CURRENT UPDATESCURRENT UPDATES on
TRAUMA EMERGENCY
K t t Siki K iKetut Siki KawiyanaOrthopaedi & Traumatology Subdivision Udayana University
Sanglah General Hospital Denpasar BaliSanglah General Hospital, Denpasar-Bali
TRAUMA
• Trauma is a leading cause of death and disability all over the world.
• Trauma management can be improved by implementing a trauma system that includes: injury prevention, education, pre hospital care transportation hospital care andpre‐hospital care, transportation, hospital care, and rehabilitation.
• If properly implemented trauma systems can reduceIf properly implemented, trauma systems can reduce mortality of severe trauma patients by at least 15%
Abu‐Zidan FM (2016). Advanced trauma life support training: How useful it is? World J Crit Care Med 2016 February 4; 5(1): 12‐16 ISSN 2220‐3141
TRIMODAL DEATH DISTRIBUTIONTRIMODAL DEATH DISTRIBUTION
PREREQUISITE
TRAUMA PRINCIPLESTRAUMA PRINCIPLES•Trauma is currently the leading cause of death all age groups•Approximately 40% of all emergency department (ED) visits are for trauma‐related complaints•Assess all trauma patients with a rapid primary survey followed by a more comprehensive•Assess all trauma patients with a rapid primary survey followed by a more comprehensive secondary evaluation.
PRIMARY SURVEY
Airway Maintenance with Cervical Spine ProtectionProtection
Breathing and ventilation
Circulation with Hemorrhage Control HEMORRHAGE FROM LONG BONE g
Disability (Neurologic Evaluation)
FRACTURES MAY BE SIGNIFICANT FEMORAL FRACTURES RESULT IN
SIGNIFICANT BLOOD LOSS INTO THE THIGHDisability (Neurologic Evaluation)
Exposure and Environmental Control
THIGH
Exposure and Environmental Control
ADJUNCTS TO PRIMARYADJUNCTS TO PRIMARY SURVEY –ECG
Urinary and Gastric Catheters
X‐Ray Examinations and Diagnostic Studies(Head, Chest and Pelvic X‐Rays)
SECONDARY SURVEY –SECONDARY SURVEY –HISTORY TAKING
• AMPLE (Allergies, Medications, Past Medical Hystory, Last Meal and Environment and events)Key Environment and events)
• Mechanism of injury• Preinjury status
Key aspect • Predisposing factors
• Prehospital observations and careaspect
SECONDARY SURVEY – PHYSICALSECONDARY SURVEY PHYSICAL EXAMINATION
THREE G l f r m nt f tr m p ti nt’THREE Goals for assessment of trauma patient’s extremities
• Id tifi ti f lif thr t nin inj ri (PRIMARY• Identification of life-threatening injuries (PRIMARY SURVEY)
• Identification of limb-threatening injuries (SECONDARY g j (SURVEY)
• Systematic review to avoid missing any other musculoskeletal injury (CONTINUOUS REEVALUATION)musculoskeletal injury (CONTINUOUS REEVALUATION)
SECONDARY SURVEY –THOROUGH ORTHOPAEDICTHOROUGH ORTHOPAEDIC INVESTIGATIONINVESTIGATION
•Complaints:•Something does not look right (Deformity, g g ( yswelling, lump)•Something does not feel right (pain, numb)•Something does not move right (Limp,
OrthopaedicHistory weakness, stiffness)
•Present and Past illness history•Family illness History
HistoryTaking
•Social History
TRUE EMERGENCY IN ORTHOPEDICS & TRAUMATOLOGYCompartment Syndrome
Open Fracturep
Septic Joint
Traumatic ArthrotomyTraumatic Arthrotomy
Necrotizing Fasciitis
Hi h P I j ti I jHigh‐Pressure Injection Injury
“Open Book” Pelvis/Hemodynamically Unstable Pelvis Fracture
Gunshot Wound
Makhni MC, et al. (2017) Orthopedic Emergencies. Springer International Publishing. ISBN 978-3-319-31524-9
Damage Control Orthopedics (DCO)( )
• Initial treatment decisions for unstable polytrauma patients depends on their physiologic state .
