TRAUMATOLOGY Ladislav Plánka & KDCHOT [USEMAP] What is traumatology But what we need? „Science of injuries and following states which are conected to the injuries“ •Skeletal surgery – traumatology, orthopedics •Abdominal surgery (urology, gynecology) •Thoracic surgery •Neurosurgery •ENT •Ophtalmology •Resuscitation care •Intensive care •Rehabilitation care http://www.officescope.com/blog/wp-content/uploads/2013/07/Puzzle-pieces.jpg [USEMAP] An adult or a child?? Administrative border divides both of the groups in their 19th birthday. Everyone is a child until their 18th + 364 days. 20243-web-088bcf 36560-dite-ilustracni-fotografie Když se ve škole nedaří 107515-top_foto2-nsttt Biological border respects rather stadium of the development and growth. [USEMAP] Epidemiology of injuries •The most frequent reason of the doctor appoitment and hospitalization up to the age of 25 •The most frequent cause of death up to the age of 40 •Economical aspects of the injuries!!!! •Every third person in their life is hospitalized because of the injury •Each person experiences the skeleton fracture up to the age of 18 [USEMAP] Epidemiology of injuries 2017 2018 2019 Adults – hospitalized 156 789 157 987 159 700 Children – hospitalized 31 090 30 456 31 786 Adults – everyone 2 456 789 2 435 678 2 501 434 Children - everyone 492 789 501 123 500 879 2015 2016 2017 2018 2019 Injuries in all 31 866 30 214 30 200 29 423 30 706 Deaths 168 (0,53 %) 161 (0,53 %) 133 (0,44 %) 122 (0,41 %) 112 (0,36 %) [USEMAP] Epidemiology of injuries 2017 2018 2019 Adults – hospitalized 156 789 157 987 159 700 Children – hospitalized 31 090 30 456 31 786 Adults – everyone 2 456 789 2 435 678 2 501 434 Children - everyone 492 789 501 123 500 879 2015 2016 2017 2018 2019 Injuries in all 31 866 30 214 30 200 29 423 30 706 Deaths 168 (0,53 %) 161 (0,53 %) 133 (0,44 %) 122 (0,41 %) 112 (0,36 %) [USEMAP] Injury division •Polytrauma – injury of multiple body systems from which at least one is life threatening •Multiple injury – injury of multiple body systems from which none of them is life threatening •Serious monotrauma – injury of one of the body system which is life threatening •Monotrauma – injury of one of the body system without life threatening [USEMAP] Polytrauma •Lung laceration, hemothorax (ventilation threatening) •Humerus fracture on the right side •Concussion, superficial wound of frontal area ct2 Foto: ÚSZS MSK [USEMAP] Monotrauma •Clavicle fracture [USEMAP] Multiple injury •Open shin wound with muscles injury •Compressionf racture of lumbal vertebrae •Femoral fracture jh_uraz_krev_rana_0702_denik_clanek_solo [USEMAP] Serious monotrauma •Kidney rupture cetecko1 [USEMAP] Etiology of injuries D:\Lada\Nemocnice\Projekty\NF MH\nemocnice modrý hroch\plakáty\Domácí úrazy\Podíl domácího prostředí na všech hospitalizovaných úrazech dětí.jpg All injuries Mechanism of injuries according to IDB – basic groups injuries Basic groups domestic transport school sport malicious free time and the other [USEMAP] Etiology of injuries Serious injuries D:\Lada\Nemocnice\Projekty\NF MH\nemocnice modrý hroch\plakáty\Domácí úrazy\Podíl domácího prostředí na život ohrožujících úrazech dětí.jpg Mechanism of injuries according to IDB – basic groups injuries domestic transport school sport malicious free time and the other Basic groups [USEMAP] http://www.omska.cz/bojkovsm/files/chemie.jpeg 1. Falls 3. Traffic accidents Etiology of injuries po%C5%BE%C3%A1r2 1117970413 radiace 4. Burn 5. Poisoning http://img.ulekarecdn.cz/dbpic/tonuti-220.jpg 6. Drowning ….. 