อ.นพ.ชัช สุมนานนท์
ภาควิชาออร์โธปิดิกส์ คณะแพทยศาสตร์ มหาวิทยาลัยขอนแก่น

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สามารถล าดับความส าคัญของภาวะฉุกเฉินในผู ้ป่วยที่มี
ภาวะบาดเจ็บทางออร์โธปิดิกส์ และภาวะบาดเจ็บร่วม
อื่นได ้
สามารถบอกแนวทางการรักษาเบื้องต ้น และสามารถ
ปฏิบัติตามแนวทางปฏิบัติได ้อย่างเหมาะสม
สามารถอธิบายลักษณะของการบาดเจ็บที่พบบ่อย และ
ที่ส าคัญของผู ้ป่วยที่มีภาวะบาดเจ็บเฉพาะทางออร์โธปิ
ดิกส์

 Musculoskeletal injury: very common in major trauma
 Incidence of significant orthopaedic injury in severe injured patient is 78%
 Permanent disability after major trauma from musculoskeletal or CNS injury

 Orthopaedic injury occurs as part of:
 Multiple orthopaedic injuries only
 Multisystem trauma, with multiple orthopaedic injuries
 Multisystem injury with minor (not lifethreatening) orthopaedic injury

 Orthopaedic haemorrhage control ( “ C ” part of primary survey)
 Secondary survey
 Injury recognition: high energy limb injuries
 Timing of surgery
 Orthopaedic intervention

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Ischaemia correction
Wound care
Long bone stabilization
Other fractures
Reaming for femoral shaft fracture – reaming and pulmonary failure
Principle of external fixation
Compartment syndrome
Limb salvage versus amputation

 Address and control sources of catastrophic haemorrhage
 Direct pressure controls (most peripheral bleeding)
 Broken bones bleed
 Femur 1000 cm3
 Tibia 750 cm3
 Plevic fracture 2000 cm3

 Splinting reduces blood loss (pre-hospital)
 Continued hypotension is unlikely in isolated long bone fracture
 Look elsewhere
 Pelvic bleeding kills
 Unstable pelvic fractures need to be stabilized quickly
20-25% of all major trauma deaths have a pelvic fracture

Orthopaedic injuries usually identified during the secondary survey
 History: mechanism of injury
 Detailed history
 Patterns of orthopaedic injury exists
 Falls from height: calcaneal fractures, tibial fractures and spinal fractures
 Examination
 Major long bone fractures usually obvious
 Limb deformed/short
 Up to 10% of lesser fracture may be missed (use
Tertiary Survey)
All fractures are important to the patient

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Assess major joints for active and passive ROM and stability
Careful palpate long bones for
 pain, crepitus, and abnormal movement
Look carefully for open fractures
 Orthopaedic emergency ( must not be missed )
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May only be a puncture wound
Bleed – local pressure
 Cover loosely by appropriate sterile dressing
 OR (debridement) within 6 h
 Broad spectrum antibiotic
 Tetanus toxoid/immunoglubulin

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Don’t forget to logroll : assess for all spine
 Splint the injury site
 Reduces pain and further damage to local structure
 Reduces blood loss
 Splint the joint above and below the fracture site
 Check distal neurological status and circulation before and after applying splint
 Femoral fractures are placed in a traction splint
(Thomas), other limb fractures use plaster of Paris

 Radiological imaging
 Low threshold for obtaining radiographs of area of concern
 Radiographs need to be repeated (if poor quality) Do not forgotten about it
 Appropriate timing of assessment
 Specialized imaging
 CT, MRI

high energy limb injuries
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The surgical fracture and soft tissue management is complex – the prognosis and outcome is corresponding worse
History
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Any road traffic accident
Fall from a height
General or localized crushing
Missile wounds
Contamination
History of entrapment in any period
History of limb ischemia

high energy limb injuries
 Examination
 Large or multiple wounds
 Imprints or contamination
 Crush or burst wounds
 Skin degloving
 Ipsilateral fracture
 Evidence of associated compartment syndrome, vascular injuries, and nerve injuries

high energy limb injuries
 Plain radiography
 Segmental fracture
 Highly comminutes fractures
 Wide displacement of bone fragments
 Evidence of air in the soft tissues

