Trauma: Initial Management & Golden Hour

• Trauma is defined as physical injury, derived from the Greek word for "a wound," indicating a transfer of kinetic energy, represented by the formula E=mv²/2.
• Fracture is defined as a break in the structural continuity of bone.
• Subluxation involves a partial loss of congruity between articular surfaces.
• Dislocation involves a total loss of congruity between articular surfaces.

Trauma and the "Golden Hour"

• The "Golden Hour" in trauma refers to the critical first hour after a severe injury.
• Rapid transport and treatment at a trauma center during this hour significantly raise the patient's survival chances.

Historical Data on Trauma Treatment Timing

• Data from a French World War I study in 1918 indicates a strong relationship between time to treatment and mortality.
• A 10% mortality rate was found when treatment occurred within one hour of injury.
• The mortality rate rose to 75% when treatment was delayed to eight hours.
• Dr. R. Adams Cowley used this data in his "Golden Hour" concept.

Trauma Evaluation and ATLS

• ATLS provides a standardized protocol for evaluating and treating trauma victims.
• ATLS stands for Advanced Trauma Life Support.
• It was developed by a Nebraska orthopedic surgeon to address the previous lack of protocol.

ATLS Steps

• ATLS prioritizes Airway management, including cervical spine immobilization.
• Breathing is next, requiring high-flow oxygen.
• Circulation is addressed.
• Disability is assessed.
• Then Exposure of the patient for full evaluation.

Primary Trauma Survey

• The primary survey focuses on a rapid assessment of the ABC's (Airway, Breathing, Circulation) to address life-threatening problems.
• Actions include establishing an airway, ensuring ventilation, inserting chest tubes, and controlling active bleeding.
• Large-bore IVs are placed and fluid replacement is initiated for patients in shock.
• Trauma X-rays of the chest, pelvis, and lateral C-spine are taken.

Secondary Trauma Survey

• The secondary survey involves assessing the entire patient for non-life-threatening injuries.
• It includes an orthopedic assessment of the skeleton, splinting fractures, reducing dislocations, and evaluating distal pulses and nerve function.
• X-rays or CT scans are obtained for affected areas once the patient is stable.

Trauma Assessment Components

• Gathering the patient's medical history to understand the injury mechanism.
• Palpation
• Note swelling, lacerations
• Assess Painful ROM
• Checking for Crepitus (a grating feeling when bone ends rub together).
• Assessing for Abnormal motion, such as the tibia bending mid-shaft.
• Check pulses, as well as sensory and motor functions.

Fracture Laceration Assessment

• Look for lacerations communicating with the fracture site.
• A closed fracture involves intact skin over the fracture.
• An open fracture has a laceration communicating with the fracture (previously known to lay persons as a compound fracture).

Emergency Skeletal Issues

• Pelvic fracture hemorrhage in patients with unstable blood pressure requires close pelvic volume.
• Open fracture hemorrhage requires direct pressure.
• Pulses are restored by realigning fractures and dislocations.

Urgent Skeletal Issues

• Open fractures need irrigation and debridement.
• Dislocations need reduction.
• Fractures need splinting.
• Compartment syndromes need evaluation.

Biomechanics of Fractures

• Bones can be fractured through Bending.
• Bones can be fractured through Axial Loading, involving Tension and Compression.
• Bones can be fractured through Torsion.

Describing a Fracture

• The Mechanism of Injury can be traumatic, pathological, or stress-related.
• Describe the Anatomical Site referencing bone and location in bone.
• Describe Fracture Geometry/Type.
• Also Displacement considering three planes of angulation, translation, shortening, and rotation.
• Determine Articular Involvement - if it involves the Joint or is a Fracture-Dislocation?
• Describe Soft Tissue Injury - is it Closed vs Open?
• Consider involvement of nerves, vessels, tendons, and tissue loss

Fracture Mechanics

• The Fracture Type Transverse may result from Tension
• The Fracture Type Oblique may result from Compression
• The Fracture Type Butterfly may result from Bending
• The Fracture Type Spiral may result from Torsion

Types of Fractures

• Normal
• Transverse
• Oblique
• Spiral
• Comminuted
• Segmental
• Avulsed
• Impacted
• Torus
• Greenstick

Reading X-rays

• State what anatomic structure is being examined and the number of views
• Understand Regional Location, such as Epiphysis, metaphysis or Diaphysis (rule of 1/3rds); assess if it is Intra/extra-articular.
• Describe the Fracture geometry/type, such as Transverse, Oblique, Spiral

Bone Condition on X-rays

• Comminution, indicated by 3+ parts.
• Segmental, indicated by a middle fragment.
• Butterfly segment.
• Check for Deformity like Angulation (varus/valgus, anterior/posterior), Translation, Rotation or Shortening/distraction

Fracture Patterns

• Transverse Fracture Pattern is produced by a distracting or tensile force.
• Spiral Fracture Pattern is Produced by a twisting/ torsional force.
• Butterfly Fracture Pattern is Produced by pure bending force.
• Comminuted Fracture Pattern is multifragmentary.
• Comminuted Fracture Pattern is associated with a High energy transfer!!

Fracture Location

• Diaphysis refers to the shaft portion of the bone.
• Metaphysis refers to the ends of the bone.
• If the fracture goes into a joint it is Intra-articular.

