23.07.

2010

Leading causes of injury death by manner of death in the USA

Initial management of the acutely injured patients.
1995. Data from Fingerhut & Warner 1997.5
Priorities.
a) the patient may have more than one injury;
b) the obvious injury is not necessarily the most important one.

Categories of injury:
1. Exigent. These are the most life-threatening conditions,
requiring instantaneous intervention (complete airway
GENERAL TRAUMA obstruction).
2. Emergency. Those conditions requiring immediate intervention
over a period of few minutes.
3 Urgent.
3. U Th
Those conditions
di i requiring
i i iintervention
i within
i hi the
h fi
first
hour.
4. Deferrable. Those conditions that may or may not immediately
apparent but will subsequently require treatment (urethral
disruption).

Steps in initial resuscitation (ABC). Chin-lift maneuver. The tips of the fingers are placed beneath the
patient's chin and the jaw is lifted anteriorly while the mouth is Endotracheal intubation is required at patients with severe
Airway opened by drawing down on the lower lip with the thumb of the head injury, profound shock.
same hand.
- removal of debris and the "chin lift" or "jaw thrust"
maneuvers (p(pull the tongue
g forward)) to clean the airwayy of less
severely injured patients.

Jaw-thrust maneuver. Two hands are placed on the mandibular rami

and pushed anteriorly, so opening the airway.

1
 23.07.2010

Cervical spine injury is always a possibility (ovoid movement of the neck). Before
intubation the spine should be stabilized until an injury has been excluded.
Endotracheal and nasotracheal intubation Consider spine injury

Potential spinal injuries. The patient is completely immobilized on a long

backboard. A rigid cervical collar and paracervical rolls are placed to protect the
cervical spine.

Surgical airway
In some situations a surgical airway may be required. Surgical cricothyroidotomy
may be preceded by needle cricothyroidotomy with jet insufflation to improve Cricothyroidotomy is a preferable emergency procedure.
oxygenation. Technique for tracheostomy.

Technique for cricothyroidotomy. Side view demonstrates that the cricothyroid

membrane is more superficial than the trachea which makes performance of a
cricothyroidotomy technically easier than a tracheostomy.

2
 23.07.2010

Breathing (ventilation) Assisted ventilation may be done using Ambu bag or with a  Most common reasons for ineffective ventilation after intubation
help of mechanical ventilator. malposition of endotracheal tube, pneumothorax, and hemothorax
(palpation, auscultation, X-ray to exclude).
 In some circumstances (tension pneumothorax) decompression of
 If there is a decreased the chest by needle catheter placement is appropriate prior to the
respiratory drive or an g p
radiograph.
unstable chest wall, an
assisted ventilation is
necessary.

Circulation (perfusion) С - циркуляция Neurologic assessment

 When possible control of the bleeding precedes placement of the i.v. lines.  Остановка кровотечения (компрессионная повязка, жгут, и др.) A brief examination is done to determine a) level of consciousness (GCS), b)
(compressive dressing, tourniquet, or placement of pneumatic antishock pupillary condition c) movement of extremities (paralysis).
garment (pelvic injuries) may be required. Minimum two i.v. lines should be
placed percutaneously, or with venous cut-down, or internal jugular Eye opening: Best verbal response
(subclavian) vein cannulation. Fluid resuscitation begins with a 1000 ml bolus of 1 point - never 1ppoint - no response
p
LR. Response to therapy is monitored by skin perfusion, UO, or CVP. 2 points - to pain 2 points - incomprehensible sounds
3 points - to verbal stimuli 3 points - inappropriate words
4 points - spontaneously 4 points - disoriented and converses
5 points - oriented and converses

Best motor response:  Total score = 3 - 15;

1 point - no response Less than 10 points a patient
2 points - extension (decerebral rigidity) is serious injury.
3 points - flexion abnormal (decortical rigidity)  15 points - clear consciousness;
4 points - flexion withdrawal  13-14 points - stupor;
 9-12 points - sopor;
5 points - localized pain
 4-8 points - coma;
6 points - obey
 3 points - death;
Newly placed central venous catheter via the subclavian access route.

3
 23.07.2010

Exposure to complete examination

a priority plane should be established for
Reexamine the patient subsequent treatment.
completely but expeditiously
Examination is done in a (diagnosing other injuries).
Examination is done in a head-
head-toe
head toe manner toe manner, obtaining
b i i and d
collecting data from laboratory
and radiologic tests. This time
is also for placement of
additional lines, catheters (NG,
Foley, etc.) and monitoring
devices.
 When the patient is
oxygenating, ventilating, and
perfusing adequately a priority
plane should be established for
subsequent treatment. Lateral radiograph demonstrating
an L1 burst fracture (arrow).

