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Chest, Abdomen and Orthopaedic Trauma
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TRAUMA PART 2: CHEST, ABDOMINAL,
ORTHOPAEDIC
Angel M Rodriguez PGY2Mercy Catholic Medical Center
Chest Trauma
Chest Trauma Accounts directly for or is a contributing factor in 50% of deaths
due to trauma Early deaths are commonly due to (1) airway obstruction, (2) flail
chest, (3) open pneumothorax, (4) massive hemothorax, (5) tension pneumothorax, and (6) cardiac tamponade.
Later deaths are due to respiratory failure, sepsis, and unrecognized injuries.
Eighty-five percent of chest injuries do not require open thoracotomy
The first priority of management should be to provide an airway and restore circulation.
Types of Injuries Chest Wall Trachea and Bronchus Pleural Space Lung Injury Heart and
Pericardium Esophagus Thoracic Duct Diaphragm
Chest Wall Rib fracture is the most common chest injury. With simple fractures, pain on inspiration is the
principal symptom; treatment consists of providing adequate analgesia.
Multiple fractures, intercostal nerve blocks or epidural analgesia may be required to ensure adequate ventilation.
Flail chest occurs when a portion of the chest wall becomes isolated by multiple fractures and paradoxically moves in and out with inspiration and expiration with a potentially severe reduction in ventilatory efficiency.
Chest Wall An associated lung contusion may produce a
decrease in lung compliance not fully manifest until 12–48 hours after injury.
Serial blood gas analysis is the best way to determine if a treatment regimen is adequate.
Most cases require ventilatory assistance for variable periods of time.
Trachea and Bronchus Blunt tracheobronchial injuries are often due to
compression of the airway between the sternum and the vertebral column in decelerating or high-velocity crush accidents.
80% of all injuries are located within 2.5 cm from the carina.
Most patients with penetrating tracheobronchial injuries have pneumothorax, subcutaneous emphysema, pneumomediastinum, and hemoptysis.
Trachea and Bronchus Tracheobronchial injury -> massive air leak or when the lung
does not readily reexpand after chest tube placement. Bronchovenous fistula-> Systemic air embolism. If suspected ->
emergency thoracotomy with cross-clamping of the pulmonary hilum on the affected side. Dx is confirmed by aspiration of air from the heart.
In blunt injuries, tracheobronchial injury may be suspected only after major atelectasis that develops several days later. Dx may require flexible or rigid bronchoscopy.
Immediate primary repair is indicated for all tracheobronchial lacerations.
Pleural Space Hemothorax-minimal (350 mL); moderate (350–1500 mL) or
massive (1500 mL or more). In 85% of cases, tube thoracostomy is the only treatment
required If bleeding is persistent-> more likely to be from a systemic (eg,
intercostal) rather than a pulmonary artery If > 200 mL/h or the total hemorrhagic output exceeds 1500 mL,
thoracoscopy or thoracotomy should usually be performed. Thoracoscopy effective in controlling chest tube bleeding in 82%
of cases. Also 90% effective in evacuating retained hemothoraces.
Pleural Space 80% of patients with pneumothorax also have blood in the
pleural cavity Most cases of traumatic pneumothorax -> tx with immediate tube
thoracostomy. Tension pneumothorax-> when a flap-valve leak allows air to
enter the pleural space but prevents its escape; intrapleural pressure rises, causing total collapse of the lung and a shift of the mediastinal viscera to the opposite side, interfering with venous return to the heart. Tx placement of a large-bore needle or plastic angiocatheter in the pleural space then tube thoracostomy.
Sucking chest wounds tx by an occlusive dressing and tube thoracostomy.
Lung Injury Pulmonary contusion due to sudden parenchymal concussion
occurs after blunt trauma or wounding with a high-velocity missile.
Occurs in 75% of patients with flail chest but can also occur following blunt trauma without rib fracture.
