special consideration in pediatric fractures, edentulous, infected fractures

7/24/2019 Special Consideration in Pediatric Fractures, Edentulous, Infected Fractures

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Special consideration in

pediatric fractures,edentulous, infectedfractures

PRESENTER: DR. ISHA KOCHAR

3RDYR PG


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Special Considerations inChildren

General principles for resuscitating multiply injuredpatients follow the advanced trauma life-supportprinciples created by the American College of Surgeons.

Infants obligate nasal beat!es

Nasal ai "assages nao# an$ easil% obst&'te$.

C!est #all in '!il$en is "liable

(a)o t!oa'i' in)&ies e*ist #it! fe#e t!an e*"e'te$ signs ofe*tenal ta&+a.

C!il$en fe,&entl% s#allo# ai #!en t!e% ae in)&e$ o fig!tene$-es&lting in gasti' $ilatation.

Ab$o+inal git! an$ ol&+e of t!e "eitoneal 'ait% in infants an$%o&ng '!il$en ae elatiel% s+all.


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Signi/'ant inta0ab$o+inal blee$ing es&lts in aa"i$ '!ange in git!.

C!il$en +aintain a no+al o bo$eline 1P leel$es"ite signi/'ant 2&i$ loss an$ t!en$e'o+"ensate a"i$l%.

C!il$en !ae a lage bo$% s&fa'e aea0to0oeall+ass atio t!an a$&lts t!eefoe +oe "one to!%"ot!e+ia.

C!il$en ae geneall% in)&e$ in lo# elo'it%a''i$ents se'on$a% to falls fo+ lo# !eig!ts-"la%go&n$ e,&i"+ent- o i$ing to%s.


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P!"A#$"C %AC"A&

%$AC#'$S

Structural and anatomicdi(erences)

C!il$en !ae 'ani&+0to0 fa'eatios of 4:5 at bit! an$ 6:5 atage 7

A$&lt!oo$ 8.7:5 on aeage

9a'ial fat "a$s- b&ttessing toot! b&$s- an$&n"ne&+atie$ sin&ses f&n'tion to stabilie t!e"e$iati' fa'ial s;eleton.


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"*"#"A&

+A*AG+*#

9o'&s on t!e A1Cs of ta&+a.

High surface-to-volume ratio- metabolicrate- oxygen demand- an$ cardiac output of'!il$en along #it! t!ei low total blood

volume 'eate a "o"ensit% fo a"i$$e'o+"ensation #it! s&bse,&ent!%"otension- !%"o*ia- an$ !%"ot!e+ia.


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#"+"*G % %$AC#'$

$PA"$

In a$&lts- 3 #ee;s a""o*i+ate "eio$ in#!i'! a fa't&e #ill begin to !eal eno&g! t!ate$&'tion be'o+es $i='&lt.

O''&s +&'! soone in '!il$en

(an$ib&la fa't&es best teate$ #it!in /st64 !o&s.

Peiobital fa't&es #it!o&t EO( enta"+entafte eal&ation of !%"oglob&s an$eno"!t!al+os s!o&l$ be teate$ #it!in >$a%s.


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!"AG*S"SComprehensive history )

Ca&se of in)&%-

Ti+e fa+e fo+ in)&% to eal&ation

H?O @OC

A&lse$ teet!

@o'ation of t!e teet!- Tans"ot +e$i&+ of t!e teet!- an$

B!et!e t!e teet! #ee inse$ o s#allo#e$ oas"iate$.

1attee$ '!il$ 'o+"le*


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C&"*"CA& A+"*A#"*

)

9a'ial e$e+a

Peiobital e''!%+osis

S&b'on)&n'tial !e+o!age

S&b'&taneo&s e+"!%se+a

Nasal blee$ing

C!in la'eations Posta&i'&la e''!%+osis 1attles sign

O"!t!al+ologi' e*a+ination 0 "&"illa% ea'tiit%-is&al s'eening- an$ e*tao'&la +oe+ents


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"*#$A$A& )

Pal"ation fo ste"s intaoall%

Assess+ent of o''l&sion?$entition

Pesen'e of e''!%+osis in t!e 2oo of t!e +o&t!