TYPES OF TRAUMATIC INJURIES The origin is unclear (overexertion, hereditary

 Ganglion? Ganglia are cystic, round, usually nontender or painful predisposition). It grows from a joint and filled with
swellings located along tendon sheaths or joint capsules. The synovial fluid like a shell
dorsum of the hand and wrist is a frequent site of involvement.
Flexion of the wrist makes ganglia more prominent; extension
tends to obscure them. Ganglia may also develop elsewhere on the
hands, wrists, ankles, and feet.

4
 23.07.2010

Ganglion cyst Treatment Treatment is only indicated if ganglion

Diagnosis is clinical, but X
X--ray is always necessary
is only indicated if ganglion causes severe pain or causes severe pain or limits activity

limits activity
 Massage (recurrence)

 Aspiration (recurrence)

 Surgical removal of all the

cyst by orthopedist

Bursitis. Swelling and inflammation of the olecranon (or any other)
bursa may result from trauma. The swelling is superficial to the
olecranon process. Bony landmarks of the joint may be attenuated
due to fluid. Also bursitis may affect any other joints.
Contusion of soft tissues is characterized by pain, edema, and
bruising as a result of laceration of small vessels of the skin and
subcutaneous tissue. Trauma to underlying structures must be
presumed requiring further investigation.
Sprain. Some fibres are torn but the whole ligament is mechanically
intact. Pain is provoked by movements in the joint, localized
tenderness. Bone percussion is painless. Local swelling and bruising
are common.
Treatment: first 24-48 hours – ice or chemical cold pack, elevation,
elastic bandage, after two days heat may be used, NSAID, no weight
bearing, removable splint or light cast, progressive active exercises
after healing

Bivalved cast.
The two halves are rejoined

5

Ligament rapture. The ligament is broken in two. Clinical picture
is the same but accompanied by joint's instability found during
local examination.
Medical therapy is the same, immobilization is necessary. Suture
is done only at some types of rapture (arthroscopic suture of the
cruciate ligament of the knee)
Local swelling and bruising. The gap is visible or palpable. Loss
of active movements may not be obvious if other muscles take
Tendon rapture.
over the function of the tendon.
Rapture of the tendon of the long head of the left biceps muscle.
When the muscle contracts the long head bunches near the
elbow.
23.07.2010
Tendon and muscle rapture. Retraction of ends (muscle contraction).
Because of the gap the healing does not occur leading to impaired
function. The active movements are lost, passive movements may be
painful. Localized tenderness.
Rapture of the insertion of the quadriceps muscle into the patella
Treatment: suturing followed by immobilization with external
splintage for 3-6 weeks. Medical treatment is the same.
Velpeau’s bandage can be used.
6
 23.07.2010

Dislocation and sublaxation

Clicking sound when the dislocation has occurred. Pain and
tenderness, edema and bruising, hemarthrosis, loss of normal
joint shape. The joint area looks like hollow. The extremity may
be shortened and loses its normal axis. The extremity may be
shortened and loses
its normal axis

Subcoracoid dislocation of the left shoulder

Treatment of dislocation
Closed joint reduction.
Commonly reduction is done under i.v. sedation. Local anesthesia (if
used) is done into joint’s cavity (20 ml 1% lidocaine). Always assess
dislocation of the neurovascular status.
ankle

dislocation of the
right shoulder

Ankle dislocation. Assistant helps to stabilize the leg. The foot is

twisted toward the side to which the tallus is dislocated.

7

Closed joint reduction.
Shoulder joint dislocation. Matson’s method is shown using two wrapped
sheets. Traction and contratraction are applied over a period of several minutes,
which should reduce the dislocation with a click. After reduction a shoulder
immobilizer is necessary at position of internal rotation and adduction.
X-ray confirms reduction.
Kocher’s method of reduction of dislocated hip. An assistant stands
on the side and steadies the pelvis. Traction is applied in the line of
the femur. Reduction is achieved with a clunk and is confirmed by
radiology.
23.07.2010
The arm hangs free off the table with appropriate weights (approximately
5kg) attached at the wrist (Stimson’s method). Usually it takes 20-30
minutes to achieve reduction. Dzhanelidze’s method uses force produced
Motais (left) and Kocher’s methods of shoulder reduction
by doctor’s weight.
Closed reduction of a radial head. The physician holds the Immobilization after reduction of dislocation
patient’ injured hand in a hand-shake position. Positioning used to immobilize a body part
 Ankle/foot: 90 0 angle between foot and leg. Neutral
eversion/inversion
 Knee: 15-200 flexion
 Shoulder: resting at the side of the body
 Elbow: 900 angle between forearm and arm. Neutral
pronation/suppination
 Wrist: Neutral pronation/suppination, 20-300 wrist
extension
 above Thumb in 450 abduction,
Thumb: wrist position as above. abduction
300 flexion
 Metacarpals, MCP joint, proximal phalanges: wrist position
as above, MCP joint in 900 flexion, DIP and PIP joints in a
full extension
 IP joints middle/distal phalanx: full extension at IP joints.
8
 23.07.2010