 An injury results in an inflammatory reaction which is promote healing and repair, but if prolonged or exaggerated leading to systemic inflammatory response syndrome , acute respiratory distress syndrome (ARDS)
 Aim: to control inflammatory response and restore normal physiology and homeostasis
ASAP

 Reducing the overall inflammatory response
 Remove necrotic/devitalized tissue by debridement/fasciotomy
 Reduce blood loss and pain by splinting/stabilizing fractures
 Reduce ischemia by joint relocation/fasciotomy/stabilizing fracture
 Inflammatory response increases in: excessive surgery – blood loss/hypothermia

 Life-saving condition should taken first
 Stable/suitable condition  limb salvage procedures
 Communication and coordination with other specialty
 The initial goal is patient survival
(life  limb  function)

 Physiologic assessment at each stage
 Danger signs
 Hypoxia
 Hypothermia
 Abnormal clotting
 Acidosis
 Increase intracranial pressure

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Ischaemia correction
Wound care
Long bone stabilization
Other fractures
Reaming for femoral shaft fracture – reaming and pulmonary failure
Principle of external fixation
Compartment syndrome
Limb salvage versus amputation

 Identify and correct the source of haemorrhagic shock
 Reduce dislocated joints
 Splint limbs in anatomical position
 Stabilized fractures if associated vascular repair is required
 Fasciotomy for compartment syndrome
 Avoid hypothermia

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Open fracture need to be debrided and stabilized within
6 h
Tourniquet (not necessary)
Remove contaminants
Excise necrotic or devitalized tissue and skin margins
Copious irrigation
 Minimum 6 liter saline
 Pressurized and pulsatile lavage
Viability of muscle: “ 4 C ” – colour, contractility, consistency, capacity to bleed
After debridement “Do not close wound primarily”

 Close joint capsule
 Cover bone end by viable soft tissue
 Re-inspect the wound within 48 h
 Definite wound closure should be within 5 days of injury
 Antibiotic until definite wound closure is controversial

 Fracture stabilization after wound care
 Choice depends on:
 Fracture configuratrion
 Fracture grade
 Extent of soft tissue damage/contamination
 Surgical experience
Gustilo and Anderson open fracture classification

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Femoral shaft fractures and pelvic stabilization should within 24 h
 Reduce overall patient morbidity and mortality
 Excellent pain control
 Avoids traction and associated difficulty sitting and moving
Femoral shaft fractures are the next priority after pelvic stabilization
 Closed IM nailing – treatment of choice
 Temporary EF

 Femoral neck fracture and talar neck fracture are the next priority ( risk of avascular necrosis )
 Followed by:
 Metaphyseal distal femoral fracture
 Proximal and distal metaphyseal tibial fractures
 Ankle fractures
 Foot fractures
 Wrist/elbow fractures

 Factors
 Patient’s general condition
 Requirement for specialized imaging
 Soft tissue swelling (foot and ankle fractures may be delay for 2 weeks)
 Ipsilateral limb (upper and lower extremities)
 Surgical and nursing expertise
 Implant avialability
 Fatigue of theatre staff

 Reamed femoral intramedullary nail should be avoid in blunt chest trauma patient (ARDS)

 Suitable for many different injury patterns
 Provisional stabilization
 Quick and easy
 Bloodless
 Easily adjustable
 Bridged fracture (complex articular fracture)
 Alternative to IM nailing
 Convert to IM nail within 2 weeks

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Results in fibrosis and nerve damage
Most common: lower leg, forearm, foot and in patient with major trauma
Easy to miss if: patient being resuscitated, paralysed or intoxicated
Signs:
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Pain-more than expected
Pain-unrelieved by immobilization
Never assume pain is from the bone
Pain on passive stretching of the affected compartment
A tense, swollen limb
Pulselessness, pallor, paresthesia and paralysis are late signs after damage has occured

 Normal compartment pressure is 0 mmHg
 Isolated compartment pressure > 40 mmHg
 Differential pressure (DBP) < 30 mmHg
 Treatment
 Fasciotomy
 Release all dressings and splints down to the skin
Compartment syndrome can occur in open fracture

