Transcript orthopaedic emergency

ORTHOPAEDIC
EMERGENCY
ั สุมนานนท์
อ.นพ.ชช
ภาควิชาออร์โธปิ ดก
ิ ส ์ คณะแพทยศาสตร์ มหาวิทยาลัยขอนแก่น
Objective
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สามารถลาดับความสาคัญของภาวะฉุกเฉินในผู ้ป่ วยทีม
่ ี
ภาวะบาดเจ็บทางออร์โธปิ ดก
ิ ส ์ และภาวะบาดเจ็บร่วม
อืน
่ ได ้
สามารถบอกแนวทางการรักษาเบือ
้ งต ้น และสามารถ
ปฏิบต
ั ต
ิ ามแนวทางปฏิบต
ั ไิ ด ้อย่างเหมาะสม
สามารถอธิบายลักษณะของการบาดเจ็บทีพ
่ บบ่อย และ
ทีส
่ าคัญของผู ้ป่ วยทีม
่ ภ
ี าวะบาดเจ็บเฉพาะทางออร์โธปิ
ดิกส ์
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
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Orthopaedic injury occurs as part of:
 Multiple
orthopaedic injuries only
 Multisystem trauma, with multiple orthopaedic
injuries
 Multisystem injury with minor (not lifethreatening) orthopaedic injury
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
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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
Orthopaedic haemorrhage control
Address and control sources of
catastrophic haemorrhage
 Direct pressure controls (most peripheral
bleeding)
 Broken bones bleed
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 Femur
1000 cm3
 Tibia 750 cm3
 Plevic fracture 2000 cm3
Orthopaedic haemorrhage control
Splinting reduces blood loss (pre-hospital)
 Continued hypotension is unlikely in
isolated long bone fracture
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 Look
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elsewhere
Pelvic bleeding kills
 Unstable
pelvic fractures need to be stabilized
quickly
20-25% of all major trauma deaths have a pelvic fracture
Secondary survey
Orthopaedic injuries usually identified during the secondary survey
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History: mechanism of injury
 Detailed
history
 Patterns of orthopaedic injury exists
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Falls from height: calcaneal fractures, tibial fractures and
spinal fractures
Examination
 Major long bone fractures
 Limb deformed/short
usually obvious
 Up
to 10% of lesser fracture may be missed (use
Tertiary Survey)
All fractures are important to the patient
Secondary survey
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Assess major joints for active and passive ROM
and stability
Careful palpate long bones for
 pain,
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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
Secondary survey
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Don’t 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
Secondary survey
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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
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Specialized imaging
 CT,
MRI
Injury recognition: high energy limb
injuries
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The surgical fracture and soft tissue management is
complex – the prognosis and outcome is corresponding
worse
History
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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
Injury recognition: high energy limb
injuries
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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
Injury recognition: high energy limb
injuries
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Plain radiography
 Segmental
fracture
 Highly comminutes fractures
 Wide displacement of bone fragments
 Evidence of air in the soft tissues
Timing of surgery
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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
Timing of surgery
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Reducing the overall inflammatory response
 Remove
necrotic/devitalized tissue by
debridement/fasciotomy
 Reduce blood loss and pain by splinting/stabilizing
fractures
 Reduce ischemia by joint
relocation/fasciotomy/stabilizing fracture
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Inflammatory response increases in: excessive
surgery – blood loss/hypothermia
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
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 Hypoxia
 Hypothermia
 Abnormal
clotting
 Acidosis
 Increase
intracranial pressure
Orthopaedic surgical priorities
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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
Ischaemia correction
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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
Wound care
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Open fracture need to be debrided and stabilized within
6h
Tourniquet (not necessary)
Remove contaminants
Excise necrotic or devitalized tissue and skin margins
Copious irrigation
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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”
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:
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 Fracture
configuratrion
 Fracture grade
 Extent of soft tissue damage/contamination
 Surgical experience
Gustilo and Anderson open fracture classification
Long bone stabilization
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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
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Femoral shaft fractures are the next priority after
pelvic stabilization
 Closed IM nailing
 Temporary EF
– treatment of choice
Other fractures
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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
Other fractures
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Factors
 Patient’s
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
Reaming for femoral shaft fracture
– reaming and pulmonary failure
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Reamed femoral intramedullary nail
should be avoid in blunt chest trauma
patient (ARDS)
Principle of external fixation
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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
Compartment syndrome
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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:
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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
Compartment syndrome
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Normal compartment pressure is 0 mmHg
Isolated compartment pressure > 40 mmHg
Differential pressure (DBP) < 30 mmHg
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Treatment
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 Fasciotomy
 Release
all dressings and splints down to the skin
Compartment syndrome can occur in open fracture
Limb salvage versus amputation
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Difficult to decision
Need to discuss options with patient
Photographic evidence useful
MESS score: for decision making but not absolute
Factors involved decision making:
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Extent of bony injury
Nerve supply (esp. posterior tibial nerve)
Crush injuries
Physiologic reserve
Smoking
Economic, psychological and social factors
Mass casualty situation
Common Musculoskeletal
Injuries
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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
Common Musculoskeletal
Injuries
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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
Serious Causes of Death in
Orthopaedic Emergency
1.
