Transcript trauma sgd
Block 5A
Gabatino, Gauiran, Go, Gomez, Gonzales E, Gonzales L, Granada
OR
54/M
RC
Sta Ana, Manila
Right handed
c/c injuries secondary to vehicular crash
DOI: 12/14/09 (3 days post injury)
TOI: 6pm
POI: Carmona complex, Makati
MOI: VC jeep vs tricycle (side of the tricycle
and front of jeep)
Brought to Ospital ng Makati, wounds
dressed, X ray done, ATS, TeANA given, THOC
to PGH secondary to lack of funds
(-) loss of consciousness
(-) fever
(-) nausea
(-) vomiting
(-) dizziness
(-) cough and colds
(-) chest pain
(-) abdominal pain
(-) bowel changes
(+) polyuria, polydipsia, polyphagia
(+) numbness of bilateral peripheral extramities (
glove and stocking distribution)
(-) Diabetes
(-) Hypertension but had episodes of
hypertension since 2 years ago, highest Bpof
160/80 usual BP of 150/80
(+) hospitalization due to head injury (2008)
(-) PTB, BA
(-) food and drug allergies
No known medical illness in the family
Smoker >30 pack year
Heavy alcoholic beverage drinker 1-2 bottles
of 500ml redhorse daily since 25 years old
Denies illicit drug use
Denies promiscuity
Works as a tricycle driver
Awake, coherent, NICRD, ambulatory
Vital Signs: BP 150/90, HR 82, RR 20, T
afebrile
HEENT: AS, PC, pupils 3 mm EBRTL, (-)
CLAD/TPC/NVE/ANM
Chest/Lungs: ECE, Clear Breath Sounds, (-)
crackles/wheezes
Heart: AP, DHS, NRRR, (-) murmurs
Abdomen: soft, flabby abdomen, NABS, (-)
tenderness, (-) masses/organomegaly
Extremities (both upper extremities and left
lower extremity): Pink nail beds, Full and
equal pulses, (-) cyanosis, (-) clubbing, (-)
gross deformities
Grossly deformed thigh (distal 1/3 of the thigh
slightly angulated medially)
(+) swelling, tenderness, warmth, redness over
distal thigh and knee
Intact sensation over (L) thigh, leg and foot
Able to wiggle toes and dorsi/plantar flex ankle
Intact and full popliteal, dorsalis pedis and post
tibial pulses, pink nailbeds, (-) cyanosis
1.5x 1.5 cm wound over the anterior distal thigh
with no bone protrusion and adequate tissue
coverage, no gross contamination with debris
Fx: Open complete comminuted distal third
femur (L) secondary to VC
-
Therapeutics:
Cefazolin 1g IV LD then 1g q8
Gentamycin 240mg IV OD
Long leg posterior splint
Surgical Plan:
Debridement
Skeletal traction
Seen at the ER 12/17/2009 (3 days post injury)
12/19/09 – debridement of anterior thigh
wound, arthrotomy of the L knee joint and
skeletal traction inserted on proximal tibia – 15kg
12/26/09 – diagnosed with hypertension stage II
fairly controlled with HHD , DM type II newly
diagnosed with nephropathy, neuropathy, t/c
retinopathy, T/c Alcoholic liver disease
12/29/09 – scheduled for OR, deferred due to
lack of funds for IM nail
18th hospital day, 21 days post injury
Awake, coherent, NICRD, ambulatory
Vital Signs: BP , HR , RR , T afebrile
HEENT: AS, PC, pupils 3 mm EBRTL, (-)
CLAD/TPC/NVE/ANM
Chest/Lungs: ECE, Clear Breath Sounds, (-)
crackles/wheezes
Heart: AP, DHS, NRRR, (-) murmurs
Abdomen: soft, flabby abdomen, NABS, (-)
tenderness, (-) masses/organomegaly
Extremities (both upper extremities and left
lower extremity): Pink nail beds, Full and
equal pulses, (-) cyanosis, (-) clubbing, (-)
gross deformities
Left lower extremity on skeletal traction inserted
in the proximal tibia
(-) erythema, warmth, discharge, swelling, pain
around pintracts.
