UPPER LIMB INJURIES IN THE MULTI TRAUMA PATIENT

George Cox - Consultant Upper Limb Surgeon

(MULTIPLE SEVERE) UPPER LIMB INJURIES IN THE

MULTI TRAUMA PATIENT

George Cox - Consultant Upper Limb Surgeon

STRUCTURE

•Principles•Problems•Practice

•Principles•Problems •Practice

STRUCTURE

WHO ARE YOU TREATING?

PRINCIPLES

Life

Limb

Pain

Function

Aesthetics

Decreasing priorit

y

‘A fracture is a soft tissue injury which is complicated by a break in

the bony cortex’ Anon

Fractures!

WHAT ARE YOU TREATING?

FRACTURE TREATMENT

• Life• Soft tissues• Nerves• Blood vessels• Muscle (compartments)• Skin

• Bones / joints• Early Movement & Rehabilitation

HOW ARE YOU GOING TO TREAT THEM?

SURGICAL TEAM

SURGICAL TEAM

• Shared decision making• Combined operating• ‘Early total care’ vs ‘Damage control’• Close working with non-surgical team

NON-SURGICAL TEAM

• Anaesthetists• Theatre team• Radiographers• Therapists

STRUCTURE

•Principles•Problems•Practice

PROBLEMS

•Soft tissues•Occult injuries•Surgical positioning •Rehabilitation•Communication

SOFT TISSUES

• Compartments / Nerve / Vessel Injury• Be suspicious→ Early intervention

• Soft tissue coverage• Required for

internal fixation→ Plastic input

• Ex-fix?• Wrist – Yes!• Elbow / humerus

→ Radial nerve!

• ETC vs DC

OCCULT INJURIES

• Problems for the patient• Difficult to treat if

missed

• Problems for you • Claims

• Keep looking & Keep asking• X-ray all injured

parts

SURGICAL POSITIONING

• Spine / Pelvis fractures with upper limb

REHABILITATION

• ITU• Early therapist

intervention• Passive

movements

• Fixation for rehabilitation• UL fixation for LL?• Clavicle for chest?• Bilateral injuries?• Type of fixation?

COMMUNICATION

• Patient• Expectation• Functional• Time scale

• Plan of treatment

• Team• (C)PPPPPP

STRUCTURE

•Principles•Problems•Practice

CASE A

• 16 year old motorbike• Extensive open upper limb injuries • ’Do you need to amputate arm/arms?’

CASE A

• Early total care vs. Damage limitation?• → Damage limitation• Debridement / Span / Scan / Plan• Systemic / local resuscitation ITU

CASE B

• 77 year old motorbike• Isolated right arm injury• Open humerus / elbow / forearm / hand• Radial nerve palsy

CASE B

• Multiple open wounds but soft tissue (not skin) coverage possible

• Early total care vs. Damage limitation?• → Early total care

SUMMARY

LifeLimbPain

FunctionAesthetics

Decreasing priorit

y

‘A fracture is a soft tissue injury which is

complicated by a break in the bony cortex’

Early total care vs.

Damage limitation

THANK YOU