Orthopaedic Trauma & ATLS

Learning Objectives

• Orthopaedic trauma education includes understanding life-threatening emergencies by referencing Advanced Trauma Life Support (ATLS).
• It also requires recognizing limb-threatening components as defined within ATLS.
• Familiarity with typical orthopaedic trauma presentations in the emergency department is vital.

Advanced Trauma Life Support (ATLS)

• Clinical medicine addresses conditions beginning with the ATLS sequence: ABCDE (Airway, Breathing, Circulation, Disability, Exposure).
• Primary ATLS surveys may not always be obvious, but are paramount in the initial assessment.
• Secondary surveys follow, addressing issues after managing life-threatening emergencies.
• A structured approach and situational awareness are essential elements of ATLS.

Timing of Death in Trauma

• There are three intervals where trauma patients are most likely to die.
• 50% of deaths typically occur within minutes, related to major blood loss or neurological damage.
• 30% of deaths are within the first few days, due to shock, hypoxia, or neurologic injuries.
• The remaining 20% of deaths take place from days to weeks due to Multi-System Organ Failure (MSOF) or infection.

When To Call For Help

• Orthopaedic assistance is not always enough to treat fractures, and additional specialists may be required.
• Vascular surgeons, neurosurgeons, and general surgeons are examples of specialities you may need to consult with.

Patient Evaluation

• Primary survey focuses on addressing immediate life threats, such as pelvic fractures.
• Initial history is a vital part of the evaluation process.
• ABCD assessment including cervical spine control form a key part of the primary review.
• Secondary surveys include physical exams and obtaining a more comprehensive history.
• Further assessment involves imaging and specialized tests.
• Tertiary surveys involve repeat physical examinations and further imaging, reducing chances of overlooking orthopaedic injuries.

Airway and Breathing Issues

• Airway obstructions can include a foreign body in the mouth, maxillofacial or neck trauma, laryngeal trauma, tracheobronchial tree injury, or sternoclavicular joint dislocation.
• Breathing problems include tension/open pneumothorax, flail chest, pulmonary contusion, massive haemothorax, or traumatic diaphragmatic injury.

Ribs and Sternum Injury

• Seatbelt injuries are a common cause of rib and sternum trauma.
• These are often complicated by cardiac and pulmonary damage.
• Patients face risks of lower respiratory tract infections (LRTI).
• Admission for pain management and chest physiotherapy is often needed.

Assessing Circulation

• Hypovolemic shock as a result of blood loss is usually caused by one of five causes: blood on the floor, chest, abdomen, retroperitoneum, pelvis or longbones.

Blood Loss

• Major arterial haemorrhage leading to blood on the floor is usually diagnosed immediately.
• Rapid hypovolemic shock may occur as a result of blood loss, particularly in children.

Pelvic Trauma

• Pelvic fractures vary in severity.
• Pelvic fractures can result in iliac vessel injury, hip joint involvement, and may or may not need surgical intervention.
• Pelvic fracture in crushing injuries indicate an unstable pelvis that is expected in high energy trauma.
• Pelvic x-rays are required for acutely injured patients showing signs of cardiovascular instability.
• Major force is demonstrated by fractures and ligamentous disruption
• Damage is caused by car accidents with pedestrians, motor vehicle/motorbike accidents, or falls.
• There is a high association of injuries to intraperitoneal/retroperitoneal viscera and vascular structures.

Sources of Blood Loss

• Unstable patients with hemorrhagic shock have a higher likelyhood of having one of four blood loss locations.
• Fractured pelvic rings are a common source of blood loss.
• Pelvic venous plexus are another blood loss source.
• Pelvic arterial injury can result in blood loss.
• Extra pelvic sources can be linked to thoracic aorta tears which is common with pelvic fractures, or intra-abdominal sources which must be assessed and treated.

How Injuries Occur

• Patterns of force when the body is injured are AP compression at 60-70%, lateral compression 15-20%, vertical shear 5-15%, or complex patterns

Patient Assessment

• Check the flank, scrotum and perianal areas immediately.
• Check for blood at the urethral meatus as well as lacerations in the perineum, vagina, rectum or buttock for open pelvic fractures.
• Avoid testing for mechanical instability.
• Look for leg length discrepancy and rotational deformity which are the first sign of mechanical instability.

Management

• ABC priorities are essential for trauma.
• Mechanical stabilization can be achieved by using a pelvic binder (or a bed sheet) to internally rotate the hip and reduce pelvic volume.
• Angiography and surgery with ORIF or external fixation may be required.

Pelvic Binders

• It is essential to know if X-rays were taken before or after binder placement.

Severe Hypovolaemia

• All bleeding must be stopped.
• Angiographic embolization may be performed.
• Pelvic packing may also be necessary.

