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TRAUMA PART 2: CHEST, ABDOMINAL, ORTHOPAEDIC Angel M Rodriguez PGY2 Mercy Catholic Medical Center

Chest, Abdomen and Orthopaedic Trauma

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Page 1: Chest, Abdomen and Orthopaedic Trauma

TRAUMA PART 2: CHEST, ABDOMINAL,

ORTHOPAEDIC

Angel M Rodriguez PGY2Mercy Catholic Medical Center

Page 2: Chest, Abdomen and Orthopaedic Trauma

Chest Trauma

Page 3: Chest, Abdomen and Orthopaedic 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.

Page 4: Chest, Abdomen and Orthopaedic Trauma

Types of Injuries Chest Wall Trachea and Bronchus Pleural Space Lung Injury Heart and

Pericardium Esophagus Thoracic Duct Diaphragm

Page 5: Chest, Abdomen and Orthopaedic Trauma

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.

Page 6: Chest, Abdomen and Orthopaedic Trauma

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.

Page 7: Chest, Abdomen and Orthopaedic Trauma

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.

Page 8: Chest, Abdomen and Orthopaedic Trauma

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.

Page 9: Chest, Abdomen and Orthopaedic Trauma

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.

Page 10: Chest, Abdomen and Orthopaedic Trauma

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.

Page 11: Chest, Abdomen and Orthopaedic Trauma

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

Page 12: Chest, Abdomen and Orthopaedic Trauma

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.

Page 13: Chest, Abdomen and Orthopaedic Trauma

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

Page 14: Chest, Abdomen and Orthopaedic Trauma

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.

Page 15: Chest, Abdomen and Orthopaedic Trauma

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.

Page 16: Chest, Abdomen and Orthopaedic Trauma

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.

Page 17: Chest, Abdomen and Orthopaedic Trauma

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

Page 18: Chest, Abdomen and Orthopaedic Trauma

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.

Page 19: Chest, Abdomen and Orthopaedic Trauma

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.

Page 20: Chest, Abdomen and Orthopaedic Trauma

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.

Page 21: Chest, Abdomen and Orthopaedic Trauma

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.

Page 22: Chest, Abdomen and Orthopaedic Trauma

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.

Page 23: Chest, Abdomen and Orthopaedic Trauma

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.

Page 24: Chest, Abdomen and Orthopaedic Trauma

Abdominal Trauma

Questions?Break?

Page 25: Chest, Abdomen and Orthopaedic Trauma

Key points Damage control Exploration Spleen Liver GI Pancreas-duodenum Vessels

Page 26: Chest, Abdomen and Orthopaedic Trauma

Damage control When in intraop metabolic failure:

Hypothermia Acidosis Coagulopathy

More likely to cause the death- unless bleeding.

Page 27: Chest, Abdomen and Orthopaedic Trauma
Page 28: Chest, Abdomen and Orthopaedic Trauma

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

Page 29: Chest, Abdomen and Orthopaedic Trauma

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

Page 30: Chest, Abdomen and Orthopaedic Trauma

Packing but not creating compartment syndrome. Controversy in closing the fascia or not

Page 31: Chest, Abdomen and Orthopaedic Trauma

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

Page 32: Chest, Abdomen and Orthopaedic Trauma

Exploration Remove from backboard Warm room-fluids Control all external bleeding c pressure blood products! Coagulation devices

Page 33: Chest, Abdomen and Orthopaedic Trauma

Exploration Laparotomy-xiphoid to pubis Four quadrant packing Rapid search for arterial bleeding

Place clamp precisely Venous

Evacuate blood and pack

Page 34: Chest, Abdomen and Orthopaedic Trauma

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

Page 35: Chest, Abdomen and Orthopaedic Trauma

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

Page 36: Chest, Abdomen and Orthopaedic Trauma

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

Page 37: Chest, Abdomen and Orthopaedic Trauma
Page 38: Chest, Abdomen and Orthopaedic Trauma

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.

Page 39: Chest, Abdomen and Orthopaedic Trauma

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…

Page 40: Chest, Abdomen and Orthopaedic Trauma

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.