(obilit% of $ental seg+ents

$A!"&G"C A+"*A#"* )

Co+"lete fa'ial seies of a$ioga"!s : 0 @eft an$ ig!t lateal obli,&e ie#s of t!e +an$ible +an$ib&la bo$% an$ a+&s

0 To#ne "o)e'tion 'on$%la in)&ies


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PA ie# +an$ible an$ +i$fa'e

Bates ie# +i$fa'ial an$ nasal fa't&e

$ete'tion

S&b+ental ete* ie# %go+ati' a'!es

30++ a*ial- 'oonal- an$ sagittal 'o+"&te$to+oga"!% CT 0 stan$a$ of 'ae

Sagittal i+ages ae "ati'&lal% &sef&l foeal&ating obital 2oo ta&+a

30D CT assess fa'ial fa't&es globall% fo++&lti"le angles an$ assist #it! s&gi'al "lanning


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#PS %

%$AC#'$SA&/&A$ %$AC#'$S )

An aleola fa't&e +a% !ae a seg+ent of teet! t!at ae

+obile as a go&"- #it! asso'iate$ soft tiss&e in)&% an$+alo''l&sion.

Pi+a% teat+ent is 'onseatie

I++obiliing t!e a'! seg+ent &sing:

0 a'! ba-

0 #ie ligation- o

0 'o+"osite s&""ote$ ot!o$onti' #ie e*ten$e$ to stableteet! in t!e in)&e$ a'!.

Signi/'ant aleola bone loss aleola bone e'onst&'te$ iaa&togeno&s bone gafting an$ stan$a$ $ental e'onst&'tion.


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+"!%AC"A&

%$AC#'$S*asal %ractures )

Signs F s%+"to+s :

e"ista*is

nasal0"eiobital e''!%+osis

nasal e$e+a

nasal se"tal e''!%+osis

asso'iate$ la'eations

Teat+ent 'lose$ e$&'tion if t!e in)&% is less t!an 5 #ee; ol$&sing nasal eleatos intanasal a""oa'!

5 #; o t!ee is an e*isting la'eation o"en e$&'tion'onsi$ee$

Se'on$a% !ino"last% "o'e$&es 'an be 'onsi$ee$ afte fa'ialgo#t! is 'o+"lete$- geneall% afte 5 %eas.


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+a0illary %ractures

P!%si'al e*a+ination eeals 'lassi' signs of a @e9otfa't&e

+a*illa% estib&la e''!%+osis-

fa'ial e$e+a-

+alo''l&sion- an$

goss +obilit% of t!e +a*illa.

9o !ig!e leel @e 9ot fa't&es t%"e 8 o 3 "eiobitale$e+a- ta&+ati' tele'ant!&s- an$ "eiobital e''!%+osis.

Close$ e$&'tion teat+ent of '!oi'e


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A""li'ation of ot!o$onti' ba';ets 'lose$ e$&'tion#it! !ea% elasti's o t!in 80 o 840ga&ge #ie

Altenatiel%- s'e# /*ation of t!e "iifo+ an$%go+ati' b&ttesses bilateall% F in t!e s%+"!%sealegion of t!e +an$ible fo I(9 an$ i++obiliation.

@i+itations ne'essit% fo t!is to be $one &n$e genealanest!esia an$ t!e is; of $a+aging &n$el%ing toot!b&$s.

I+"essions +a% be ta;en an$ +o$els "o&e$ an$se'tione$ to fa'ilitate s"lint 'onst&'tion fo 'lose$e$&'tion.

Close$ e$&'tion fo 8 to 3 #ee;s #it! 80ga&ge #iefollo#e$ b% 3 #ee;s of "ogessiel% lig!te elasti's


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rbital %ractures

J > %eas obital oof #it! e*tension to t!e fontal sin&s&n$e$eelo"+ent of t!e sin&ses

> %eas in)&% to t!e obital oof- +e$ial an$ lateal #alls- 2oo-

an$ fontal sin&s ae +oe fe,&ent Co+"lete o"!t!al+ologi' e*a+ination s!o&l$ "e'e$e obital

e*"loation.

Classi1cation )

#ype 2) Pure rbital %ractures

5a2oo fa't&es 5b+e$ial #all fa't&es

5'oof fa't&es

5$lateal #all fa't&es

5e'o+bine$ 2oo an$ +e$ial #all fa't&es


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#ype 3) Craniofacial %ractures

8ago#ing s;&ll fa't&es

#ype 4) rbital %ractures Associated 5ith Common %racture Patterns

3afa't&es of 2oo in infeio obital i+

3b%go+ati' +a*illa% 'o+"le* fa't&es

3'naso0obital0et!+oi$ NOE fa't&es

3$ot!e fa't&e "atten

Physical e0amination

"eiobital e$e+a an$ e''!%+osis-

s&b'on)&n'tial !e+o!age-

eno"!t!al+os-

$i"lo"ia- an$

infaobital nee "aest!esia


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9o'e$ $&'tion test to eal&ate fo infeio e't&s +&s'leenta"+ent

(ost 'o++on t%"e of "e$iati' obital fa't&e t%"e 5

fa't&e "&e obital T%"es 5 F 8 Conseatie +anage+ent

S&gi'al inteention : enta"+ent- eno"!t!al+os- o eti'alobital $%sto"ia.