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Difficult to decision
Need to discuss options with patient
Photographic evidence useful
MESS score: for decision making but not absolute
Factors involved decision making:
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Extent of bony injury
Nerve supply (esp. posterior tibial nerve)
Crush injuries
Physiologic reserve
Smoking
Economic, psychological and social factors
Mass casualty situation

 Multiple trauma: head, thoraco-abdominal injuries, long bone fracture and open joint injury
 Crushed limb / blast injury / high fall
 Traumatic amputation of limb or part of limb
 Fx pelvis, severe, unstable with bleeding
 Fx-dislocation long bone with vascular complication
 Open (compound) Fx / joint injury
 Gunfire / shotgun / high velocity missile injury

 Fx-dislocation / spinal cord / brachial plexus injury
 Fx-dislocation of major bone and joint
 Compartment syndrome / ischemic limb
 Ligamentous injury (rupture) of knee / ankle
 Ruptured muscle / tendon
 Bone and joint infection, hematogenous
 Acute bursitis / tendinitis

1.
2.
3.
High (upper) cervical spine injury
Severe fracture of pelvis with unstable and massive bleeding
Multiple crushed limb and trunk injury

Pelvis
Femur
100-4,000 cc
400-2,700 cc
Tibia 250-1,800 cc
Humerus 200 – 800 cc

 Glasgow coma scale (GCS)
 Musculoskeletal abbreviated injury score
(AIS)  ISS
 Revised trauma score
 Trauma injury severity score (TRISS)

Glasgow Coma Scale (GCS)
Parameter
Eye opening
Spontaneous
To voice
To pain
None
Verbal response
Oriented
Confused
Inappropriate words
Incomprehensible sounds
None
Motor response
Obeys command
Localized pain
Withdraws to pain
Flexible to pain
Extension to pain
None
5
4
3
2
1
6
5
4
3
2
1
Score
4
3
2
1

Musculoskeletal Abbreviated Injury Score (AIS)
Injury Score
Contusions / sprains
Interphalangeal dislocation
Digital fracture
Hip dislocation
Closed humerus fracture
Clavicle fracture
Open humeral fracture
Crushed elbow or shoulder
Femoral fracture
Open tibial fracture
Above knee amputation
Severe pelvic fracture with blood loss
< 20% by volume
Severe pelvic fracture with blood loss
> 20% by volume
Unsurvivable
3
3
3
3
4
4
2
2
2
1
1
1
5
6

Revised Trauma Score (RTS)
Result
1-49
0
GCS
13-15
9-12
6-8
4-5
3
Respiratory rate (breaths/min)
10-29
>29
6-9
1-5
0
Systolic blood pressure (mm/Hg)
>89
76-89
50-75
Score
4
2
1
0
4
3
2
1
0
4
3
2
1
0

TRISS score  to predict the probability of survival

 Resuscitation / treatment protocol based on ATLS guidelines

Resuscitation/Treatment Protocol Based on ATLS Guidelines
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1. Primary survey and resuscitation (patient stabilization)
A Airway and cervical spine
B Breathing and oxygenation
C Circulation and hemorrhage
D Dysfunction of the CNS
E Exposure and environmental
2. Consider transfer to more appropriate hospital if indicated
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3. Secondary survey
A Allergies
M Medicines
P Previous medical history/pregnancy
L Last meal
E Events leading to trauma
4. Definitive care
Early total care
Damage control surgery
5. Tertiary survey
Missed injuries

1. The important initial steps are to check that the airway is clear and maintained .
2. Breathing and oxygenation are maintained by examining for and treating a blocked airway, pneumothorax, tension pneumothorax, hemothorax, flail chest, or pericardial tamponade

3. Control hemorrhage and maintain circulation bilateral femoral fractures and pelvic fracture
Associated with significant occult blood loss
4. Fluid resuscitation (2 large-bore venous cannulas)
5. Immediate cross match

6. A thorough examination of the abdomen , pelvis, and limb  looking for signs of abdominal and pelvic bleeding, pelvic instability, and hemorrhage and limb damage, particularly open fractures

7. Complete CNS examination  patient’s responsiveness and GCS including neurological examination of the limb
8. Radiographical examination of the chest and pelvis (head, neck and spine if clinically required)