Page 41: Chest, Abdomen and Orthopaedic Trauma

Push together- not down-

Page 42: Chest, Abdomen and Orthopaedic Trauma

Finger fracture

Page 43: Chest, Abdomen and Orthopaedic Trauma

Packing-

Page 44: Chest, Abdomen and Orthopaedic Trauma

Foley and penrose

Page 45: Chest, Abdomen and Orthopaedic Trauma

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

Page 46: Chest, Abdomen and Orthopaedic Trauma

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

Page 47: Chest, Abdomen and Orthopaedic Trauma

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

Page 48: Chest, Abdomen and Orthopaedic Trauma

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

Page 49: Chest, Abdomen and Orthopaedic Trauma

Consider t-tube – feeding tube – drain area

Page 50: Chest, Abdomen and Orthopaedic Trauma

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

Page 51: Chest, Abdomen and Orthopaedic Trauma

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

Page 52: Chest, Abdomen and Orthopaedic Trauma
Page 53: Chest, Abdomen and Orthopaedic Trauma

Arteries Celiac artery

Ligation Renal artery

Nephrectomy in most cases SMA

Shunt Iliac

Shunt if feasible If ligated- need fasciotomies

Page 54: Chest, Abdomen and Orthopaedic Trauma

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

Page 55: Chest, Abdomen and Orthopaedic Trauma

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

Page 56: Chest, Abdomen and Orthopaedic Trauma

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

Page 57: Chest, Abdomen and Orthopaedic Trauma

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

Page 58: Chest, Abdomen and Orthopaedic Trauma

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!

Page 59: Chest, Abdomen and Orthopaedic Trauma

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?

Page 60: Chest, Abdomen and Orthopaedic Trauma

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.

Page 61: Chest, Abdomen and Orthopaedic Trauma

Orthopaedic TraumaQuestions?

Break?

Page 62: Chest, Abdomen and Orthopaedic Trauma

Open fractures fracture that is exposed to the outside

environment high-energy injuries immediate irrigation and débridement

combined with skeletal stabilization

Page 63: Chest, Abdomen and Orthopaedic Trauma

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.

Page 64: Chest, Abdomen and Orthopaedic Trauma

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

Page 65: Chest, Abdomen and Orthopaedic Trauma

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.

Page 66: Chest, Abdomen and Orthopaedic Trauma

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.

Page 67: Chest, Abdomen and Orthopaedic Trauma

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.

Page 68: Chest, Abdomen and Orthopaedic Trauma

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.

Page 69: Chest, Abdomen and Orthopaedic Trauma

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

Page 70: Chest, Abdomen and Orthopaedic Trauma

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

Page 71: Chest, Abdomen and Orthopaedic Trauma

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

Page 72: Chest, Abdomen and Orthopaedic Trauma

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.

Page 73: Chest, Abdomen and Orthopaedic Trauma

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.

Page 74: Chest, Abdomen and Orthopaedic Trauma

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.

Page 75: Chest, Abdomen and Orthopaedic Trauma

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.

Page 76: Chest, Abdomen and Orthopaedic Trauma

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.

Page 77: Chest, Abdomen and Orthopaedic Trauma

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

Page 78: Chest, Abdomen and Orthopaedic Trauma

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.

Page 79: Chest, Abdomen and Orthopaedic Trauma

Calcaneus lumbar fracture Those with minimal displacement are treated

closed. Any displacement of an articular fragment

involving the subtalar joint should be reduced.

Page 80: Chest, Abdomen and Orthopaedic Trauma

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.

Page 81: Chest, Abdomen and Orthopaedic Trauma

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.

Page 82: Chest, Abdomen and Orthopaedic Trauma

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

Page 83: Chest, Abdomen and Orthopaedic Trauma

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.

Page 84: Chest, Abdomen and Orthopaedic Trauma

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.

Page 85: Chest, Abdomen and Orthopaedic Trauma

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.

Page 86: Chest, Abdomen and Orthopaedic Trauma

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

Page 87: Chest, Abdomen and Orthopaedic Trauma

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

Page 88: Chest, Abdomen and Orthopaedic Trauma

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

Page 89: Chest, Abdomen and Orthopaedic Trauma

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

Page 90: Chest, Abdomen and Orthopaedic Trauma

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.

Page 91: Chest, Abdomen and Orthopaedic Trauma

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.

Page 92: Chest, Abdomen and Orthopaedic Trauma

Questions?