Trauma



Trauma


Greg Osgood



POLYTRAUMA



  • Cause of death



    • 50% central nervous system (CNS), most occur in the field


    • 30% CNS within days


    • 20% infection and multisystem organ failure


  • Injury Severity Score (ISS)



    • Sum of square of highest three Abbreviated Injury Scale scores for patient (Table 5.1)


    • ISS > 15 is polytrauma


    • Correlated with mortality and length of stay


  • Glasgow Coma Scale (GCS)





    • Intubate if GCS is less than 8.


  • Shock



    • Blood loss



      • Systolic pressure decreases after loss of 30% blood volume (class III blood loss) from 1500 to 2000 mL.


      • Tachycardia occurs with class III blood loss.


      • Most common cause of shock in trauma patients is hypovolemic shock.


    • Lactate



      • Patient is in shock if serum lactate is more than 2.5.


      • Elevated lactate correlates with mortality.


    • Compensated shock: normal BP, urine output, improved with resuscitation by other measures, but lactate more than 2.5


  • FAST (focused assessment with sonography in trauma) examination



    • Accurate for intraperitoneal fluid, pericardial fluid, right upper quadrant, left upper quadrant, and pelvis








      Table 5.1 Abbreviated Injury Scale



























      Score


      Description


      0


      None


      1


      Minor


      2


      Moderate


      3


      Serious


      4


      Severe


      5


      Critical


      6


      Maximal, possibly fatal









      Table 5.2 Glasgow Coma Scale





































      Parameter


      Score


      6


      5


      4


      3


      2


      1


      Eye opening




      Spontaneous


      To voice


      To pain


      None


      Verbal response



      Oriented


      Confused


      Inappropriate


      Incomprehensible


      None


      Motor response


      Obeys command


      Localizes pain


      Withdraws from pain


      Flexion to pain


      Extension to pain


      None




    • Unreliable for retroperitoneal injury


    • May not detect retroperitoneal hemorrhage


  • Borderline patients: ISS > 40, ISS > 20 with thoracic trauma, hypothermia, large pulmonary contusion, bilateral femoral fractures, moderate or severe traumatic brain injury


  • Damage control—external fixation is stabilization of fractures, and limited incision and drainage (I&D)/wound stabilization to assist in early resuscitation for borderline patients



    • Polytrauma patients have high physiologic inflammatory response 2 to 5 days following trauma.


    • Nonessential operations should be avoided during this time to prevent “second hit” phenomenon, causing adult respiratory distress syndrome (ARDS) or multiple system organ failure.


  • Early total care



    • Immediate long-bone surgery in the setting of polytrauma


    • Fewer intensive care unit (ICU) days


    • Less ARDS for femur fracture patients in polytrauma


  • Elevated IL-6 predicts acute lung injury: decrease pulmonary complications and ICU days


OPEN FRACTURE



  • Gustilo and Anderson classification



    • Type I—minimal periosteal stripping; less than 1-cm wound


    • Type II—moderate periosteal stripping; >1cm wound


    • Type III—first generation cephalosporin



      • Type IIIa—significant periosteal stripping; wound closes at time of debridement


      • Type IIIb—significant periosteal stripping; wound does not close and requires free soft-tissue transfer


      • Type IIIc—significant soft-tissue wound with a vascular injury that requires repair


  • Infection and nonunion increase with Gustilo grade.


  • Antibiotics based on Gustilo and Anderson classification



    • All open wounds warrant tetanus prophylaxis.


    • Type I—first-generation cephalosporin


    • Type II—first-generation cephalosporin


    • Type III—first-generation cephalosporin



      • Addition of Zosyn is controversial.


      • Addition of percutaneous nephrostomy for gram-negative exposure and soil contamination


    • Timing of antibiotics less than 1 hour after injury is greatest predictor of lack of infection.


  • Timing of surgery



    • There is no absolute rule on when an open fracture must go to the operating room (OR) for I&D.


    • Consensus is that all open fractures should be irrigated and, more importantly, debrided within 24 hours.


    • Grossly contaminated open fractures should be brought to the OR urgently, taking into account the patient’s overall condition.


  • Best irrigation fluid is low pressure, high volume.



    • High pressure irrigation is associated with deep penetration of contamination.