9. Adequate stabilization
10. Secondary survey and appropriate investigation
11. Management plan for definitive treatment  life-threatening injuries should be treated first
12. Tertiary survey within 24 hours

1.
Recognition
2
. Recussitation if required
3
. Respective system evaluation
4
. Respective system treatment
5
. Retention (retainment) I : temporary splinting, wound coverage, etc.
6
. Reduction
7
. Retention (retainment) II : definitive immobilization
8
. Rehabilitation
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. Reconstruction

Resuscitation/Treatment Protocol Based on ATLS
Guidelines
1. Primary survey and resuscitation (patient stabilization)
A Airway and cervical spine
B Breathing and oxygenation
C Circulation and hemorrhage
D Dysfunction of the CNS
E Exposure and environmental
2. Consider transfer to more appropriate hospital if indicated
3. Secondary survey
A Allergies
M Medicines
P Previous medical history/pregnancy
L Last meal
E Events leading to trauma
4. Definitive care (Fracture treatment)
Early total care
Damage control surgery
5. Tertiary survey
Missed injuries

 Early femoral fracture fixation was associated with decreased pulmonary complications and reduced hospital stay
 Long bones are more benefited

 Early reamed femoral nailing or external fixation followed by secondary nailing
 The second one is associated with less blood loss, shorter operating times and lower incidence of multiple organ failure
(MOF) and ARDS

Parameters Associated with Adverse
Outcome in Multiple Injured Patient
1. Unstable condition or difficult resuscitation
2. Coagulopathy (platelet count < 90,000)
3. Hypothermia (<32 c)
4. Shock and > 25 units of blood replacement
5. Bilateral lung contusions on initial radiographs
6. Multiple long bones plus truncal injury AIS > 2
7. Probable operating time > 6 hr
8. Arterial injury and hemodynamic instability (BP< 90)
9. Exaggerated inflammatory response (IL-6 > 800 pg/ml)

Conditions in Which Damage Control
Surgery Should Be Considered
1. Polytrauma + ISS > 20 and thoracic trauma (AIS >2)
2. Polytrauma with severe abdominal/pelvic trauma and hemodynamic shock (BP <90 mm Hg)
3. ISS > 40
4. Bilateral lung contusions
5. Initial mean pulmonary arterial pressure > 24 mmHg
6. Pulmonary artery pressure increase >6 mmHg during long bone intramedullary nailing

 Facial bone fracture
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Base of skull fracture
C spine injury
:
C1 fracture, C1-2 subluxation/dislocation, C 2 dens fracture
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 Posterior dislocation of shoulder glenohumeral joint
 Scaphoid fracture, lunate / peri-lunate dislocation

 Radial head fracture
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Pelvic fracture: body of sacrum
Seat
belt fracture: T
/
L compression
 Fracture and dislocation of the hip with femoral shaft fracture
 Ligamentous injuries of the knee
 Fracture tibial platea
 Fracture talus

Some important factors
 Golden period
8 hr
12 hr. potentially infected
 Environment / atmosphere
ไต้ฝุ่น / สงคราม / ตกน ้า
 Types: Gustilo - I, II, III A,B,C
 Foreign body in wound
 Associated injury

Type Definition
I
II
Open fracture with a clean wound < 1 cm in length
Open fracture with a laceration of > 1 cm long and without extensive soft tissue damage, flaps, or avulsions

Type Definition
III Either an open fracture with extensive soft-tissue laceration , damage , or loss ; an open segmental fracture ; or a traumatic amputation .
Also: High-velocity gunshot injuries
Farm injuries
Open fracture requiring vascular repair
Open fracture older than 8 hr

Type Definition
IIIa Adequate periosteal cover of a fractured bone despite extensive soft tissue laceration or damage
High-energy trauma irrespective of size of wound
IIIb Extensive soft-tissue loss with significant periosteal stripping and bone damage
Usually associated with massive contamination
IIIc Association with arterial injury requiring repair , irrespective of degree of soft-tissue injury

Outline of treatment in emergency unit
1
. Temporary dressing
2. Splinting
3
. Initial c/s (+ anarobic)
4.
Stop bleeding
5.
Check associated injuries
6
. X-Ray, etc.
7
. Prophylactic Antibiotics
8
. Tetanus Toxoid, Antitoxin