Orthopedic Trauma Lecture
Terms
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- what injuries are the most common in trauma?
- limb injuries are most common, but head and visceral injuries are the most fatal
- what are the leading cause of accidental deaths?
- MVA
- what are the leading cause of non-fatal injuries?
- falls
- what changes have had signigicant effect on injury pattern in MVA's?
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automobile design change; use of safety devices
airbags reduce abdominal and chest injuries, but increase ortho limb injuries - tri-modal distribution of death
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death within minutes
death in the first hour (golden hour)
death in days/weeks - initial assesment plans
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resuscitation
primary survey
detailed secondary survey
initiation of definitive care - primary survey
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A: airway maintenance with C-spine control
B: breathing and ventilation
C: circulation
D: disability (neurological status)
E: exposure (water, high/low temps) - secondary survey
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A: allergies
M: medication
P: past medical history
L: last time of food or drink
E: events and environment related to injury - stages of multiple trauma patient treatment
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I: treatment at scene--EMS
II: evaluation and resuscitation in ER
III: early treatment of chest and abdominal complications
IV: treatment of musculo injuries
V: long term rehab - MESS
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mangled extremity severity score--
energy of trauma: 4 points
shock: 2 points
limb ischemia: 3 points
age: 2 points
*primary amputation is more than 6 points - fracture immediate demands
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vascular compromise
hemorrhage - sprains vs. strains
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sprain= supporting structures of a joint
strain= stretching or partial tear of a muscle - dislocation
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joint surfaces are completely displaced and are no longer in contact
-should be reduced promptly
-shoulder is most frequent dislocation - subluxation
- lesser degree of displacement such that the articular surfaces are still partly apposed
- fracture
- disrupt in continuity of a bone
- closed fracture
- skin over and near fracture is intact
- open fracture
- skin over and near fracture is lacerated or abraded by the injury
- fractures occur because of:
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1. traumatic events
2. repetitive stress
3. abnormal weakening of bone - fracture classification and description
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1. by location on bone
2. orientation/extent of fracture line(s)
3. amt of displacement of fracture fragments
4. integrity of skin and soft tissue envelop around fracture - orient/extent of lines
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-transverse (perpendicular to shaft of bone
-oblique (angulated)
-spiral (multiplanar and complex)
-comminuted (more than two fragments)
-segmental - location
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epiphyseal- end of bone
metaphyseal-flared portion of bone at ends of shaft
diaphyseal-shaft of long bone - orientation, ctd.
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intra-articular (line crosses articular cart and enters joint)
torus (buckle)
compression (impaction; vert or proximal tibia)
greenstick (incomplete with angulation deformity)
pathologic (bone weakened by disease or tumor - amt of displacement
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nondisplaced
displaced
angulated
bayonetted (distal frag longitudinally overlaps proximal frag)
distracted (distal frag separated from proximal by gap) - diagnosis is confirmed with:
- x-rays- always get joint above and below the bone involved
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pathologic fracture
bone may be weakened by: -
tumor
osteoporosis
metabolic conditions (paget's) - secondary bone healing
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1. inflammatory phase (1-5 days)
2. reparative phase (7-40)
3. remodeling phase (>50) - delayed union
- fracture fails to consolidaate in timeusually required for union to occur
- causes of delayed union
- inaccurate reduction, inadequate or interrupted immobilization, severe local trauma, infection, loss of bone substance, distraction of fragments
- non-union
- process of bone repair ceases after having failed to produce firm union (> 6 months)
- causes of nonunion
- separation of fragments, loss of bone substance, inadequate immobilization, repeated manipulation, interposition of soft tissue, infection, impairment of circulation
- diaphyseal impaction
- from axial compression load; usually intercondylar humerus, femur, tibial plafond
- transverse
- from bending; usually long bone diaphysis
- spiral
- torsion; any long bone diaphysis; often tibia, humerus
- oblique transverse (butter-fly)
- axial compression and bending; usually femur, tibia, humerus
- oblique
- axial compression + bending + torsion; usually tibial-fibular or forearm
- fracture types
- closed, open, fatigue, pathological
- type I open fracture
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clean wound less than 1 cm, inside/out injury, simple fractures (Ski injury)
no evidence of contamination - type II
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skin laceration larger than 1 cm, some minor contusion around laceration, minimal comminution (low velocity auto accident)
-no soft tissue stripped from bone - type IIIA
- moderate soft tissue injury, adequate soft tissue coverage of fractured bone
- IIIB
- extensive soft tissue injury, periosteal stripping with significant bone exposure
- IIIC
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all of IIIB and vascular injury
*this is an amputation risk - treatment
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dress wounds, splint fractures, irrigation and debridement
*open contamination of wounds should be left open - treatment option
- internal fixation, external fixation
- complications of fractures
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venous thrombosis and pulmonary embolism- dilemma is anticoagulant versus mechanical measures only
tetanus, gas gangrene, fat embolism, infection, avascular necrosis, amputation, malunion, delayed union, non-union - compartment syndrome
- compression of nerves and blood vessels within an enclosed space, leading to impaired blood flow and nerve damage; most common in lower leg and forearm, but can also occur in hand, foot, thigh, and upper arm
- signs of compartment syndrome
- extreme pain out of proportion, pain on passive ROM of fingers/toes, pt holds injured part in position of flexion, pallor of extremity, paralysis, paresthesias (early loss of vibratory sensation), pulses