ORTHOPAEDICORTHOPAEDICEMERGENCYEMERGENCY

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Background Background

Musculoskeletal injury: very common in major trauma

Incidence of significant orthopaedic injury in severe injured patient is 78%

Permanent disability after major trauma from musculoskeletal or CNS injury

BackgroundBackground

Orthopaedic injury occurs as part of: Multiple orthopaedic injuries only Multisystem trauma, with multiple orthopaedic

injuriesMultisystem injury with minor (not life-

threatening) orthopaedic injury

Resuscitation Resuscitation

Orthopaedic haemorrhage control (“C” part of primary survey)

Secondary survey Injury recognition: high energy limb injuries Timing of surgery Orthopaedic intervention

Orthopaedic surgical priorities Orthopaedic surgical priorities

Ischaemia correction Wound care Long bone stabilization Other fractures Reaming for femoral shaft fracture – reaming

and pulmonary failure Principle of external fixation Compartment syndrome Limb salvage versus amputation

Orthopaedic haemorrhage controlOrthopaedic haemorrhage control

Address and control sources of catastrophic haemorrhage

Direct pressure controls (most peripheral bleeding)

Broken bones bleed Femur 1000 cm3Tibia 750 cm3Plevic fracture 2000 cm3

Orthopaedic haemorrhage controlOrthopaedic haemorrhage control

Splinting reduces blood loss (pre-hospital) Continued hypotension is unlikelyunlikely in

isolated long bone fracture Look elsewhere

Pelvic bleeding kills Unstable pelvic fractures need to be stabilized

quickly

-2025% of all major trauma deaths have a pelvic fracture

Secondary survey Secondary survey Orthopaedic injuries usually identified during the secondary surveyOrthopaedic injuries usually identified during the secondary survey History: mechanism of injury

Detailed history Patterns of orthopaedic injury exists

Falls from height: calcaneal fractures, tibial fractures and spinal fractures

Examination Major long bone fractures usually obvious

Limb deformed/short Up to 10% of lesser fracture may be missed (use

Tertiary Survey)

All fractures are important to the patient

Secondary surveySecondary survey Assess major joints for active and passive ROM

and stability Careful palpate long bones for

pain, crepitus, and abnormal movement Look carefully for open fractures

Orthopaedic emergency (must not be missed) May only be a puncture wound Bleed – local pressure Cover loosely by appropriate sterile dressing OR (debridement) within 6 h Broad spectrum antibiotic Tetanus toxoid/immunoglubulin

Secondary surveySecondary survey

Don’t forget to logroll: assess for all spine Splint the injury site

Reduces pain and further damage to local structure Reduces blood loss Splint the joint above and below the fracture site Check distal neurological status and circulation before

and after applying splint Femoral fractures are placed in a traction splint

(Thomas), other limb fractures use plaster of Paris

Secondary surveySecondary survey

Radiological imaging Low threshold for obtaining radiographs of

area of concern Radiographs need to be repeated (if poor

quality) Do not forgotten about it Appropriate timing of assessment

Specialized imaging CT, MRI

Injury recognition: Injury recognition: high energy limb high energy limb injuries injuries The surgical fracture and soft tissue management is

complex – the prognosis and outcome is corresponding worse

History Any road traffic accident Fall from a height General or localized crushing Missile wounds Contamination History of entrapment in any period History of limb ischemia

Injury recognition: Injury recognition: high energy limb high energy limb injuriesinjuries Examination

Large or multiple wounds Imprints or contamination Crush or burst woundsSkin degloving Ipsilateral fracture Evidence of associated compartment

syndrome, vascular injuries, and nerve injuries

Injury recognition: Injury recognition: high energy limb high energy limb injuriesinjuries Plain radiography

Segmental fractureHighly comminutes fracturesWide displacement of bone fragments Evidence of air in the soft tissues

Timing of surgery Timing of surgery

An injury results in an inflammatory reaction which is promote healing and repair, but if prolonged or exaggerated leading to systemic inflammatory response syndrome, acute respiratory distress syndrome (ARDS)

Aim: to control inflammatory response and restore normal physiology and homeostasis ASAP

Timing of surgeryTiming of surgery

Reducing the overall inflammatory response Remove necrotic/devitalized tissue by

debridement/fasciotomy Reduce blood loss and pain by splinting/stabilizing

fractures Reduce ischemia by joint

relocation/fasciotomy/stabilizing fracture

Inflammatory response increases in: excessive surgery – blood loss/hypothermia

Orthopaedic intervention Orthopaedic intervention

Life-saving condition should taken first Stable/suitable condition limb salvage

procedures Communication and coordination with

other specialty The initial goal is patient survival

(lifelimbfunction)