• Timing for definitive fracture fixation especially in polytrauma patients controversial
• Delayed definitive fixation in unstable polytrauma patients• Can avoid “second‐hit” to body & decrease chance of developing acute respiratory distress syndrome multisystem failure or deathacute respiratory distress syndrome, multisystem failure, or death
• However, delay in definitive treatment associated with inferior outcomes in otherwise stable patients
Makhni MC, et al. (2017) Orthopedic Emergencies. Springer International Publishing. ISBN 978-3-319-31524-9
Damage Control Orthopedics (DCO)(DCO)
• Other indications for DCO• Hemodynamic instability with associated trauma to
l i / bdpelvis/abdomen• Pulmonary contusions/respiratory distress• Bilateral femur fractures• Bilateral femur fractures• Polytrauma with significant head injury• Increased injury severity scoreIncreased injury severity score
Makhni MC, et al. (2017) Orthopedic Emergencies. Springer International Publishing. ISBN 978-3-319-31524-9
TIMING FOR DEFINITIVE SURGERYPHYSIOLOGICAL STATUS INTERVENTION TIMINGPHYSIOLOGICAL STATUS INTERVENTION TIMING
RESPONSE TO RESUCITATION ‐ LIFE SAVING SURGERY+ DAMAGE CONTROL? LAY I A Y
DAY 1
? DELAYED PRIMARY SURGERY
HYPERINFLAMMATION SECOND LOOK ONLY DAY 2 3HYPERINFLAMMATION
WINDOW OPPURTUNITY
SECOND LOOK ONLY
DEFINITIVE SURGERY
DAY 2‐3
DAY 5‐10
IMMUNOSUPRESION
RECOVERY
NO SURGERY
SECONDARY RECONSTRUCTIVE SURGERY
WEEK 3RECONSTRUCTIVE SURGERY
Damage Control OrthopedicsDamage Control Orthopedics (DCO)
DCO involves temporary stabilization with plan for delayed definitive treatment
• Physiologic and metabolic management• Pelvic binder/sheet• Skeletal traction• Skeletal traction• External fixation
Makhni MC, et al. (2017) Orthopedic Emergencies. Springer International ( ) p g p gPublishing. ISBN 978-3-319-31524-9
PARAMETER AND CRITERIA SUCCESFULL RESUCITATION
•STABLE HEMODINAMIC•NO HIPOXEMIA, NO HIPERCAPNIA•LACTATE < 2MMOL/ L•NORMAL COAGULATIONNORMAL COAGULATION•NORMOTHERMIA
/ /•URINE OUTPUT > 1 CC/KG/HOUR•NO NEED VASOACTIVE OR INOTROPIC
UNSTABLE PELVIC FRACTURESUNSTABLE PELVIC FRACTURES
UNSTABLE PELVIC FRACTURES
C l hibit di ti f th
UNSTABLE PELVIC FRACTURES
• Commonly exhibit disruption of the posterior osseus-ligamentous (sacroiliac, sacrospinous, ( , p ,sacrotuberous) ~ sacroiliac fracture, sacral fracture
• These are often the results of motor vehicle accidents
A t bl i j b h t i dAn unstable injury may be characterized by the type of displacement as:
• Rotationally unstableRotationally unstable (open and externally rotated, or compressed and internally rotated).p y )
• Vertically unstable
PresentationPresentation
• ABCs (airway, breathing, circulation) presentation on admittion
• Important the patient's mechanismImportant the patient s mechanism of injury.
Clinical:• Destot sign (superficial hematoma
above the inguinal ligament, in the scrotum, or in the thigh)
• Look for a rotational deformity of the pelvis or lower extremities. LLD l i h l i• LLD may also present with pelvic fractures.
• Lower extremities must undergo a gthorough neurovascular examination
• Unexplained hypotension may be the only• Unexplained hypotension may be the only indication of major pelvic disruption
• Physical signs: progressive flank, scrotal, perianalPhysical signs: progressive flank, scrotal, perianal swelling and bruising
Stability:• Mechanical instability, is test by manualMechanical instability, is test by manual
manipulation (should be performed only once!)• Sign of instability:
• leg length discrepancy or rotational deformity usually external• Open wound in flank, perinium, rectum
ImagingImaging
Plain radiography• Unstable fractures characterized byUnstable fractures characterized by
• Hemipelvic cephalad displacement that exceeds 0.5 cm SI diastasis that exceeds 0 5 cmSI diastasis that exceeds 0.5 cm.
