Multiple Trauma ATLS

Multiple Trauma / ATLS http://www.orthoteers.com/(S(hpd3fo55tk2scq45w2e4vp45))/printPage...

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Multiple Trauma / ATLSSee Powerpoint presentation

outline

receptionprimary surveysecondary surveyradiologyprocedureslimb injuriesspinal injuries

reception

Prehospital InformationNature of IncidentNumber, age & sex of casualtiesABCDManagement & EffectETA

Airway & Cervical Spine control

Assess: Ask name, facial/neck injuries, vomit

Clear Airway: with sucker or Magill forceps

Chin Lift - one hand on chin, thumb in mouth, pull forward.

Jaw Thrust

Orotracheal intubation with in-line neck stabilisation: absent gag & poor ventilation, headinjury..

100% oxygen at flow rate 15 l/min.

Full cervical spine immobilisation - hard collar & lateral supports with straps acrossforehead & chin.

Breathing

Inspect neck & thorax - NB trachea, neck veins

Respiratory Rate

Auscultate

Life Threatening thoracic conditions: (Trauma Clinicians Often Miss Fractures )

Tension pneumothoraxCardiac tamponadeOpen chest woundMassive haemothoraxFlail chest

circulation

Shock assessment: skin colour, capillary refill, mental state, pulse, blood pressure

control haemorrhage

2 large(14g) cannulas peripherally.

Withdraw 20ml blood for FBC, U&E, Gluc., X-match.

warmed crystalloids

Blood:

full x-match


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type specificO Neg.

dysfunction

pupils - size, equal, response to light.

conscious level:

A lertV erbal stimuliP ain stimuliU nresponsive

exposure

clothing - remove all

cold - be aware of Hypothermia, keep warm (warmed blankets)

secondary survey

head-to-toe

log-roll

PR (& PV)

tubes - 2 large peripheral IV; urinary catheter, NGT, (chest drain, DPL, central line,arterial line)

analgesia, anti-tetanus, antibiotics

X-Rays: (done after Primary Survey)

lateral cervical spine (followed by AP & peg view in X-Ray dept. when patientstable- do not remove collar until all 3 films cleared) chestpelvis

ATLS-C-spine, pelvis, chest AP

A- adequacy & alignment

B- bones - margins & architecture - follow bone margins & comment on general density& architecture.

C- cartilage/joints - joint spaces, surfaces.

S- soft tissues - swelling, air in tissues (open wound/ open fracture)

history (AMPLE)

Allergies

Medications

Past medical history

Last meal

Events of injury

cricothyroidotomy

last resort for airway control. Y connector with O2 at 15 l/min.Intermittent jet insufflation- sedate & paralyze, only for 30-45min., caution for FB


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intercostal drain

4th or 5th intercostal space, mid-axillary linelocal anaesthetic down to pleura'above the rib below'blunt dissection. finger explorationpass large drain on forceps superior & posterior.underwater drainpursestring suture

pericardiocentesis

Beck's Triad- shock,distended neck veins, muffled heart sounsECG monitorwide bore long sheathed needleenter 2cm below left xiphochondral junction, aiming 45 degrees posterior towards

tip of left scapula. positive -> urgent thoracotomy


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Limb injuries

Primary survey

Secondary survey

Immobilisation & reduction

Pain control

Wound Care:

Antibiotic prophylaxisTetanus coverPhotographBetadine dressing

Culture swab Debridement (generous)IrrigationFracture stabilisationLEAVE WOUND OPEN

spinal injuries

primary suvey:

A:cervical spine control, intubation(blind tracheal, fibre-optic laryngoscope,naso-tracheal), nasogastric tube (ileus)

B:intercostal paralysis

immobilisation - scoop, spinal board

secondary survey:

Log Roll -swelling, tenderness, steps, gapsNeurological exam. - NB. bulbocavernosus reflex

Neurogenic shock: - hypotension, bradycardia [be aware of Pt.s on B-blockers], warm periphery

Spinal Shock: flaccid limbs, reduced reflexes, reduced sensation, Urinary retention, paralytic ileus. [return of bulbocavernosus reflex indicates end of Spinal Shock]

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Open (Compound) fractures http://www.orthoteers.com/(S(hpd3fo55tk2scq45w2e4vp45))/printPage...

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Open (Compound) fracturesGoals

Prevention of infection

Healing of the fracture

Restoration of function

Classification - Gustilo and Anderson

Type 1 Wound less than 1cm long

Moderately clean puncture, where spike of bone has pierced the skin

Little soft tissue damage

No crushing

Fracture usually simple transverse or oblique with little comminution

Type 11

Laceration more than 1cm long

No extensive soft tissue damage, flap or contusion

Slight to moderate crushing injury

Moderate comminution

Moderate contamination Type 111

Extensive damage to soft tissues

High degree of contamination

Fracture caused by high velocity trauma 111A Includes any segmental or severely comminuted closed or open

fractures, regardless of the size of the wound

Soft tissue coverage of the bone is adequate. 111B Extensive injury to or loss of soft tissue, with periosteal

stripping and exposure of bone,

Massive contamination

Severe comminution of fracture

After debridement a segment of bone is exposed and a local or free flap is required to cover it

111C Any fracture with an arterial injury which requires repair, regardless of the degree of soft tissue injury

Steps in management

ABC

30% of patients with an open fracture have other life threatening injuries

Assess neurovascular status of the limb

Swab wound

Photograph & Cover wound

Tetanus prophylaxis


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Give IV antibiotics

Cephalosporin (Cefuroxime 1.5g stat)

If type 11 or 111 add an aminoglycoside (Gentamycin ). This combination covers gram positive and gram negative bacteria

Penicillin added if a farmyard injury to cover Clostridium Perfringens

Give IV antibiotics for 48-72 hours post injury and again for 48-72 hours each time a further procedure is performed. Prolonged antibiotics for more than 3 days does not further prevent infection . Restricting the antibiotics should minimise the emergence of resistant bacteria

70% of open fractures are contaminated with bacteria at the time of injury

Most common initial contaminants are skin flora (Staph Epidermidis, proprionobacterium acnes, Corynebacterium species, Micrococcus)

Despite this, many infections are caused by Staph aureus and pseudomonas aeruginosa suggesting hospital acquired infection

Operative debridement and copious irrigation

Small wounds should be extended and excised to allow adequate exposure

Unattached bone should be discarded

For type 11 and 111 fractures irrigate with 5-10 litres of saline

Repeat debridement at 48 hourly intervals

Stabilisation of the fracture

Reduces rates of infection

Promotes soft tissue healing

Facilitates wound care

Allows mobilisation of the limb , particularly important in multiply injured patients

Preferably performed at the time of initial debridement

Coverage and closure of the wound

Aim for soft tissue coverage of the wound as early as possible to avoid infection, optimise the milieu for bone healing

Timing of coverage- 1990 aiming for coverage by 5-7 days was reasonable

Now 'fix and flap' treatment advocated by some ( Gopal et al. JBJS. [Br] 2000;82-B:959-66. )

Options in stabilisation of an open fracture

No one method is optimum for stabilisation of all open fractures

External fixation

Advantages Disadvantages Versatile

Ease of application with minimal operative trauma

Risk of pinsite infection


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Maintenance of access to wound

Intramedullary nailin g

Plate and screws

Useful in displaced intraarticular fracture fixation

Splints casts and traction

Can be used in stable type 1 fractures

Beware compartment syndrome

Options in coverage and closure of the wound

Primary delayed closure

Suturing skin directly

Split skin graft

Flaps

Choice depends on

Age and needs of patient

Location size and condition of the defect

The likelihood that further reconstruction will be needed

The associated zone of surrounding soft tissue injury

The tissues available for the flap

Types of flap

Fasciocutaneous

Transposed muscle pedicle

Free microvascular muscle flap

Compartment syndrome

Can occur in open fractures beware!!!!!!