Orthopaedic interventionOrthopaedic intervention

Physiologic assessment at each stage Danger signs

Hypoxia Hypothermia Abnormal clotting Acidosis Increase intracranial pressure

Orthopaedic surgical priorities Orthopaedic surgical priorities

Ischaemia correction Wound care Long bone stabilization Other fractures Reaming for femoral shaft fracture – reaming

and pulmonary failure Principle of external fixation Compartment syndrome Limb salvage versus amputation

Ischaemia correction Ischaemia correction

Identify and correct the source of haemorrhagic shock

Reduce dislocated joints Splint limbs in anatomical position Stabilized fractures if associated vascular repair

is required Fasciotomy for compartment syndrome Avoid hypothermia

Wound careWound care Open fracture need to be debrided and stabilized within

6 h Tourniquet (not necessary) Remove contaminants Excise necrotic or devitalized tissue and skin margins Copious irrigation

Minimum 6 liter saline Pressurized and pulsatile lavage

Viability of muscle: “4 C4 C” – colour, contractility, consistency, capacity to bleed

After debridement “Do not close wound primarily”

Wound careWound care

Close joint capsule Cover bone end by viable soft tissue Re-inspect the wound within 48 h Definite wound closure should be within 5

days of injury Antibiotic until definite wound closure is

controversial

Wound careWound care

Fracture stabilization after wound care Choice depends on:

Fracture configuratrion Fracture grade Extent of soft tissue damage/contamination Surgical experience

Gustilo and Anderson open fracture classification

Long bone stabilization Long bone stabilization

Femoral shaft fractures and pelvic stabilization should within 24 h Reduce overall patient morbidity and mortality Excellent pain control Avoids traction and associated difficulty sitting and

moving Femoral shaft fractures are the next priority after

pelvic stabilization Closed IM nailing – treatment of choice Temporary EF

Other fracturesOther fractures

Femoral neck fracture and talar neck fracture are the next priority (risk of avascular necrosis)

Followed by: Metaphyseal distal femoral fracture Proximal and distal metaphyseal tibial fractures Ankle fractures Foot fractures Wrist/elbow fractures

Other fracturesOther fractures

Factors Patient’s general conditionRequirement for specialized imaging Soft tissue swelling (foot and ankle fractures

may be delay for 2 weeks) Ipsilateral limb (upper and lower extremities) Surgical and nursing expertise Implant avialability Fatigue of theatre staff

Reaming for femoral shaft fracture Reaming for femoral shaft fracture – reaming and pulmonary failure– reaming and pulmonary failure Reamed femoral intramedullary nail

should be avoid in blunt chest trauma patient (ARDS)

Principle of external fixationPrinciple of external fixation

Suitable for many different injury patterns Provisional stabilization Quick and easy Bloodless Easily adjustable Bridged fracture (complex articular fracture) Alternative to IM nailing Convert to IM nail within 2 weeks

Compartment syndromeCompartment syndrome

Results in fibrosis and nerve damage Most common: lower leg, forearm, foot and in patient

with major trauma Easy to miss if: patient being resuscitated, paralysed or

intoxicated Signs:

Pain-more than expected Pain-unrelieved by immobilization Never assume pain is from the bone Pain on passive stretching of the affected compartment A tense, swollen limb

Pulselessness, pallor, paresthesia and paralysis are late signs after damage has occured

Compartment syndromeCompartment syndrome

Normal compartment pressure is 0 mmHg Isolated compartment pressure > 40 mmHg Differential pressure (DBP) < 30 mmHg Treatment

Fasciotomy Release all dressings and splints down to the skin

Compartment syndrome can occur in open fracture

Limb salvage versus amputationLimb salvage versus amputation

Difficult to decision Need to discuss options with patient Photographic evidence useful MESS score: for decision making but not absolute Factors involved decision making:

Extent of bony injury Nerve supply (esp. posterior tibial nerve) Crush injuries Physiologic reserve Smoking Economic, psychological and social factors Mass casualty situation

Common Musculoskeletal Common Musculoskeletal InjuriesInjuries

Multiple trauma: head, thoraco-abdominal injuries, long bone fracture and open joint injury

Crushed limb / blast injury / high fall Traumatic amputation of limb or part of limb Fx pelvis, severe, unstable with bleeding Fx-dislocation long bone with vascular

complication Open (compound) Fx / joint injury Gunfire / shotgun / high velocity missile injury

Fx-dislocation / spinal cord / brachial plexus injury

Fx-dislocation of major bone and joint Compartment syndrome / ischemic limb Ligamentous injury (rupture) of knee / ankle Ruptured muscle / tendon Bone and joint infection, hematogenous Acute bursitis / tendinitis