2.
3.
High (upper) cervical spine injury
Severe fracture of pelvis with unstable
and massive bleeding
Multiple crushed limb and trunk injury
Estimated Blood Loss from
Fracture
Pelvis
Femur
Tibia
Humerus
100-4,000 cc
400-2,700 cc
250-1,800 cc
200 – 800 cc
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)
Parameter
Score
Eye opening
Spontaneous
4
To voice
3
To pain
2
None
1
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
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
< 20% by volume
4
Severe pelvic fracture with blood loss
> 20% by volume
5
Unsurvivable
6
Revised Trauma Score (RTS)
Result
Score
Respiratory rate (breaths/min)
10-29
4
>29
3
6-9
2
1-5
1
0
0
Systolic blood pressure (mm/Hg)
>89
4
76-89
3
50-75
2
1-49
1
0
0
GCS
13-15
9-12
4
RTS = 0.9368 GCS
+ 0.7326 SBP + 0.2908 RR
3
6-8
2
4-5
1
3
0
TRISS score  to predict the probability of survival
Resuscitation
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Resuscitation / treatment protocol based
on ATLS guidelines
Resuscitation/Treatment Protocol Based on ATLS Guidelines
1. Primary survey and resuscitation (patient stabilization)
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A Airway and cervical spine
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B
C
D
E
Breathing and oxygenation
Circulation and hemorrhage
Dysfunction of the CNS
Exposure and environmental
2. Consider transfer to more appropriate hospital if indicated
3. Secondary survey
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A Allergies
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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
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
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
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
Steps
7. Complete CNS examination  patient’s
responsiveness and GCS including
neurological examination of the limb
8. Radiographical examination of the chest
and pelvis (head, neck and spine if
clinically required)
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
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
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
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?
Parameters Associated with Adverse
Outcome in Multiple Injured Patient
1. Unstable condition or difficult resuscitation
2. Coagulopathy (platelet count < 90,000)
3. Hypothermia (<32 c)
4. Shock and > 25 units of blood replacement
5. Bilateral lung contusions on initial radiographs
6. Multiple long bones plus truncal injury AIS > 2
7. Probable operating time > 6 hr
8. Arterial injury and hemodynamic instability (BP< 90)
9. Exaggerated inflammatory response (IL-6 > 800
pg/ml)
Conditions in Which Damage Control
Surgery Should Be Considered
1. Polytrauma + ISS > 20 and thoracic trauma (AIS >2)
2. Polytrauma with severe abdominal/pelvic trauma and
hemodynamic shock (BP <90 mm Hg)
3. ISS > 40
4. Bilateral lung contusions
5. Initial mean pulmonary arterial pressure > 24 mmHg
6. Pulmonary artery pressure increase >6 mmHg during
long bone intramedullary nailing
Tertiary Survey
(Common missed injuries)
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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
Tertiary Survey
(Common missed injuries)
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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
Open Fracture
Some important factors
 Golden period - 8 hr
12 hr. potentially infected
 Environment / atmosphere
ไต้ฝ่ น
ุ / สงคราม / ตกนา้
 Types: Gustilo - I, II, III A,B,C
 Foreign body in wound
 Associated injury
Gustilo Classification of Open
Fractures
Type
Definition
I
Open fracture with a clean wound < 1 cm
in length
II
Open fracture with a laceration of > 1 cm
long and without extensive soft tissue
damage, flaps, or avulsions
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
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
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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