T%"e 3 fa't&es teate$ s&gi'all% as "at of t!e 'on'o+itant

fa't&e

Obital fa't&es in '!il$en #it! ei$en'e of +&s'leenta"+ent teate$ soone to aoi$ necrosis of theextraocular musculature and associated oculorotarydysfunction


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%$AC#'$S % #6

7G+A#"C C+P&

Physical 1ndings )

Peiobital e$e+a

Tis+&s if t!e a'! is fa't&e$ an$ $is"la'e$ Infaobital nee !%"oest!esia

9lattening of t!e +ala "o'ess- an$

Pal"able bon% ste"s

0 Re$&'tion of t!e fa't&e$ a'! of t!e %go+a onl% teat+ent

ne'essa%- if a 'os+eti' $efo+it% e*ists o if notable tis+&s "esent 30"oint stabiliation is i$eal : Dis"la'e$?'o++in&te$

0 L%go+ati'o0fontal "o'ess-

0 Infaobital i+- an$

0 L%go+ati' b&ttess


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+A*!"8'&A$

%$AC#'$S%ractures of the +andibular Condyle )

J %s inta'a"s&la

%s 'on$%la ne'; egion 8 iss&es &ni,&e to "e$iati' 'on$%la fa't&es :

0 Ris; of te+"oo+an$ib&la )oint T(M an;%losis

0 Potential "ogessie go#t! $ist&ban'es of t!e fa'e.

Physical e0amination:

0 Tis+&s

0 (an$ible $eiates to t!e ae'te$ si$e

0 Pea&i'&la s#elling

0 (alo''l&sion o"en bite +alo''l&sion on t!e &nae'te$ si$e


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Re+o$eling "ost0in)&% in t!e "e$iati' "o"&lation.

Remodeling can be dened as an uprighting of thecondylar process and restoration of TMJ joint

function.

8 a'tie +e'!anis+s inole$ in e+o$eling

0 eso"tion of t!e fa't&e$- $is"la'e$ 'on$%la seg+ent

0 a""osition of bone to 'eate a ne# 'on$%le.

#$A#+*# )

(ini+all% $is"la'e$ 'onseatie +anage+ent

(an$ib&la as%++et% ((9 fo 8 #;s follo#e$ b% "!%si'alt!ea"%


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Absolute indications for open reduction)

Dis"la'e+ent of t!e 'on$%le into t!e +i$$le 'anial fossa

Inabilit% to obtain a$e,&ate o''l&sion b% 'lose$ e$&'tion @ateal e*ta 'a"s&la 'on$%la $is"la'e+ent

Pesen'e of a foeign bo$%

$elative indications for open reduction)

Seee sei&e $iso$e

(ental eta$ation

Seee &""e ai#a% obst&'tion

Ps%'!ologi'all% &nable to toleate ((9


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+andibular Angle, 8ody,

and Symphysis %ractures

Teate$ 'onseatiel% ia 'lose$ e$&'tion

8 to 3 #ee;s of ((9 bon$ing ot!o$onti' a""lian'es

@ing&al s"lint

Asso'iate$ 'on$%la fa't&es intenal /*ation ofs%+"!%sis li+its t!e nee$ fo ((9 "e+its eal%f&n'tion of t!e 'on$%les

(i$fa'e 5.70++ "o/le "lates

Pla'e$ as infeiol% as "ossible to aoi$ toot! b&$s

Re+oal afte 6 to +ont!s to ens&e no esti'tionin +an$ib&la go#t!


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C*C&'S"*

C!il$en 'annot be teate$ as little a$&lts.

Alt!o&g! 'onseatie +anage+ent is best in+ost 'ases- igi$ /*ation +a% be nee$e$ in +oeseee in)&ies an$ 'ae +&st be ta;en to aoi$'o+"o+ising f&t&e $entition an$ s;eletal

go#t!.


