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Musculoskeletal Trauma Cambridge Trauma weekend 2011 Mr Lee Van Rensburg www.easytrauma.co.uk Slide 2 Slide 3 Slide 4 Fatal accident deaths England and Wales 1988-92 ~ 5 years Swimming 191 Boating/sailing 69 Motor sports 65 Horse riding 62 Air sports 51 Mountaineering 51 Fishing 50 Soccer 14 Running/jogging 9 Badminton 3 Cricket 2 Hockey 2 Rugby 2 Golf 1 Gymnastics 1 Tennis 1 Slide 5 Musculoskeletal Trauma Life threatening Limb threatening Slide 6 Musculoskeletal Trauma Life threatening Major pelvic disruption with haemorrhage Major arterial haemorrhage Crush syndrome (rhabdomyolysis) Limb threatening Slide 7 Musculoskeletal Trauma Life threatening Limb threatening Open Fractures, joint injuries Vascular injuries Compartment syndrome Neurologic injury Slide 8 Life Threatening Injuries Major pelvic disruption with haemorrhage Major arterial haemorrhage Crush syndrome (rhabdomyolysis) Slide 9 Anatomy Slide 10 Binding of book Slide 11 Pelvis Slide 12 Pelvic injury 3 patterns Anterior posterior compression (APC) Lateral compression Vertical shear Slide 13 APC Slide 14 Lateral Compression Slide 15 Vertical shear Slide 16 3 pelvic injuries Slide 17 Treatment Emergency Definitive Slide 18 Treatment Emergency Resuscitation ATLS Fracture pattern Pelvic binder External fixation - anterior C Clamp - posterior Traction Angiography - embolisation Pelvic packing Definitive Slide 19 Treatment Emergency Resuscitation ATLS Fracture pattern Pelvic binder External fixation - anterior C Clamp - posterior Traction Angiography - embolisation Pelvic packing Slide 20 Emergency Slide 21 At level of greater trochanters and the symphysis pubis Pelvic binder Slide 22 Splinting Lower Limbs Slide 23 54 hours in binder Slide 24 Slide 25 Emergency Slide 26 Slide 27 Binder and traction limb Slide 28 C Clamp Slide 29 Slide 30 Slide 31 Slide 32 Slide 33 Angiography Slide 34 Slide 35 Pelvic packing Slide 36 Slide 37 Slide 38 Slide 39 Complex/ combination Slide 40 Slide 41 Slide 42 Urethral injury Blood at meatus Frank haematuria Perineal haematoma Scrotal/ penile haematoma High riding prostate Slide 43 Slide 44 Complications Slide 45 Life Threatening Injuries Major pelvic disruption with haemorrhage Major arterial haemorrhage Crush syndrome (rhabdomyolysis) Slide 46 Major Arterial Haemorrhage Penetrating / blunt injury in close proximity to artery Haemorrhage, haematoma, hypotension Ischaemic extremity Stop the bleeding! Slide 47 NeurovascularNeurovascular Slide 48 Slide 49 Crush Syndrome Myoglobinuria Metabolic acidosis, K +, Ca ++ and coagulopathy IV fluids, alkalisation of urine Slide 50 Limb-Threatening Injuries Open Fractures, joint injuries Vascular injuries Compartment syndrome Neurologic injury Slide 51 Slide 52 Open Fractures, Joint Injuries Wide spectrum of soft-tissue injury Open wound = Open fracture Slide 53 Open Fractures, Joint Injuries Treatment Antibiotics? Wound swab ???? Photograph Sterile dressings (betadine or saline) Splint REDUCE YES, DOCUMENT Tetanus prophylaxis Surgical debridement Co-amoxiclav 1.2g, 8 hrly Or Cefuroxime 1.5g, 8 hrly Penicillin allergy Clindamycin 600mg, 6 hrly Slide 54 Slide 55 Vascular Injury, Amputation Variable presentation: Assess pulses Associated with fractures / dislocations Realign Check pulses after splinting Immediate surgical consult Slide 56 Slide 57 Keep moist Keep cool Dont freeze Dont macerate Slide 58 Slide 59 Compartment Syndrome Slide 60 Compartment pressure Nerve / muscle ischaemia necrosis NO 5 Ps Pain, Pain passive stretch Elevate (level of heart) Release constricting devices (keep splint) Suspect tibial, forearm fractures after revascularisation in unconscious patient Early surgical consult Slide 61 Slide 62 Compartment syndrome