TRAUMA SGD
Block 5AGabatino, Gauiran, Go, Gomez, Gonzales E, Gonzales L, Granada
General Data
OR 54/M RC Sta Ana, Manila Right handed c/c injuries secondary to vehicular crash
History of Present Illness
DOI: 12/14/09 (3 days post injury) TOI: 6pm POI: Carmona complex, Makati MOI: VC jeep vs tricycle (side of the tricycle
and front of jeep)
History of Present Illness
Brought to Ospital ng Makati, wounds dressed, X ray done, ATS, TeANA given, THOC to PGH secondary to lack of funds
Review of Systems
(-) loss of consciousness (-) fever (-) nausea (-) vomiting (-) dizziness (-) cough and colds (-) chest pain (-) abdominal pain (-) bowel changes (+) polyuria, polydipsia, polyphagia (+) numbness of bilateral peripheral extramities ( glove and
stocking distribution)
Past Medical History
(-) Diabetes (-) Hypertension but had episodes of
hypertension since 2 years ago, highest Bpof 160/80 usual BP of 150/80
(+) hospitalization due to head injury (2008) (-) PTB, BA (-) food and drug allergies
Family Medical History
No known medical illness in the family
Personal Social History
Smoker >30 pack year Heavy alcoholic beverage drinker 1-2 bottles
of 500ml redhorse daily since 25 years old Denies illicit drug use Denies promiscuity Works as a tricycle driver
Physical Examination at the ER
Awake, coherent, NICRD, ambulatory Vital Signs: BP 150/90, HR 82, RR 20, T
afebrile HEENT: AS, PC, pupils 3 mm EBRTL, (-)
CLAD/TPC/NVE/ANM Chest/Lungs: ECE, Clear Breath Sounds, (-)
crackles/wheezes
Physical Examination at the ER
Heart: AP, DHS, NRRR, (-) murmurs Abdomen: soft, flabby abdomen, NABS, (-)
tenderness, (-) masses/organomegaly Extremities (both upper extremities and left
lower extremity): Pink nail beds, Full and equal pulses, (-) cyanosis, (-) clubbing, (-) gross deformities
Physical Examination: Left LE
Grossly deformed thigh (distal 1/3 of the thigh slightly angulated medially)
(+) swelling, tenderness, warmth, redness over distal thigh and knee
Intact sensation over (L) thigh, leg and foot Able to wiggle toes and dorsi/plantar flex ankle Intact and full popliteal, dorsalis pedis and post tibial
pulses, pink nailbeds, (-) cyanosis 1.5x 1.5 cm wound over the anterior distal thigh with no
bone protrusion and adequate tissue coverage, no gross contamination with debris
RADIOGRAPHS
Assessment at the ER
Fx: Open complete comminuted distal third femur (L) secondary to VC
Plan at the ER
Therapeutics:- Cefazolin 1g IV LD then 1g q8- Gentamycin 240mg IV OD- Long leg posterior splint
Surgical Plan:- Debridement - Skeletal traction
Course in the Wards/ER
Seen at the ER 12/17/2009 (3 days post injury) 12/19/09 – debridement of anterior thigh wound,
arthrotomy of the L knee joint and skeletal traction inserted on proximal tibia – 15kg
12/26/09 – diagnosed with hypertension stage II fairly controlled with HHD , DM type II newly diagnosed with nephropathy, neuropathy, t/c retinopathy, T/c Alcoholic liver disease
12/29/09 – scheduled for OR, deferred due to lack of funds for IM nail
Present Physical Examination
18th hospital day, 21 days post injury
Awake, coherent, NICRD, ambulatory Vital Signs: BP , HR , RR , T afebrile HEENT: AS, PC, pupils 3 mm EBRTL, (-)
CLAD/TPC/NVE/ANM Chest/Lungs: ECE, Clear Breath Sounds, (-)
crackles/wheezes
Present Physical Examination
Heart: AP, DHS, NRRR, (-) murmurs Abdomen: soft, flabby abdomen, NABS, (-)
tenderness, (-) masses/organomegaly Extremities (both upper extremities and left
lower extremity): Pink nail beds, Full and equal pulses, (-) cyanosis, (-) clubbing, (-) gross deformities
Present Physical Examination
Left lower extremity on skeletal traction inserted in the proximal tibia
(-) erythema, warmth, discharge, swelling, pain around pintracts.