Angiographic Embolization

• Angiography is the process of taking xrays of blood vessels to identify possible sites of bleeds
• Embolization is a very targeted treatment
• Procedure is minimally/non-invasive
• Procedure has documented effectiveness if performed within 3 hours upon admission

Angiographic Embolization Shortcomings

• Much of the bleeding may not be arterial, only 20% of bleeds are arterial.
• Time consuming, can take between 60 and 100 minutes.
• The IR suite will need to be fully furnished equivalent to a resuscitation bay/ICU.
• If proximal, infection may occur after the procedure if further pelvic surgery is required
• The procedure may not be universally avaliable.

Treatment

• External fixation delivers a stable pelvis to pack against.
• It may be a temporary or definitive therapy.
• Easy to apply and can be performed at the bedside.

Managing Pelvic Injuries

• The skin around the area being worked on should be prepped
• An incision should be made
• A frame design on how to plan the repair.
• Reduce injured area, where two assistants may be needed to reduce it to greater Troch.
• The frame is tightened.
• Do not reduce using pins

Summary

• Actions include stabilizing the clot, stopping the bleed through Packing, Angio, Ex-Fix, 'Antishock', SI screw or C-clamp.
• Be aware of pelvic binders
• If dealing with open fractures, debride, pack, and divert.

Clinical Case Example

• A patient who had a fracture and soft tissue damage 2 years prior had fully healed and was walking unaided.

Complications: Crush Syndrome

• For those who suffer crush injuries, renal function and creatinine kinase should be checked.
• This is a concern for those with longer periods of entrapment.
• Intensive Care Unit (ICU) supervision and consultation with a renal physician is needed, because rhabdomyolysis might cause acute kidney failure

Complications: Compartment Syndrome

• Compartment Syndrome is characterised by increased tissue pressure.
• High tissue pressure is located within a myofascial section which exceeds capillary pressure, with compromised tissue function and perfusion.
• Muscle and nerve damage can occur as a result.
• The lower leg is the most commonly affected area.
• Compartment Syndrome can occur in the arm, forearm, hand, thigh, foot, or gluteal area..
• Fractures, crush injury, contusions, gunshot wounds, burns or when IV fluids leak is the etiology.
• Absolute pressure value is >40mm Hg

Causes of Compartment Syndrome

• Contents such as blood, fracture or soft tissue can be a cause, as well as ischaemic muscle.
• External Compression can also contribute.

Signs of Compartment Syndrome

• Disproportionate, generalized pain in the limb.
• Distal joints hurt during passive movement.
• Tense on palpation but not a sensitive sign.
• Pulse is absent and can be a late sign of the syndrome.
• Paraesthesia or loss of sensation are late signs.

Management of Compartment Syndrome

• Seek help early if Compartment Syndrome is suspected
• Remove or open the cast or dressing and re-examine.
• Measure intra-compartment pressure.
• Check CPK (Creatine Phosphokinase) level
• Perform decompressive fasciotomy.

Open Fractures & Joint Injuries

• Communication exists between the environment and bone.
• Muscles and skin become injured and bacterial contamination ensues.
• Likely issues include infection, poor healing, and function.

Initial Management

• Suspect an open fracture if there is a corresponding wound in the same limb segment.
• Paramedic documentation is very important.
• If well documented, avoid further inspection.
• Only inspect the segment under sterile conditions if the wound is not well docmented.
• Do not probe the site.
• Open wounds and joint proximity, assume the wound breaches joint
• Consultation with a surgeon is urgent -/+surgical exploration

Ongoing Management

• Make a diagnosis quickly.
• Immobilize the fracture and document the wound information.
• Check for neurovascular involvment.
• Consult with a surgeon.
• Schedule a surgical debridement and stabilization after antibiotic and tetanus prophylaxis.

Traumatic Amputation

• A traumatic amputation is a severe form of open fracture, leading to loss of an extremity.
• Tourniquets can be useful.
• Extremities can be considered for Amputation due to prolonged ischaemia, neurological injury, and potential muscle damage.
• Prioritize life over limb.

Considerations for Reimplantation

• Consider whether reimplantation is possible.
• These are clean, sharp amputations which is often the fingers or below the knee or elbow is the limb.
• Intensive resuscitation or emergency surgery patients may not be candidates for reimplantation.

Action With Amputated Part

• Rinse with ringers lactate.
• Soak in aqueous penicillin.
• Wrap in a moist sterile towel.
• Seal in a plastic bag.
• Place in a cooling chest with crushed ice.
• Transport to a replantation centre with the patient with the amputated part.
• Ensure that it does not freeze.

Hip Dislocation

• Hips should be reduced as fast as possible, and particularly in younger demographics.
• In this case it is a native hip.
• Can occur after THR (Total Hip Replacement)

Fractures and Injuries of other Limbs

• Hip, Shoulder, Elbow, Wrist & Hand and Ankle fractures plus other injuries are covered in their own dedicated lecture.