35% of these patients have an associated myocardial contusion. x-ray findings may not appear until 12–48 hours after injury-
>patchy parenchymal opacification or diffuse linear peribronchial densities that may progress to diffuse opacification ("white-out“)
15% of patients with pulmonary contusion die
Lung Injury Lung lacerations are caused by penetrating injuries, and
hemopneumothorax is usually present Tube thoracostomy is indicated to evacuate pleural air or blood
and to monitor continuing leaks. Lung hematomas are the result of local parenchymal destruction
and hemorrhage. The x-ray appearance is initially a poorly defined density that
becomes more circumscribed a few days to 2 weeks after injury. Most resolve adequately with expectant treatment. Cystic cavities occasionally develop if damage is extensive.
Heart and Pericardium Blunt injury to the heart is most often from
compression against the steering wheel in MVA
In decline with the increasing prevalence of airbag technology
Blunt myocardial injury Early -> friction rubs, chest pain, tachycardia, murmurs,
dysrhythmias, or signs of low cardiac output. EKG if normal and the patient is asymptomatic, the workup is
complete. An abnormal EKG -> echocardiogram. IF injury on echocardiogram or hemodynamic instability (or both),
then -> ICU and managed depending the injury. An abnormal EKG with a normal echocardiogram -> at least 24
hours in telemetry unit and daily repeat EKGs until stable or the dysrhythmia resolves.
Standard measurement of cardiac enzymes is not useful and has no role in the diagnosis of blunt myocardial injury.
Blunt myocardial injury Management of symptomatic blunt myocardial injury -> same as
for acute myocardial infarction. Hemopericardium may occur without tamponade and can be
treated by pericardiocentesis. Tamponade in blunt cardiac trauma is often due to myocardial
rupture or coronary artery laceration. ->distended neck veins, shock, and cyanosis -> thoracotomy and
control of the injury If cardiopulmonary arrest occurs before the patient can be
transported to the operating room -> emergency room thoracotomy with relief of tamponade.
Penetrating cardiac injuries
Tx-> prompt thoracotomy, pericardial decompression, and control of hemorrhage.
Most patients do not require cardiopulmonary bypass. The standard approach has been to repair the laceration using
mattress sutures with pledgets while controlling hemorrhage with a finger on the heart.
Several studies have demonstrated that in most cases, emergency temporary control of hemorrhage from cardiac lacerations can be achieved with the use of a skin stapler
Following stabilization of the patient, the staples can be removed after definitive suture repair is performed in the operating room.
Heart and Pericardium Pericardiocentesis or creation of a pericardial
window is reserved for selected cases when the diagnosis is uncertain or in preparation for thoracotomy.
In approximately 75% of cases of stab wounds and 35% of cases of gunshot cardiac wounds, the patient survives the operation.
However, it is estimated that 80–90% of patients with gunshot wounds of the heart do not reach the hospital
Esophagus well protected perforation from penetrating trauma infrequent. Blunt injuries are exceedingly rare. The most common symptom of esophageal perforation is pain;
fever develops within hours in most patients. Hematemesis, hoarseness, dysphagia, or respiratory distress
may also be present. Hamman's sign (pericardial or mediastinal "crunch" synchronous
with cardiac sounds). X-ray findings on plain chest films include evidence of a foreign
body or missile and mediastinal air or widening. Pleural effusion or hydropneumothorax usually on the left side.
Esophagus Contrast x-rays of the esophagus should be performed but are
positive in only about 70% of proven perforations. NGT should be passed to evacuate gastric contents. If recognized within 24–48 hours after injury, the esophageal
perforation should be closed and pleural drainage instituted with large-bore catheters.
Repair include buttressing of the esophageal closure with pleural or pericardial flaps; pedicles of intercostal, diaphragmatic, or cervical strap muscles; and serosal patches from stomach or jejunum.
Illness and death are due to mediastinal and pleural infection.
Thoracic Duct Chylothorax and chylopericardium are rare
complications of trauma but are difficult to manage Symptoms are due to mechanical effects of the
accumulations, eg, shortness of breath from lung collapse or low cardiac output from tamponade.
The diagnosis is established when the fluid is shown to have characteristics of chyle.
