Lecture 4 - Trauma Overview 2024 PDF

Ms Kezia Brown Senior clinical lecturer Consultant orthopaedic surgeon Body in Motion MBChB Trauma overview  MBChB Body in...

Ms Kezia Brown Senior clinical lecturer Consultant orthopaedic surgeon Body in Motion MBChB Trauma overview  MBChB Body in Motion Overview Trauma Trauma is a big topic Highlights in this lecture More detail in the online vids (about 1hr 30m) Fracture healing (14m) Basic fracture care (22m) Life-threatening injuries (21m) Limb-threatening injuries (17m) A bit gory!  MBChB Body in Motion Trauma Intro to trauma  MBChB Body in Motion Content Trauma What is trauma and how does it happen Who is affected by MSK trauma MSK trauma on radiographs  MBChB Body in Motion So what is trauma? Trauma Any external force applied to the body which results in injury High amount of morbidity in working age and the elderly Loss of income, pain, prolonged bed rest etc. Leading cause of death and disability in first 4 decades of life 50% of Orthopaedics is dealing with consequences of trauma  MBChB Body in Motion Trauma Trauma  MBChB Body in Motion What causes more injuries? Trauma  MBChB Body in Motion Mechanism of injury Trauma Falls – 70 % RTA – 15% Assault – 5% Other – 10%  MBChB Body in Motion Mechanism of injury Trauma Falls < 2m – 59 % Falls > 2m – 11 % RTA – 15% Assault – 5% Other – 10%  MBChB Body in Motion Nomenclature Trauma Fracture: A disruption in bone continuity Dislocation: Complete loss of continuity of 2 bones forming a joint Subluxation: Partial loss of continuity of 2 bones forming a joint Comminution: Multiple fragments Intra-articular: Fracture extend into a joint Fracture dislocation: A dislocated joint with associated fracture Open fracture: A direct communication between the fracture and the external environment  MBChB Body in Motion What causes a fracture? Trauma 1. Injury mechanism that exceeds maximum force the bone can withstand leading to fracture NORMAL bone, ABNORMAL force  MBChB Body in Motion What causes a fracture? Trauma 2. Co-morbidity that increases risk of fracture after injury Congenital Osteogenesis imperfecta (brittle bones) Acquired Metabolic Rickets/osteomalacia Degenerative Osteoporosis Tumour Primary Secondary Haematogenous  MBChB Body in Motion What causes a fracture? Trauma 2. Co-morbidity that increases risk of fracture after injury Congenital Osteogenesis imperfecta (brittle bones) ABNORMAL bone, NORMAL force Acquired Metabolic Rickets/osteomalacia Degenerative Osteoporosis Tumour Primary Secondary Haematogenous  MBChB Body in Motion What causes a fracture? Trauma 3. Co-morbidity that increases risk of injury Visual impairment Alcohol/drug use Neuropathy Balance disorder Epilepsy NORMAL bone, ABNORMAL force, INCREASED RISK of trauma  MBChB Body in Motion Epidemiology Trauma General trend Young male Older female Bimodal distribution Peak 1 Young males High energy n/105 Assault, falls >2m, RTC Peak 2 Older females Low energy Falls osteoblasts If too much movement then no OBs Time  MBChB Body in Motion Secondary healing Trauma Repair OPC differentiation depends on mechanical environment Strain = movement at fracture site Strain More movement = chondroblasts Chondroblasts Less movement = osteoblasts 10% Soft callus stabilises fracture, Osteoblasts reducing movement -> osteoblasts If too much movement then no OBs Time  MBChB Body in Motion Secondary healing Trauma Remodelling Remodelling Begins in middle of repair Woven bone -> lamellar bone Cutting cones Wolff’s law Remodels according to stress Can take years!  