Common Musculoskeletal Common Musculoskeletal InjuriesInjuries

Serious Causes of Death in Serious Causes of Death in Orthopaedic EmergencyOrthopaedic Emergency

1.1. High (upper) High (upper) cervical spinecervical spine injury injury

2.2. Severe fracture of Severe fracture of pelvispelvis with unstable with unstable and massive bleeding and massive bleeding

3.3. Multiple crushedMultiple crushed limb and trunk injury limb and trunk injury

Estimated Blood Loss from Estimated Blood Loss from Fracture Fracture

Pelvis 100-4,000 cc

Femur 400-2,700 cc

Tibia 250-1,800 cc

Humerus 200 – 800 cc

Assessment Assessment

Glasgow coma scale (GCS) Musculoskeletal abbreviated injury score

(AIS) ISS Revised trauma score Trauma injury severity score (TRISS)

Glasgow Coma Scale Glasgow Coma Scale (GCS)(GCS)

ParameterParameter ScoreScore

Eye opening Eye opening

SpontaneousSpontaneous 44

To voice To voice 33

To painTo pain 22

None None 11

Verbal response Verbal response

OrientedOriented 55

ConfusedConfused 44

Inappropriate words Inappropriate words 33

Incomprehensible soundsIncomprehensible sounds 22

NoneNone 11

Motor responseMotor response

Obeys commandObeys command 66

Localized painLocalized pain 55

Withdraws to pain Withdraws to pain 44

Flexible to pain Flexible to pain 33

Extension to pain Extension to pain 22

NoneNone 11

Musculoskeletal Abbreviated Injury Score (AIS) Musculoskeletal Abbreviated Injury Score (AIS)

Injury Injury ScoreScore

Contusions / sprains Contusions / sprains 11

Interphalangeal dislocationInterphalangeal dislocation 11

Digital fractureDigital fracture 11

Hip dislocation Hip dislocation 22

Closed humerus fractureClosed humerus fracture 22

Clavicle fracture Clavicle fracture 22

Open humeral fracture Open humeral fracture 33

Crushed elbow or shoulderCrushed elbow or shoulder 33

Femoral fracture Femoral fracture 33

Open tibial fractureOpen tibial fracture 33

Above knee amputationAbove knee amputation 44

Severe pelvic fracture with blood loss Severe pelvic fracture with blood loss << 20% by volume 20% by volume

44

Severe pelvic fracture with blood loss Severe pelvic fracture with blood loss >> 20% by volume 20% by volume

55

Unsurvivable Unsurvivable 66

Revised Trauma Score (RTS) Revised Trauma Score (RTS)

ResultResult ScoreScore

Respiratory rate (breaths/min) Respiratory rate (breaths/min)

10-2910-29 44

>29>29 33

6-96-9 22

1-51-5 11

00 00

Systolic blood pressure (mm/Hg)Systolic blood pressure (mm/Hg)

>89>89 44

76-8976-89 33

50-7550-75 22

1-491-49 11

00 00

GCS GCS

13-1513-15 44

9-129-12 33

6-86-8 22

4-54-5 11

33 00

RTS = 0.9368 GCS + 0.7326 SBP + 0.2908 RR

TRISS score TRISS score to predict the probability of survival to predict the probability of survival

ResuscitationResuscitation

Resuscitation / treatment protocol based Resuscitation / treatment protocol based on ATLS guidelines on ATLS guidelines

Resuscitation/Treatment Protocol Based onResuscitation/Treatment Protocol Based on ATLSATLS GuidelinesGuidelines

1. Primary survey and resuscitation (patient stabilization) 1. Primary survey and resuscitation (patient stabilization) • A Airway and cervical spine A Airway and cervical spine • B Breathing and oxygenation B Breathing and oxygenation • C Circulation and hemorrhage C Circulation and hemorrhage • D Dysfunction of the CNS D Dysfunction of the CNS • E Exposure and environmental E Exposure and environmental

2. Consider transfer to more appropriate hospital if indicated2. Consider transfer to more appropriate hospital if indicated

3. Secondary survey3. Secondary survey• A Allergies A Allergies • M Medicines M Medicines • P P Previous medical history/pregnancy Previous medical history/pregnancy • L Last meal L Last meal • E Events leading to trauma E Events leading to trauma

4. Definitive care4. Definitive care

Early total care Early total care

Damage control surgeryDamage control surgery

5. Tertiary survey 5. Tertiary survey

Missed injuriesMissed injuries

Steps Steps

1. The important initial steps are to check that the 1. The important initial steps are to check that the airway is clear and maintainedairway is clear and maintained. .