Amputation indications

Absolute indications

Type 111C injury accompanied by damage to the posterior tibial nerve

Type 111 C injury with massive loss of bone

See MESS score

Fix and flap: the radical orthopaedic and plastic treatment of severe open fractures of the tibia

S. Gopal, S. Majumder, A. G. B. Batchelor, S. L. Knight, P. De Boer, R. M. Smith From St James's University Hospital, Leeds and York District Hospital, York, England

J Bone Joint Surg [Br] 2000;82-B:959-66.

We performed a retrospective review of the case notes of 84 consecutive patients who had suffered a severe (Gustilo IIIb or IIIc) open fracture of the tibia after blunt trauma between 1990 and 1998. All had been treated by a radical protocol which included


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early soft-tissue cover with a muscle flap by a combined orthopaedic and plastic surgery service. Our ideal management is a radical debridement of the wound outside the zone of injury, skeletal stabilisation and early soft-tissue cover with a vascularised muscle flap. All patients were followed clinically and radiologically to union or for one year.

After exclusion of four patients (one unrelated death and three patients lost to follow-up), we reviewed 80 patients with 84 fractures. There were 67 men and 13 women with a mean age of 37 years (3 to 89). Five injuries were grade IIIc and 79 grade IIIb; 12 were site 41, 43 were site 42 and 29 were site 43. Debridement and stabilisation of the fracture were invariably performed immediately. In 33 cases the soft-tissue reconstruction was also completed in a single stage, while in a further 30 it was achieved within 72 hours. In the remaining 21 there was a delay beyond 72 hours, often for critical reasons unrelated to the limb injury. All grade-IIIc injuries underwent immediate vascular reconstruction, with an immediate cover by a flap in two. All were salvaged. There were four amputations, one early, one mid-term and two late, giving a final rate of limb salvage of 95%. Overall, nine pedicled and 75 free muscle flaps were used; the rate of flap failure was 3.5%. Stabilisation of the fracture was achieved with 19 external and 65 internal fixation devices (nails or plates). Three patients had significant segmental defects and required bone-transport procedures to achieve bony union. Of the rest, 51 fractures (66%) progressed to primary bony union while 26 (34%) required a bone-stimulating procedure to achieve this outcome. Overall, there was a rate of superficial infection of the skin graft of 6%, of deep infection at the site of the fracture of 9.5%, and of serious pin-track infection of 37% in the external fixator group. At final review all patients were walking freely on united fractures with no evidence of infection.

The treatment of these very severe injuries by an aggressive combined orthopaedic and plastic surgical approach provides good results; immediate internal fixation and healthy soft-tissue cover with a muscle flap is safe. Indeed, delay in cover (>72 hours) was associated with most of the problems. External fixation was associated with practical difficulties for the plastic surgeons, a number of chronic pin-track infections and our only cases of malunion. We prefer to use internal fixation. We recommend primary referral to a specialist centre whenever possible. If local factors prevent this we suggest that after discussion with the relevant centre, initial debridement and bridging external fixation, followed by transfer, is the safest procedure.

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Physeal Fractures http://www.orthoteers.com/(S(hpd3fo55tk2scq45w2e4vp45))/printPage...

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Physeal Fractures


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Aetiology of premature partial growth plate arrest

Trauma: 80%Salter-Harris Type 1: 5%Salter Harris Type 2: 5%Salter Harris Type 3: 5%Salter Harris Type 4: 85%Salter Harris Type 5: 0% ?

1.

Infection: 10%2.Tumour: 5%3.Iatrogenic (pins, stapes): 2%4.Irradiation: 2%5.Burns: 1%6.

Location of physeal arrest

Distal Femur: 39%1.Proximal Tibia: 18%2.Distal Tibia: 30%3.Distal Radius: 5%4.Distal Ulna: 3%5.Distal Fibula: 1%6.Proximal Humerus: 1%7.Proximal Phalanx Great Toe: 1%8.Pelvis (tri-radiate): 1% 9.

Types of Bridge formation

1. PeripheralInvolves the zone of Ranvier, important in latitudinal growth of the physis.May -> severe angular deformity -> surgical approach from the periphery excising the overlying periosteum. 2. LinearOsseous bridge extends as a linear structure across the physis. Most common site is the medial malleolus. May also lead to significant angular deformity -> may remove making a tunnel through the bone.


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3. CentralThe most severe type of injury and the most difficult to rectify surgically. Bridge is completely surrounded by normal cartilage. Affects longitudinal growth predominantly. Needs to be approached from the metaphysis. Do not replace bone excised from the bridge in filling the metaphyseal defect.

Harris lines appear after restoration of growth following a physeal injury, the line being due to slowing of growth for a variable period following injury. If these lines are parallel to the physis then damage to growth is unlikelyExcision of an osseous bridge that constitutes 50% or more of the entire area of the physis usually gives a poor result.

Substances used to fill defect

Fat

Autogenous, no need to remove May need second incision to get graft May float out with release of tourniquet Shown to enlarge as growth occurs

Silastic

Inert, mouldable to cavity and easily removed Need special authorisation for use Must be sterilised, infections reported Fractures at site of insertion reported

PMMA

Light, inert, non-conductive, transparent (no barium) Mouldable to defect, good haemostasis, No fractures reported No need to remove later but may be difficult if necessary Packed sterile, no infections reported

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Physical Abuse of Children / Non-Accidental Injuries http://www.orthoteers.com/(S(hpd3fo55tk2scq45w2e4vp45))/printPage...

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Physical Abuse of Children / Non-Accidental InjuriesStatistics show that more than half the victims of child abuse have fractures. The orthopedicsurgeon will often be the first person to identify a potentially abused child.

The safest pathway for the child and clinician is to make a child abuse report in all suspicious cases.

Risk Factors for Child Abuse

single parent household, particularly father-only households

Household income does not relate to increase risk

Medical History

(1) Who witnessed the event?

Child abuse is unusual in a group setting. If, by history, multiple adults witnessed the event, it is more likely to be accidental, and it is easy to verify the history.

If possible, the adult witnesses should be interviewed separately.

(2) Was there a delay in seeking medical care?

Child abusers tend to delay seeking care for their injured children.

(3) Is the history plausible?

(4) What is the mechanism of injury?

Does the parent's story fits that mechanism

(5) Does the history change over time?

Parents who have abused their children may modify the medical history over time.

(6) History of failure to thrive

(7) previous unusual injury (eg, fractured femur in a child 6 months of age)

(8) A history of a serious high-risk injury or unexplained death in a sibling

(9) Missed immunizations

(10) Lack of medical records

Physical Examination

The child should be weighed and measured, since abused and neglected children are often small for their age.

Every child should be undressed and examined for cutaneous injury, including a careful inspection of the genitalia and anus, since many children who are victims of physical abuse may also be sexually abused.

Palpation over the long bones and joints and assessment of joint motion

Any tender area suggesting a fracture should be radiographed even in an older child where the skeletal survey is less valuable.