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!*#'&'S%$AC#'$S


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!*#'&'S

%$AC#'$STeat+ent "lanning $e'isions in2&en'e$ b% :

Ris;s of "olonge$ o inasie s&ge%

I+"a't on f&n'tion fo+ inte+a*illa% /*ation Re'&"eation fo+ o"en s&ge%

Ps%'!ologi'al i+"li'ations

Pee*isting +e$i'al 'on$itions

1on% '!anges Aleola bone ato"!%

+A"&&A$ %$AC#'$S

(ost 'o++on +a*illa% fa't&e )&n'tion of t!e !oiontal"late of t!e "alatine bone an$ "osteio "at of t!e +a*illa


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E*isting s&itable $ent&es $ent&e is altee$ to be &sef&lin "ositioning an$ i++obiliing t!e +a*illa.

Holes ae $ille$ in t!e a'%li' aea of t!e $ent&e to ai$ inse'&ing a'! bas to t!e $ent&e- +a;ing stabiliation tot!e &n$el%ing bone easie.

G&nnings s"lint 'an be fabi'ate$

Se'&e$ to +a*illa ia :

Tansaleola #iing

Tansaleola "in "la'e+ent o

S&s"ension #ies fo+ t!e +ala b&ttess- "iifo+ i+s-nasal s"ine- o %go+a


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Ci'&+0+an$ib&la #ies 0 se'&ing a +an$ib&la"ost!esis o f&ll +an$ib&la $ent&es

$8"#A& %$AC#'$S ) Infaobital a""oa'! "oi$es $ie't an$ eas% a''ess to

t!e infaobital i+ an$ obital 2oo.

Aging 'a&ses la*it% an$ $o#n#a$ s!ift of e%eli$ tiss&esan$ ato"!% of t!e obital fat

0 e'to"ion

0 ento"ion

0 $e+ato'!alasis- an$

0 "tosis


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Tans'on)&'tial a""oa'!- #it! an$ #it!o&tlateal 'ant!al e*tension fo

e'onst&'tion of L(C an$ isolate$ obitalfa't&es

(ini+al "osto"eatie 'o+"li'ations

Cos+eti'all% a''e"table

(ini+al in'i$en'e of e'to"ion 'o+"ae$#it! '&taneo&s a""oa'!es.


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+A*!"8'&A$

%$AC#'$SClosed reduction )

(an$ib&la f&ll $ent&e stabilie$ #it! 'i'&++an$ib&la#ies

G&nning s"lints E*tenal /*ation 0 Stein+ann "ins o Kis'!ne

#ies


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pen reduction and internal10ation )

se of lage "lates- 8.60++ +an$ib&la fa't&e oe'onst&'tion "lates an$ bi'oti'al s'e#s ato"!i' +an$ib&la bo$% fa't&e

Seeel% ato"!i' +an$ibles- in #!i'! t!e

+a*i+&+ bone !eig!t J 7 ++ a&g+entation&sing feee0$ie$ 'a$aei' +an$ible "a';e$ #it!a&togeno&s 'an'ello&s ilia' bone


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C*C&'S"*

Re'o++en$ations abo&t t!e tiage an$ es&s'itation ofol$e ta&+a "atients:

2.A$an'e$ age s!o&l$ lo#e t!e t!es!ol$ fo tiage $ie'tl%

to a ta&+a 'ente.

3.Age alone is not a "e$i'to of "oo o&t'o+e an$ s!o&l$ notbe t!e $ete+ining fa'to in li+iting 'ae.

4.T!e "esen'e of "ee*isting +e$i'al 'on$itions a$esel%ae'ts t!e o&t'o+e in ol$e ta&+a "atients.

9.Ol$e ta&+a "atients Q7 %eas #it! a Glasgo# Co+aS'ale s'oe less t!an 4 !ae a e% "oo "ognosis.

If i+"oe+ent is not "ossible #it!in >8 !o&s- li+itation of'ontin&e$ aggessie t!ea"% s!o&l$ be 'onsi$ee$.


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:.@o# s&ial ates an$ longe lengt!s of sta% ae asso'iate$#it! "ostin)&% 'o+"li'ations.

;. Gien t!at 47 of ol$e ta&+a "atients #ill et&n toin$e"en$ent f&n'tion- es&s'itation s!o&l$ be "&s&e$aggessiel% on "atients #!o ae not +oib&n$ on aial.


