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

THANK YOUTHANK YOU