In young children with signs of head injury, such as altered states of consciousness, seizure, apnea, or abnormal head growth, a detailed fundoscopic examination should be done to assess for retinal hemorrhages.

Bruises to the external ears and face are commonly seen in children with closed head injury.

The mouth should be examined for evidence of a torn frenulum of the upper lip or other dental or mucous membrane trauma.

Physical Abuse of Children / Non-Accidental Injuries http://www.orthoteers.com/(S(hpd3fo55tk2scq45w2e4vp45))/printPage...

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The external ear canal and tympanic membranes may reveal evidence of "hidden" injury such as hemotympanum.

Abdominal bruises or abdominal distension and vomiting may be clues to a ruptured viscus.

Radiographic Evaluation

A skeletal survey should be obtained in any child less than 2 years of age where there is a suspicion of physical child abuse.

If the skeletal survey is negative and there is a strong suspicion of fracture, an isotope bone scan may identify fractures not seen on skeletal survey

Laboratory

Because children with certain genetic syndromes can bruise more easily, if the physical examination suggests a syndrome (eg, laxity of skin and hypermobile joints seen in Ehlers-Danlos syndrome), a genetic evaluation is indicated.

In a child with bruising, parents often suggest that the child bruises easily. A prothrombin time, partial thromboplastin time, and platelet count are always indicated. In a situation where easy bruising persists in a protected environment or history or physical examination suggests coagulopathy, further more sophisticated coagulation evaluation is suggested. .

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Plaster of Paris http://www.orthoteers.com/(S(hpd3fo55tk2scq45w2e4vp45))/printPage...

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Plaster of ParisPlaster of Paris

K Sampathkumar, 2005

Plaster of Paris is a derivative of Gypsum Gypsum is a very soft mineral composed of Calcium sulphate dihydrate Chemical formula for Gypsum CaSO 4 2H 2 O. Because the gypsum from the quarries of the Montmartre district of Paris has long furnished burnt gypsum used for various purposes, this material has been called plaster of Paris.

How is Plaster of Paris formed?

Heating gypsum above approximately 150 C partially dehydrates the mineral by driving off exactly 75% of the water contained in its chemical structure.

CaSO 4 2H 2 O + heat ' CaSO 4 H 2 O + 1 H 2 O (steam)

The partially dehydrated mineral is called calcium sulfate hemihydrate or commonly known as plaster of Paris (CaSO 4 H 2 O).

The dehydration (specifically known as calcination ) begins at approximately 80 C (176 F) and the heat energy delivered to the gypsum atthis time tends to go into driving off water (as water vapor) rather than increasing the temperature of the mineral, which rises slowly until the water is gone, then increases more rapidly.

This is an endothermic reaction.

calcium sulfate hemihydrate has an unusual property: when mixed with water at normal (ambient) temperatures, it quickly reverts chemically to the preferred dihydrate form, while physically "setting" to form a rigid and relatively strong gypsum crystal lattice:

CaSO 4 H 2 O + 1 H 2 O ' CaSO 4 2H 2 O This reaction is exothermic .

This phenomenon is responsible for the ease with which gypsum can be cast into various shapes including sheets (for drywall), sticks (for blackboard chalk), and molds (to immobilize broken bones, or for metal casting).

(CaSO 4 , 2 H 2 O) + heat = (CaSO 4 , H 2 O) + 1.5 H 2 O

Plaster of Paris is a calcium sulfate hemi-hydrate : (CaSO 4 , H 2 O) derived from gypsum, a calcium sulfate dihydrate (CaSO 4 , 2 H 2 O), by firing this mineral at relatively low temperature and then reducing it to powder. Calcination of the gypsum at higher temperatures produces different types of anhydrites (CaSO 4 ), as shown on the table below

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Post-fracture infection http://www.orthoteers.com/(S(hpd3fo55tk2scq45w2e4vp45))/printPage...

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Post-fracture infectionPost-Fracture

Infection

Pathology & Diagnosis Prevention & Treatment

Diagnosis - Soft tissues/discharge - X-rays - Blood cultures - ESR/CRP/WBC - Further imaging

Gavin Bowyer Anatomic Classification

Cierny & Mader; Orthop Rev 1987

Assessing the Problem

Staging - Cierny & Mader - Anatomy and Physiology - Stability - Soft tissues - Bacteriology

Post-Fracture Infection

Physiological Class of Host - A - Normal - B - Compromised - B1 - locally - B2 - systemically (inc. smoker!) - B3 - local and systemic - C - Treatment worse than disease

Skeletal stability - Stable, quality soft tissue envelope - Eradication of infection

Return to Function

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Robert Danis http://www.orthoteers.com/(S(hpd3fo55tk2scq45w2e4vp45))/printPage...

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Robert DanisBy A. Danis

The work of Robert Danis on rigid internal fixation and early functional rehabilitation served as a stimulus to the founding of AO in 1958.

A graduate of the Free University of Brussels in 1904, Robert Danis enjoyed a long and brilliant career. Interested in thoracic surgery, he conceived and constructed a positive pressure anaesthetic apparatus that prevented lung collapse with open thoracotomy (1909), followed in 1912 with a more simplified second model. He then became interested in the surgery of the blood vessels. He experimented with vascular anastomoses and investigated the uses of blood clotting after anastomosis. He invented an automatic citration syringe for direct transfusion from donor to recipient, as well as an instrument for porto-caval anastomosis without interruption of the circulation. His works provide the material for his thesis on "Vascular Anastomosis and Ligatures" (1912).

He then undertook work on regional anesthesia, particularly of the trunk and the sacral roots, for which he was awarded the Seutin prize in 1914.

Attached to the Hospice de Bruxelles during the period 1913 to 1920, he became familiar with the surgery of hernias, amputation, of the breast and thyroidectomy, performed under local or regional anesthesia on ambulant patients who, in the evening after surgery, were taken home by cab. Danis then followed them up on a domiciliary basis.

In 192 1 he occupied the Chair of Theory and Practice of Operative Surgery and was entrusted with the Directorship of the Gynaecological Clinic. Together with his mentor Antoine Depage he developed a radical technique for mastectomy for breast cancer, with a 51 % five year survival.

A new area then started to absorb him, namely the operative treat-treatment of fractures. On a new table of his own invention, the fracture was immobilized by traction and the fragments then sutured with stainless steel wire, either using a transcortical technique, or by cerdage. His book "Technique of Osteosynthesis" summarized his early results (1932). Exasperated by the slowness of manufacturers, he installed in his cellar a fully equipped mechanical workshop where he fashioned screws of various types and the necessary associated instrumentation. He even manufactured a reciprocating saw driven by a cable motor.

Constantly seeking perfection of his instrumentation he finally produced an axial compression plate. By axially compressing the main bone fragments, it produced such stability that early functional rehabilitation, without external splintage, became possible. The sum of he and his collaborators' vast experience, almost 2000 cases in 20 years was published in 1949 as " The Theory and Practice of Osteosynthesis ". This major work earned him an international reputation and his election to the Presidency of the International Society of Surgery. Without affecting his natural modesty he accepted numerous honourable distinctions, including Doctor Honoris Causa of the Universities of Strasbourg, Dublin and Paris, Honorary Fellowship of the Royal College of Surgeons of England, of the American College of Surgeons, and the Association of Surgeons of Great Britain and Northern Ireland, as well as Member of Honour of the Societies of Lyon, Marseilles, of Greece and of Switzerland. He became Vice President of the Royal Academy of Medicine of Belgium.