    • No additive value of antibiotics or Castile soap in irrigant fluid


    • Amputated part treatment: rinse, moist gauze, plastic bag over ice


BALLISTIC FRACTURE



  • High velocity (>2000 ft/s) versus low velocity (<2000 ft/s)


  • Implication for injury pattern




    • Low-velocity gunshot wound (GSW) open fractures can be treated with local wound care, I&D in the ED, and closed treatment principles.


    • High-velocity GSW open fractures should be debrided in the OR with possible second-look surgery to assess progression of normal-appearing tissue to death over 1 to 3 days.


  • Nerve injury/neuropraxia in the setting of GSW is usually caused by traction/concussive injury and should be observed.


COMPARTMENT SYNDROME



  • Definition—high pressure inside closed tissue space leads to tissue necrosis (tissue pressure falls below critical level for perfusion)


  • Diagnosis—pain out of proportion, pain on passive stretch of the compartment


  • Measurement—in unreliable, anesthetized, and intoxicated patients, patients with distracting injuries and children


  • Timing of intervention



    • Compartment syndrome is a surgical emergency.


    • Operative intervention should be performed prior to 6 hours of warm ischemia time to prevent nerve and muscle death.


  • Stryker monitoring



    • ΔP = diastolic pressuremeasured pressure


    • ΔP < 30 mm Hg means the patient has compartment syndrome.


    • ΔP more than diastolic pressure means the patient has compartment syndrome.


  • Intervention



    • Leg—two incisions, four-compartment fasciotomy



      • Look for superficial peroneal nerve overlying lateral and anterior compartments in distal lateral incision


      • Incomplete deep posterior compartment release is the most common incompletely released compartment.


    • Thigh—two incisions, three-compartment syndrome


    • Forearm



      • Three compartments—volar, dorsal, and mobile wad


      • Volar incision—release volar compartment and carpal tunnel


PELVIS AND ACETABULUM FRACTURE


Pelvic Fracture



  • Anatomy



    • Ligaments



      • Pelvic floor ligaments



        • Sacrospinous


        • Sacrotuberous


      • Posterior sacroiliac (SI) ligaments are the strongest.


    • Corona mortis: vascular anastomosis between obturator and external iliac/femoral/inferior epigastric systems (most frequently venous)


    • Nerves



      • L5 nerve root lies on ala of S1 sacrum


      • Most common (88%) course of sciatic nerve is anterior to piriformis muscle and posterior to obturator internus muscle.


      • Most common variant (11%) is split piriformis and split nerve.


    • Radiographic anatomy (Figure 5.1)



      • L5 nerve root on anterior sacrum axial image


      • Lateral view of sacrum shows safe zone for iliosacral screws, avoiding L5 nerve root and S1, 2 nerve roots.


      • Obturator outlet shows teardrop for low anterior external fixation frame.







        Figure 5.1 Anteroposterior pelvis radiographs showing the six cardinal lines (and their corresponding structures) as dashed lines on the uninjured (A) and fractured (B) sides of the pelvis. Red = ilioischial line (posterior column), dark blue = iliopectineal line (anterior column), purple = anterior rim (anterior wall), orange = posterior rim (posterior wall), green = roof (dome of acetabulum), and circle = teardrop (cotyloid fossa, section of quadrilateral surface and outer wall of obturator canal). From Ahn J, Reilly M, Lorich D, Helfet D. Acetabular fractures: acute evaluation. In: Schmidt A, Teague D, eds. Orthopaedic Knowledge Update: Trauma 4. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2010:312.


  • Radiographs



    • Anteroposterior (AP, Figure 5.2)


    • Inlet: detects rotational displacement and AP displacement


    • Outlet: detects cephalocaudal displacement


  • Early management



    • Binder



      • Appropriate for pelvic fracture with other sources of bleeding that require surgery


      • Any pelvic fracture with shock should have binder applied.


      • Potential volume into which pelvic ring can bleed is proportional to fourth power of radius of true pelvis.


    • Pelvic fracture in binder, still hypotensive and refractory to fluid and blood: definitive intervention is warranted



      • Laparotomy


      • Angiogram and embolization






        Figure 5.2 Screening pelvic anteroposterior plain radiographs demonstrate an unstable pelvic ring injury. A, The symphysis pubis and left sacroiliac joint are completely disrupted. Manual traction was applied to the left lower extremity and a circumferential pelvic sheet was placed around the patient and clamped. B, The reduction has been achieved. The injury sites mostly are concealed by the reduction. From Rout ML Jr. Pelvic fractures and acute management. In: Ricci WM, Ostrum RF, eds. Orthopaedic Knowledge Update: Trauma 5. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2016:375-390.