2. Hitting and punching [USEMAP] Trauma care system Selected score value •ISS •RTS (PTS) •GCS (MGCS) •Risk facts Triage + Triage - 4884d028f44ecfba1a530100 bigec004 nemocnice2 Záchranka přepravila 18letého pacienta na traumacentrum do pražské vinohradské nemocnice. (Ilustrační foto: Mediafaxfoto.cz) Prehospital care [USEMAP] Trauma care system Selected score value •ISS ≥ 16 •RTS (PTS) ≤ 8 •GCS (MGCS) ≤ 12 •Risk facts Prehospital care •Fall from height ³ 6 m •Hit by car in speed ³ 35 km/h •Run by vehicle •Vehicle catapult •Vehicle impaction •Burn ≥ 12 % •Penetrating neck, chest, abdomen, groin injury •Waving chest •Age < 5 let •Comorbidity [USEMAP] Trauma care system Paediatric trauma score [USEMAP] Trauma care system Glasgow coma scale with infant modification Image0003 Assessment Eyes opening Verbal response Motor responce spontanious on adressing on painful stimuli without responding Infant Child spontanious on adressing on painful stimuli without responding gurgles and babbles cranky crying cries on painful stimuli moans due to painful stimuli without responding oriented, possible confusing verbal response impossible, disorientated difficult to understand words or sounds without responding spontanious and effective movement dodges touch dodges painful touch posture decortication in reaction of pain decerebrate posture in reaction of pain without responding comply with commands targeted reaction on pain dodges painful touch flexion reaction on pain extensive reaction on pain without responding [USEMAP] Trauma care system mapacr-servis 006[1] D001F2B4-73E9-4073-9510-5BB116CBB8AE[2] obdobi-1948-1989-obr1[1] obrazky_187[1] nemocnice_Motol[2] loch_tn[1] foto[1] titulka[1] UL2[1] Trauma centers for adults [USEMAP] Trauma care system mapacr-servis D001F2B4-73E9-4073-9510-5BB116CBB8AE[2] Trauma centers for children nemocnice_Motol[2] fakultni-nemocnice-ostrava-2-t[1] loch_tn[1] foto[1] titulka[1] [USEMAP] Skeletal injury Soft tissues Organs and organ system Muscles, ligaments, joints Skin, subcutaneous tissue Injury Flat skull bones Spine injury Limb skeleton Traumatology http://www.krasobrana.cz/editor/filestore/Image/detska_plet.jpg http://www.prokarneval.cz/_data/s_3050/shop/big_havajska-podprsenka-dospely-rozmer.jpg Coagulation Circulation reserves Respiratory reserves Post-op complication Speed of healing Bones remodeling Rehabilitation http://www.lidskezdravi.cz/wp-content/uploads/2015/01/kostra-ditete-dospeleho.jpg Modified by medicaments Low due to comorbidity Mostly great High tendency Lowering Null Long Normal Great Minimal Low tendency High Very active Short [USEMAP] Skeletal injury Diagnosis •Clear signs of fracture •Shape change •Crepitus •Pathological movement •Visible bone •Unclear signs of fracture •Hematoma •Swelling •Pain •Function suppressed K:\FOTO ARCHIV\3. TRAUMATOLOGIE\Otevřené zlomeniny\Tihon 9907304022\P9062977.JPG K:\FOTO ARCHIV\3. TRAUMATOLOGIE\fractura antebrachia disloc\Dvořák 1993 1.JPG [USEMAP] Skeletal injury http://www.krasobrana.cz/editor/filestore/Image/detska_plet.jpg http://www.prokarneval.cz/_data/s_3050/shop/big_havajska-podprsenka-dospely-rozmer.jpg RTG in two projections US examinatioon CT examination Magnetic resonance imaging RTG in two projections CT examination Diagnosis [USEMAP] Skeletal injury http://www.krasobrana.cz/editor/filestore/Image/detska_plet.jpg http://www.prokarneval.cz/_data/s_3050/shop/big_havajska-podprsenka-dospely-rozmer.jpg Epiphyseal injury Separation and fracture epiphysis Intra-articular fractures