Goals of Fracture Treatment

• Restore patient to optimal functional state
• Prevent fracture and soft tissue complications
• Achieve fracture healing in a satisfactory position for optimal functional recovery.
• Rehabilitate as early as possible

Inflammatory/Hematoma Phase (1st)

• This lasts up to 1 week.
• This includes: Acute inflammation, hematoma formation (48-72 hours), Inflammatory cytokines, Fibroblasts - granulation tissue and Angiogenesis

Soft Callus Phase (2nd)

• This lasts 1 week - 1 month.
• The phases include: Chondroblasts + fibroblasts, Fibrous tissue + cartilage + woven bone.

Hard Callus Phase (3rd)

• This lasts 1 - 4 months.
• Ths phase includes: Soft callus resorbed and replaced by osteoid from osteoblasts. Osteoid mineralised (hydroxyapatite)
• The bone becomes: United, solid, pain free

Remodeling Phase (4th)

• This lasts up to several years
• This involves: Hard callus remodels to woven bone then lamellar bone.
• Also Osteoclasts/ osteoblasts, Medullary canal reforms and Remodels according to stresses/ loading by Wolff's Law (1892)

Factors Affecting Fracture Healing

• The Energy transfer of the injury is a factor.
• The tissue response is a factor: Two bone ends in apposition or compressed, Micro-movement or no movement, Blood supply or Infection.
• The patient is a factor.
• The method of treatment is a factor.

Diagnosing Bone Injury

• History of mechanism
• Determine If Pain Precedes Trauma, suggesting a Pathological Fracture.
• Perform a General ABCDE Examination.
• Assess with Local - the fracture, swelling, tenderness (crepitus?), abnormal posture and skin wound.
• Assess: Distal Circulation and check for vascular injury or Neurological sensory/motor deficit.
• Perform Imaging Investigations.
• Need 2 Views (AP/Lateral)
• Need 2 Joints (above and below injury)
• 2 Sides (for comparison, mainly in children).
• 2 Times (before and after treatment)

Treatment of Fractures

• Reduce the fracture.
• Maintain reduction (+ hold until union).
• Rehabilitate the patient to restore function.
• Prevent and treat complications.

Maintaining Reduction

• External method: POP (+ equivalents), traction, external fixator
• Internal method: Wires, pins, plates, nails, screws

Maintaining Reduction: External Method: POP

• POP is a plaster of paris cast
• Mould with palms
• Adv - cheap, easy to use, convenient, easily moulded
• Disadv - susceptibility to damage if wet, taking up to 48hrs to dry.

Maintaining Reduction: External Method: Resin

• Resin Cast
• Adv - lighter and stronger, sets in 5-10mins and reaches max strength in 30mins.
• Disadv - Cost, more difficult to apply/remove and more rigid with greater risk of complications eg. swelling and pressure necrosis

Maintaining Reduction: External Method: Skin Traction

• Skin Traction is a temporary measure.
• It is used when operative fixation is not available for awhile.
• Skin can be injured if applied for long periods of time

Maintaining Reduction: External Method: Skeletal

• Skeletal traction involves a more invasive procedure, and is required for longer term traction using heavier weights.
• Complications associated with pin insertion eg. infection

Maintaining Reduction: External Method: External Fixator

• Indications: Fractures associated with severe soft tissue or N/V damage, Severely comminuted and unstable fractures, Unstable pelvic fracture and Infected fractures
• Complications: Pin track infection and Delayed union

Maintaining Reduction: Internal Method

• Advantages: Shorter hospital stay, Enables individuals to return to fxn earlier and Reduces incidence of non and mal-union
• Indications: Fractures that need operative fixation, Inherently unstable fractures prone to re-displacement after reduction (eg. mid-shaft femoral fractures), Pathological fracture, Polytrauma (minimise ARDS) and Patients with nursing difficulties (paraplegics, v. elderly, multiple trauma)

Maintaining Reduction: Materials

• Stainless steel, titanium, cobalt
• Complications: Infection, Non-union, Implant failure or Re-fracture

Maintaining Reduction: Wires

• Wires can be used in conjunction with other forms of internal fixation
• Used to treat fractures of small bones

Maintaining Reduction: Pins

• Pins are usually used in pieces of bone that are too small to be fixed with screws
• Usually removed after a certain period of time, but may be left in permanently for some fractures

Maintaining Reduction: Plates

• Plates extend along the bone and screwed in place
• Plates may be left in place or removed (in selected cases) after healing is complete

Maintaining Reduction: Nails and Rods

• Nails or rods are held in place by screws until the fracture is healed
• May be left in the bone after healing is completed

Maintaining Reduction: Screws

• Screws are the most commonly used implant
• Can be used alone to hold a fracture, as well as with plates, nails or rods.
• May be designed for a specific fracture and may be left in place or removed after the bone heals

Maintaining Fracture Reduction

• Each case is judged on its own merits.
• Assess with X-ray in POP for position; out of POP to clinically assess state of healing
• Sticky - "Deformable but not displaceable"
• Union (weeks)- Incomplete repair; Part moves as one; Local tenderness; Local pain on stress; See fracture line on-x-ray
• Consolidation (months) Complete repair; No external protection needed; Upper limb 6/52; Lower limb 12/52; Half for child; Double for transverse fractures

Early Complications of Fractures

• Visceral/vascular/nerve injury, Haemarthrosis, Infection, Fat embolism and Compartment syndrome

Late Complications of Fractures

• Mal-union, Delayed union, Non-union, Tendon rupture, Myositis ossificans, Osteonecrosis, Complex regional pain syndrome and Osteoarthritis and joint stiffness