        • Posterior arterial bleed is usually superior gluteal artery.


        • Anterior arterial bleed is usually obturator or pudendal artery.


    • Retrograde urethrogram required for:



      • Blood at urethral meatus


      • High-riding prostate on rectal examination


      • Any clinical suspicion of genitourinary injury with pelvic fracture


  • Interventions



    • Anterior fixation



      • External fixation



        • Iliac crest pins


        • Anterior inferior iliac spine (AIIS) pins (Hannover frame)


      • Open reduction and internal fixation (ORIF): symphysial plate


      • Anterior percutaneous screws: superior ramus screws


    • Posterior fixation



      • Iliosacral screws



        • Transiliac screws stronger


        • Two screws improve rotational stability


      • Posterior ORIF



        • Posterior transiliac fixation


        • Wound complications in 33% to 50%


  • Fracture patterns (Figure 5.3)



    • Lateral compression (LC)



      • LC1



        • Most common pelvic fracture pattern


        • Almost always nonoperative






          Figure 5.3 Classification of acetabular fractures according to Letournel. A, Posterior wall fracture. B, Posterior column fracture. C, Anterior wall fracture. D, Anterior column fracture. E, Transverse fracture. F, Associated posterior column and posterior wall fracture. G, Associated transverse and posterior wall fracture. H, T-shaped fracture. I, Associated anterior wall or column and posterior hemitransverse fracture. J, Both-column fracture. From Dickson KF. Fractures of the acetabulum. In: Brinker MR, ed. Review of Orthopaedic Trauma. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2013:224-243.



        • Weight bearing as tolerated (WBAT)


        • “BAD LC1” fractures: comminution through entire sacral fracture dissociating central sacrum from lateral iliac segment; posterior and anterior fixation indicated


      • LC2



        • Crescent fracture posteriorly


        • Closed treatment (rarely for undisplaced fractures) or anterior and posterior fixation


      • LC3



        • Windswept pelvis


        • Anterior and posterior fixation


        • Associated head injury and abdominal injury is common.


    • Anterior posterior compression (APC)



      • APC1



        • Nonoperative


        • Less than 2.5-cm anterior symphysis displacement


      • APC2



        • More than 2.5-cm anterior symphysis widening; anterior SI ligaments are torn but posterior SI ligaments are intact


        • Anterior ± posterior fixation


      • APC3



        • Posterior SI ligamentous disruption; posterior displacement seen on outlet; may have associated vertical displacement


        • Anterior and posterior fixation


    • Vertical shear



      • Rotationally and vertically unstable


      • Vertical displacement preset and best seen on outlet view


      • Anterior and posterior internal fixation


    • Combined mechanism of injury: anterior and posterior internal fixation


Acetabulum Fracture



  • Anatomy: dome of acetabulum is equivalent to cephalad 10 mm of acetabulum


  • Radiographs



    • AP view



      • Six acetabular lines



        • Ilioischial line


        • Iliopectineal line


        • Sourcils (eyebrow) = acetabular dome


        • Posterior wall line


        • Anterior wall line


        • Teardrop


      • Roof arc angle of less than 45° (on AP view) means fracture is in dome of acetabulum.


    • Obturator oblique



      • Anterior column


      • Posterior wall


      • Best view for spur sign


    • Iliac oblique



      • Posterior column


      • Anterior wall


  • Interventions



    • ORIF



      • Ilioinguinal approach


      • Stoppa approach


      • Posterior Kocher-Langenbeck approach



      • Extended iliofemoral and extensile T approaches are associated with significant wound healing and infection complications.


    • Percutaneous fixation



      • Indicated when reduction requirements for the individual patient can be achieved percutaneously, given risks of open operative intervention versus potential benefits of this long-duration surgery


      • May be adequate to achieve stabilization of acetabulum fractures to allow earlier mobilization than nonoperative treatment


  • Fracture patterns

Dec 19, 2019 | Posted by in ORTHOPEDIC | Comments Off on Trauma
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