Cyril Mauffrey and David J. Hak (eds.)Passport for the Orthopedic Boards and FRCS Examination10.1007/978-2-8178-0475-0_9

Assessment and Principles of Treatment

Natalie Casemyr¹, Cyril Mauffrey¹ and David Hak¹

(1)

Department of Orthopaedic Surgery, Denver Health Medical Center, 777 Bannock Street, Denver, 80204, CO, USA

Cyril Mauffrey

Take-Home Message

Initiate blood product transfusion in patients who fail to respond to 2 l crystalloid bolus
Massive transfusion protocol: 1:1:1 of pRBC:FFP:platelets
Employ damage control orthopedics in severely injured patients with decreased base deficits and increased serum lactate levels
Hemodynamic parameters are not sufficient end points to measure adequacy of resuscitation
Base deficit and serum lactate levels are proxies for anaerobic metabolism and more accurately indicate adequacy of resuscitation
Glasgow Coma Scale is predictive of injury severity and mortality

1 Radiologic Workup

Trauma X-ray series
- AP chest
  
  Mediastinal widening, pneumothorax
- AP pelvis
  
  Pelvic ring injury, acetabulum, proximal femur
- Lateral c-spine
  
  Must visualize C7–T1 junction
  
  Often replaced by CT c-spine
  
  Valuable in patients going emergently to OR prior to CT scan
CT scan
- C-spine, chest, abdomen, pelvis
- Increasingly used in the initial evaluation of the trauma patient
Additional X-rays
- Investigate potential injuries identified in secondary and tertiary surveys
- Failure to image an extremity is the most common cause of delayed fracture diagnosis

Recognition of the impact of early definitive surgical care on resuscitation and brain injury lead to the concept of damage control orthopedics
Subset of critically injured patients who may benefit from initial provisional stabilization to improve immediate survival with the least stress to the patient’s physiologic condition
- Minimize the second hit
- Indicated for patients whose inflammatory response will be overwhelmed by further stimuli
Stabilization of major fractures still imperative to decrease inflammatory mediators and catecholamine release, decrease analgesic requirements, and facilitate ICU care
- Acute stabilization primarily achieved with external fixation, pelvic sheets/binders, and skeletal traction
- Convert to definitive management of pelvic fractures within 7–10 days
- Convert femur fractures to intramedullary nail fixation within 3 weeks
- Convert tibia fractures to intramedullary nail fixation within 7–10 days