Immobilization after reduction of dislocation

Splint padding is done to entire area to be splinted. Evenly, circular fashion, at Commercial sling. The elbow is fixed at 900 angle. With the
least two layers with extra over bony prominences. Posterior elbow splint (above) and sugar tong forearm splint (below) are used for
forearm and wrist injuries. Note: the splint reaches the level of MCP joints
arm resting across the chest the wrist is elevated higher when
Fiberglass (prefabricated splints can be measured and cut)/plaster (10-15 layers): the elbow with the thumb pointing upward.
generally immobilize one joint above and one joint below injury.
The splint is applied to the soft roll (after water deepening). Hold the bandage in
desired position until splint hardens (5-10min with fiberglass, 10-15 min with
plaster)
l )

Ulnar gutter splint is used for 4th -5th metacarpal or phalanx injuries
Thumb spica splint Long leg splint is used for knee and tibia injuries (it consists
(above). Radial gutter splint is used for 2nd -3rd metacarpal or fingers
injuries (below). of two splints for additional stability)

9
 23.07.2010

Ankle splint is used at isolated ankle injuries (it consists of two Complications of casts: burns, cast sores, joint contracture Fracture is a structural break in the normal continuity of the bone.
Complications of dislocation: ischemia (vascular compression), neurologic,
splints). infectious, joint stiffness, instability, recurrent dislocation.

Mechanism of tubular
bone fracture:
- direct force and indirect
force

Mechanism of cancellous
bone fracture:
- compression and traction
injuries (avulsion).

Range-of-motion exercises for the affected Compression of

joint after period of healing and immobilization the popliteal artery

Fracture healing (union) Clinical signs

A) Formation of hematoma; B) after 1 week osteoblasts start to form as the clot
retracts; C) after 3 weeks a procallus begins to form and stabilize the fracture; D)
from 6 to 12 weeks a callus forms with bone cells; E) in 3 to 4 months osteoclasts
begin to remodel the fracture site; F) with normal apposition the bone will be
completely remodeled in 12 months.
 Relative signs: local tenderness, swelling and bruising, deviation Fracture of extremity. Peripheral blood circulation and nervous
of extremity's axis, disturbance of function of extremity. function must be examined (physical examination or using
additional tools).
 Absolute signs (pathognomonic) to fractures: exposure of the bone
fragments or obvious protrusion of bone fragments under the
intact skin, pathologic mobility, bone crepitation, and radiologic
signs
i n off th
the fr
fracture.
t r

10
 23.07.2010

Obvious
deformity of Obvious deformity of the limb
the limb

Radiologic confirmation of fracture is absolutely necessary. It is

done at two planes (AP and lateral view).

Pelvic disruption (arrow).

Unstable burst fracture of L1 (arrow)
(result of a motor vehicle accident).

11
 23.07.2010

Description according to fracture line Description according to displacement of bone fragments Treatment of fractures

General management

 ABC approach
 Correction of blood loss and shock (pelvic fracture may
lead to approximately 2 L blood loss)
 Pain: splintage and analgesics
 Coexisting injuries are treated according to priority plane
 Tetanus toxoid and AB (for open fractures)

Splintage is done at the scene of injury (to reduce pain and

additional trauma due to displacement of bone fragments)

Buck’s traction may be used for hip

fractures until surgery is performed.

12
 23.07.2010

Treatment of open fracture

Local management Possible methods of fracture treatment The aim of surgery is to convert open fracture to closed one. Tetanus toxoid
and AB are considered.
 protection alone Wound irrigation. An open fracture of the tibia at initial operation.
 immobilize with external splint without reduction Dissection and excision of tissue as well as lavage with copious quantities of
Scheme for fracture management  closed reduction (manipulation or traction) followed by
fluid (by a jet lavage system). Surgery is finished by closure of the wound.
 Define
D fi ffracture immobilization with external splint or traction;
 Detect complications  open reduction and external fixation;
 Does the fracture need reduction?  excision of fractured fragment and prosthetic replacement
 Is the fracture stable or unstable?
 How can the fracture be stabilized?
 Does the fracture need immobilization and for how long?
 How can the patient best be rehabilitated?

Distal superficial femoral artery traumatized at the site of a fracture of the distal
Fracture reduction using:
third of the femur. Blood supply is restored parallel to open reduction of fracture
Gravity reduction U-slab Closed manipulations
Restoration of bone integrity (methods of fracture reduction) with collar and cuff sling.