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>. Des"ite +eeting t!e 'iteia fo tiage to a ta&+a'ente- ta&+a "atients #!o ae 77 %eas an$ ol$e ae

+&'! +oe li;el% to be i+"o"el% tiage$.2?. Inasie !e+o$%na+i' +onitoing is in$i'ate$ fogeiati' ta&+a "atients #it! &n'etain 'a$ioas'&lao enal $isease.

22. Eot s!o&l$ be +a$e to o"ti+ie t!e 'a$ia' in$e*

6 lite?+in?+8 an$ o*%gen 'ons&+"tion in$e* 5>+@?+in?+8.


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"*%C#!%$AC#'$S


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"*%C#!

%$AC#'$ Ris; of infe'tion $e"en$s on 3 fa'tos:

5. A+o&nt F t%"e of +i'obial 'onta+ination of #o&n$

8. Con$ition of #o&n$ at t!e en$ of teat+ent e.g.- "esen'e ofesi$&al ne'oti' tiss&e- foeign bo$ies- ba'teial no.

3. Host s&s'e"tibilit%

. Infe'tion of +a*illo0+an$ib&la fa't&es oiginate fo+ :

0 Ina$e,&ate intefag+ent stabilit%

0 9oeign bo$ies

0 @oose !a$#ae

0 Toot! in t!e line of fa't&e

0 Ne'oti' bone fag+ent


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%actors in@uencing infection in the traumapatient scheduled for surgery are as follows)

U @engt! of t!e "eo"eatie "eio$ of !os"italiation U se of aos to s!ae t!e o"eatie site

U Nat&e of "e"aation of t!e o"eatie site

U (aintaining no+ot!e+ia

U O*%gen t!ea"%

U Asso'iate$ es&s'itatie "o'e$&es allogenei'bloo$ tansf&sions


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%AC"A& 8*

%$AC#'$S

9a't&es not 'onsi$ee$ 'onta+inate$ :

Close$ of s&b'on$%la egion

Close$ of %go+a F ot!e fa'ial bones

If $e/nitie teat+ent $ela%e$- te+"oa% I(9 in$i'ate$ to"eent +e'!ani'al "&+"ing of salia F ba'teia into site.

I(9 s'e#s o- 1i$le0t%"e #ie

(oe+ent of also 'a&ses eblee$ing at t!e fa't&e site-#!i'! in'eases t!e lo'al !e+ato+a F 'a&ses a +oeanaeobi' enion+ent.


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%AC#$S G'"!"*G

C6"C % A*#"8"#"C

I$enti/'ation of t!e 'a&satie agent o t!e &s&aloganis+ t!at +a% 'a&se an infe'tion if "o"!%la*is

is in$i'ate$ se of t!e least to*i' antibioti'

Patients $&g !isto%to aoi$ ;no#n $&gs to#!i'! t!e "atient !as "eio&sl% ea'te$ a$esel%

se of a ba'tei'i$al as o""ose$ to a ba'teiostati'$&g- be'a&se t!e ba'tei'i$al $&g elies less ont!e !osts esistan'e- ;ills t!e ba'teia $ie'tl%- an$#o;s faste

Cost of t!e antibioti' egi+en


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+A*AG+*# % ##6ASSC"A#! 5"#6

+A*!"8'&A$ %$AC#'$

Conte+"oa% fa't&e +anage+ent s&""ots e+oingteet! in t!e line of onl% if t!e follo#ing 'on$itions e*ist:

U T!e toot! is loose.

U T!e toot! is gossl% 'aio&s o "eio$ontall% inole$.

U (oe t!an 7 of t!e oot is e*"ose$ in t!e fa't&e line.

U A$e,&ate e$&'tion is +e'!ani'all% blo';e$ b% its

etention.

Retention of !ealt!% /+ teet! +a% !el" in t!e e$&'tion ofa fa't&e an$ "esee t!e $entition.


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"*%C#"*S ASSC"A#!

5"#6 %$AC#'$S

Infe'tion of t!e +an$ible follo#ing a fa't&e is;no#n as "ost0ta&+ati' osteo+%elitis.

Eal% signs of an a'&te s&""&atie osteo+%elitis : Dee" intense "ain

U Hig! inte+ittent fee

U Paest!esia o anest!esia of t!e +ental nee

aising afte t!e ta&+a an$ e$&'tion of t!e

fa't&e

U A 'leal% $e/ne$ 'a&se


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Osteo+%elitis "ogesses to 'ell&litis lea$ing to intaoal o'&taneo&s sites of $ainage- o bot!.