http://www.wikiskripta.eu/images/thumb/4/4a/Displaced_distal_radius_fracture.jpg/300px-Displaced_di stal_radius_fracture.jpg Diagnosis [USEMAP] Skeletal injury http://www.krasobrana.cz/editor/filestore/Image/detska_plet.jpg http://www.prokarneval.cz/_data/s_3050/shop/big_havajska-podprsenka-dospely-rozmer.jpg Epiphyseal injury Separation and fracture epiphysis Avulsive fractures Intra-articular fractures http://www.wikiskripta.eu/images/thumb/4/4a/Displaced_distal_radius_fracture.jpg/300px-Displaced_di stal_radius_fracture.jpg http://telemedicina.med.muni.cz/pdm/detska-chirurgie/res/image/zlomeniny-panve-a-nohy/avulzepanev.j pg Diagnosis [USEMAP] Skeletal injury http://www.krasobrana.cz/editor/filestore/Image/detska_plet.jpg http://www.prokarneval.cz/_data/s_3050/shop/big_havajska-podprsenka-dospely-rozmer.jpg Epiphyseal injury Metaphyseal injury Separation and fracture epiphysis Avulsive fractures Torus fractures Greenstick fracture Intra-articular fractures Comminuted fractures Complete fracture http://katalog.lf3.cuni.cz/katalog/items/49-full.jpg http://www.drfoot.co.uk/pictures/CollesFracture.gif Diagnosis [USEMAP] http://vx800.wz.cz/images/Bouracka/bour01.jpg Skeletal injury http://www.krasobrana.cz/editor/filestore/Image/detska_plet.jpg http://www.prokarneval.cz/_data/s_3050/shop/big_havajska-podprsenka-dospely-rozmer.jpg Epiphyseal injury Metaphyseal injury Diaphysial fractures Separation and fracture epiphysis Avulsive fractures Torus fractures Greenstick fracture Fracture due to flexion Intra-articular fractures Comminuted fractures Complete fracture Complete fracture greenstick Diagnosis [USEMAP] Skeletal injury http://www.krasobrana.cz/editor/filestore/Image/detska_plet.jpg Healthy bone Bowing fracture Torus fracture Greenstick fracture Complete fracture [USEMAP] Skeletal injury http://www.krasobrana.cz/editor/filestore/Image/detska_plet.jpg http://www.prokarneval.cz/_data/s_3050/shop/big_havajska-podprsenka-dospely-rozmer.jpg Epiphyseal injury Metaphyseal injury Diaphysial fractures Salter – Harris classification Local specific classification AO classification AO classification Local specific classification AO classification Local specific classification AO classification http://image.slidesharecdn.com/salterharris1-101020103225-phpapp01/95/fractura-salter-harris-8-728. jpg?cb=1287571261 http://www.wikiskripta.eu/images/thumb/5/52/Neer2.png/500px-Neer2.png http://telemedicina.med.muni.cz/pdm/detska-chirurgie/res/image/diafyza-berce/berec4.jpg Classification anatomical cervix surgical neck great tuberosity minor tuberosity 2 splinters 3 splinters 4 splinters [USEMAP] Skeletal injury http://www.krasobrana.cz/editor/filestore/Image/detska_plet.jpg http://www.prokarneval.cz/_data/s_3050/shop/big_havajska-podprsenka-dospely-rozmer.jpg Frequently closed Possible Cast fixation is often enough Miniinvasive, adaptive Shorter After healing Kirschner wire FFS Kirschner wire Tractional srew Elastic nails External fixator Frequently open Necessary anatomical reposition Osteosynthesis Stabel Long-term Right after OS Reconstructive splint Tractional screws Splint systems Rigid nails External fixator Reposition Dislocation left Retention Osteosynthesis Length of healing Rehabilitation Epiphysis fractures Metaphysis fractures Diaphysis fractures Open fractures Therapy [USEMAP] Skeletal injury http://www.krasobrana.cz/editor/filestore/Image/detska_plet.jpg Fixation Traction Reposition •Cutaneous •Skeletal •Traction bandages •Temporary •Definitive •Soft bandage •Semirigid •Rigid •Braces •Critical •Manipulation in callus •Plaster