His teaching sessions enriched by blackboarddrawings, executed with both hands at the sametime, and also by cin film in the operatingtheatre, led to a diagnostic and therapeutic style farfrom dogmatic theory. He was a great patron and a

Robert Danis http://www.orthoteers.com/(S(hpd3fo55tk2scq45w2e4vp45))/printPage...

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teacher of rare authority, respected by his pupils.adored by his patients.

As a student he was an accomplished swordsman and shot. As a young doctor he hunted game in Sudan in the company of Arnold Solvay. His trophies of antelopes, buffalo and lion illustrated a synergetic passion, which lasted his whole life. During the German occupation of Belgium his guns were replaced by a fishing rod.

In 1919, judging the car to be beyond his finances, he conceived of a vehicle made of metal tubing with a motor in the centre and the radiators on the sides. Unfortunately, the weakness of the brakes caused him to give up the project alter a year.

As a youngster it became evident that he was an accomplished artist in drawing water colour, copper engraving and oil painting. His life never ceased to he enriched by his pictures, sketches and caricatures. To his own self portraits he added those of his family, the family pets and the countryside.

Finally setting aside the scalpel, his passion for music took over. Brought up among musicians he had received his first piano lessons from his mother. He studied musical theory and was able to learn by heart many entire musical scores. He played the guitar to keep his fingers supple and then the saxophone, which he rapidly abandoned for the harmonium, before returning to the piano.

In his last years he improvised numerous musical pieces, which he recorded as written scores. On one of his trips he discovered the novel sounds of the electronic organ; thus equipped, he played and recorded ceaseless dozens of compositions born of his musical personality. Those gathered at his table, discovered with surprise that he also had great talents in the kitchen.

His robust health shielded him from illness and without infirmity and in full possession of his faculties he ignored the ageing process. His end was brief and without suffering.

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Traction http://www.orthoteers.com/(S(hpd3fo55tk2scq45w2e4vp45))/printPage...

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Traction

Introduction Definitions Specific Types of Traction Knots

Introduction [Back To Top]

Traction produces a reduction through the surrounding soft parts which align the fragments by their tension.

When the shaft of a long bone is fractured the elastic retraction of muscles surrounding the bone tends to produce over-riding of the fragments. This tendency is greater when the muscles are powerful and long bellied as in the thigh, when the fracture is imperfectly immobilised so that there is pain and therefore muscle spam and when the fracture is mechanically unstable because the fragments are not in apposition or because the fracture line is oblique.

Continuous traction generated by weights and pulleys in addition to causing reduction of a deformity will also produce a relative fixation of the fragments by the rigidity conferred by the surrounding soft tissue structures when under tension. It also enables maintenance of alignment while at the same time it is possible to devise apparatus which permit joint movement.

Traction may be applied through traction tapes attached to skin by adhesives or by direct pull by transfixing pins through or onto the skeleton.

Traction must always be apposed by counter traction or the pull exerted against a fixed object, otherwise it mealy pulls the patient down or off the bed.

Traction requires constant care and vigilance and is costly in terms of the length of hospital stay and all the hazards of prolonged bed rest - thromboembolism, decubiti, pneumonia and atelectasis must be considered when traction is used

Excessive traction which leads to distraction of the fracture is undesirable. Once the fracture is reduced a decreasing amount of weight is required to maintain a reduction once the muscle stretch reflex has been overcome and the fracture immobilised. For a femoral fracture no more than 10lbs should be used and for fractures of the tibia and upper limb less weight is required.

Skin Traction

Traction is applied to the skeleton through its attached soft tissued and in the adult should be used only as a temporary measure. Skin is designed to bear compression forces and not shear. If much more than 8lbs is applied for any length of time it results in superficial layers of skin pulled off. Other difficulties such as migration of the bandage may occur with lower weights.

Skeletal Traction

First achieved by the use of tongs. The application of traction applied by a pin transfixing bone was introduced by Fritz Steinmann. Now a threaded Denham pin is preferred to prevent early loosening of the device. The threaded portion of the Denham pin is offset, closer to the end of the pin held in the drill chuck and should engage only the proximal cortex of the recipient long bone. Max. 18kg(40lb) can be used Steinmann pin - 3mm diameter Denham pin - 3mm & central threaded portion (resists lateral motion & thus infection) Bohler Stirrup, Simonis Swivels(allow joint motion) Braun Frame- can attach calcaneal/tibial/femoral Pearson Attachment- for Thomas splint, allows knee flexion, with tibial skeletal traction, hinge centred on adductor tubercle of femur (axis knee rotation)

Traction by Gravity Really only applies to fractures of the upper limb (hanging cast)

Definitions [Back To Top]

Traction on a limb demands either a fixed point from which the traction may be exerted (fixed traction) or an equal counter-traction in the opposite direction (balanced traction)

Fixed Traction

The length of the limb remains constant and there is continuous diminution of traction force as the tone in the muscles diminishes and no further stimuli results in activation of the muscle stretch reflex. Pull is exerted against a fixed point for example tapes are tied to the cross piece of a Thomas splint and the leg pulled down until the root of the limb abuts against the ring of the splint. Pins in plaster is a form of fixed traction

Balanced Traction

The pull is exerted against an opposing force provided by the weight of the body when the foot of the bed is raised.

Combined Traction

May be used in conjunction with fixed traction where the weight takes up any slack in the tapes or cords while the splint maintains a reduction. This combination facilitates less frequent checks and adjustment of the apparatus

Sliding Traction

First introduced by Pugh by applying traction tapes to the limb and fastening them to the raised foot of the bed which was then inclined head down. He utilised this traction in the treatment of conditions such as Perthes where only one limb was fastened to the end of the bed enabling the pelvis on the opposite side to slide down the bed more thus creating traction and abduction. The extent to which the patient slides down the bed is limited by the friction of the body against the mattress. The traction was subsequently modified by Hendry using a mattress on a sliding frame which resulted in the same amount of traction with an inclination of 10


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o as that with that on a normal mattress at 30 - 40 o inclination. This is also really a form of balance traction where the amount of weight is determined by the inclination of the bed.

Specific Types of Traction [Back To Top]

Thomas Splint Traction Hugh Owen Thomas introduced his splint which he called "The Knee Appliance" in 1875. The method of Hugh Owen Thomas uses fixed traction with the counter traction being applied against the perineum by the ring of the splint. This is in contrast to other methods using weight traction which is countered by the weight of the body. Backward angulation of the distal fragment can never be corrected by traction in the axis of the femur which only results in elongation with persistence of the deformity. A Thomas splint and fixed traction is only capable of maintaining a reduction previously achieved by manipulation. The use of supports enables correction of angulation caused by muscle tension. Placement of a large pad behind the lower fragment acts as a fulcrum over which backward angulation is then corrected by the traction force. The pad should be ~ 6" in width, 9" long and 2" thick applied transversely across the splint under the distal fragment and popliteal fossa It is the splint which controls alignment and not the traction. The tension in the apparatus should only be that sufficient to balance resting muscle tone. Suspension of the splint using an overhead beam in such a way to enable the splint to move easily with the patient when they move in bed. Its use in combination with a Pearson Knee-flexion piece enables mobilisation of the knee while maintaining traction, alignment and splintage of the fracture.

