dr.otman siregar spot.(k)spine april 2009 -...
TRANSCRIPT
Limb Threatening InjuriesCan be caused by:
� MVA
� Occupational accident
Domestic accident� Domestic accident
� Open injury
� Closed injury
Limb Threatening Injuries� Is an emergency
situation
� Need accurate diagnosis and prompt treatmentand prompt treatment
Limb Threatening Injuries� Fracture
- Open fracture
- Closed Fracture
Vascular Injury� Vascular Injury
� Compartment syndrome
Fracture� Definition:
structural break in continuity weather of a bone, an epiphyseal bone, an epiphyseal plate, or a cartilaginous joint surface
� Fracture also mean soft tissue injury
Fracture DiagnosisPatient History, ask about
� Pain
� Deformity
Time of injury
� Mechanism of injury:
- Fall
- Direct blow
- Road accident� Time of injury - Road accident
- Gun Shot Wound
- Often lack of detail
Fracture Diagnosis� Always do Primary Survey (ABC)
� General condition
� Local Condition:
- Look- Look
-Feel
-Move
� Principle: DO NO FURTHER HARM!
Fracture DiagnosisLook:
� Local swelling
� Deformity ( angulations, rotation, discrepancy)rotation, discrepancy)
� Discoloration of the skin
� Open wound (size, margin, depth, contamination)
Fracture DiagnosisFeel
� Sharply localized tenderness
� Aggravation of pain and muscle spasm
Crepitation� not necessary� Crepitation� not necessary
� Neurovascular Condition is important
� Always look and feel for other less apparent injuries
Fracture DiagnosisMove
� Not necessary if the deformity is obvious
� Abnormal movement
Usually ROM limited due to pain� Usually ROM limited due to pain
Fracture DiagnosisSpecial Test and measurement
� Allen test: vascular patency in forearm
� True, apparent, and anatomical length
Drawer test ( is better to do it under anesthesia)� Drawer test ( is better to do it under anesthesia)
Diagnostic Imaging� Immobilized the limb before being
subjected to imaging examination
� Plain X ray
CT Scan� CT Scan
� MRI
� angiography
Diagnostic ImagingX ray : Rules of two
� 2 joint
� 2 projection
2 extremities (paediatric)� 2 extremities (paediatric)
� 2 densities (able to differ hard and soft tissue)
Special projection may be necessary
Diagnostic Imaging� CT Scan and MRI can
provide useful additional data especially for pelvis and spinal injuryand spinal injury
� Angiography is performed if vascular injury is suspected
� Doppler duplex sonogram
Descriptive Term Pertaining to
Fractures� Site
-diaphyseal, metaphyseal, epiphyseal or intraarticular
� Extent
- Complete or incomplete- Complete or incomplete
� Configuration
-transverse, oblique or spiral
-comminuted or segmental
� Relationship of the fracture fragments to each other
-translated,angulated,rotated,distracted,overriding, impacted
Descriptive Term Pertaining to
Fractures� Relationship of the
fracture to the external environment
-open or closed-open or closed
� Complications
-uncomplicated or complicated
Complications of Musculoskeletal
InjuriesClassified as :
� Initial (immediate) complications
- Local and Remote
Early� Early
-Local and remote
� Late complications
-Local and remote
Complications of Musculoskeletal
InjuriesInitial Complication:
� Local complication
-Skin injuries (from within or without)
-vascular injuries (artery or vein, division, contusion or -vascular injuries (artery or vein, division, contusion or spasm)
-neurological injuries (brain, spinal cord, peripheral nerve)
-muscular
-visceral
� Remote complication
-multiple injuries and hemorrhagic shock
Complications of Musculoskeletal
InjuriesEarly Complication
� Local complication
-Skin necrosis, gangrene, compartment syndrome, compartment syndrome, etc
-Joint complication (septic arthritis)
-Bony complications (Osteomyelitis or avascular necrosis)
Complications of Musculoskeletal
InjuriesEarly
� Remote Complications
-Fat embolism
-Pulmonary embolism-Pulmonary embolism
-Pneumonia
-Tetanus
-Delirium Tremens
Complications of Musculoskeletal
InjuriesLate Complications
� Local Complication
-Joint: stiffness, degenerative arthritis
-Bony: abnormal fr healing, growth disturbance, chronic -Bony: abnormal fr healing, growth disturbance, chronic osteomyelitis
-Muscular :myositis ossificans, late rupture tendon
-Neurological : Tardy nerve plasy
Complications of Musculoskeletal
InjuriesLate
� Remote complications
-Renal calculi
-accident neurosis-accident neurosis
An open An open
fracture fracture
indicates …indicates …
… a communications
between the fracture between the fracture
and the external
environment …
Classification
• Gustillo / Anderson 1976
• Oestern & Tscherne 1984
Open Fractures
AO Courses Jakarta 2008
• Oestern & Tscherne 1984
Gustillo / AndersonOpen Fx.
• Gustillo I
• skin lesion < 1cm
• skin perforation inside out
• minimal muscle contusion
• simple fracture pattern• simple fracture pattern
• Gustillo II
• skin lesion > 1cm
• limited soft tissue damage
• no degloving
• simple fracture pattern
Gustillo RB (1984) J Trauma;24:742-6
Gustillo / AndersonOpen Fx.