• Findings suggestive of pelvicinstability include cephaladhemipelvic displacement lesshemipelvic displacement lessthan 1 cm and/or a diastaticfracture of the sacrum or iliumless than 0 5 cmless than 0.5 cm.
Managementh l d id fl id i i• Hemorrhage control and rapid fluid resuscitation
• Pelvic Binder or Pelvic C-clamp• Longitudinal skin or skeletal traction• Longitudinal skin or skeletal traction• Pelvic sling• PASGPASG• Open pelvic fracture packing the open wound
Pelvic wrapwrap
Pelvic C-Clampp
Treatment • Hemodynamically unstable aggressiveresuscitation and prevention of furtherTreatment resuscitation and prevention of further hemorrhage.
• External fixation in a hemodynamicallyExternal fixation in a hemodynamically unstable patient with an unstable pelvic fracture.
• Operative indications • diastases of pubic symphysis greater than 2.5 cm,
ili j i t di l ti• sacroiliac joint dislocations, • displaced sacral fractures, • crescent fractures, • posterior or vertical displacement of the hemipelvis
(>1 cm), • rotationally unstable pelvic ring injuriesrotationally unstable pelvic ring injuries, • sacral fractures in patients with unstable pelvic ring
injuries that require mobilization, d di l d l f t ith l i• and displaced sacral fractures with neurologic
injury
MAJOR ARTERIAL HEMORRHAGEHEMORRHAGE
• Penetrating extremity woundsCaused by wounds
• Blunt traumaCaused by
• External bleeding• Loss a previously palpable pulseLoss a previously palpable pulse• Change in pulse equality• Doppler toneA kl /b hi l i d
Assessment• Ankle/brachial index• Rapidly expanding hematoma
Management• Application of direct pressures to the
dopen wound• Aggressive fluid resuscitation• Pneumatic tourniquetq• Vascular clamp is not recommended
unless superficial vessel is clearly identified
• If a fracture is associated with an open hemorrhaging wound, fracture should be realignment and splintingg p g
• Consultation with surgeon skilled in vascular and extremity trauma
CRUSH INJURY &
CRUSH SYNDROMECRUSH SYNDROME
• Crush injury compression of extremities and body parts that causes y pmuscle swelling and/or neurological disturbances in the affected parts of the bodythe body
C h d l li d h• Crush syndrome localized crush injury with systemic manifestations.Systemic effects caused by a y ytraumatic rhabdomyolysis and the release of toxic muscle cell components and electrolytes intocomponents and electrolytes into the circulation
Synonym : Bywaters’ Syndrome
PathophysiologyPathophysiology
Management in crush injuries
• Apply pressure dressing to gross arterial bleeding • Correct gross misalignment of extremities by gentle application andCorrect gross misalignment of extremities by gentle application and
repositioning• Flood open wounds with sterile saline solution and cover with antiseptic
k d d isoaked gauze dreesings.• Apply splinting material to immobilize the injured extremity• Apply adequate antibiotic and antitetanus
S rgical management in cr sh inj ries
• Apply adequate antibiotic and antitetanus
Surgical management in crush injuries • Remember damage control principal • Wound debridement• Temporary vascular shunting (for vascular injury)• External fixation
Clinical manifestations of crushClinical manifestations of crush syndrome
• Hypotension acute hypovolemia• Renal failure rhabdomiolisis releases myoglobin,
t i h d ti i i t bl dpotassium, phosporus and creatinine into blood circulation
• Metabolic abnormalities• Metabolic abnormalities • calcium flow into muscle cell through leaky
membranes systemic hypocalcemiay yp• Potassium released from ischemic muscle into
systemic circulation hyperkalemia• Lactic acid released from ischemic muscle into
systemis circulation metabolic acidosis• Imbalance of potassium and calcium cardiac• Imbalance of potassium and calcium cardiac
arrhytmias cardiac arrest
Diagnosis criterias of crush syndromesyndrome
1. Crushing injury to a large mass of skeletal muscle
2 The sensory and motor2. The sensory and motor disturbances, tense and swollen
3. Myoglobinuria and/or hematuria4. Peak creatine kinase (CK) >
1000 U/L
Management of crush syndromeManagement of crush syndrome• ABC• Hypotension fluid replacement• Renal failure
• Prevent renal failure through appropriate hydration• Maintain diuresis 300cc/hr with IV fluids and mannitol 20%