(+) surgical incision over the anterior knee and
thigh, good healing, no discharge, no redness, no
necrotic tissue at incision site
(+) warmth over the periphery of the (L) knee, (+)
mild swelling, (+) mild erythema
Intact popliteal, dorsalis pedis and post tibial
pulses
Intact sensation on thigh, leg, toes and feet
Osseous disruption in which a break in the
skin and underlying soft tissue communicates
directly with the fracture and its hematoma
Any wound occurring on the same limb
segment as a fracture must be suspected to
be a consequence of an open fracture until
proven otherwise
Contamination of the wound and fracture by
exposure to the external environment
Crushing, stripping, and devascularization that
results in soft tissue compromise and increased
susceptibility to infection
Destruction or loss of the soft tissue envelope
may affect the method of fracture
immobilization, compromise the contribution of
the overlying soft tissues to fracture healing and
result in loss of function from muscle, tendon,
nerve, vascular, ligament, or skin damage.
Results from application of violent force
which is dissipated by soft tissues and
osseous structures
The applied force is directly proportional to
resulting osseous displacement, comminution
and degree of soft tissue injury
ABCDE
Resuscitation and attention to life-threatening
injuries
Evaluate injuries to head, chest, abdomen,
pelvis, spine and all extremities
Assess neurovascular status of affected limbs
Assess skin and soft tissue involvement
Removal of obvious foreign bodies
Irrigation with pNSS
Radiographic evaluation
Type
Wound
Level of
Contamination
Soft Tissue Injury
Bone Injury
I
< 1 cm
long
Clean
Minimal
Simple, minimal
comminution
II
> 1 cm
long
Moderate
Moderate, some muscle
damage
Moderate
communition
Severe with crushing
Usually comminuted,
soft tissue coverage of
bone possible
III
A
B
C
Usually >
10 cm
long
High
Very severe loss of coverage,
usually requires
reconstructive surgery
Very severe loss of coverage
plus vascular injury requiring
repair, may require soft tissue
injury
Bone coverage poor,
may be moderate to
severe comminution
Contamination
Exposure to soil, water, fecal matter, oral flora
Gross contamination on PE
Delay in treatment > 12 hrs
Signs of high-energy mechanism
Segmental fracture
Bone loss
Compartment syndrome
Crush mechanism
Extensive degloving of SQ fat and skin
Requires flap coverage
Perform a careful clinical and radiographic
evaluation
Wound hemorrhage should be addressed with direct
pressure rather than limb tourniquets or blind
clamping
Initiate parenteral antibiosis
Assess skin and soft tissue damage; place a salinesoaked sterile dressing on the wound
Perform provisional reduction of fracture and place a
splint
Operative intervention: open fractures constitute
orthopaedic emergencies, because intervention less than 8
hours after injury has been reported to result in a lower
incidence of wound infection and osteomyelitis
Do not irrigate, debride, or probe the wound in the
emergency room if immediate operative intervention is
planned
Bone fragments should not be removed in the emergency
room, no matter how seemingly nonviable they may be
Gustilo I: Cefazolin 1 g IV q8h
Gustilo II: Cefazolin 1 g IV q8h
Gustilo III: Cefazolin 1 g IV q8h +
Aminoglycoside 3-5 mg/kg/day
Organic contamination: Penicillin 2,000,000
units q4h or Metronidazole 500 mg q6h
Incomplete (<3 doses) or unknown: (+) dT,
(+/-) TIG
Complete and > 10 years since last dose: (+)
dT, (-) TIG
Complete and < 10 years since last dose: (-)
dT, (-) TIG
Irrigation and debridement
Removal of foreign bodies
Fracture stabilization
Soft tissue coverage and bone grafting
Limb salvage
EXTERNAL FIXATION
Severe contamination: any site
Periarticular fractures
Definitive
▪ Distal radius
▪ Elbow dislocation
▪ Selected other sites
Temporizing
▪ Knee
▪ Ankle
▪ Elbow
▪ Wrist
▪ Pelvis
Distraction osteogenesis
In combination with screw
fixation for severe soft tissue
injury
INTERNAL FIXATION
Periarticular fractures
Distal/proximal tibia
Distal/proximal femur
Distal/proximal humerus
Proximal ulnar radius
Selected distal radius/ulna
Acetabulum/pelvis
Diaphyseal fractures
Femur
Tibia
Humerus
Radius/ulna