emergency management and decision making for complex trauma
TRANSCRIPT
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17th Annual Hand Surgery Symposium
Hand Rehabilitation Foundation
Philadelphia, March 7-9, 2015
Daniel A. Rikli, MD
University Hospital
Basel, Switzerland
Emergency Management
and Decision Making
for Complex Trauma
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Features of Evolution
• Grey substance
• Upright gait
• Thumb Opposition
• Pro/Supination
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Task of the Upper Extremity
Positioning of
the Hand
in the Space
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Goal of treatment
• Functional restoration of
• The hand
• The «motor chain» that positions the
hand in space
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Long Term Loss of Function
• Loss of soft tissue
• Neurological impairment
• Stiffness of joints
• Bone: defects, infection
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Wilhelm Conrad Röntgen *27.3.1845 +10.1.1923
1895: Discovery of
„X-ray‘s“
2015: „X-ray“ single
criteria to base
treatment decisions on
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« a fracture is a soft-
tissue injury in which
the bone happens to
be broken…»
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« a fracture is a soft-
tissue injury in which
the bone happens to
be broken…»
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Assessment
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Polytrauma Pathophysiology
Trauma
Bleeding
Hypoxemia
Soft Tissue Damage
Direct Injury to Organs
Mass Transfusion
Shock-
Systemic Reaction
(„host defense response“)
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Polytrauma: Definition
„Systemic Surgical Desease“:
Multiple injuries of high severity (ISS>17) introducing a Systemic Inflammatory Response that can eventually lead to failure of remote organs initially not injured
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Life before Limb
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ATLS
A Airway maintenance w/ c-spine protection
B Breathing and ventilation
C Circulation w/ hemorrhage control
D Disability: Neurologic status
E Exposure / Environmental control: completely
undress the patient, prevent hypothermia
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Plastic Surgeon
Trauma Surgeon
Orthopedic Surgeon Anesthesiologist
Neurosurgeon
Subspecialists
Intesivist
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„Local Crush Injury“
2nd priority in
acute phase
Can promote
systemic response
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Mechanism of Injury
• Fall, MVA, Assault etc.
• Amount of energy involved
• Blunt vs. penetrating injury
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Assessment of extremity
• Neurovascular status
• Loss of skin/soft tissue
• Fractures
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Classification systems
• Open Fractures
• Closed Soft Tissue Injury
• Injury to nerves and vessels
• Injury to muscles and tendons
• «mangled extremity» scores
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Open Fractures
I
II
III
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Infection
Grad I 0-2%
Grad II 2-7%
Grad III A 7%
B 10-20%
C 25-50% Gustilo, J Trauma 1984
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Treatment Principles in Open Fx
Soft Tissue Débridement
• Senior surgeon, radical, repeated
Early Definite Soft Tissue Cover
• Day 2 or 3
Stabilisation of Bony Injury
• Ex Fix, early exchange Internal Fixation
Antibiotics
• Prophylactic for I/II°, Therapy for III°
Godina 1986, Najean 1996, Hertel 1999
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• Wound:
• Thorough mechanical cleansing
• Excise of avital tissues, repeate within 24h
• Bone:
•Remove all devitalised small fragments
•Keep large fragments, if important for stability
•Keep fragments with soft tissue bridge
Débridement
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High Energy Injury
• Primary Bone Loss
• Comminution
• Open Injuries,
Contamination
• Cartilage Damage
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Townsend A 160748 po
4M
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Kadrijaj A 030176
po
3M
Plating and
Bone Graft after
6 W
3M after bone graft
13-B1.3
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• Amputation
• Non-Union
• Poor functional and cosmetic results
Open Fx: Infection = main reason for
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Open Fractures Infection
n Infection
Upper Extremity 64 2 (3%)
Lower Extremity 174 30 (17%)
Roth, J Trauma 1986
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Hrs p/Injury bacteria/g tissue
2.2 <10 2
3 10 2 - 10 5
5.1 >10 5
Robson et al., J Surg Res 1973
Open Fractures Time factor
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Open Fx: secondary contamination
• Wound covered w/sterile
dressing immediately: 4.3%
• Wound left open
until OR: 18.2%
Tscherne 1983
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• Vascular
reconstruction
• Repeated
debridements
• Compartment!
• Ex Fix
• Nerve
Reconstruction?
CHARITE
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Reconstruction of
axillary artery and vein
Temp. Stabilisation
of Bone w/ Ex Fix
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External fixator
Temporary cover with
artificial skin
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Therapists
Upper Extremity
Surgeon
Rehabilitation
Specialists Psychologists
Social
environment
Subspecialties
Pain Specialists
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Penetrating Injury
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Closed Soft Tissue Injury
direct vs.indirect
w/ or w/o fracture
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IC1 no or minimal
IC2 Bruising, Contusion
IC3 local Degloving
IC4 extensive Degloving;
Compartment-Sy.
IC5 Skin Necrosis
Closed Soft Tissue Injury
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Classification: Muscle / Tendon
1 comp. 2 comp. Defect, Tear,
Contusion
Crush, Comp.-
Syndrome
none
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Classification: neurovascular
none Nerv
isolated
Vessel
local
Amputation Vessel
segmental
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Degloving
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Diagnostik
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Diagnostics?
X-Ray?
Sonography?
MRI?
Blood Tests?
Clinical
Assessment!
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Compartmentsyndrome
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Compartmentsyndrom Forearm
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Compartmentsyndrome Hand
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Summary
• Complex Trauma = High Energy
• Goal: Restore Function
• Life before Limb: ATLS
• Soft Tissue >>> Bone
• Multidisciplinary Approach
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