S%ste+i' signs :

(il$ le&;o'%tosis #it! a s!ift to +oe i++at&e ban$fo+s of P(Ns-

Rise in te+"eat&e- an$

An in'ease in ESR

To "lan t!e a""o"iate s&ge% an$ ens&e a$e,&ateteat+ent- s'intiga"!% is a &sef&l a$)&n'tie st&$%.

S'intiga"!% is also &sef&l fo +onitoing t!e 'o&se of t!e$isease an$ e='a'% of teat+ent an$ +a% also in$i'ate#!en teat+ent 'an be safel% sto""e$.


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+A*AG+*#

Co+bine$ s&gi'al an$ +e$i'al a""oa'!.

Nonital tiss&e- foeign bo$ies- an$ asso'iate$ teet! +&st bee+oe$.

At t!e s&gi'al "o'e$&e- s"e'i+ens of bone s!o&l$ beobtaine$ &sing +eti'&lo&s te'!ni,&e an$ s&b+itte$ ,&i';l%fo '&lt&e an$ sensitiit% testing- #it!o&t se'on$a%'onta+ination.

DVbi$ing infe'te$ aeas an$ establis!ing $ainage ae

i+"otant.

Contin&o&s iigation an$ $ainage s%ste+s 'an be "la'e$t!o&g! a 'lose$ #o&n$ follo#ing a""o"iate $Vbi$e+ent ift!e infe'tion is e*tensie o efa'to% to 'onentional$ainage an$ iigation.


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A +eans of /*ation +&st be &se$ to "eent f&t!e+oe+ent of t!e fa't&e seg+ents.

se of e*tenal "ins to s"an t!e ga" 'eate$ b% t!e

e+oal of t!e inole$ bone.

Re'onst&'tion of bon% $efe't is not atte+"te$ &ntil allsigns of infe'tion ae gone- geneall% afte at least 8+ont!s.

Absen'e of infe'tion is $ete+ine$ on t!e basis of la';of lo'al signs of infe'tion- s&'! as $ainage o 'ell&litis.

A bone s'an &sing t!e te'!neti&+ an$ galli&+s&bta'tion te'!ni,&e 'an be 'aie$ o&t to 'ooboatet!e 'lini'al i+"ession t!at t!e infe'tie "o'ess !as'leae$.


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+"!%AC"A&

%$AC#'$S Inole+ent of sin&ses

(i'obiologi' '!aa'teisti's 0 "esen'e of Streptococcuspneumoniae an$ H. inuenza in infected sinus

Choice of antibiotics

@e 9ot II an$ III fa't&es +a% 'o++&ni'ate #it! t!e'anial 'ait%- as ei$en'e$ b% a 'eebos"inal 2&i$CS9 lea; fo+ t!e nose o e*tenal ea 'anals CS9

oto!ino!ea. Ris; of +eningitis

Eal% e$&'tion of t!e fa't&es is in$i'ate$- #!i'! #illno+all% sto" t!e CS9 lea;.


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#$A#"*G #6 PA#"*#5"#6

/"$A& "*%C#"* Pe$i'tos of a "ee*isting ial infe'tion :

age 8 to 6W %eas-

IX $&g ab&se- "io HIX testing-

s!o';- an$

Deat!

IX $&g ab&se single +ost signi/'ant "e$i'to Patients #!o e,&ie$ es&s'itation o eent&all% $ie$ of

t!e ta&+a !a$ a 58 to 85 infe'tion ate #it! HIX-!e"atitis 1 i&s H1X- o bot!


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Single gloing 5 in'i$en'e of gloe "efoation#!en &sing #ies

3> #it! t!e &se of $o&ble gloes.

Ti"le gloing eli+inates t!e inne gloe "efoationentiel% $&ing a'! ba "la'e+ent b&t 'a&ses "aest!esiaof t!e s&geons /nges an$ e$&'e$ $e*teit%.

Po'e$&es lasting longe t!an 3 !o&s o +oe t!an 3+@ of total bloo$ loss

In'ease$ "e0o" an$ "ost0o" infe'tion ates.

O"en e$&'tion #as asso'iate$ #it! a 67 infe'tion ate 'lose$ e$&'tion s!o&l$ be &se$ if "ossible


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#he man who says itcannot be done shouldnot interrupt the mandoing it.

#6A*B'

special consideration in pediatric fractures, edentulous, infected fractures

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