Thomas splint traction with Pearson knee flexion piece

Hamilton Russell Traction Robert Hamilton Russell wrote "Fracture of the femur: A clinical study" in which he described his traction in 1924. Sling under the distal 1/3 of the thigh providing upward lift as well as longitudinal traction in the line of the tibia. The sling under the distal fragment controls posterior angulation and the lifting force is related to the main traction force through the medium of pullies. No rigid splintage is used in this method Combines a means of suspending the lower extremity and a means of applying traction in the axis of the femur. Many other varieties of both skeletal and skin traction result in a similar effect. Summary- 2 vectors, sling under knee, single cord + 3 pulleys or 2 traction cords (modified HR) (Need Balkan beams)

Buck Traction Buck introduced simple horizontal traction in 1861. Traction is analogous to Pugh's traction only the inclination of the bed is replaced by the application of weights over a pulley.

Bryant's traction Vertical extension traction was described by Bryant in 1873 and applied to the management of femoral fractures. The development of ischaemia of the lower leg through reduced perfusion resulted in limitation of its application to the short term management of a fractured femur. A modification of his traction has been shown to reduce the risk of limb ischaemia and may be applicable where prolonged traction is required in an infant.

Braun Frame This is mearly a cradle for the limb but a disadvantage is that the position of the pulleys cannot be altered and the size of the splint often does not fit the limb as might be wished. Lateral bowing is common as the splint and the distal fragment are fixed to the frame while the patient and the proximal fragment can move sideways leaving the frame behind.

Perkins Traction Here no splintage is used at all, the posterior angulation of the thigh is controlled by a pillow and the alignment and fixation depend entirely on the action of continuous traction

Fisk Traction

Hinged version of a Thomas splint is arranged to allow 90 o of knee movement. It is particularly attractive as it allows active extension of the knee joint. Fixation and alignment is dependent entirely on the weight traction and the splint merely applies the motive power for assisted knee movement.

90 - 90 Traction

The thigh is suspended in the vertical plane by weight traction pulling vertically upwards. The ill effect of gravity as the cause of backward angulation of the fragments is thus eliminated.


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CharnleyStrongly recommends the use of a BK POP incorporating the Steinmann or Denham pin in the upper end in order to reduce pressure on the soft structures around the knee.

Benefits of POP/Traction unit: (Charnley)

Foot supported at right angles to the tibia Common peroneal nerve and calf muscles protected from pressure against the slings of the splint and the splint itself. The tibia is suspended from the skeletal pin inside the POP so that an air space develops under the tibia as the calf muscles loose their bulk. External rotation of the foot and distal fragments is controlled. The tendo achilles is protected from pressure sores Comfort; The patient is unaware of the traction when applied through the medium of a nail

Upper Limb A number of skin traction methods have been described and a number more utilised without documentation in the literature.

Dunlop's sidearm skin traction

for humeral supracondylar # shoulder abducted 45deg, elbow flexed 45deg, weighted sling over distal humerus 0.5kg + weighted skin traction to forearm 1kg -> resultant force in line of humerus.

Graham's extension skin traction

Ingerbrightsen's overhead skin traction

Skeletal pin traction can also be utilised:

Overhead Overhead with secondary distal forearm traction directed cephalad side arm pin traction

Spine

Halter- cervical spine spondylosis, 1.4-2.3kg

Cotrels- intermittent, for scoliosis, legs + halter

Useful Knots [Back To Top]

Overhandloop

Slip knot

Reef knot

Clove hitch

passes around an object in only one direction, thus puts very little strain on the rope fibers. Tying it over an object that is open at one end is done by dropping one overhand loop over the post and drawing them together. The other method of tying it is used most commonly if the object is closed at both ends or is too high to toss loops over. The latter is used in starting and finishing most lashings.

Barrel hitch


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Definitions [Back To Top]

Traction on a limb demands either a fixed point from which the traction may be exerted (fixed traction) or an equal counter-traction in the opposite direction (balanced traction)

Fixed Traction

The length of the limb remains constant and there is continuous diminution of traction force as the tone in the muscles diminishes and no further stimuli results in activation of the muscle stretch reflex. Pull is exerted against a fixed point for example tapes are tied to the cross piece of a Thomas splint and the leg pulled down until the root of the limb abuts against the ring of the splint. Pins in plaster is a form of fixed traction

Balanced Traction

The pull is exerted against an opposing force provided by the weight of the body when the foot of the bed is raised.

Combined Traction

May be used in conjunction with fixed traction where the weight takes up any slack in the tapes or cords while the splint maintains a reduction. This combination facilitates less frequent checks and adjustment of the apparatus

Sliding Traction

First introduced by Pugh by applying traction tapes to the limb and fastening them to the raised foot of the bed which was then inclined head down. He utilised this traction in the treatment of conditions such as Perthes where only one limb was fastened to the end of the bed enabling the pelvis on the opposite side to slide down the bed more thus creating traction and abduction. The extent to which the patient slides down the bed is limited by the friction of the body against the mattress. The traction was subsequently modified by Hendry using a mattress on a sliding frame which resulted in the same amount of traction with an inclination of 10 o as that with that on a normal mattress at 30 - 40 o inclination. This is also really a form of balance traction where the amount of weight is determined by the inclination of the bed.

Specific Types of Traction [Back To Top]

Thomas Splint Traction Hugh Owen Thomas introduced his splint which he called "The Knee Appliance" in 1875. The method of Hugh Owen Thomas uses fixed traction with the counter traction being applied against the perineum by the ring of the splint. This is in contrast to other methods using weight traction which is countered by the weight of the body. Backward angulation of the distal fragment can never be corrected by traction in the axis of the femur which only results in elongation with persistence of the deformity. A Thomas splint and fixed traction is only capable of maintaining a reduction previously achieved by manipulation. The use of supports enables correction of angulation caused by muscle tension. Placement of a large pad behind the lower fragment acts as a fulcrum over which backward angulation is then corrected by the traction force. The pad should be ~ 6" in width, 9" long and 2" thick applied transversely across the splint under the distal fragment and popliteal fossa It is the splint which controls alignment and not the traction. The tension in the apparatus should only be that sufficient to balance resting muscle tone. Suspension of the splint using an overhead beam in such a way to enable the splint to move easily with the patient when they move in bed. Its use in combination with a Pearson Knee-flexion piece enables mobilisation of the knee while maintaining traction, alignment and splintage of the fracture.

Thomas splint traction with Pearson knee flexion piece

Hamilton Russell Traction Robert Hamilton Russell wrote "Fracture of the femur: A clinical study" in which he described his traction in 1924. Sling under the distal 1/3 of the thigh providing upward lift as well as longitudinal traction in the line of the tibia. The sling under the distal fragment controls posterior angulation and the lifting force is related to the main traction force through the medium of pullies. No rigid splintage is used in this method Combines a means of suspending the lower extremity and a means of applying traction in the axis of the femur. Many other varieties of both skeletal and skin traction result in a similar effect. Summary- 2 vectors, sling under knee, single cord + 3 pulleys or 2 traction cords (modified HR) (Need Balkan beams)

Buck Traction Buck introduced simple horizontal traction in 1861. Traction is analogous to Pugh's traction only the inclination of the bed is replaced by the application of weights over a pulley.