2. Breathing and oxygenation are maintained2. Breathing and oxygenation are maintained by by examining for and treating a blocked airway, examining for and treating a blocked airway, pneumothorax, tension pneumothorax, pneumothorax, tension pneumothorax, hemothorax, flail chest, or pericardial hemothorax, flail chest, or pericardial tamponadetamponade

StepsSteps3. Control hemorrhage and maintain 3. Control hemorrhage and maintain

circulationcirculation bilateral femoral fractures and bilateral femoral fractures and

pelvic fracturepelvic fracture Associated with significant occult blood lossAssociated with significant occult blood loss

4. Fluid resuscitation (2 large-bore 4. Fluid resuscitation (2 large-bore venous cannulas)venous cannulas)

5. Immediate cross match5. Immediate cross match

6. A thorough examination of the 6. A thorough examination of the abdomen , abdomen , pelvis, and limbpelvis, and limb looking for signs of looking for signs of abdominal and pelvic bleeding, pelvic abdominal and pelvic bleeding, pelvic instability, and hemorrhage and limb instability, and hemorrhage and limb damage, particularly open fracturesdamage, particularly open fractures

StepsSteps

7. Complete 7. Complete CNS examinationCNS examination patient’s patient’s responsiveness and GCS including responsiveness and GCS including neurological examination of the limbneurological examination of the limb

8. Radiographical examination of the 8. Radiographical examination of the chestchest and and pelvispelvis (head, neck and spine if (head, neck and spine if clinically required) clinically required)

StepsSteps

9. Adequate 9. Adequate stabilizationstabilization

10. Secondary survey10. Secondary survey and and appropriate appropriate investigationinvestigation

11. Management plan11. Management plan for definitive for definitive treatment treatment life-threatening injuries life-threatening injuries should be treated first should be treated first

12. Tertiary survey within 24 hours12. Tertiary survey within 24 hours

StepsSteps

9Rs9Rs1. Recognition2. Recussitation if required3. Respective system evaluation4. Respective system treatment5. Retention (retainment) I : temporary splinting,

wound coverage, etc.6. Reduction7. Retention (retainment) II : definitive immobilization8. Rehabilitation9. Reconstruction

Resuscitation/Treatment Protocol Based on ATLS Resuscitation/Treatment Protocol Based on ATLS GuidelinesGuidelines1. Primary survey and resuscitation (patient stabilization) 1. Primary survey and resuscitation (patient stabilization)

A Airway and cervical spine A Airway and cervical spine

B Breathing and oxygenation B Breathing and oxygenation

C Circulation and hemorrhage C Circulation and hemorrhage

D Dysfunction of the CNS D Dysfunction of the CNS

E Exposure and environmental E Exposure and environmental

2. Consider transfer to more appropriate hospital if indicated2. Consider transfer to more appropriate hospital if indicated

3. Secondary survey3. Secondary survey

A Allergies A Allergies

M Medicines M Medicines

P P Previous medical history/pregnancy Previous medical history/pregnancy

L Last meal L Last meal

E Events leading to trauma E Events leading to trauma

4. Definitive care (Fracture treatment) 4. Definitive care (Fracture treatment)

Early total care Early total care Damage control surgeryDamage control surgery

5. Tertiary survey 5. Tertiary survey

Missed injuriesMissed injuries

Early Total CareEarly Total Care

Early femoral fracture fixation was Early femoral fracture fixation was associated with associated with decreased pulmonary decreased pulmonary complicationscomplications and and reduced hospital stayreduced hospital stay

Long bonesLong bones are more benefited are more benefited

Damage Control Surgery Damage Control Surgery

Early reamed femoral nailing or external Early reamed femoral nailing or external fixation followed by secondary nailing fixation followed by secondary nailing

The second one is associated with less The second one is associated with less blood loss, shorter operating times and blood loss, shorter operating times and lower incidence of multiple organ failure lower incidence of multiple organ failure (MOF) (MOF) andand ARDS ARDS

Which patients are suitable?Which patients are suitable?

