ORTHO HAND SGD

TRAUMA SGD Block 5AGabatino, Gauiran, Go, Gomez, Gonzales E, Gonzales L, GranadaGeneral DataOR54/MRCSta Ana, ManilaRight handedc/c injuries secondary to vehicular crashHistory of Present IllnessDOI: 12/14/09 (3 days post injury)TOI: 6pmPOI: Carmona complex, MakatiMOI: VC jeep vs tricycle (side of the tricycle and front of jeep)

History of Present IllnessBrought to Ospital ng Makati, wounds dressed, X ray done, ATS, TeANA given, THOC to PGH secondary to lack of funds

4Review of Systems(-) loss of consciousness(-) fever(-) nausea(-) vomiting(-) dizziness(-) cough and colds(-) chest pain(-) abdominal pain(-) bowel changes(+) polyuria, polydipsia, polyphagia(+) numbness of bilateral peripheral extramities ( glove and stocking distribution)

Past Medical History(-) Diabetes(-) Hypertension but had episodes of hypertension since 2 years ago, highest Bpof 160/80 usual BP of 150/80(+) hospitalization due to head injury (2008)(-) PTB, BA(-) food and drug allergies

Family Medical HistoryNo known medical illness in the family

Personal Social HistorySmoker >30 pack year Heavy alcoholic beverage drinker 1-2 bottles of 500ml redhorse daily since 25 years oldDenies illicit drug useDenies promiscuityWorks as a tricycle driver

Physical Examination at the ERAwake, coherent, NICRD, ambulatoryVital Signs: BP 150/90, HR 82, RR 20, T afebrileHEENT: AS, PC, pupils 3 mm EBRTL, (-) CLAD/TPC/NVE/ANMChest/Lungs: ECE, Clear Breath Sounds, (-) crackles/wheezes

Physical Examination at the ERHeart: AP, DHS, NRRR, (-) murmursAbdomen: soft, flabby abdomen, NABS, (-) tenderness, (-) masses/organomegalyExtremities (both upper extremities and left lower extremity): Pink nail beds, Full and equal pulses, (-) cyanosis, (-) clubbing, (-) gross deformities

Physical Examination: Left LEGrossly deformed thigh (distal 1/3 of the thigh slightly angulated medially)(+) swelling, tenderness, warmth, redness over distal thigh and kneeIntact sensation over (L) thigh, leg and footAble to wiggle toes and dorsi/plantar flex ankleIntact and full popliteal, dorsalis pedis and post tibial pulses, pink nailbeds, (-) cyanosis1.5x 1.5 cm wound over the anterior distal thigh with no bone protrusion and adequate tissue coverage, no gross contamination with debris

RADIOGRAPHSAssessment at the ERFx: Open complete comminuted distal third femur (L) secondary to VC

Plan at the ERTherapeutics:Cefazolin 1g IV LD then 1g q8Gentamycin 240mg IV ODLong leg posterior splint

Surgical Plan:Debridement Skeletal tractionCourse in the Wards/ERSeen at the ER 12/17/2009 (3 days post injury)12/19/09 debridement of anterior thigh wound, arthrotomy of the L knee joint and skeletal traction inserted on proximal tibia 15kg12/26/09 diagnosed with hypertension stage II fairly controlled with HHD , DM type II newly diagnosed with nephropathy, neuropathy, t/c retinopathy, T/c Alcoholic liver disease12/29/09 scheduled for OR, deferred due to lack of funds for IM nail

Present Physical Examination18th hospital day, 21 days post injury

Awake, coherent, NICRD, ambulatoryVital Signs: BP , HR , RR , T afebrileHEENT: AS, PC, pupils 3 mm EBRTL, (-) CLAD/TPC/NVE/ANMChest/Lungs: ECE, Clear Breath Sounds, (-) crackles/wheezes

Present Physical ExaminationHeart: AP, DHS, NRRR, (-) murmursAbdomen: soft, flabby abdomen, NABS, (-) tenderness, (-) masses/organomegalyExtremities (both upper extremities and left lower extremity): Pink nail beds, Full and equal pulses, (-) cyanosis, (-) clubbing, (-) gross deformities

Present Physical ExaminationLeft lower extremity on skeletal traction inserted in the proximal tibia(-) erythema, warmth, discharge, swelling, pain around pintracts.(+) surgical incision over the anterior knee and thigh, good healing, no discharge, no redness, no necrotic tissue at incision site(+) warmth over the periphery of the (L) knee, (+) mild swelling, (+) mild erythemaIntact popliteal, dorsalis pedis and post tibial pulsesIntact sensation on thigh, leg, toes and feet