Bryant's traction Vertical extension traction was described by Bryant in 1873 and applied to the management of femoral fractures. The development of ischaemia of the lower leg through reduced perfusion resulted in limitation of its application to the short term management of a fractured femur. A modification of his traction has been shown to reduce the risk of limb ischaemia and may be applicable where prolonged traction is required in an infant.

Braun Frame This is mearly a cradle for the limb but a disadvantage is that the position of the pulleys cannot be altered and the size of the splint often does not fit the limb as might be wished. Lateral bowing is common as the splint and the distal fragment are fixed to the frame while the patient and the proximal fragment can move sideways leaving the frame behind.

Perkins Traction Here no splintage is used at all, the posterior angulation of the thigh is controlled by a pillow and the alignment and fixation depend entirely on the action of continuous traction

Fisk Traction

Hinged version of a Thomas splint is arranged to allow 90 o of knee movement. It is particularly attractive as it allows active extension of the knee joint. Fixation and alignment is dependent entirely on the weight traction and the splint merely applies the motive power for assisted knee movement.

90 - 90 Traction

The thigh is suspended in the vertical plane by weight traction pulling vertically upwards. The ill effect of gravity as the cause of backward angulation of the fragments is thus eliminated.


5 of 5 08/10/2007 11:09

CharnleyStrongly recommends the use of a BK POP incorporating the Steinmann or Denham pin in the upper end in order to reduce pressure on the soft structures around the knee.

Benefits of POP/Traction unit: (Charnley)

Foot supported at right angles to the tibia Common peroneal nerve and calf muscles protected from pressure against the slings of the splint and the splint itself. The tibia is suspended from the skeletal pin inside the POP so that an air space develops under the tibia as the calf muscles loose their bulk. External rotation of the foot and distal fragments is controlled. The tendo achilles is protected from pressure sores Comfort; The patient is unaware of the traction when applied through the medium of a nail

Upper Limb A number of skin traction methods have been described and a number more utilised without documentation in the literature.

Dunlop's sidearm skin traction

for humeral supracondylar # shoulder abducted 45deg, elbow flexed 45deg, weighted sling over distal humerus 0.5kg + weighted skin traction to forearm 1kg -> resultant force in line of humerus.

Graham's extension skin traction

Ingerbrightsen's overhead skin traction

Skeletal pin traction can also be utilised:

Overhead Overhead with secondary distal forearm traction directed cephalad side arm pin traction

Spine

Halter- cervical spine spondylosis, 1.4-2.3kg

Cotrels- intermittent, for scoliosis, legs + halter

Useful Knots [Back To Top]

Overhandloop

Slip knot

Reef knot

Clove hitch

passes around an object in only one direction, thus puts very little strain on the rope fibers. Tying it over an object that is open at one end is done by dropping one overhand loop over the post and drawing them together. The other method of tying it is used most commonly if the object is closed at both ends or is too high to toss loops over. The latter is used in starting and finishing most lashings.

Barrel hitch

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Traumatology and Orthopedic surgery in Europe http://www.orthoteers.com/(S(hpd3fo55tk2scq45w2e4vp45))/printPage...

1 of 3 08/10/2007 11:09


Traumatology and Orthopedic surgery in EuropeAdapted from U. Heim's historical review previously published in EFORT Bulletin

Accidental injury can be traced back throughout the history of mankind. Its treatment is surgical and first concerned with saving life, and only then limbs or organs.

Emergency surgery is a dramatic art, the progress of which has been intimately linked to warfare. Two remarkable military surgeons were J.F. Percy (1754-1825) and D. Larrey(1768-1842) (Fig.1). Against military orders, they went with teams and equipment (the flying ambulance) on to the Napoleonic battlefields to render immediate aid to the wounded. Their example was long forgotten. It is only very recently that the surgeon himself has again been able to be present at the site of modern traffic carnage.

Orthopedic surgery has its roots in antiquity. There was knowledge of the malformations and deformities of growth, but no means of remedying them. "Cripples were left to survive only by begging. Their plight was finally addressed (J. Rousseau: Discourse on the origins and foundations of the inequality among men: Academy of Dijon, 1754) with a new concept to take care of them: to correct their lesions, to educate them and, if possible, to return them to society. By clearing them from the streets and into closed establishments the esthetic sensibilities of the bourgeoisie were protected!

The first person to propose constructive therapeutic ideas was Andry (1658-1742), the irascible Professor of Medicine in Paris and enemy of surgeons, who wrote in 1741 Orthopaedics or The art of preventing and correcting body deformities in children, published in English in 1743 and in German in 1744. He had launched a movement.

In 1780 J.A.Venel(1740-179l), who qualified in Monipellier, founded the first Orthopedic Institute at Orbe, in the Bernese countryside of the Vaud. This served as a model for many similar Europe-wide establishments that were to open in the first decades of the 19th century.

Early on, orthopedics became an independent discipline in which long-term treatment was dominated by the goal of the improvement of the patients' "quality of life" (using current terminology) but not an unattainable cure. Surgery played only occasionally a role. Children were in-patients for months or years. These institutions were equipped for mechanical therapy and gymnastics, each manufacturing prostheses, apparatus, machines and instruments, and each with a school. Light, fresh air, sun and hydrotherapy were part of their treatment, tire results of which were sometimes quite remarkable.

J.M. Delpech (1777-1832), Professor of Surgery at the University of Montpellier, was typical. In 1828, he constructed his own Orthopedic Institute, equipped with vast therapeutic installations. Delpech also first described subcutaneous tenotomy of tendo Achilhis for clubfoot (1816). The young Stroniever (1804-1876) from Hannover learned of this technique and began to practise it himself, but with gradual postoperative correction. A young English surgeon, W. Little (1810-1894), himself a sufferer of clubfoot, went to Hannover to have his deformity corrected by Stromeyer. Little had done research work on the anatomy of clubfoot under Professor J. Muller (1801-1858) of Berlin, one of the leading anatomists of his time. Delighted by Stromeyer's surgery, Little traveled back to Berlin to


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demonstrate the cure to Professor Muller. Working with Muller at that time was Dieffenbach, who was so amazed by the transformation that he immediately adopted subcutaneous Achilles tenotomy for clubfoot, although he believed in immediate, single-stage correction.

The Success of Little's treatment was such that, shortly afterwards in London, he founded his own Institute for the Treatment of Club Foot, which in 1840 became the "RoyalOrthopedic Hospital'. This is an example of the transfer of knowledge within a Europe where journeys were long and uncomfortable and where a variety of languages were spoken.

Everything then changed with the introduction of the plaster cast in 1851 by Mathijsen(1805-1878) and of anesthesia. Surgery became painless and the limbs could reliably and individually be immobilized. But it was not before J. Lister (1827- 1912) described antisepsis in 1867 that bony operations were safer. Expanded orthopedic surgery did not eclipse the need for long-term cures of chronic illnesses such as rickets and tuberculosis, which were treated in large country hospitals, such as Berck-Plage.

In the large towns of Germany, adult handicap was treated in a semi-ambulatory way in those orthopaedic polyclinics (Leipzig 1875 was the first) which were associated with universities. It was thus that German orthopedics developed a structure the Society was founded in 1901) and became an independent branch of surgery before 1914.

In the UK, the hospital service was based entirely on a private system. Orthopedic hospitals existed, but there were no truly specialised surgeons. The protagonists of change were H. Thomas (1834-1891), known for Iris Thomas's splint, and his nephew, R. Jones(1858-1933), who became the first president of SICOT. For them and their American friends, limb traumatology was always part of orthopedics. It was, nevertheless, not until 1946 with the advent of the National Health Service, that each British hospital had its own orthopedic and traumatology service.