Pitfalls Simple transverse tibial fracture Open fractures Depressed level of consciousness Pressure 30mmHg P (Diastolic compartment) > 30mmHg Slide 63 Slide 64 Neurologic Injury Due to fracture / dislocation Anterior shoulder: Axillary nerve Posterior hip: Sciatic nerve Recognise injury and immobilise Early surgical consult Careful reduction, if possible, reassess and splint Slide 65 Damage Control Orthopaedics Beyond ATLS Slide 66 SR 21 YO, Male 13/05/06 - 23H50 ISS 57ISS 57 SAH, DAISAH, DAI R HaemothoraxR Haemothorax Pelvic ring fracturePelvic ring fracture (Dissociation R hemipelvis) # L Acetabulum# L Acetabulum # L Femur# L Femur Compartment syndrome both lower legs and thighsCompartment syndrome both lower legs and thighs Slide 67 Slide 68 Theatre - 1 hr arrival LaparotomyLaparotomy Pelvis packed, Vac dressing C clamp and pelvic ex fixC clamp and pelvic ex fix AngiogramAngiogram EmbolisationEmbolisation Slide 69 EVD 14/05/06 20:45 Slide 70 Theatre 14/05 08h20 Retrograde femoral nailRetrograde femoral nail FasciotomyFasciotomy Both thighs both calvesBoth thighs both calves Slide 71 15/05/06 AngiogramAngiogram IVC filterIVC filter Repeat bleedingRepeat bleeding Laparotomy change of packsLaparotomy change of packs Bladder repairBladder repair Pubic symphysis ORIFPubic symphysis ORIF Slide 72 Theatre 15/05/06 AngiogramAngiogram IVC filterIVC filter Repeat bleedingRepeat bleeding Laparotomy change of packsLaparotomy change of packs Bladder repairBladder repair Pubic symphysis ORIFPubic symphysis ORIF 2 hour rewarming on table2 hour rewarming on table Slide 73 Theatre 15/05/06 Removal of C clampRemoval of C clamp Anterior platingAnterior plating R Sacroiliac jointR Sacroiliac joint Debridement washout closure C clamp and Ex fix woundsDebridement washout closure C clamp and Ex fix wounds Slide 74 Theatre Vac dressing change 17/05/06Vac dressing change 17/05/06 Closure of thigh woundsClosure of thigh wounds Vac dressing change 23/05/06Vac dressing change 23/05/06 Closure of L lower leg woundClosure of L lower leg wound Vac dressing change 28/05/06Vac dressing change 28/05/06 Closure R lower leg woundClosure R lower leg wound Slide 75 Theatre 30/05/06 Planned ORIF acetabulumPlanned ORIF acetabulum Wound breakdownWound breakdown L iliac crestL iliac crest Both thighsBoth thighs Washout and vac dressingsWashout and vac dressings Slide 76 JM 20 YO, Male 27/02/06 15:48 #BOS#BOS #Nasal bone#Nasal bone APC pelvic injuryAPC pelvic injury # R Supracondylar femur# R Supracondylar femur # R Tibia shaft (open)# R Tibia shaft (open) # L Tibial plateau (open)# L Tibial plateau (open) # Bimalleolar L ankle# Bimalleolar L ankle Slide 77 Pre hospital Intubated through windowIntubated through window Pre hospital arrestPre hospital arrest Hr 144, Systolic 60Hr 144, Systolic 60 GCS 3GCS 3 Slide 78 Slide 79 Slide 80 Slide 81 Pre theatre CT brainCT brain BOSBOS AngiogramAngiogram Very small bleeder embolisedVery small bleeder embolised Slide 82 Slide 83 Theatre 27/05/06 External fixatorExternal fixator PelvisPelvis R legR leg L legL leg Debridement washout, fasciotomy and vac dressingDebridement washout, fasciotomy and vac dressing R thighR thigh R lower legR lower leg L lower legL lower leg LaparotomyLaparotomy EVDEVD Slide 84 Theatre 01/03/06 Plating pubic symphysisPlating pubic symphysis Intramedullary nailIntramedullary nail R femur retrogradeR femur retrograde R tibiaR tibia Change of VacsChange of Vacs Slide 85 Theatre 05/03/06 ORIF L Tibial plateauORIF L Tibial plateau ORIF L fibulaORIF L fibula Free Flap R tibiaFree Flap R tibia Rotation flap L TibiaRotation flap L Tibia Slide 86 Theatre 23/03/06 Debridement and SSG L AnkleDebridement and SSG L Ankle Medial sideMedial side Slide 87 Slide 88 Slide 89 Questions www.easytrauma.co.uk