• Gustillo III A• Extensive soft tissue damage (skin, muscles,
neurovascular strucures) with still sufficient
bone coverage (periosteum)
• Gustillo III B• Gustillo III B• Extensive soft tissue damage with periosteal
detachment and exposed bone
• Massive contomination of the wound
• Gustillo III C
• Vascular injury to be reconstructed
Erfurt algorithm
• remove wound dressing only in OR
• foto documentation
• debridement
management of open fx.
• fracture fixation (FixEx)
• leave the wound open or
• temporary wound coverage by
� skin substitute or
� vacuum therapy
Mechanisms of Vascular Injury in
the Extremities
� Gunshot wound – 54%
� Stab wound – 15%
� Shotgun wound – 12%� Shotgun wound – 12%
� Blunt trauma – 15%
� Iatrogenic – 3%
Presentation of Vascular Injury
� First priority is hemorrhage control followed by control followed by appropriate diagnostic work-up
Presentation of Vascular Injury� Dislocations and
displaced or angulated fractures: realigned realigned immediately if vascularity is compromised
Evaluation for Vascular Injury� Physical Examination� Doppler Flowmeter� Duplex Ultrasonography� Arteriogram� Local wound exploration should not be � Local wound exploration should not be
done in an uncontrolled setting� Close coordination with a general or
vascular surgeon recommended
Physical Examination
Hard Signs
� Absent or diminished distal pulses
� Active hemorrhage
� Large, expanding or pulsatile hematomaLarge, expanding or pulsatile hematoma
� Bruit or thrill
� Distal ischemia (pain, pallor, paralysis, paresthesias, coolness)
Physical Examination
Soft Signs
� Small, stable hematoma
� Injury to anatomically related nerveInjury to anatomically related nerve
� Unexplained hypotension
� History of hemorrhage no longer present
� Proximity of injury to major vessel
Doppler Examination
� Non-invasive adjunct to physical examination� Small, hand-held (non-directional) Doppler
flowmeter provides for subjective interpretation of flowmeter provides for subjective interpretation of audible signal
� Useful as modality for determining the Ankle-Brachial Index (ABI)
Arteriography� Gold standard for evaluation of peripheral vascular
injuries
� Formal arteriograms done in radiology may cause critical delays in diagnosis or interventioncritical delays in diagnosis or intervention
� Single-shot arteriograms done in the emergency room or operating room should be considered in cases where arteriography is indicated.
Indications for Arteriography� Multiple potential sites of injury (shotgun wounds)� Missile track parallels vessel over long distance� Blunt trauma with signs of vascular trauma� Chronic vascular disease� Extensive bone or soft tissue injury� Extensive bone or soft tissue injury� Thoracic outlet wounds� Evaluation of equivocal results from non-invasive
tests� Proximity (gsw, knife wound) (controversial)� ABI < .9
Compartment SyndromeDefinition
� Elevated tissue pressure within a closed fascial space
� Reduces tissue perfusion� Reduces tissue perfusion
� Results in cell death
� Pathogenesis
� Too much inflow (edema, hemorrhage)
� Decreased outflow (venous obstruction, tight dressing/cast)
Compartment SyndromeHistorical Review
� Late complications of ischemic contracture� Volkmann, 1881
� Ischemia of forearm
venous stasis leading
to irreversible contracture to irreversible contracture
� Ellis, 1958; Seddon, 1966� Lower extremity
� Retrospective reviews � Advised the early recognition of the syndrome and
fasciotomies of the affected limbs
Compartment SyndromeTissue Survival
� Muscle� 3-4 hours - reversible changes
� 6 hours - variable damage� 6 hours - variable damage
� 8 hours - irreversible changes
� Nerve � 2 hours - looses nerve conduction
� 4 hours - neuropraxia
� 8 hours - irreversible changes
Compartment SyndromeEtiology
� Fractures-closed and open
� Blunt trauma
� Exertional states
� GSW
� Temp vascular occlusion
� Cast/dressing
� Closure of fascial defects
� Burns/electrical
� IV/A-lines
� Hemophiliac/coag
� Intraosseous IV(infant)
� Snake bite
� Arterial injury
Compartment SyndromeDiagnosis
� Pain out of proportion
� Palpably tense compartment
� Pain with passive stretch� Pain with passive stretch
� Paresthesia/hypoesthesia
� Paralysis
� Pulselessness/pallor
Compartment SyndromeDifferential diagnosis
� Arterial occlusion
� Peripheral nerve injury
� Muscle rupture
Compartment SyndromeEmergent Treatment
� Remove cast or dressing
� Place at level of heart
(DO NOT ELEVATE to optimize (DO NOT ELEVATE to optimize perfusion)
� Alert OR and Anesthesia
� Bedside procedure
� Medical treatment
Compartment SyndromeSurgical Treatment
� Fasciotomy - prophylactic release of pressure before permanent damage occurs. Will not reverse injury from trauma.
� Fracture care – rigidstabilization
� Ex-fix
� IM Nail