TRAUMA PART 2: CHEST, ABDOMINAL,

ORTHOPAEDIC

Angel M Rodriguez PGY2Mercy Catholic Medical Center

Chest 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.

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

Pericardium Esophagus Thoracic Duct Diaphragm

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.

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.

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.

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.

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.

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.

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

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.

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

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.

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.

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.

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

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.

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.

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.

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.

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.

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.

Abdominal Trauma

Questions?Break?

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

Damage control When in intraop metabolic failure:

Hypothermia Acidosis Coagulopathy

More likely to cause the death- unless bleeding.

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

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

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

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

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

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

Place clamp precisely Venous

Evacuate blood and pack

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

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

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

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.

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…

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.

Push together- not down-

Finger fracture

Packing-

Foley and penrose

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

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

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

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

Consider t-tube – feeding tube – drain area

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

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

Arteries Celiac artery

Ligation Renal artery

Nephrectomy in most cases SMA

Shunt Iliac

Shunt if feasible If ligated- need fasciotomies

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

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

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

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

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!

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?

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.

Orthopaedic TraumaQuestions?

Break?

Open fractures fracture that is exposed to the outside

environment high-energy injuries immediate irrigation and débridement

combined with skeletal stabilization

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.

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

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.

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.

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.

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.

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

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

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

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.

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.

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.

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.

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.

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

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.

Calcaneus lumbar fracture Those with minimal displacement are treated

closed. Any displacement of an articular fragment

involving the subtalar joint should be reduced.

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.

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.

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

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.

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.

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.

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

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

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

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

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.

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.

Questions?