• Metabolic abnormalitiesMetabolic abnormalities• IV Sodium bicarbonate 50-100 meq/l until urine pH reach 6,5• Hyperkalemia/Hypocalcemia administer calcium, sodium bicarbonate, insulin/D5%• Cardiac arrhytmias close monitoring• Cardiac arrhytmias close monitoring
• Amputation• Fasciotomy: controversialy• Hyperbaric oxygen therapy
Li b Th i i j iLimb-Threatening injuries
Open CompartmentOpen fractures Dislocation Compartment
syndrome
OPEN FRACTURES • Osseous disruption in which a break in the skin and underlying soft tissue communicates directly ywith the fracture and its hematoma
• Soft tissue injuries :• Contamination of the wound
and fracture • Crushing, stripping, and
devascularization soft tissue• Destruction or loss of the softDestruction or loss of the soft
tissue envelope
Complete assessment of the open fracture• reviewing the mechanism of injury,reviewing the mechanism of injury, • condition of the soft tissues, • degree of bacterial contamination, • characteristics of the fracture
Help to classify the fracture, determine the treatment
i d bli h hregimen, and establish the prognosis and potential
clinical outcome
CLINICAL EVALUATIONCLINICAL EVALUATION
ABCDE• ABCDE• Initiate resuscitation and
address life-threateningaddress life threatening injuries.
• Evaluate injuries to the head, chest, abdomen, pelvis, and spine.
• Identify all injuries to the• Identify all injuries to the extremities.
• Assess the neurovascular status of injured limb(s).
• Assess skin and soft tissue ddamage
• Obtain necessary radiographs
CLASSIFICATION : Gustilo and Anderson
Type Wound Level of contamination
Soft tissue injury Bone injury
I <1 cm long
Clean Minimal Simple, minimal comminution
II >1cm Moderate Moderate, some muscle damage Moderate comminutionlong
, g
III
A Usually High Severe with crushing Usually comminuted;A Usually >10 cm long
High Severe with crushing Usually comminuted; soft tissue coverage of bone possible
B Us all High Ver se ere loss of co erage; Bone co erage poor;B Usually >10 cm long
High Very severe loss of coverage; usually requires soft tissue reconstructive surgery
Bone coverage poor; variable, may be moderate to severe comminution
C Usually >10 cm long
High Very severe loss of coverage plus vascular injury requiring repair; may require soft tissue
Bone coverage poor; variable, may be moderate to severe o g y equ e so ssue
reconstructive surgeryode e o seve e
comminution
Type~I of Open Fracture of the Lower LegType I of Open Fracture of the Lower Leg
Type I <1 cm long
Clean Minimal Simple, minimal comminutionlong comminution
Type~II Open Fracture of theType II Open Fracture of the Lower Leg
Type II >1cm long
Moderate Moderate, some muscle damage
Moderate comminution
Type~II Open Fracture of the forearm
Type II >1cm long
Moderate Moderate, some muscle damage
Moderate comminution
Type~III Open Fracture of the ForearmForearm
Type III
Type A Usually >10 cm long
High Severe with crushing Usually comminuted; soft tissue coverage of bone g gpossible
Type B Usually >10 cm long
High Very severe loss of coverage; usually requires soft tissue reconstructive
Bone coverage poor; variable, may be moderatecm long requires soft tissue reconstructive
surgeryvariable, may be moderate to severe comminution
Type~IIIC Open Fracture of FemurFemur
Type IIIC
Usually >10 cm long
High Very severe loss of coverage plus vascular injury requiring repair; may require soft tissue reconstructive surgery
Bone coverage poor; variable, may be moderate to severe comminutionreconstructive surgery comminution
Principles treatment ofPrinciples treatment of open fractures
1. All open fractures treated as an emergency
2 Th h i iti l l ti t di2. Thorough initial evaluation to diagnose other life-threatening injuries
3. Appropriate and adequate antibiotic ththerapy
4. Adequate debredement and irrigation5. Stabilization of the fracture6. Perform delayed closure of the wound
within 3 to 7 days7. When indicated, early cancelous bone , y
grafting ( 1 to 6 weeks)8. Decide on early amputation9. Treat compartment syndrome9. Treat compartment syndrome10. Rehabilitation of the involved extremity
Antibiotic coverage for open Antibiotic coverage for open g pfractures
g pfractures
G d I II fi t ti h l i (C f t il h l i• Grade I, II : first-generation cephalosporin (Cefacetrile, cephalexin, cephalotin, cephaloridine, cephapirin, cefatrizine, cefazedone, cefazolin, cephradine, cefroxadine, ceftezole) 2 g i.v.
