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Topics
Initial management
Multiple injuries
Open fracture
Pelvic ring fracture
Fractures and
dislocations
Cast and Splint
Cast care
Compartment
syndrome
Fat embolism
Tendon injuries
Peripheral nerve
injuries
Arterial injuries
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Initial management
Primary survey
Secondary survey
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Secondary survey-Ortho
Careful history taking and physical
examination
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Secondary survey-Ortho
Careful history taking and physical
examination
› Predict x-ray findings with a high degree of
accuracy
› If a fracture is suspected clinically, but x-ray
appears negative, the patient initially should
be managed with immobilization as though
a fracture were present
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Secondary survey-Ortho
Careful history taking and physical
examination
Palpate the extremities
Palpate the spine
Pelvic compression
Active movement of the extremities
Specific test for each part
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Secondary survey-Ortho
Plain radiographs
Special imaging techniques
› Rarely use in emergency settings
› Bone scan
› CT scan
› MRI
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Secondary survey-Ortho
Criteria for adequate radiographic
studies exist; inadequate studies should
not be accepted
X-ray studies should be performed
before attempting most reduction
except when a delay would be
potentially harmful to the patient or in some field situation
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Plain radiographs
Lateral crosstable C-spine
Chest AP
Pelvis AP
Specific part
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Orthopaedic management
1. Irrigation and wound closure
2. Pressure dressing for vascular injury
3. Immobilization
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Immobilization
Pain relieve
Prevent further damage
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Immobilization
Collar for neck injury
Splint for extremities
Pelvic wrapping for pelvic injury
(may simply use bed sheet)
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Early death from
orthopaedic conditions
Bleeding from pelvic fracture
Pulmonary failure from femoral and
pelvic fracture
Early stabilization is needed
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Multiple injuries
Recussitation
First manage
› Dislocation
› Fracture with vascular injury
› Open fracture
Do definite fracture stabilization later
Aware deep vein thrombosis and pulmonary embolism
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Open fracture
Fracture that
connected to the
external environment
Higher rate of
infection
Early surgery within the
first twenty-four hours
(as early as possible)
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Open fracture
ER management:
Remove and irrigate gross
contamination with NSS
Stop active bleeding – pressure
dressing, do not ligate vessels
Splint without reduction, unless
vascular compromise is present
Begin IV ATB (1st generation
cephalosporin) and tetanus toxoid
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Open fracture
Definite management:
Debridement
Stabilize the bone
Wound closure
Antibiotic
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Pelvic ring injury
Life threatening
Up to 40% of patients with an unstable
pelvic ring injury die from their injuries,
and hemodynamic instability is the main
predictor of death.
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Pelvic ring injury
Pelvic compression test
› From anterior
› From lateral
PR – floating prostate, bleeding
PV – bleeding
Neurologic examination
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Pelvic ring injury
IV fluid
Urinary catheter
Pelvic wrapping
X-ray
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Pelvic ring injury
Young classification
Lateral compression (LC)
Anterio-posterior compression (APC)
Vertical shear (VS)
Combined
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Pelvic ring injury
Instability
Displacement of posterior part of
pelvis >1 cm
Symphysis diastasis >2.5 cm
Vertical shear > 2 cm
Any neurologic injury
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Hemodynamic assessment
after pelvic wrapping
› If hemodynamic is continue severely
unstable -> laparotomy
› If hemodymanic is partially control -> search
for intraperitoneal bleeding (FAST, DPL, CT)
--->evidence of intraperitoneal bleeding
Yes No
Laparotomy Angiography (& embolization)
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Pelvic ring injury
Type of external fixator
Open anterior –
external fixator
Open posterior or
vertical shear – C-clamp
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Fractures and dislocations
Clinical diagnosis
Pain, swelling, deformity
Tender, false motion, crepitus
Distal neurovascular status
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Fractures and dislocations
Clinical diagnosis
Pain, swelling, deformity
Tender, false motion, crepitus
Distal neurovascular status
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Fractures and dislocations
Radiographic diagnosis
At least 2 views
› (commonly AP, lateral)
Additional:
› Oblique view
› Compare 2 sides
› Stress view
› Special view
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Fractures and dislocations
Closed reduction
Reducible Irreducible
Maintain reduction Operative
Able Unable
Non-operative (Cast, splint, traction)
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Fractures and dislocations
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Common fractures
Distal radius fracture
Forearm fracture
Humeral fracture
Tibial fracture
Femoral fracture
Femoral neck fracture
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Common dislocations
Elbow dislocation
Shoulder dislocation
Hip dislocation
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Common dislocation
Elbow dislocation
Shoulder dislocation
Hip dislocation
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Common dislocations
Elbow dislocation
Shoulder dislocation
Hip dislocation
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Nerye injuries accompanying dislocation
Orthopedic injury Nerve injury
Elbow dislocation Median or ulna
Shoulder dislocation Axillary
Hip dislocation Sciatic
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Children are different from adults
Different in anatomy, physiology and
bone property
Less dislocation
Physeal injuries occur more commonly
than ligamentous disruption because of
the relative ligamentous strength
compared with the ease of disrupting
the physis
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Children are different from adults
Specific injuries in children:
Physeal injuries
Buckle fracture
Greenstick fracture
Plastic deformation
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Physeal injuries
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Greenstick
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Buckle or torus
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Plastic deformation
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Common children fractures
Entire distal humeral physeal injury
Supracondylar fracture
Lateral condyle fracture
Femoral fracture
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Type of casts and slabs
Extremity
› Short
› Long
› Cylinder
› Spica (thumb, shoulder, hip)
Body
› Minerva
› Body jacket
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Cast care
Elevate the limb
Frequently move
Let the cast dry for 1 day (do not cover)
Do not get wet
Do not put anything inside
Weight bearing or not
Expected cast period
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Cast care
Bad signs, need to come back urgently
Pain out of proportion
Markedly swelling
Pale or congested
Loss of sensation
Discharge or bleeding
Wet cast
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Mangled extremity
If either of the following criteria present,
immediate amputation is better
1. Loss of arterial inflow for longer than 6
hours, particularly in the present of a
crush injury that disrupts collateral
vessels
2. Disruption of posterior tibial nerve
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Thank you
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Time
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Compartment syndrome
Surgical emergency
Most common in tibial fracture
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Compartment syndrome
Early signs
Tight
Escalating pain
Pain with passive stretch of the
involved muscle
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Compartment syndrome
Late signs -6P
Pain
Pallor
Pulselessness
Paresthesia,
Paralysis
Poikilothermia
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Compartment syndrome
Intracompartment
pressure
Adjunction to clinical
examination, NOT diagnostic› >30mmHg or
› >30mmHg difference between intracompartmental pressure and diastolic blood pressure
indication for fasciotomy?