In Italy, two orthopedic hospitals must be mentioned: The first, in an old monastery above the city of Bologna and named after its donor, the surgeon F. Rizzoli (1809-80), and the second in Milan, the Instituto Ortopedico. Galeazzi (1866-1852), whose founder described in 1934 the forearm injury that bears his name.

In Bologna two directors were famous: A. Codivilla (1861-1912) (Fig.2), who published and conversed fluently in four languages. He described in 1903 transcalcaneal limb traction. hissuccessor V. Putti (1880-1940), also a multilingual scholar, described in 1916 a compression hand for the stable fixation of oblique shaft fractures and, in 1938 a compression screw for fractures of the neck of the femur. At the meeting of the International Society of Orthopedic Surgery in 1936 in Bologna he was then President. He successfully proposed adding to the title "et de tramatologie". SICOT was born.

In France, orthopedics was firmly attached to pediatric surgery (the Chair of Kirmisson (1848-1927) in 1901, then of Ombrdanne). It was not until 1934 that P. Mathieu(1877-1971) became a Professor of Adult Orthopedics. The turning point for French and British orthopedics was the presence of all surgeons in the military front hospitals of theFirst World War. This was their immersion in trauma. It was therefore not merely by chance


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that their two societies were formed in 1918 arid 1919.

In Belgium, he work of Robert Danis on rigid internal fixation and early functional rehabilitation served as a stimulus to the founding of AO in 1958.

The German orthopaedic surgeons worked in large military hospitals, practically excluded from experience at the battle front. The general surgeons preserved their interest in traumatology, which became progressively independent after 1960. Now, each large German hospital has a practically independent traumatology service which treats all accidents and has but rare contact with orthopedics. The large, insurance companies hospitals (BGU), founded since 1890 in the large industrial centres, have an intermediate organisation. German traumatology (as in Austria and Hungarv, concentrating on emergencies. is well developed. There is little contact between orthopedic traumatologists in other European countries.

We must encourage future generations to learn not only the science and art of surgery but also to learn languages, and to break down those barriers which remain.

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Injury severity scoreBackground:

The Injury Severity Score was developed in 1974 by Baker et. al. from Abbreviated Injury Scale to evaluate motor vehicle victims with multiple injuries.

The Injury Severity Score (ISS) was used to compare the severity of injuries with an original study group of 2,128 victims, it was observed that the mortality increased with the AIS grade of the most severe injury.

The mortality increased with regular increments when plotted against the square of the AIS grade (a quadratic relationship).

When the victims with identical AIS grades for their most severe injury were compared, injuries in the second and third body regions tended to increase the risk of death. The Injury Severity Score was therefore defined as " the sum of the squares of the highest AIS grade in each of the three most severely injured areas ".

Bull (1975) found an age-dependent relationship and determined that LD50 (Lethal dose for 50% patients) was an ISS of 40 for ages 15-44, 29 for ages 45-64 and 20 for ages 65 and older.

Bergvist et al (1983) while reviewing thirty years' cases of blunt abdominal trauma found that in vehicular accident cases, ISS increased successively through the periods indicating more severe trauma. Although not significant, the frequency of severe trauma cases (ISS more than 50) increased and the frequency of mild trauma decreased (ISS less than 25).

Simplified Trauma Chart made by Lorne Greenspan, Barry A. McLellan and Helen Greig (1985) and used at Toronto General Hospital, Canada includes all the necessary information for scoring found in 36 page AIS dictionary. This chart not only facilities the scoring but also increases reliability by preventing errors in searching through the AIS dictionary. The incorporation of the LD50 reference table allows for the rapid evaluation of victim's age specific index severity.

Scores:

When ISS is below 25, the mortality risk is minimal and above 25, it is an almost linear increase.

When ISS is 50, the mortality is 50%

When above 70, it is close to 100%.

If an injury is assigned an AIS of 6 (unsurvivable injury), the ISS score is automatically assigned to 75.

Highest ISS score obtainable is 75.

For trauma patients of vehicular accidents, the scoring system is important for assessing the effectiveness of medical care in reducing morbidity and mortality.

Advantages:

virtually the only anatomical scoring system in use

correlates linearly with

mortality 1.

morbidity 2.

hospital stay 3.

other measures of severity. 4.

Weaknesses:

Any error in AIS scoring increases the ISS error


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Many different injury patterns can yield the same ISS score

Injuries to different body regions are not weighted

Not a useful triage tool, as a full description of patient injuries is not known prior to full investigation & operation

ISS Calculator: (From Trauma.org )

Injury AIS Score 1 Minor 2 Moderate 3 Serious 4 Severe 5 Critical 6 Unsurvivable

ISS Calculator

Abbreviated Injury Scale: Head Face

Chest Abdomen

Extremity External

Calculate

ISS:

Baker SP et al, "The Injury Severity Score: a method for describing patients with multiple injuries and evaluating emergency care", J Trauma 14:187-196;1974

Copes WS, Sacco WJ, Champion HR, Bain LW, "Progress in Characterising Anatomic Injury", In Proceedings of the 33rd Annual Meeting of the Association for the Advancement of Automotive Medicine, Baltimore, MA, USA 205-218


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Mangled Extremity Severity Score (MESS) http://www.orthoteers.com/(S(hpd3fo55tk2scq45w2e4vp45))/printPage...

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Printout from Orthoteers.com website, member id 1969. 2007 All rights reserved. Please refer to the sitepolicies for rules on diseminating site content.

Mangled Extremity Severity Score (MESS)Johansen et al. 1990

Skeletal / soft-tissue injury

Low energy (stab; simple fracture; pistol gunshot wound) 1

Medium energy (open or multiple fractures, dislocation) 2

High energy (high speed RTA or rifle GSW) 3

Very high energy (high speed trauma + gross contamination) 4

Limb ischaemia

Pulse reduced or absent but perfusion normal 1*

Pulseless, paraesthesias, diminished capillary refill 2*

Cool, paralysed, insensate, numb 3*

Shock

Systolic BP always > 90 mm 0

Hypotensive transiently 1

Persistent hypotension 2

Mangled Extremity Severity Score (MESS) http://www.orthoteers.com/(S(hpd3fo55tk2scq45w2e4vp45))/printPage...

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Age (years)

< 30 0

30-50 1

> 50 2

* Score doubled for ischaemia > 6 hours

Limb salvage vs. amputation. Preliminary results of the Mangled Extremity Severity Score

In both the prospective and retrospective studies, a MESS score of greater than or equal to 7 had a 100% predictable value for amputation

Objective criteria accurately predict amputation following lower extremity trauma.

Johansen K, Daines M, Howey T, Helfet D, Hansen ST Jr Department of Surgery, Harborview Medical Center, University of Washington School of Medicine, Seattle 98104.