 Gravity methods: collar and cuff, “hanging cast”

 Closed manipulations
 Traction (fixed or sliding)
 Operation

13
 23.07.2010

Fracture reduction using skeletal and skin traction (fixed or sliding) Stabilisation of fractures using Plaster cast
Methods of stabilisation of fractures (immobilization of the fracture)

 External splint: a) plaster of Paris or plastic cast; b) external fixation;

 Internal splint
p ((screws,, p
plate,, nail))
 Continuous traction a) “hanging cast”; b) fixed or sliding traction (skin or
skeletal)

The principal elements of sliding Russel traction, a form of skin traction, may Volkmann’s contracture following
traction: traction and countertraction A split plaster of Paris cast.
be used for fractures of the hip and femur. fracture of the humerus.

Stabilisation of fractures using external fixation Stabilisation of fractures using internal splints At elderly patients a surgery should be considered over closed stabilization
especially sustained to fracture of the femoral neck.
External fixator applied to a severe lower limb injury, which was associated with Extracapsular fracture of neck of femur fixed by internal fixation with a
Intramedullary nail. The nail stabilizes Lumbar fracture-dislocation treated by sliding compression screw and six-hole plate
extensive soft tissue damage with blistering and skin loss. The fixator provided
a femoral fracture and both proximal posterior spinal instrumentation and
early stability and allowed for care of the soft tissues.
and distal locking help maintain fusion from L2 to L5.
length,
g , rotation and alignment.
g

14
 23.07.2010

General rules of bone healing (duration of immobilization)

Causes of delayed and nonunion of fractures
Stabilization of fracture using  Fracture of low limb heals twice longer
continuous traction
 Compound fractures  Fracture in adults heals twice longer
 Severe initial injury  Transverse heals longer then spiral and oblique
 Foreign body  C
Compound d andd comminuted
i d are particularly
i l l slow
l to unite
i
 Soft tissue interposition
 No fracture unites in less then 3 weeks
 Distraction
 Infection
 Poor blood supply Surgical treatment with open reduction of bone fragments is
 Inadequate immobilization indicated at the following situations:
 Pathological
g fracture
 Osteoporosis  Compound fractures
 Nutritional disorders (malnutrition, vit. D deficit)  Reduction of fracture (failure of other types of reduction)
 Metabolic disorders (uremia, hyperparathyroidism)
 Stabilisation of fracture (failure of other types of reduction)
 Drugs (steroids, cytotoxic drugs)
 Management of complications (vascular or head injury)
 Soft tissue management

Complications of fractures Pathology of the crash-syndrome

Local (nerve, arterial injury followed by acute arterial ischemia, acute
compartment syndrome (edema of muscle compartments).
Early: skin necrosis, gas gangrene, infection, DVT, embolism;
Late: joint stiffness, osteomyelitis, pseudoarthrosis, deformed union.
Crash-syndrome is a condition caused by prolonged compression
and crashing of soft tissues (mainly muscles) resulting in
characteristic local and general pathologic changes in the body
developing during and after release of compression
compression → acute arterial ischemia (compression of arteries, pain is followed
by angiospasm, hypovolemia)
release of compression → reperfusion injury (edema of muscle compartments,
compartment syndrome, and ischemic muscle necrosis)
→ resorption of toxins from necrotic tissues → endotoxicosis → multiple organ
failure

Most common complication of the syndrome are:

- MODS (ARF and AHF) and purulent septic complications

15
 23.07.2010

Clinical picture At the early period it is very difficult to determine how much tissues are
General: early period – signs of traumatic shock with characteristic hemodinamic Second period is characterized by signs of ARF and poliorganic failure with devitelized. So an extend of surgery is difficult to measure.
changes. characteristic clinical and laboratory picture with progress of fluid-electrolyte
Local: Initially the skin is warm, PS on arteries is present. Further an edema disorders and intoxication. Treatment
increases, skin necroses appear, and signs of compartment syndrome develop Local changes are less important and characterized by edema and local septic - elastic bandaging (to decrease postischemic edema)
(acute arterial ischemia) complications. - cooling and splinting of the extremity
Late period is accompanied by necrosis and sequestration of dead muscles, - aggressive antishock and detoxication therapy
purulent complications,
p p , muscle and jjoint contractures - treatment of ARF,
ARF anemia,
anemia hypoproteinemia,
h poproteinemia etc.
etc

 Early surgery is indicated at case of steadily progressing edema and development of

life-threatening ARF
 Without aforementioned indications a surgical procedure is done only after
demarcation of necrotized tissues.
Early surgery – fasciotomy, is done to decompress compartment pressure
A postoperative wound is managed according to common
rules of untidy wound care preventing cumulation of necrotic
tissues, etc.
external fixation is useful if a patient has coexisting fracture.

Formely used subcutaneous fasciotomy Open fasciotomy with or without

is currently less popular necrectomy is a method of choice

16