MBChB Body in Motion Secondary healing Trauma Haematoma New blood vessels Remodelling External callus Internal callus Hard callus  MBChB Body in Motion Primary vs secondary healing Trauma Primary Secondary Haversian remodelling Endochondral ossification Absolute stability Relative stability Plate and screws Plaster cast Some operations (IM nail)  MBChB Body in Motion Trauma Fracture management  MBChB Body in Motion Broad goals Trauma In the least intrusive way: Prevent pain Preserve function Avoid complications Must take into account the risks/benefits to the patient  MBChB Body in Motion Broad goals Trauma The 4 ‘R’s of fracture management Resuscitate Reduce Restrict Rehabilitate  MBChB Body in Motion Non-operative management Trauma 1. Nothing 2. Simple splints for comfort 3. Devices to help control position  MBChB Body in Motion Non-operative management Trauma Advantages – Cheap – Easy to apply – Reduces risks of operation Disadvantages – Stiffness – Does not fully control fracture – (unstable types) – Pressure issues – Patient comfort  MBChB Body in Motion Operative management Trauma Advantages – Less immobilisation – Earlier rehabilitation and pain control – Possibility of anatomical reduction and fixation- prevent future disability Articular surfaces (Joints) Forearm Disadvantages – Expensive – May slow healing (periosteum/endosteum) – Risk of complications  MBChB Body in Motion Operative management Trauma  MBChB Body in Motion Features of high energy trauma Trauma Polytrauma Multiple body parts injured Soft tissue injuries Wounds Open fractures Tissue loss Other injuries (burns) Fracture patterns Complex Displaced  MBChB Body in Motion Features of high energy trauma Trauma Polytrauma Multiple body parts injured Fracture patterns Complex Displaced Soft tissue injuries Wounds Open fractures Tissue loss Other injuries (burns)  MBChB Body in Motion Features of high energy trauma Trauma Polytrauma Multiple body parts injured Fracture patterns Complex Displaced Graphic content warning! Soft tissue injuries Wounds/open fractures Tissue loss Neurovascular Other injuries (burns)  MBChB Body in Motion Trauma High energy trauma  MBChB Body in Motion The assessment map Trauma AIRWAY and C-spine control BREATHING CIRCULATION DISABILITY EXPOSURE  MBChB Body in Motion Life-threatening trauma Trauma AIRWAY OBSTRUCTION TENSION PNEUMOTHORAX OPEN PNEUMOTHROAX MASSIVE HAEMOTHORAX FLAIL CHEST CARDIAC TAMPONADE  MBChB Body in Motion Open fractures Trauma ‘Compound fracture’ historical term Direct communication between external environment (skin) and fracture Bone penetrates skin Bone can go back in! Skin penetrated from outside Prompt management is imperative Increased risk of infection (infected non-union)  MBChB Body in Motion Management - ED Trauma IV antibiotics Early as possible Cefuroxime 1.5g TDS Clindamycin (pen allergy) Gentamicin if heavy contamination Anti Tetanus No tetanus within 5yrs- give booster Splint or Cast Correct length and alignment Get the bone back in Tamponade bleeding vessels Sterile saline soaked dressing/Cover wound/Photograph  MBChB Body in Motion Management - Surgery Trauma Sequential operations Primary Wound debridement ASAP with gross contamination otherwise within 24 hours Removing all contaminants Removing all compromised or dead tissue, including bone Dead tissue = culture for bacteria Skeletal stabilisation IM nailing External fixation Secondary Tissue inspection and further debridement Wound closure  MBChB Body in Motion Tibial shaft fracture Trauma 25 y/o male High level athlete Isolated injury to left lower leg High energy!  MBChB Body in Motion Tibial shaft fracture Trauma Severe pain, increasing in severity Refractory to strong opiates Pain on passive stretching of toes Paraesthesia Pulses normal Muscles in calf feel tight  MBChB Body in Motion Compartment syndrome Trauma Devastating condition Injury Increased pressure inside a fixed fascial compartment Tissue Result in reduced tissue Swelling perfusion Cell Increased Membrane Compartment Severe muscle pain from Damage Pressure pressure and ischaemia Tissues in compartment become ischaemic, then necrotic leading to Local Hypoxia Decreased Perfusion irreversible damage Pressure  MBChB Body in Motion Compartment syndrome Trauma EMERGENCY! Needs fasciotomies ASAP Can occur anywhere there is a fascial layer Most common leg, forearm, thigh, Classic signs PAIN disproportionate to the injury PAIN on passive stretch Distal pulse does not mean no compartment syndrome