Thoracic Duct Tx-> fat-free, high-carbohydrate, high-protein diet and the
effusion aspirated. Chest tube drainage should be instituted if the effusion recurs. Lipid-free total parenteral nutrition with no oral intake may be
effective in treating persistent leaks. Three or 4 weeks of conservative treatment usually are curative. If daily chyle loss exceeds 1500 mL for 5 successive days or
persists after 2–3 weeks of conservative treatment, the thoracic duct should be ligated via a right thoracotomy.
Intraoperative identification of the leak may be facilitated by preoperative administration of fat containing a lipophilic dye.
Diaphragm Penetrating injuries of the diaphragm outnumber blunt
diaphragmatic injuries by a ratio of at least 6:1. Diaphragmatic lacerations occur in 10–15% of cases of
penetrating wounds to the chest and in as many as 40% of cases of penetrating trauma to the left chest.
as many as 25% of patients are in shock when first seen. CXR is a sensitive diagnostic tool, it may be entirely normal in
40% of cases. The most common finding is ipsilateral hemothorax, which is
present in about 50% of patients.
Diaphragm Passage of a NGT before x-rays will help to identify an
intrathoracic stomach. CT scan or contrast x-rays may be necessary A transabdominal surgical approach should be used in
cases of acute rupture. The diaphragm should be reapproximated and closed with
interrupted or running nonabsorbable sutures. Chronic herniation is associated with adhesions of the
affected viscera to the thoracic structures and should be approached via thoracotomy, with the addition of a separate laparotomy when indicated.
Abdominal Trauma
Questions?Break?
Key points Damage control Exploration Spleen Liver GI Pancreas-duodenum Vessels
Damage control When in intraop metabolic failure:
Hypothermia Acidosis Coagulopathy
More likely to cause the death- unless bleeding.
Damage control Hypothermia
If initial temp less than 35 or progressive decrease->inability to control bleeding
Acidosis Leads progressive decrease in cardiac
performance and increase susceptibility to arrythmias.
Damage control should be practiced when pH<7.2
Damage Control Coagulopathy
Bleeding from edges- diffuse oozing Principles
Rapid control of bleeding Temporizing measures for non bleeding injuries Packing of oozing surfaces Rapid abdominal closures RESUSCITATION IN ICU
Packing but not creating compartment syndrome. Controversy in closing the fascia or not
Exploration Blunt trauma
Hypotensive c evidence of intra-abdominal hemorrhage or hollow viscus injury
Stable c ongoing bleeding, or other condition req tx- perf-SI
Penetrating Transperitoneal trajectory Thoraco-abdominal trajectory c evidence of abd
injury
Exploration Remove from backboard Warm room-fluids Control all external bleeding c pressure blood products! Coagulation devices
Exploration Laparotomy-xiphoid to pubis Four quadrant packing Rapid search for arterial bleeding
Place clamp precisely Venous
Evacuate blood and pack
Exploration Adequate retraction! Thorough search
Spleen- slide hand to diaphragm and feel outer surface-assess for continuity
Liver- slide hand to diaphragm and assess continuity- examine porta and left lobe
Exploration E-G junction- examine anterior stomach to
duodenum Duodenum-look for staining of peritoneum Small intestine- ligament of treitz-follow to
ileo-cecal valve
Exploration Colon- retract SI medially and examine right,
transverse and left for continuity, air and staining…. Sigmoid and upper rectum
Retroperitoneum- open lesser sac and examine posterior stomach and pancreas- zones I, II, and III for hematomas-kidneys
Spleen Splenectomy- prefered operative technique
for grade III-V in unstable pts Grade I and II controlled c pressure,
coagulations agents, splenorrhaphy, or mesh wrapping.
In damage control with coagulopathy, hyporthermia, or ventricular irritability- rapid splenectomy must be done unless bleeding can be stopped by other means.
Liver In pt that cannot be managed non-
operatively-many will require damage control Simple injuries can be controled with CUSA,
argon beam, finger fracture and ligation, deep packing, absorbable mesh, wrapping, etc…
Liver Damage control techniques
Hepatotomy Resectional debridement
Major resection in the face of metabolic failure has mortality of 50%
Selective vascular ligation- ?? Wrapping – takes time Perihepatic packing
Often will not work for arterial injuries Temporize to allow transfer to angiography if surgical
exposure of bleeding would jeopardize pt.