OPEN FRACTURESOPEN FRACTURESOsseous disruption in which a break in the skin and underlying soft tissue communicates directly with the fracture and its hematomaAny wound occurring on the same limb segment as a fracture must be suspected to be a consequence of an open fracture until proven otherwiseCONSEQUENCES of OPEN FRACTURESContamination of the wound and fracture by exposure to the external environmentCrushing, stripping, and devascularization that results in soft tissue compromise and increased susceptibility to infectionDestruction or loss of the soft tissue envelope may affect the method of fracture immobilization, compromise the contribution of the overlying soft tissues to fracture healing and result in loss of function from muscle, tendon, nerve, vascular, ligament, or skin damage.MECHANISM of INJURYResults from application of violent force which is dissipated by soft tissues and osseous structuresThe applied force is directly proportional to resulting osseous displacement, comminution and degree of soft tissue injuryCLINICAL EVALUATION of PATIENTS with OPEN FRACTURESABCDEResuscitation and attention to life-threatening injuriesEvaluate injuries to head, chest, abdomen, pelvis, spine and all extremitiesAssess neurovascular status of affected limbsAssess skin and soft tissue involvementRemoval of obvious foreign bodiesIrrigation with pNSSRadiographic evaluation

GUSTILO and ANDERSON Classification of OPEN FRACTURESTypeWoundLevel of Contamination Soft Tissue InjuryBone Injury I< 1 cm longCleanMinimalSimple, minimal comminutionII> 1 cm longModerateModerate, some muscle damageModerate communitionIIIAUsually > 10 cm longHighSevere with crushingUsually comminuted, soft tissue coverage of bone possibleBVery severe loss of coverage, usually requires reconstructive surgeryBone coverage poor, may be moderate to severe comminutionCVery severe loss of coverage plus vascular injury requiring repair, may require soft tissue injuryFACTORS which MODIFY CLASSIFICATIONContaminationExposure to soil, water, fecal matter, oral floraGross contamination on PEDelay in treatment > 12 hrsSigns of high-energy mechanismSegmental fractureBone lossCompartment syndromeCrush mechanismExtensive degloving of SQ fat and skinRequires flap coverageGENERAL MANAGEMENT PRINCIPLESPerform a careful clinical and radiographic evaluation Wound hemorrhage should be addressed with direct pressure rather than limb tourniquets or blind clampingInitiate parenteral antibiosisAssess skin and soft tissue damage; place a saline-soaked sterile dressing on the wound

GENERAL MANAGEMENT PRINCIPLESPerform provisional reduction of fracture and place a splintOperative intervention: open fractures constitute orthopaedic emergencies, because intervention less than 8 hours after injury has been reported to result in a lower incidence of wound infection and osteomyelitisDo not irrigate, debride, or probe the wound in the emergency room if immediate operative intervention is plannedBone fragments should not be removed in the emergency room, no matter how seemingly nonviable they may beEMPIRIC ANTIBIOTICSGustilo I: Cefazolin 1 g IV q8hGustilo II: Cefazolin 1 g IV q8hGustilo III: Cefazolin 1 g IV q8h + Aminoglycoside 3-5 mg/kg/dayOrganic contamination: Penicillin 2,000,000 units q4h or Metronidazole 500 mg q6hTETANUS PROPHYLAXISIncomplete ( 10 years since last dose: (+) dT, (-) TIGComplete and < 10 years since last dose: (-) dT, (-) TIG OPERATIVE TREATMENTIrrigation and debridementRemoval of foreign bodiesFracture stabilizationSoft tissue coverage and bone graftingLimb salvage

FRACTURE STABILIZATIONEXTERNAL FIXATIONSevere contamination: any site Periarticular fractures Definitive Distal radius Elbow dislocation Selected other sites Temporizing Knee Ankle Elbow Wrist Pelvis Distraction osteogenesis In combination with screw fixation for severe soft tissue injury

INTERNAL FIXATIONPeriarticular fractures Distal/proximal tibia Distal/proximal femur Distal/proximal humerus Proximal ulnar radius Selected distal radius/ulna Acetabulum/pelvis Diaphyseal fractures Femur Tibia Humerus Radius/ulna