Damage Control Surgery Damage Control Surgery

Parameters Associated with Adverse Parameters Associated with Adverse Outcome in Multiple Injured PatientOutcome in Multiple Injured Patient

1. Unstable condition or difficult resuscitation1. Unstable condition or difficult resuscitation

2. Coagulopathy (platelet count < 90,000) 2. Coagulopathy (platelet count < 90,000)

3. Hypothermia (<32 c) 3. Hypothermia (<32 c)

4. Shock and > 25 units of blood replacement4. Shock and > 25 units of blood replacement

5. Bilateral lung contusions on initial radiographs5. Bilateral lung contusions on initial radiographs

6. Multiple long bones plus truncal injury AIS 6. Multiple long bones plus truncal injury AIS >> 2 2

7. Probable operating time > 6 hr7. Probable operating time > 6 hr

8. Arterial injury and hemodynamic instability (BP< 90) 8. Arterial injury and hemodynamic instability (BP< 90)

9. Exaggerated inflammatory response (IL-6 > 800 pg/ml)9. Exaggerated inflammatory response (IL-6 > 800 pg/ml)

Conditions in Which Damage Control Conditions in Which Damage Control Surgery Should Be ConsideredSurgery Should Be Considered

1. Polytrauma + ISS > 20 and thoracic trauma (AIS >2) 1. Polytrauma + ISS > 20 and thoracic trauma (AIS >2) 2. Polytrauma with severe abdominal/pelvic trauma and 2. Polytrauma with severe abdominal/pelvic trauma and hemodynamic shock (BP <90 mm Hg) hemodynamic shock (BP <90 mm Hg) 3. ISS 3. ISS >> 40 40

4. Bilateral lung contusions 4. Bilateral lung contusions

5. Initial mean pulmonary arterial pressure > 24 mmHg 5. Initial mean pulmonary arterial pressure > 24 mmHg

6. Pulmonary artery pressure increase >6 mmHg during 6. Pulmonary artery pressure increase >6 mmHg during long bone intramedullary nailing long bone intramedullary nailing

Tertiary Survey Tertiary Survey (Common missed injuries)(Common missed injuries)

Facial bone fracture Base of skull fracture C spine injury: C1 fracture, C1-2

subluxation/dislocation, C 2 dens fracture. Posterior dislocation of shoulder glenohumeral

joint Scaphoid fracture, lunate / peri-lunate

dislocation

Radial head fracture Pelvic fracture: body of sacrum Seat-belt fracture: T/L compression Fracture and dislocation of the hip with femoral

shaft fracture Ligamentous injuries of the knee Fracture tibial platea Fracture talus

Tertiary Survey Tertiary Survey (Common missed injuries)(Common missed injuries)

Open Fracture Open Fracture Some important factors Golden period - 8 hr

12 hr. potentially infected Environment / atmosphere

ไต้�ฝุ่��น / สงคราม / ต้กน��า Types: Gustilo - I, II, III A,B,C Foreign body in wound Associated injury

Gustilo Classification of Open Gustilo Classification of Open FracturesFractures

TypeType DefinitionDefinition

I I Open fracture with a clean wound < 1 cm Open fracture with a clean wound < 1 cm in length in length

IIII Open fracture with a laceration of > 1 cm Open fracture with a laceration of > 1 cm long and withoutlong and without extensive soft tissue extensive soft tissue damage, flaps, or avulsionsdamage, flaps, or avulsions

Gustilo Classification of Open Gustilo Classification of Open FracturesFractures

Type Type DefinitionDefinition

IIIIII Either an open fracture with Either an open fracture with extensive extensive soft-tissue lacerationsoft-tissue laceration, , damagedamage, or , or lossloss; ; an an open segmental fractureopen segmental fracture; or a ; or a traumatic amputationtraumatic amputation. .

Also: Also: High-velocity gunshot injuriesHigh-velocity gunshot injuries

Farm injuries Farm injuries

Open fracture requiring vascular repair Open fracture requiring vascular repair

Open fracture older than 8 hr Open fracture older than 8 hr

TypeType DefinitionDefinitionIIIaIIIa Adequate periosteal coverAdequate periosteal cover of a fractured bone of a fractured bone

despite extensive soft tissue laceration or despite extensive soft tissue laceration or damage damage

High-energy trauma irrespective of size of wound High-energy trauma irrespective of size of wound

IIIbIIIb Extensive soft-tissue loss with Extensive soft-tissue loss with significant significant periosteal stripping and bone damage periosteal stripping and bone damage

Usually associated with massive contamination Usually associated with massive contamination

IIIcIIIc Association with Association with arterial injury requiring repairarterial injury requiring repair, , irrespective of degree of soft-tissue injury irrespective of degree of soft-tissue injury

Gustilo Classification of Open Gustilo Classification of Open FracturesFractures

Management Management

Outline of treatment in emergency unit

1. Temporary dressing2. Splinting3. Initial c/s (+ anarobic) 4. Stop bleeding 5. Check associated injuries6. X-Ray, etc.7. Prophylactic Antibiotics8. Tetanus Toxoid, Antitoxin

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