cast wedging Nursing intervention [USEMAP] Skeletal injury http://www.krasobrana.cz/editor/filestore/Image/detska_plet.jpg Operative treatment Nursing intervention > MIO Nursing intervention [USEMAP] Skeletal injury http://www.krasobrana.cz/editor/filestore/Image/detska_plet.jpg http://www.prokarneval.cz/_data/s_3050/shop/big_havajska-podprsenka-dospely-rozmer.jpg Splint systems https://encrypted-tbn0.gstatic.com/images?q=tbn:ANd9GcQUBOFFViZH3wmwsA5m8ZwdzohPikk--M857K7nPWK0X0d fTIaxlQ Surgical care [USEMAP] Skeletal injury http://www.krasobrana.cz/editor/filestore/Image/detska_plet.jpg http://www.prokarneval.cz/_data/s_3050/shop/big_havajska-podprsenka-dospely-rozmer.jpg Splint systems Kirschner wire https://encrypted-tbn0.gstatic.com/images?q=tbn:ANd9GcQUBOFFViZH3wmwsA5m8ZwdzohPikk--M857K7nPWK0X0d fTIaxlQ Surgical care [USEMAP] Skeletal injury http://www.krasobrana.cz/editor/filestore/Image/detska_plet.jpg http://www.prokarneval.cz/_data/s_3050/shop/big_havajska-podprsenka-dospely-rozmer.jpg Splint systems Kirschner wire FFS https://encrypted-tbn0.gstatic.com/images?q=tbn:ANd9GcQUBOFFViZH3wmwsA5m8ZwdzohPikk--M857K7nPWK0X0d fTIaxlQ Surgical care [USEMAP] Skeletal injury http://www.krasobrana.cz/editor/filestore/Image/detska_plet.jpg http://www.prokarneval.cz/_data/s_3050/shop/big_havajska-podprsenka-dospely-rozmer.jpg Splint systems Kirschner wire FFS Compresed screws https://encrypted-tbn0.gstatic.com/images?q=tbn:ANd9GcQUBOFFViZH3wmwsA5m8ZwdzohPikk--M857K7nPWK0X0d fTIaxlQ Surgical care [USEMAP] Skeletal injury http://www.krasobrana.cz/editor/filestore/Image/detska_plet.jpg http://www.prokarneval.cz/_data/s_3050/shop/big_havajska-podprsenka-dospely-rozmer.jpg Splint systems Kirschner wire FFS Compresed screws Inter-medullary nail https://encrypted-tbn0.gstatic.com/images?q=tbn:ANd9GcQUBOFFViZH3wmwsA5m8ZwdzohPikk--M857K7nPWK0X0d fTIaxlQ Surgical care [USEMAP] Skeletal injury http://www.krasobrana.cz/editor/filestore/Image/detska_plet.jpg http://www.prokarneval.cz/_data/s_3050/shop/big_havajska-podprsenka-dospely-rozmer.jpg Splint systems Kirschner wire FFS Compresed screws Inter-medullary nail External fixation berec2 http://www.mmspektrum.com/content/image/gallery/2012-07_12_1340274342/piska_obr_01b.jpg Surgical care [USEMAP] Skeletal injury http://www.krasobrana.cz/editor/filestore/Image/detska_plet.jpg http://www.prokarneval.cz/_data/s_3050/shop/big_havajska-podprsenka-dospely-rozmer.jpg Secondary healing by callus Ability of remodeling Quick course Obrazek1 Healing by first intention Necessary anatomical reposition Stable compressive osteosynthesis http://img.mf.cz/207/675/hreb.jpg Bone healing [USEMAP] Growth plates http://www.krasobrana.cz/editor/filestore/Image/detska_plet.jpg •A place which enable growth of the bone to the length •Peripheral parts of the bones •Histologically hyaline cartilage •The weakest place of the child long bones •Growth dysfunction occures due to its injuries Question: How many cm shorter will be thigh bone after its complete destruction of its distal growth disc. We know that the heatlhy bone on the other side has grown up 20 cm since the injury and the thigh bone distal growth disc provides 70% of growing of the whole bone. 14 cm [USEMAP] Growth plate http://www.krasobrana.cz/editor/filestore/Image/detska_plet.jpg J:\A00040F01.jpg 166_Growth_Plate_JPEG.jpg [USEMAP] Growth plate http://www.krasobrana.cz/editor/filestore/Image/detska_plet.jpg •A – Spare layer •Germinal •Protein synthesis •Low division •B – Proliferative layer •Layer of dividing cells •C – Hypertrophic layer •Chondrocyte regression •Sept calcification •Line refraction spot •Layer of dividing cells •D – Calcified layer [USEMAP] Fracture complication •Blood loss •Surrounding tissues injury •Compartment syndrome •Suppressed movement •Growth arrest due to GP damage •Growth dysfunction •Shape dysfunction •Avascular necrosis •False joint •Atrophic •Hypertrophic •Synostosis •Sudeck bone dystrophia Critical Late [USEMAP] > > > > Compartment syndrome Ischemia SWELLING A-V gradient decrease Capillary flow decrease •A state when the perfusion pressure is the same as the tissue one (!↓BP!) •In etiology mainly swelling, bleeding, solid bandage •Clinical and physical diagnostics (IFP measure) •Treatment is surgical • [USEMAP] Compartment syndrome •Clinical symptoms •Resting pain (progressive) even after immobilization •More pain by passive finger strain •Sensitivity deficiency (even as paresthesia) •Functional failure (immoility) •Up to stone hardness area •Changes of child behaviour, growing disturbance •Pain does not correspond to the injury •Tugging is usually maintained!!! •Tissue pressure – over 30 Torr • CompartmentSyndrome_3c_540 - Whitesides.gif [USEMAP] Compartment syndrome •Fasciotomy of all compartments • kmpartmenty bérec.jpg [USEMAP] Flesh wound •Nerve wound •Neurapraxia – functional disorder, RHB •Neurotmesis – severance of some fibres, RHB •Axonotmesis – severance of nerves, necessary suture or replacement •Tendon wound •Dislocation – reposition, immobilization •Tear - immobilization •Rupture (exceptionally at the healthy one, more likely avulsion), severance – suture, immobilization •Muscle wound •Contusion – resting regimen •Rupture – minor range conservatively, great suture •Herniation – suture fascia •Crush – syndrome!! – total treatment, dialysis [USEMAP] Fracture complication •Blood loss •Surrounding tissues injury •Compartment syndrome •Suppressed movement •Growth arrest due to GP damage •Growth dysfunction •Shape dysfunction (malunion) •Avascular necrosis •Non union •Atrophic •Hypertrophic •Synostosis •Sudeck bone dystrophia Critical Late http://www.bjj.boneandjoint.org.uk/content/89-B/12/1615/F4/graphic-8.large.jpg [USEMAP] Fracture complication •Blood loss •Surrounding tissues injury •Compartment syndrome •Suppressed movement •Preterm extinction of physis •Growth dysfunction •Shape dysfunction •Avascular necrosis •Non union •Atrophic •Hypertrophic •Synostosis •Sudeck bone dystrophia Critical Late http://www.orthoinfo.nl/patienteninfo/heup/images_heup/avn1.jpg [USEMAP] Fracture complication •Blood loss •Surrounding tissues injury •Compartment syndrome •Suppressed movement •Preterm extinction of physis •Growth dysfunction •Shape dysfunction •Avascular necrosis •Nonunion •Atrophic •Hypertrophic •Synostosis •Sudeck bone dystrophia Critical Late http://www.tankonyvtar.hu/hu/tartalom/tamop425/2011_0001_524_Sebeszet/images/image533.png [USEMAP] Fracture complication •Blood loss •Surrounding tissues injury •Compartment syndrome •Suppressed movement •Preterm extinction of physis •Growth dysfunction •Shape dysfunction •Avascular necrosis •Non union •Atrophic •Hypertrophic •Synostosis •Sudeck bone dystrophia Critical Late http://www.bjj.boneandjoint.org.uk/content/89-B/1/109/F3/graphic-4.large.jpg [USEMAP] Thank you for your attention http://www.mirekvostry.cz/sites/default/files/field/image/2014/04/2023.jpg Your screenshot showed that you have broken cervical vertebrae but you can relax as I have already changed it in Photoshop. 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