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Management
Remove any cast or bandage around
the limb immediately – all layers should
be clear down to skin
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Management
Fasciotomy
Emergency
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Management
Delay>12 hr. often results in irreversible
muscle and nerve damage in that
compartment
If left untreated, acute compartment
syndrome can lead to more severe
conditions including rhabdomyolysis and kidney failure
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Management
While the patient is awaiting definitive
treatment, the affected part should not
be elevated above the level of the heart
because this maneuver does not
improve venous outflow and reduces
arterial inflow
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Fat embolism
Fat embolism – presence of fat globules
in the lung parenchyma and peripheral
circulation
Common as a subclinical event after
long bone fractures
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Fat embolism syndrome
Serious manifestation of fat embolism
Common after long bone fracture in
young adults (tibia/fibula) and hip
fractures in elderly
Syndrome usually appear in 1-2 days
after an acute injury or after IM nailing
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Fat embolism syndrome
Respiratory distress syndrome is the
earliest, most common, and serious
manifestation
Neurologic involvement, manifest as
restlessness, confusion, or deteriorating
mental status, is also an early sign, as are thrombocytopenia and petichial rash
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Tendon injury
Flexor tendons in hand – common and
important
2 tendons in each digit: FDS, FDP
Digital flexor sheath
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Tendon injury
Zones of flexor
tendon injury
Zone II –no
man’s land
Stiffness VS.
rupture
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Tendon injury
Diagnosis
› Position
› Passive tenodesis
› Active motion
Suspect digital nerve injury when there is FDP tear
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Tendon injury
Repair strong enough
(Core+epitendinous stitches)
Early range of motion exercise
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Tendon injury
Repair strong enough
(Core+epitendinous stitches)
Early range of motion exercise
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Peripheral nerve injury
Diagnosis
› Location of wound
› Sensory
› Motor
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Peripheral nerve injury
Nerye injuries accompanying orthopedic injuries
Orthopedic injury Nerve injury
Elbow injury Median or ulna
Shoulder dislocation Axillary
Sacral fracture Cauda equina
Acetabular fracture Sciatic
Hip dislocation Sciatic
Femoral shaft fracture Peroneal
Knee dislocation Tibial or peroneal
Lateral tibial plateau fracture Peroneal
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Peripheral nerve injury Neuralpraxia
› the least severe form of nerve injury, with complete recovery
› actual structure of the nerve remains intact, but there is an
interruption in conduction of the impulse
Axonotemesis
› disruption of the neuronal axon, but with maintenance of the
myelin sheath
› Mainly seen in crush injury
› the axon may regenerate, leading to recovery
Neurotemesis
› Not only the axon, but the encapsulating connective tissue lose
their continuity
› Regeneration
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Peripheral nerve injury
Neurotemesis needs repair
Primary nerve repair
Secondary nerve repair (delay)
› Severe contamination
› Blast effect
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Arterial injury
Diagnosis
Hard signs
Soft signs
Other issues of observation
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Arterial injury
Hard signs
6 P (pain, pallor, pulselessness,
paresthesia, paralysis, poikilothermia)
Massive bleeding
Rapidly expanding hematoma
Palpable thrill or audible bruit over a
hematoma
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Arterial injury
Other issues of observation
No pulse detected, observe
› Position of extremity
› Deformity of long bone or joint
› Capillary refill time
< 1 sec = congestion
> 3 sec = poor perfusion
Arteriography may need if pulse absent after reduction
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Investigation
Localization of the defect is necessary (duplex ultrasound, arteriogram)
Except: patients with impending limb loss
from arterial occlusion or significant
external bleeding from an extremity,
immediate surgery without preliminary
arteriography of the injured extremity is
justified
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Management
Non-operative VS. operative
Patient with soft signs and distal arterial pulse may have 3%-25% arterial injuries
but may not need surgery
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Management
Non-operative
› Observe
Non-occlusive arterial injuries (spasm, intimal
flap, subintimal or intramural hematoma)
Careful arteriographic follow-up is necessary
› Therapeutic embolization
Isolated traumatic aneurysms of branches of
the axillary, brachial, superficial femoral, or
popliteal arteries of the profunda femoris , or of one of the named arteries in the shank
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Management
Operative› Lateral arteriorrhaphy or venorrhaphy
› Patch angioplasty
› Panel or spiral vein graft
› Resection of injured segment
End-to-end anastomosis
Interposition graft
Polytetrafluoroethylene
Dacron
› By pass graft
In situ
Extra-anatomic
› Ligation
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Thank you