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Dr Bhaskar Borgohain
Asst Professor of Orthopaedics
NEIGRIHMS, Shillong, India
Acute cervical Spine Injury: high cervical cord injury can cause instant
respiratory paralysis due to involvement of root values of both the phrenic
nerves. Temporary Immobilization for transportation is essential,
Key to management: Resuscitation with oxygen, IV Fluids, may need a
Tracheostomy + Ventilatory support, Foley’s catheterization, Ryle’s tube to
avoid aspiration, Radiological investigations, Skeletal Traction . High dose
IV Methyl prednisolone (within 1ST 8 Hrs of injury)
Symptomatic management, avoidance of bed sores through good nursing
care, Input- output chart. Clinical diagnosis of type of neural deficits:
complete Vs incomplete cord lesion depending on return of bulbocavernosus
reflex after resolution of spinal shock, identification of type of cord
syndrome, if incomplete Decompression & definitive # fixation.
Unstable Pelvic Fracture with Hypotension: Profound shock may
occur in major pelvic fractures and more than three litres of blood may be
lost internally even without major arterial bleed.
Open fracture with major vascular injury (Grade III C #) any open fracture
with major vascular injury. If not treated promptly gangrene will develop
and amputation will become madatory to save the life particularly in lowert
limb injuries
Acute Septic Arthritis of hip joint: This may be life as well as limb
damaging/threatening in newborne infants particularly low birth weight
babies who are the usual victim.
Acute Gout
Key to management: Rest, NSAID, avoidance of allopurinol & high purin
containing foods for example red meat & spinach, may add colchicin to
prevent further attack .
Special views: better but difficult, avoided due to lack of exposure. Example of
underutilization of special view is axially lateral view in suspected shoulder
dislocation. Relatively rare posterior dislocation of shoulder is commonly missed in
the casualty department due to lack of an axially lateral view.
Radiation involved: TAKE CARE in Pregnant, children, serial X-ray examinations.
USG (ultrasosnography) is better (Plus Points are Cheap, widely available, portable)
ROLE OF ADVANCE INVESTIGATIONS IN FRACTURES
CT-Important additional information can be obtained in injuries of Spine, complex intra-articular #s,
#-Dislocations (shoulder, hip, spine), # pelvis &acetabulum, assessment of # union; especially when # was
reduced accurately with implants, consolidation of spinal fusion
MRI-It is very useful in evaluation of Spinal injury with neural deficits, acute knee injury, Shoulder injury,
epiphyseal injury in young children & diagnosis of chondral damage &AVN.
BONE SCAN –It can confirm a doubtful # line, stress #, pathological #, vascularity assessment in small
bone fragment
ULTRASOUND---- It can assess #union –callus is seen earlier than in conventional x-ray by expert
radiologists.
Interpretation of Radiograph of Spine
As said before a radiographic image is just a shadow; like the 1 ST impression, careful
close observation might change your view for better. Before any interpretation it is
important to assess the quality of the radiograph. In Cx spine it is very crucial to include
the cervico-dorsal junction to be visible in lateral view, this area is often not visualized in
emergency dept due to patient’s shoulder superimposition & serious # or dislocation is
missed. A shoulder pulled down view should be done to avoid this menace.In dorso-
lumbar & lumbar spine intestinal gas shadow may jeopardize any fruitful
interpretation .If any doubt exists bowel preparation should be done with a laxative and
charcoal tablet and a repeat x-ray taken to rule out any fracture. It is possible that the
cervico-dorsal & lumbo-sacral junctions are not adequately visualized for any
meaningful interpretation with plain X-rays; a CT scan is the logical second option if
advised by expert.
1. Alignment---scoliosis
2. Bone --------interpedicular distance, transverse processes, pedicle destruction, sup. & Inf.
Articular Processes, Cx rib if any, spina bifida, sacralization of lumbar vertebra, ribs
3. Cartilages---facet joints
4. Density --- osteopenia,porosis, sclerosis
5. Soft tissue --any Para-vertebral soft tissue shadow, ligament calcification, psoas shadow.
Any other calcified mass in abdomen e.g.—renal calculus etc
2) REDUCTION
By Traction, Counter-traction & Manipulation (save the limb integrity/stability)
BENEFITS OF TRACTION
Pain relief, correct shortening /angulation/shift/joint friction and reduce muscle spasms etc
DANGERS OF TRACTION
Skin damage, infection, nerve palsy, vascular damage, ligament damage (knee), spinal cord
damage (skull traction in unstable spine injury)
►In Open #
► # associated with major vascular injury (open grade IIIC #)
►Along with /Before Vascular Repair
►# With Poor skin & soft tissue condition / burn
►# with Infection: infected fracture or nonunion
►Large wounds especially over a joint
►# with Bone loss
►# with Compartment syndrome needing fasciotomy
►For ligamentotaxis to maintain reduction in comminuted intra-articular #
►# Femur in restless adolescent
Polytrauma: orthopaedic injury management in Polytrauma
A-B-C-D-E OF RESUSCITATION FIRST
A-----Airway Clearance
B-----Breathing
C-----Circulation
D-----Disability Assessment (Paralysis for example)
E----- Exposure (Over or Under-exposure i.e. environment/Hypothermia/ missed injuries)
A-B-C-D-E-F-G-H-I-S OF RESUSCITATION
A-----Airway Clearance
B-----Breathing
C-----Circulation
D-----Disability Assessment (Neurovascular in particular)
E----- Exposure
F----- Fracture (Look for it or else you will miss it)
G-----Go Back (Secondary survey)
H-----Help (Team involvement)
I------Investigations (trauma series)
S-----Surgery (if needed urgently)
MANAGEMENT PRINCIPLE:
Save the life, then save the limb, then save the function of the limb as a
whole.
► RESUSCITATION
► SERIAL DEBRIDEMENT:
Flaps: to know the exact blood supply is important for microvascular anastomosis. e.g.
Medial gastrocnemius: medial sural vessels
Lateral gastrocnemius: lateral sural vessels