TRAUMA SGD

Block 5AGabatino, Gauiran, Go, Gomez, Gonzales E, Gonzales L, Granada

General Data

OR 54/M RC Sta Ana, Manila Right handed c/c injuries secondary to vehicular crash

History of Present Illness

DOI: 12/14/09 (3 days post injury) TOI: 6pm POI: Carmona complex, Makati MOI: VC jeep vs tricycle (side of the tricycle

and front of jeep)

History of Present Illness

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

Review 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 History

No known medical illness in the family

Personal Social History

Smoker >30 pack year Heavy alcoholic beverage drinker 1-2 bottles

of 500ml redhorse daily since 25 years old Denies illicit drug use Denies promiscuity Works as a tricycle driver

Physical Examination at the ER

Awake, coherent, NICRD, ambulatory Vital Signs: BP 150/90, HR 82, RR 20, T

afebrile HEENT: AS, PC, pupils 3 mm EBRTL, (-)

CLAD/TPC/NVE/ANM Chest/Lungs: ECE, Clear Breath Sounds, (-)

crackles/wheezes

Physical Examination at the ER

Heart: AP, DHS, NRRR, (-) murmurs Abdomen: soft, flabby abdomen, NABS, (-)

tenderness, (-) masses/organomegaly Extremities (both upper extremities and left

lower extremity): Pink nail beds, Full and equal pulses, (-) cyanosis, (-) clubbing, (-) gross deformities

Physical Examination: Left LE

Grossly deformed thigh (distal 1/3 of the thigh slightly angulated medially)

(+) swelling, tenderness, warmth, redness over distal thigh and knee

Intact sensation over (L) thigh, leg and foot Able to wiggle toes and dorsi/plantar flex ankle Intact and full popliteal, dorsalis pedis and post tibial

pulses, pink nailbeds, (-) cyanosis 1.5x 1.5 cm wound over the anterior distal thigh with no

bone protrusion and adequate tissue coverage, no gross contamination with debris

RADIOGRAPHS

Assessment at the ER

Fx: Open complete comminuted distal third femur (L) secondary to VC

Plan at the ER

Therapeutics:- Cefazolin 1g IV LD then 1g q8- Gentamycin 240mg IV OD- Long leg posterior splint

Surgical Plan:- Debridement - Skeletal traction

Course in the Wards/ER

Seen 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 – 15kg

12/26/09 – diagnosed with hypertension stage II fairly controlled with HHD , DM type II newly diagnosed with nephropathy, neuropathy, t/c retinopathy, T/c Alcoholic liver disease

12/29/09 – scheduled for OR, deferred due to lack of funds for IM nail

Present Physical Examination

18th hospital day, 21 days post injury

Awake, coherent, NICRD, ambulatory Vital Signs: BP , HR , RR , T afebrile HEENT: AS, PC, pupils 3 mm EBRTL, (-)

CLAD/TPC/NVE/ANM Chest/Lungs: ECE, Clear Breath Sounds, (-)

crackles/wheezes

Present Physical Examination

Heart: AP, DHS, NRRR, (-) murmurs Abdomen: soft, flabby abdomen, NABS, (-)

tenderness, (-) masses/organomegaly Extremities (both upper extremities and left

lower extremity): Pink nail beds, Full and equal pulses, (-) cyanosis, (-) clubbing, (-) gross deformities

Present Physical Examination

Left 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 erythema

Intact popliteal, dorsalis pedis and post tibial pulses Intact sensation on thigh, leg, toes and feet

OPEN FRACTURES

OPEN FRACTURES

Osseous disruption in which a break in the skin and underlying soft tissue communicates directly with the fracture and its hematoma

Any wound occurring on the same limb segment as a fracture must be suspected to be a consequence of an open fracture until proven otherwise

CONSEQUENCES of OPEN FRACTURES

Contamination of the wound and fracture by exposure to the external environment

Crushing, stripping, and devascularization that results in soft tissue compromise and increased susceptibility to infection

Destruction 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 INJURY

Results from application of violent force which is dissipated by soft tissues and osseous structures

The applied force is directly proportional to resulting osseous displacement, comminution and degree of soft tissue injury

CLINICAL EVALUATION of PATIENTS with OPEN FRACTURES

ABCDE Resuscitation and attention to life-threatening

injuries Evaluate injuries to head, chest, abdomen, pelvis,

spine and all extremities Assess neurovascular status of affected limbs Assess skin and soft tissue involvement

Removal of obvious foreign bodies Irrigation with pNSS

Radiographic evaluation

GUSTILO and ANDERSON Classification of OPEN FRACTURES

Type Wound Level of Contamination

Soft Tissue Injury Bone Injury

I < 1 cm long Clean Minimal Simple, minimal

comminution

II > 1 cm long Moderate Moderate, some muscle

damageModerate communition

III

A

Usually > 10 cm long

High

Severe with crushingUsually comminuted, soft tissue coverage of bone possible

BVery severe loss of coverage, usually requires reconstructive surgery Bone coverage poor,

may be moderate to severe comminution

CVery severe loss of coverage plus vascular injury requiring repair, may require soft tissue injury

FACTORS which MODIFY CLASSIFICATION

Contamination Exposure to soil, water, fecal matter, oral flora Gross contamination on PE Delay in treatment > 12 hrs

Signs of high-energy mechanism Segmental fracture Bone loss Compartment syndrome Crush mechanism Extensive degloving of SQ fat and skin Requires flap coverage

GENERAL MANAGEMENT PRINCIPLES

Perform a careful clinical and radiographic evaluation

Wound hemorrhage should be addressed with direct pressure rather than limb tourniquets or blind clamping

Initiate parenteral antibiosis Assess skin and soft tissue damage; place a saline-

soaked sterile dressing on the wound

GENERAL MANAGEMENT PRINCIPLES

Perform provisional reduction of fracture and place a splint

Operative 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 osteomyelitis

Do not irrigate, debride, or probe the wound in the emergency room if immediate operative intervention is planned

Bone fragments should not be removed in the emergency room, no matter how seemingly nonviable they may be

EMPIRIC ANTIBIOTICS

Gustilo I: Cefazolin 1 g IV q8h Gustilo II: Cefazolin 1 g IV q8h Gustilo III: Cefazolin 1 g IV q8h +

Aminoglycoside 3-5 mg/kg/day Organic contamination: Penicillin 2,000,000

units q4h or Metronidazole 500 mg q6h

TETANUS PROPHYLAXIS

Incomplete (<3 doses) or unknown: (+) dT, (+/-) TIG

Complete and > 10 years since last dose: (+) dT, (-) TIG

Complete and < 10 years since last dose: (-) dT, (-) TIG

OPERATIVE TREATMENT

Irrigation and debridement Removal of foreign bodies Fracture stabilization Soft tissue coverage and bone grafting Limb salvage

FRACTURE STABILIZATION

EXTERNAL FIXATION

Severe 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 FIXATION

Periarticular 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