• Grade III: add an aminoglycosides 3,0 to 5,0 mg/kg
T tTetanus Prophylaxis
Immunization history
dT TIG
p yThe current dose of toxoid is 0.5 mL; for
Incomplete (<3 doses) or not
+ ‐
immune globulin, the dose is 75 U for patients <5 years of age, 125 U for those 5 to 10 years old, and 250 U for those >10
ld
known
years old. Complete/>10 years since last dose
+ ‐
C l t / 10Complete/<10 years since last dose
‐ ‐
OPERATIVE TREATMENTOPERATIVE TREATMENT
• Irrigation, debridement and remove foreignand remove foreign bodies
• Fracture stabilization• Fracture stabilization• Soft tissue coverage and
b ftibone grafting• Limb salvage
Principal of irrigation and debridement
• The wound should be extended proximally and distally to examine the zone of injury.
• Large skin flaps should not be developed • Tendons, unless severely damaged or
i d h ld b dcontaminated, should be preserved.• Pulsatile lavage irrigation, with or
without antibiotic solution, should be ,performed
• Meticulous hemostasis should be maintainedmaintained
I !!Important!!• Do not irrigate, debride, or probe the
wound in the ER if immediate operative intervention is planned
• If a surgical delay is anticipated, performed gentle irrigation with normal saline.
• Lavage is used to deliver irrigating fluids g g g(normal saline solution)
• For type I : 1.000 to 2.000 cc• For type II and III: 5.000 to 10.000 yp
cc• For final irrigation, usually use 2.000
cc of mixture of bacitracin and l i i l tipolymyxin in solution
• Bone fragments should not be removed in the emergency room, no matter how
i l i bl th bseemingly nonviable they may be.
Fracture stabilizationFracture stabilization (internal or external fixation)
• provides protection from additional soft tissue
Fixationadditional soft tissue injury,
• maximum access for
Devices:maximum access for wound management,
• maximum limb and
1. Plate and ScrewFixation
2 Intramedullary Nailingpatient mobilization 2. Intramedullary Nailing3. External Fixation
Devices
S f i d b f iSoft tissue coverage and bone grafting• Bone grafting can be performed when theBone grafting can be performed when the
wound is clean, closed, and dry. • The timing of bone grafting after free flap
i t i lcoverage is controversial. • Some advocate bone grafting at the time of
coverage; others wait until the flap has healed g ; p(normally 6 weeks).
Li b l l iLimb salvage or early amputation
In Gustilo Gr III, immediate or earlyimmediate or early amputation indicated if: • The limb is nonviable:
irreparable vascular injury, warm ischemia time >8 hours or severetime >8 hours, or severe crush with minimal remaining viable tissue.
DISLOCATIONDISLOCATIONDISLOCATIONDISLOCATIONMost commonly dislocated major joint • ShoulderShoulder• Elbow• HipHip• Knee
Sh ld di l iShoulder dislocation
• Anterior dislocationP i di l i• Posterior dislocation
• Inferior dislocation
A i Sh ld Di l iA i Sh ld Di l iAnterior Shoulder DislocationAnterior Shoulder Dislocation
• 90% of shoulder dislocationsMOI• MOI :
• indirect trauma shoulder in abduction, extension and external rotationexternal rotation
• direct: anteriorly directed impact to the posterior shoulder
• Patient presents with the injured shoulder held in slight abduction and external rotation.