(+) surgical incision over the anterior knee and thigh, good healing, no discharge, no redness, no necrotic tissue at incision site
(+) warmth over the periphery of the (L) knee, (+) mild swelling, (+) mild erythema
Intact popliteal, dorsalis pedis and post tibial pulses Intact sensation on thigh, leg, toes and feet
OPEN FRACTURES
OPEN FRACTURES
Osseous disruption in which a break in the skin and underlying soft tissue communicates directly with the fracture and its hematoma
Any wound occurring on the same limb segment as a fracture must be suspected to be a consequence of an open fracture until proven otherwise
CONSEQUENCES of OPEN FRACTURES
Contamination of the wound and fracture by exposure to the external environment
Crushing, stripping, and devascularization that results in soft tissue compromise and increased susceptibility to infection
Destruction or loss of the soft tissue envelope may affect the method of fracture immobilization, compromise the contribution of the overlying soft tissues to fracture healing and result in loss of function from muscle, tendon, nerve, vascular, ligament, or skin damage.
MECHANISM of INJURY
Results from application of violent force which is dissipated by soft tissues and osseous structures
The applied force is directly proportional to resulting osseous displacement, comminution and degree of soft tissue injury
CLINICAL EVALUATION of PATIENTS with OPEN FRACTURES
ABCDE Resuscitation and attention to life-threatening
injuries Evaluate injuries to head, chest, abdomen, pelvis,
spine and all extremities Assess neurovascular status of affected limbs Assess skin and soft tissue involvement
Removal of obvious foreign bodies Irrigation with pNSS
Radiographic evaluation
GUSTILO and ANDERSON Classification of OPEN FRACTURES
Type Wound Level of Contamination
Soft Tissue Injury Bone Injury
I < 1 cm long Clean Minimal Simple, minimal
comminution
II > 1 cm long Moderate Moderate, some muscle
damageModerate communition
III
A
Usually > 10 cm long
High
Severe with crushingUsually comminuted, soft tissue coverage of bone possible
BVery severe loss of coverage, usually requires reconstructive surgery Bone coverage poor,
may be moderate to severe comminution
CVery severe loss of coverage plus vascular injury requiring repair, may require soft tissue injury
FACTORS which MODIFY CLASSIFICATION
Contamination Exposure to soil, water, fecal matter, oral flora Gross contamination on PE Delay in treatment > 12 hrs
Signs of high-energy mechanism Segmental fracture Bone loss Compartment syndrome Crush mechanism Extensive degloving of SQ fat and skin Requires flap coverage
GENERAL MANAGEMENT PRINCIPLES
Perform a careful clinical and radiographic evaluation
Wound hemorrhage should be addressed with direct pressure rather than limb tourniquets or blind clamping
Initiate parenteral antibiosis Assess skin and soft tissue damage; place a saline-
soaked sterile dressing on the wound
GENERAL MANAGEMENT PRINCIPLES
Perform provisional reduction of fracture and place a splint
Operative intervention: open fractures constitute orthopaedic emergencies, because intervention less than 8 hours after injury has been reported to result in a lower incidence of wound infection and osteomyelitis
Do not irrigate, debride, or probe the wound in the emergency room if immediate operative intervention is planned
Bone fragments should not be removed in the emergency room, no matter how seemingly nonviable they may be
EMPIRIC ANTIBIOTICS
Gustilo I: Cefazolin 1 g IV q8h Gustilo II: Cefazolin 1 g IV q8h Gustilo III: Cefazolin 1 g IV q8h +
Aminoglycoside 3-5 mg/kg/day Organic contamination: Penicillin 2,000,000
units q4h or Metronidazole 500 mg q6h
TETANUS PROPHYLAXIS
Incomplete (<3 doses) or unknown: (+) dT, (+/-) TIG
Complete and > 10 years since last dose: (+) dT, (-) TIG
Complete and < 10 years since last dose: (-) dT, (-) TIG
OPERATIVE TREATMENT
Irrigation and debridement Removal of foreign bodies Fracture stabilization Soft tissue coverage and bone grafting Limb salvage
FRACTURE STABILIZATION
EXTERNAL FIXATION
Severe contamination: any site Periarticular fractures
Definitive ▪ Distal radius ▪ Elbow dislocation ▪ Selected other sites
Temporizing ▪ Knee ▪ Ankle ▪ Elbow ▪ Wrist ▪ Pelvis
Distraction osteogenesis In combination with screw fixation for
severe soft tissue injury
INTERNAL FIXATION
Periarticular fractures Distal/proximal tibia Distal/proximal femur Distal/proximal humerus Proximal ulnar radius Selected distal radius/ulna Acetabulum/pelvis
Diaphyseal fractures Femur Tibia Humerus Radius/ulna