Transcript trauma sgd

Block 5A
Gabatino, Gauiran, Go, Gomez, Gonzales E, Gonzales L, Granada
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OR
54/M
RC
Sta Ana, Manila
Right handed
c/c injuries secondary to vehicular crash
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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)
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Brought to Ospital ng Makati, wounds
dressed, X ray done, ATS, TeANA given, THOC
to PGH secondary to lack of funds
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(-) 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)
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(-) 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
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No known medical illness in the family
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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
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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
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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
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Fx: Open complete comminuted distal third
femur (L) secondary to VC
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Therapeutics:
Cefazolin 1g IV LD then 1g q8
Gentamycin 240mg IV OD
Long leg posterior splint
Surgical Plan:
Debridement
Skeletal traction
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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
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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
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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
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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
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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.
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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
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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
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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
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Contamination
 Exposure to soil, water, fecal matter, oral flora
 Gross contamination on PE
 Delay in treatment > 12 hrs
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Signs of high-energy mechanism
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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
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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
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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
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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
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Irrigation and debridement
Removal of foreign bodies
Fracture stabilization
Soft tissue coverage and bone grafting
Limb salvage
EXTERNAL FIXATION
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Severe contamination: any site
Periarticular fractures
 Definitive
▪ Distal radius
▪ Elbow dislocation
▪ Selected other sites
 Temporizing
▪ Knee
▪ Ankle
▪ Elbow
▪ Wrist
▪ Pelvis
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Distraction osteogenesis
In combination with screw
fixation for severe soft tissue
injury
INTERNAL FIXATION
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Periarticular fractures
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Distal/proximal tibia
Distal/proximal femur
Distal/proximal humerus
Proximal ulnar radius
Selected distal radius/ulna
Acetabulum/pelvis
Diaphyseal fractures
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Femur
Tibia
Humerus
Radius/ulna