J Trauma 1990 May;30(5):568-72; discussion 572-3

MESS (Mangled Extremity Severity Score) is a simple rating scale for lower extremity trauma, based on skeletal/soft-tissue damage, limb ischemia, shock, and age. Retrospective analysis of severe lower extremity injuries in 25 trauma victims demonstrated a significant difference between MESS values for 17 limbs ultimately salvaged (mean, 4.88 +/- 0.27) and nine requiring amputation (mean, 9.11 +/- 0.51) (p less than 0.01). A prospective trial of MESS in lower extremity injuries managed at two trauma centers again demonstrated a significant difference between MESS values of 14 salvaged (mean, 4.00 +/- 0.28) and 12 doomed (mean, 8.83 +/- 0.53) limbs (p less than 0.01). In both the retrospective survey and the prospective trial, a MESS value greater than or equal to 7 predicted amputation with 100% accuracy. MESS may be useful in selecting trauma victims whose irretrievably injured lower extremities warrant primary amputation.


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Revised Trauma ScoreThe Revised Trauma Score is a physiological scoring system, with high inter-rater reliabilityand demonstrated accurracy in predictng death. It is scored from the first set of data obtained on the patient, and consists of Glasgow Coma Scale, Systolic Blood Pressure and Respiratory Rate.

Glasgow Coma Scale(GCS)

Systolic Blood Pressure(SBP)

Respiratory Rate(RR)

Coded Value

13-15 >89 10-29 4

9-12 76-89 >29 3

6-8 50-75 6-9 2

4-5 1-49 1-5 1

3 0 0 0

RTS = 0.9368 GCS + 0.7326 SBP + 0.2908 RR

Values for the RTS are in the range 0 to 7.8408. The RTS is heavily weighted towards the Glasgow Coma Scale to compensate for major head injury without multisystem injury or major physiological changes. A threshold of RTS < 4 has been proposed to identify those patients who should be treated in a trauma centre, although this value may be somewhat low.

The RTS correlates well with the probability of survival :

RTS Calculator: (From Trauma.org)

Systolic BP:

Resp. Rate:

Coma Score:

Calculate

RTS:


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Glascow Coma Scale:

The GCS is scored between 3 and 15, 3 being the worst, and 15 the best. It is composed of three parameters : Best Eye Response, Best Verbal Response, Best Motor Response, as given below :

Best Eye Response. (4)No eye opening. 1.Eye opening to pain. 2.Eye opening to verbal command. 3.Eyes open spontaneously.4.

Best Verbal Response. (5)No verbal response 1.Incomprehensible sounds. 2.Inappropriate words. 3.Confused 4.Orientated 5.

Best Motor Response. (6)

No motor response. 1.Extension to pain. 2.Flexion to pain. 3.Withdrawal from pain. 4.Localising pain. 5.Obeys Commands. 6.

Note that the phrase 'GCS of 11' is essentially meaningless, and it is important to breakthe figure down into its components, such as E3V3M5 = GCS 11.

A Coma Score of 13 or higher correlates with a mild brain injury, 9 to 12 is a moderate injury and 8 or less a severe brain injury.

Teasdale G., Jennett B., LANCET (ii) 81-83, 1974.

Champion HR et al, "A Revision of the Trauma Score", J Trauma 29:623-629,1989Champion HR et al, "Trauma Score", Crit Care Med 9:672-676,1981

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Bibliography, Links & Recommended Reading http://www.orthoteers.com/(S(hpd3fo55tk2scq45w2e4vp45))/printPage...

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Bibliography, Links & Recommended ReadingThe following Websites & Books were used in compiling the Orthoteer Summaries: ( Bold = Essential)

Books:

Review of Orthopaedics - Mark Miller

Campbells Operative Orthopedics - Terry Canale

Principles of Orthopaedic Practice - Dee & Hurst

Apley

Orthopaedic Knowledge Updates

Websites:

South Australian Orthopaedic Registrars' Notebook

Entrez-PubMed

University of Washington Radiology Webserver

Journals:

Current Orthopaedics

The Journal of Bone and Joint Surgery

BASIC SCIENCE

Sciences Basic to Orthopaedics - Sean Hughes & Ian McCarthy; WB Saunders, 1998.


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The Developing Human - Moore & Persuad

duPont PedOrtho Education Modules Resident Education Home Page, ALFRED I. DUPONT INSTITUTE British Society for Children's Orthopaedic Surgery

McGloughlin & Mann.Surgery of the Foot and Ankle. 1999. Mosby.

Barton. The Upper Limb & Hand. 1999. Electronic Textbook of Hand Surgery eRadius - International Distal Radius Fracture Study Group Copeland. Operative Shoulder Surgery. 1995. Churchill Livingstone.


Websites:


Entrez-PubMed


Journals:



BASIC SCIENCE


The Developing Human - Moore &

Persuad

duPont PedOrtho Education Modules


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Resident Education Home Page, ALFRED I. DUPONT INSTITUTE British Society for Children's Orthopaedic Surgery




Websites:


Entrez-PubMed


Journals:



BASIC SCIENCE


The Developing Human - Moore &

Persuad



Barton. The Upper Limb & Hand. 1999.


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Electronic Textbook of Hand Surgery eRadius - International Distal Radius Fracture Study Group Copeland. Operative Shoulder Surgery. 1995. Churchill Livingstone.

Apley


Websites:


Entrez-PubMed


Journals:



BASIC SCIENCE


The Developing Human - Moore & Persuad




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Clinical governance http://www.orthoteers.com/(S(hpd3fo55tk2scq45w2e4vp45))/printPage...

1 of 1 08/10/2007 11:11


Clinical governanceCMO 's Update 22 - a communication to all doctors from the Chief Medical Officer

Clinical governance: quality in the new NHS was issued to the National Health Service (NI-IS) on 16 March 1999. It provides the detailed guidance promised in A first class service2, and builds on the responses to that consultation exercises.

The guidance provides a vision for the next five years, identifying the key features that all NHS organisations will be expected to demonstrate. It takes a developmental approach, focusing on the fundamental shift required to enable good clinical quality. The vision emphasises the need for a move to a culture of learning - an open and participative culture in which education, research and sharing of good practice thrive. It focuses in on the need for a commitment to quality - across the organisation -supported by clearly identified local resources. It reinforces the importance of multidisciplinary team-working, and the need for clear accountability to and by the NHS Trust Board. It also makes the important link to the need to work with users, carers and the public.

The guidance also makes the important links to other policies designed to modernise the NHS, in particular the need for integrated planning, having the right workforce n place, access to good information ~nd good research to support clinical lecisions.

The document recognises the need to deal with poor performance; tackling it early, and learning from experience. Clinical governance is about improving quality - not just about managing poor performance. The guidance focuses on the need to improve the quality of services of the majority, by fostering a culture that enables learning and improvement, so that quality infuses all aspects of the organisation's work.

There is however a need to identify the first steps to achieving the vision. The guidance highlights the expectations of the NHS in the coming year. These focus on establishing leadership, accountability and working arrangements, the conducting of a baseline assessment, the formulation of a development plan and finally, the reporting arrangements underpinning these steps.

Further information from: Mr Julian Brookes, Room 606 Richmond House, 79 Whitehall, London SWIA 2NS.

Copies of the guidance can be obtained from Department of Health, PG Box 410, Wetherby, LS23 7LN. Fax orders on 0990 210 266.

1.Department of Health. Clinical governance: quality in the new NHS.

London: Department of Health, 1999 (Health Circular: HSC 1999/065).

2. Department of Health. A first class service: quo/itt in the new NHS. London:

Department of Health, 1998 (Health Circular HSC 1998/113).

3. Department of Health. A first class service: quality in the new NHS. Feedback on Consultations. London. Department of Health, 1999 (Health Circular HSC 1999/033).

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