Push together- not down-
Finger fracture
Packing-
Foley and penrose
GI tract SB injuries can be resected and
reanastomosed in almost all situations Multiple within a short segment- should be
resected en-bloc and re-anastomosed Careful closing holes
Narrowing/strictures Inadequate closure Staple when feasible
SI damage control Don’t waste time putting bowel together
Stop further soilage Will be back in 2-3days
Techniques Rapid one layer closure or reanastomoses Staple ends Umbilical tape Control mesenteric hemorrhage
Colon Recent studies- most wounds can be primarily
reanastomosed Comfort decreases as you approach rectum Deep shock, massive soilage, massive hemorrhage
may prompt diversion Unwise to bring out ostomy during initial damage
control Vascular supply may be compromised Will likely be removed later
Duodenum Lacerations
Where lumen will not be compromised- primary repair is indicated
If unable to close – pyloric exclusion should be performed with some drainage procedure
Obviously complete duodenal resection can only yield survivors in stable pts
Consider t-tube – feeding tube – drain area
Pancreas Contusion/laceration not involving duct
Omental plug Multiple drains
Head of pancreas Resection in stable pts Other opts
Sphincterectomy Operative ERCP Post op stenting
Pancreas Injury to body or tail
Stable- distal pancreatectomy Unstable- distal pancreatectomy and splenectomy
Can pack and reassess once condition has stabilized at second surgery
Arteries Celiac artery
Ligation Renal artery
Nephrectomy in most cases SMA
Shunt Iliac
Shunt if feasible If ligated- need fasciotomies
Venous Iliac, infrarenal IVC, smv, portal
Ligation can be tolerated in most cases Pelvic veins
Packing will likely be the only method of control Retohepatic vena cava
Pack Extensive surgery in this area in an unstable
patient will be fatal
Skin closure Abdomen must be closed in some fashion to
place pressure Rapid skin closure with towel clips or running
suture Can use temporary silos
Non-operative considerations Blunt trauma- Spleen
Grade III or higher have 25% overall of failure Arterial blush on CT have increase risk of failure Patients should be stable
No more than 2 units of blood No hypotension Benign abd exam
Unstable pts with minor injuries require operative intervention
Non-operative- Liver
Degree of injury on CT does not correlate well with need for OP intervention
Decision made on hemodynamic status Almost any liver injury can be observed in a
stable pt Arterial blush in stable pt may warrant
arteriographic intervention
Non-operative Free fluid- no organ injury
Very bothersome Recommendations
Peritonitis->OR Benign exam-> repeat CT in 6-8 hours
If fluid increases, or free air-> OR Make sure oral contrast is given!
Non-operative Pancreas
Controversial Definitive transection seen in CT-> OR Contusion and hemorrhage around pancreas
Rpt ct in 6-8 hours If increased fluid, increased inflammation->OR
ERPC?
Conclusions Splenorrhaphy or splenectomy acceptable
depending on degree of injury Large liver resections not warranted on initial
operation Si can be resected and put together in most
situations Colon can be closed or put together in >90% cases Pancreas – distal resection for severe injuries
Otherwise pack or drain.
Open fractures fracture that is exposed to the outside
environment high-energy injuries immediate irrigation and débridement
combined with skeletal stabilization
Pelvic Fractures If hemodynamic instability occurs, stabilization of the pelvis
combined with possible arteriography and embolization can be life saving.
Stabilization of the pelvis can consist of formal application of an external fixator, emergent application of a pelvic fixator clamp, or simple pelvic binders.
Continued, unexplained blood loss despite fracture stabilization and aggressive resuscitation is an indication for angiography.
In patients who are hemodynamically stable, an emergent external fixator is not required. Atomic and definitive fixation with open reduction and internal fixation should improve the outcome.
Classifications Tile
Type A fractures- stable Type B fractures - rotationally unstable but vertically stable Type C fractures - rotationally and vertically unstable.
Burgess and Young- according to the mechanism of injury lateral compression anterior-posterior compression vertical shear or combined mechanism injuries
Acetabular Fractures Any degree of incongruence involving the
weight-bearing surface of the acetabulum is unacceptable and is an indication for surgical treatment.