• Squaring of the shoulder • Careful neurovascular examination is important (axillary
nerve and musculocutaneous nerve integrity)
Treatment of anterior shoulder dislocations
Closed reduction should beClosed reduction should be performed after adequate clinical evaluation and d i i t ti f l iadministration of analgesics
and/or sedation. Described techniques include:q
• Traction-counter traction
• Hippocratic t h itechnique
• Stimson technique• Milch technique• Milch technique• Kocher maneuver
ComplicationComplication• Tear of rotator cuff• Avulsion of greater tuberosityAvulsion of greater tuberosity• Brachial plexus or axillary nerve injury• Instability reccurrence (the most y (
common complication
ELBOW DISLOCATIONELBOW DISLOCATIONP i di l i i• Posterior dislocation is most common.
• Simple dislocations are• Simple dislocations are those without fracture.
• Complex dislocations areComplex dislocations are those that occur with an associated fracture and
t j t d 50% frepresent just under 50% of elbow dislocations.
• Highest incidence in the 10• Highest incidence in the 10-to 20-year old age group associated with sports injuries
MOIMOIM t l i j• Most commonly, injury is caused by a fall onto an outstretched hand or elbowelbow,
• Posterior dislocation: This is a combination of elbow hyperextension, valgus stress, arm abduction, and forearm
i isupination
TREATMENT ofTREATMENT of Simple Elbow dislocation
Conservative• For posterior dislocations, reduction should be performedFor posterior dislocations, reduction should be performed
with the elbow flexed while providing distal traction.• Neurovascular status should be reassessed, followed by y
evaluation of stable range of elbow motion.• Postreduction management should consist of a posterior
li 90 d d l isplint at 90 degrees and elevation.• Early, gentle, active range of elbow motion is associated
with better long term resultswith better long-term results• Recovery of motion and strength may require 3 to 6 months.
HIP DISLOCATIONSHIP DISLOCATIONSA t i• Anterior dislocations constitute 10% to 15% of traumatic15% of traumatic dislocations of the hip, with posterior dislocationsdislocations accounting for the remainder.S i ti i j• Sciatic nerve injury is present in 10% to 20% of posterior dislocationsdislocations
MOIMOIAl t l lt f• Almost always result from high-energy trauma, such as motor vehicle accident, fall from a height or industrialfrom a height, or industrial accident.
• Force transmission to the hip joint occurs with application to one of three common sources:
• The anterior surface of the flexed knee striking an object
• The sole of the foot, with ,the ipsilateral knee extended
• The greater trochanterThe greater trochanter
Anterior Anterior DislocationsDislocations
C i 10% t 15% f• Comprise 10% to 15% of traumatic hip dislocations.
• Result from external rotation and abduction of the hip.
Posterior DislocationsPosterior Dislocations• Much more frequent
than anterior hip dislocations.
• Result from trauma toResult from trauma to the flexed knee (e.g., dashboard injury) with the hip in varying p y gdegrees of flexion
TREATMENT Closed ReductionClosed Reduction
Allis MethodP i i i h h• Patient supine with the surgeon standing above the patient on the stretcher
• Surgeon applies in-line traction while the assistant applies countertraction by stabilizing the y gpatients pelvis.
• Surgeon should slowly increase the degree of flexion to approximatelydegree of flexion to approximately 70 degrees.
• Gentle rotational motions of the hip ll li ht dd tias well as slight adduction
• A lateral force to the proximal thigh may assist in reduction. g y
STIMSON GRAVITY TECHNIQUETECHNIQUE
• Patient is placed prone on the stretcher with the affected leg hanging off the side of the stretcher.
• This brings the extremity into a position of hip flexion and kneeposition of hip flexion and knee flexion of 90 degrees each.
• In this position, the assistant immobilizes the pelvis and theimmobilizes the pelvis, and the surgeon applies an anteriorly directed force on the proximal calfcalf.
