General Traumatology 1st Dpt. Of Surgery University Hospital of St. Anne, Masaryk university, Brno Polytrauma “ What people die of ? “ 1.Cardiovascular disease (IHD, strokes) 52% 2.Tumors 26% 3.Trauma (external causes) 7% a.Traffic, work, sports, home, industria, criminal ★Trauma under 40y on 1st place ! Terms and Definitions Monotrauma - single systeme injury Polytrauma - significant injury in at least two body regions (one of which or their combination is immediately life-threatening) Body regions: ●Head, neck, and cervical spine ●Face ●Chest and thoracic spine ●Abdomen and lumbar spine ●Limbs and bony pelvis ●External (skin) Injured systemes ●Limbs 90% ●Skull and brain 72% ●Chest 53% ●Abdomen 29% ●Pelvis 24% ●Spine 10% ●Heart and vessels 10% “Lethal triad” 1.Hypothermia 1.Acidosis 1.Coagulopathy Approach to polytraumatised patient Pre-hospital care (pre-medical, technical, medical) Transport to the trauma center Damage control Definitive treatment 3 “R” rule 1.Right patient 1.Right hospital 1.Right time Field triage (ATLS) ●Vital signs and level of consciousness ○GCS < 13 ○Systolic blood pressure < 90 ○Respiratory rate < 10 or > 29 (or need for ventilatory support) ●Anatomy of injury ○All penetrating injuries ○Pelvic fractures ○Two or more proximal long-bone fractures ○Crushed, degloved, mangled, or pulseless extremity ○Amputation proximal to wrist or ankle ○Open or depressed skull fracture ○Paralysis ●Mechanism of injury ○Falls > 6 meters (second floor) ○High risk auto crash (ejection, intrusion, death of another passenger, telemetry) ○Motorcycle crash > 30 km/h ○Auto vs. pedestrian/bicyclist > 30 km/h ●Consider special conditions ○Age < 6y or > 55y ○Cardiopulmonar comorbidity ○Pregnancy ○etc Scoring systemes ●Glasgow coma scale ●Abbreviated injury scale (AIS) ●Injury severity score (ISS) ●AO classification ●Tscherne, Gustillo-Anderson Pre-hospital medical care 1.“ABCDE” 2.Resuscitation 3.Secondary treatment 4.Transport to place of definitive treatment (trauma center) ●Cervical spine immobilization ●Immobilization of unstable fractures ●Analgesia ●Monitoring Procedures in trauma patients 1.ABC 2.Urgent procedures ○Tension pneumothorax, hearth tamponade, urgent laparotomy for major bleeding, stabilisation of long bone/hip fractures 3.Acute (3-6 hours) 4.Delayed (1-2 days) 5.Planned (weeks) Damage control Resustitation / surgery / orthopedics ●Analgosedation, OTI + ventilation, volume therapy (TU, FFP, crystaloids/coloids) ●Surgery - life saving procedures in unstable patient, time-limited (max 90´) ○Control of bleeding, contamination ○return to operating room after stabilisation on ICU ●Stabilization of long bone fractures (pelvic fractures) - external fixator Death following polytrauma Trimmodal distribution curve 1.Immediate death (on sceen) - 50-60% ○Lethal injuries 2.Early death - 30% ○Within hours after admision (max. 24 hours) ○Potentially reversible (disruption of airways, blood loss) 3.Late death - 10-20% ○days to weeks after injury ○ARDS, sepsis, MOF, PE ○Potentially reversible Fractures and bone healing Fracture ●Partial or complete break in the continuity of the bone. ●Damage to the soft tissues with the breakage of the bone. Fractures (classification basics) ●Traumatic x Pathologic x Stress ●Complete x Incomplete ●Closed x Open ●Extra-articular x Intra-articular Classification of fractures ●X-ray descriptive / anatomical ●AO classification ●Specific classification systemes ○e.g. proximal femur fractures (Pipkin, Garden, Pauwels) ○Salter-Harris (pediatric fractures involving growth plate) ○Tscherne (open fractures) ○etc. Mechanism of fractures ●Energy ○High energy ○Low energy ●Forces ○Direct forces ○Indirect forces Some fracture patterns suggest causal mechanism... X-ray descriptive classification ●Location ○bone and were (diaphysis, proximal femur...) ●Orientation / fracture pattern ○Transverse, oblique, spiral, segmental, comminuted (complex), avulsion, impaction/compression ●Displacement of main fragments ○with contraction/distraction, axial