Nondisplaced fractures may be treated with a period of traction followed by progressive weight bearing.
Hip Dislocation The most common mechanism of injury is
motor vehicles accidents. Posterior dislocations are often associated
with a fracture of the posterior wall of the acetabulum.
Prompt reduction of hip dislocations is essential in minimizing the incidence of osteonecrosis of the femoral head.
Anterior Hip Dislocations 10 to 15% of all hip dislocations Femoral head fractures may occur in a significant
percentage of these cases and late osteonecrosis may occur in approximately 10%.
abducted and externally rotated Closed reduction is possible under adequate
sedation by longitudinal traction and subsequent flexion and internal rotation.
Intra-articular fragments or inadequate reduction are an indication for arthrotomy and open reduction.
Posterior Hip Dislocations associated with posterior wall fractures adducted, internally rotated, and flexed once the hip has been completely dislocated
posteriorly, it may appear shortened and externally rotated.
Sciatic nerve injuries are present in up to 15% Closed reduction is usually accomplished by
longitudinal traction, followed by gentle abduction and external rotation
If the reduction is unstable and associated with a posterior wall fracture, open reduction and internal fixation is indicated.
FEMORAL NECK FRACTURES complains of pain in the groin or thigh and is
unable to bear weight on the injured extremity.
shortened and externally rotated
Garden classification
FEMORAL NECK FRACTURES Internal fixation is indicated in nondisplaced
fractures. treatment of displaced femoral neck fractures is
controversial. best functional outcome and the least number of repeat
operations are performed when these patients are treated with initial total hip replacement.
Displaced femoral neck fractures can also be treated with reduction and internal fixation.
high incidence of probable embolic disease
Intertrochanteric and Subtrochanteric Fractures mechanically less stable than femoral neck fractures varus deformity of the proximal femur shortening, external rotation of the lower
extremity, and often swelling or ecchymosis about the hip
may have more significant blood loss related to the hip fracture.
the sliding hip screw with a side plate continues to be the preferred implant for most stable and unstable intertrochanteric hip fractures
Fractures of the Femoral Shaft pain with motion, external rotational deformity,
and shortening of the affected lower extremity. injury to the sciatic or femoral nerve or femoral
artery Open femur fractures are associated with a 10%
incidence of limb-threatening vascular injury. Any signs of distal ischemia should be evaluated by
vascular surgeons and is indication for immediate vascular exploration.
Fractures of the Femoral Shaft Traction used as a temporizing measure until
patients are stable enough to undergo definitive surgical stabilization.
The gold standard of treatment of these fractures is reamed, locked, antegrade intramedullary nailing performed through a closed technique.
Distal Femur Fractures pain, swelling, and deformity (1) anatomic reduction of the fracture
fragments, particularly intra-articular reduction; (2) preservation of the blood supply to the fracture fragments; (3) stable internal fixation; and (4) early, active, pain-free motion.
Patella Fractures Disruption of the extensor retinaculum will
make active extension of the knee impossible.
Nondisplaced fractures of the patella require immobilization in extension.
Displaced fractures require open reduction and internal fixation.
Tibial Plateau Fractures articular step-off of greater than 3 mm or a
widening of greater than 5 mm are indicators for surgery
Nonsurgical treatment consists of short-term immobilization with a long leg cast followed by bracing or immediate cast-bracing with delayed weight bearing.
Tibial Shaft Fractures 30% of fractures are open injuries->result of
the subcutaneous position of the bone Nondisplaced fractures may present with
localized pain and swelling, and an inability to bear weight
compartment syndrome
Tibial Shaft Fractures Closed tibia fractures, in general, can be treated
successfully with closed reduction and cast immobilization.
Management of open tibia fractures remains a challenge salvage of the limb may be impossible Stabilization of open tibia fractures can be performed with
internal fixation or external fixation. External fixation ->limit any further devascularization of the
leg while providing needed stability. Studies comparing external fixation with intramedullary
nailing conclude that intramedullary nailing gives better results.