• Gentle rotation of the limb may assist in reduction
OPEN REDUCTIONOPEN REDUCTIONI di i f d i f di l d hiIndications for open reduction of a dislocated hip include:
• Dislocation irreducible by closed means.y• Nonconcentric reduction.• Fracture of the acetabulum or femoral head
i i i i d ti drequiring excision or open reduction and internal fixation.
• Ipsilateral femoral neck fracture.p
COMPLICATIONSCOMPLICATIONSO t i b d i 5% t 40% f• Osteonecrosis: observed in 5% to 40% of injuries
• Posttraumatic osteoarthritis: the most frequent qlong-term complication of hip dislocations
• Recurrent dislocation: rare (<2%)N l i j• Neurovascular injury
KNEE DISLOCATIONSKNEE DISLOCATIONSHi h A t hi l• High-energy: A motor vehicle accident with a dashboard injury involves axial loading to a flexed kneeflexed knee.
• Low-energy: This includes athletic injuries and falls.
• Hyperextension with or without varus/valgus leads to anterior dislocation.dislocation.
• Flexion plus posterior force leads to posterior dislocation (dashboard inj r )(dashboard injury).
Dislocation of Knee
Classification• Anterior dislocation: mostAnterior dislocation: most
common• Posterior dislocation• Superior dislocation
Cli i l E l iClinical EvaluationG k di t ti• Gross knee distortion
• Extent of ligamentous injury is related to the degree of di l t i t bilitdisplacement, gross instability may be realized after reduction
• Ligament examination is iimportant
• A careful neurovascular examination is critical, both before and after reduction
• Vascular injury : popliteal artery disruption (20% to 60%)
• Neurologic injury : peronealnerve (10% to 35%). Commonly associated with posterolateraldislocations
TREATMENT
• The posterolateraldislocation isdislocation is irreducible owing to buttonholing of the medial femoral condyle ythrough the medial capsule dimple sign over the medial aspect pof the limb requires open reduction
• The knee should beThe knee should be splinted at 20 to 30 degrees of flexion
Operative• Indications :
• Unsuccessful closed reductionreduction.
• Residual soft issue interposition.
• Open injuries.• Vascular injuries.
• V l d li t• Vascular and ligamentous injuries should be repaired.
COMPLICATIONSCOMPLICATIONSLi it d f ti t• Limited range of motion: most common
• Ligamentous laxity and instability: uncommon
• Vascular compromise: result in atrophic skin changes, hyperalgesia, claudication, and muscle contracture.and muscle contracture.
• Nerve traction injury
ACUTE COMPARTMENT SYNDROME
Increased pressure within a closed fascial spaces of the arm, leg or other extremity, most often due to injury, exceeds the perfusion pressure (enough to occlude capillary blood flow) and results in muscle and nerve ischemia.
Etiologies of CSD d C t t Si• Decreased Compartment Size:
• Crush syndrome• Closure of fascial defect• Tight dressing or cast• External pressure(PASG or direct pressure)
• Increased Compartment Content:Increased Compartment Content:• Bleeding• Edema• Postischemic swelling• Postischemic swelling• Exercise• Trauma
B• Burn• Intra arterial drug• Orthopaedic surgery or trrauma• Venous obstruction
C f dCauses of compartment syndrome
Injury Energy is dissipated i h lInjury into the muscle
intracellular Increased pressure,
ithi th l d swellingwithin the closed space
circulatory Ischemia and tissue yembarrassment damage
Clinical picture:picture: 6~P1. Pain2. Pallor1. Pain2. Pallor3. Puffiness4. Paresthesia5 P l i
3. Puffiness4. Paresthesia5 P l i5. Paralysis6. Pulselessness5. Paralysis6. Pulselessness
The earliest, most consistent, and mostreliable sign is deep, unrelenting, vague butprogressive PAIN that is out of proportionto the injury and not responsive to normalto the injury and not responsive to normaldoses of pain medication.
Techniques of Tissue-PressureTechniques of Tissue PressureMeasurement Infusion technique
S i l t t tSurgical treatmentV l i d f i• Vascular repair and fasciotomy
Fasciotomy of the Lower Leg
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