angulation, rotation (twist), lateral displacement (translation) How to describe this fracture ? AO classification Diaphyseal fractures Proximal / Distal epiphysis Structure of bones ●Mineral component ○Hydroxyapatite (Ca5(PO4)3(OH)) ○strength, stiffness, and rigidity characteristic of bone ●Organic component ○primarily type I collagen ○tensile strength and resiliency ●Cortical / cancellous bone ●Periosteum ○vascular supply - leading role for fracture healing ! Microanatomy of the bone Bone healing ●Primary (direct) bone healing ○anatomic reposition and stable fixation ○by direct osteonal remodeling, ○no or minimal callus formation ○need more time to heal strong ●Secondary (indirect) bone healing ○Physiological respond of a bone to fracture ○Sequence of bone healing ■Hematoma callus ●day 1-5 ■Gelatinous callus day ●day 5-10 ■Granulation callus ●day 10-15 ■Endochondral ossification ●day 15-21 ■Remodeling ●day 21- Primary bone healing – contact/direct Secondary bone healing – gap/indirect Indirect bone healing Diagnostic approach ●Anamnesis ●Physical exam ○definite x possible signs of fracture ●X-ray ○at least 2 projections in perpendicular plane ○special projections (Judet, Drasnar...) ●Ultrasound ○including FAST ●CT ○Intraarticular fractures ○Cranial, spine, pelvic fractures ○Doubts on X-ray… ●MRI ○rarely in acute stage Fracture management (in general) 1.Reposition ○Closed x Open 2.Retention ○Plaster ○Internal fixation ○External fixation 3.Rehabilitation Fracture management ●Conservative treatment ○undisplaced or minimally displaced stable fractures, incomplete fractures ○stable fractures after proper reposition and fixation ○(most) pediatric fractures ○contraindication of anesthesia and surgery ●Osteosynthesis ○displaced fractures ○unstable fractures ○(most) intra-articular fractures ○open fractures Principles of osteosynthesis ●Absolute stability ○Primary bone healing process ○Anatomic reposition, interfragmentary compression, minimal motion ●Lag screw ●Tension band ●Compression plate ●Relative stability ○Secondary bone healing process ○Allows small degrees of motion between the fragments ●Intramedullary nails ●Bridge plateing ●External fixateur Lag screw Absolute stability Relative stability Complications of bone healing 1.Prolonged healing, pseudoarthrosis (“non-union”) 2.Aseptic necrosis 3.Infection (osteomyelitis) 4.Secondary dislocation Open fractures Management (basics) 1.Pre-hospital care ○reposition (if possible without force), sterile coverage, immobilization (vacuum splint) 2.ATB (broad spectrum) and TAT prophylaxis 3.Revision on aseptic operating room ○only 25% of open fractures are contaminated before admission ○debridement and lavage ○primary skin closer / temporary closer 4.Stabilisation and fixation (Tscherne I,II - OS, external fixator) 5.Rehabilitation 6.(Reconstructive surgery) Compartment syndrome Výsledok vyhľadávania obrázkov pre dopyt compartment syndrome Where can you expect compartment syndrome? ●Shank ●Thigh ●Gluteal region ●Forearm ●Arm ●Foot ●Hand ● ●Abdominal cavity!!! Výsledok vyhľadávania obrázkov pre dopyt compartment syndrome where Výsledok vyhľadávania obrázkov pre dopyt compartment syndrome thigh Výsledok vyhľadávania obrázkov pre dopyt compartment syndrome thigh Diagnostic ●Increased pain greater than expected, altrought adequate analgesia ● swelling, tenderdnessblisters ●Neurological disability - altered sensation, parestesia ●Pulsation peripheraly intact!!! ●Measurement: more than 30-35mmHg ● ●Compartment syndrome is a clinical dg. and is not solely determined by pressure measurement!!!! Výsledok vyhľadávania obrázkov pre dopyt compartment syndrome pressure Treatment - fasciotomy!!! If you are concidering fasciotomy, perform it!!! ●Dermatomyofasciotomy ●Releasing ALL compartments ●Identifying source of swelling /bleeding, necrosis/ ●Debridement ●Covering: - dynamic suture - synthetic covering - NPWT - …. ● Výsledok vyhľadávania obrázkov pre dopyt compartment syndrome treatment Thank you for attention!