Calcaneus lumbar fracture Those with minimal displacement are treated
closed. Any displacement of an articular fragment
involving the subtalar joint should be reduced.
Metatarsal Fractures and Toes Metatarsal Fractures
result of direct trauma easily treated by nonweight bearing for 4 to 6
weeks Toes
Treatment is almost always only taping to the adjacent toe.
If the great toe has a displaced fracture, pin fixation may be indicated.
Clavicle 80% occur in the middle third managed nonoperatively as long as there is
not gross displacement Fractures that occur in the middle third of the
clavicle are treated by placing the injured arm in a sling
In the past, a "figure-of-eight" splint was used but it is uncomfortable and is no longer felt to be needed.
Anterior Shoulder Dislocation most commonly dislocated large joint in the body 95% of cases generally occur after an indirect trauma with the arm
abducted, externally rotated, and extended painful shoulder held in slight external rotation
and abduction axillary nerve is the most common nerve injured-
>sensation over the lateral deltoid region Reduction of the dislocated shoulder should be
performed expeditiously with sedation
Chronic Dislocation If a shoulder joint has been dislocated for a few
days, becomes much harder to reduce by closed techniques.
Open reduction is the only means to reduce the shoulder joint in this circumstance- very difficult
In elderly patients with low functional demands and minimal pain with a chronic shoulder dislocation, conservative treatment leaving the shoulder joint dislocated may be the best option.
Posterior Shoulder Dislocation direct trauma to the anterior humerus or
indirectly from seizures or electric shock pain, the shoulder held in internal
rotation, and adduction. prominent coracoid process, fullness of the
posterior shoulder, and limited external rotation and elevation of the shoulder.
Reduction is performed using the Hippocratic technique with longitudinal traction.
Humeral Shaft Fractures pain, swelling, and difficulty moving the shoulder
and elbow crepitus and motion at the fracture site Radial nerve palsies are commonly associated
injuries, particularly with fractures of the middle third of the humerus.
Operative stabilization of humeral shaft fractures is recommended when-> inability to obtain an adequate alignment with a splint or brace, open fracture, floating elbow (fractures of humerus and radius/ulna), fracture with vascular injury, polytrauma, and pathologic fracture.
Elbow Fractures Open reduction and rigid internal fixation is
recommended in the adult. In children with supracondylar fractures,
closed reduction can almost always be done. Those with minimal initial displacement can
be treated in a cast; however, those with complete displacement (unstable supracondylar fractures) are best treated with percutaneous fixation after the closed reduction
Forearm Fractures Monteggia-fracture of the ulna with an
associated dislocation of the radial head treated with a closed manipulation and cast
immobilization for children and open reduction and internal fixation in adults.
Displaced, both-bone forearm fractures in adults are usually unstable and are best treated with open reduction and internal fixation
Distal Radius Fractures lower-energy fall from ground level onto an
outstretched hand with the wrist extended Colles-Pouteau-> fracture of the distal
radial metaphysis with dorsal displacement of the distal fragment-> most common fracture of the distal radius
Most tx with closed reduction
Spinal Injuries most devastating rigid backboard and with a rigid cervical collar Both acutely unstable and chronically unstable
spines need to be stabilized. general rule, if two or more columns are injured, the
spine is considered unstable. anterior column -> vertebral body. middle column ->posterior cortex of the vertebral body and
posterior longitudinal ligament posterior column -> facet joints and posterior processes
Cervical Spine Stable injuries without nerve deficit can generally be
treated with a cervical orthosis or a halo vest. The presence of spinal cord compression with
incomplete nerve injury generally necessitates operative decompression of the spine to facilitate recovery and prevent further damage to the cord.
In cases of complete spinal cord injury, decompression may allow for recovery of the nerve roots at the level of injury although there is usually little functional recovery distally.
Cervical Spine Atlas fractures are axial loading injuries and are generally
stable injuries without spinal cord injury. They can usually be treated with a rigid cervical orthosis or a halo vest.
Patients with neurologic injuries seen within 24 hours of their injury are started on 30 mg/kg methylprednisolone, then 5.4 mg/kg per hour for 24 hours.
Questions?