Dr.Farzad Ravari MPH, M.D Specialist Orthopedic Surgeon CEDARS J.A intl.Hospital

AA……………. Airway BB………….….Breathing CC……….…….Circulation DD………….….Digestive EE……………..Excretory FF……………..FX GG………..…..Glascow coma scale HH……………..Homeostasis II……………….Immobilization JJ……….……..Journey(shifting of patient)

EYE RESPONSE 4-Opens eyes on own 3- Opens eyes when asked to in a loud voice 2-Opens eyes when pinched 1-NIL VERBAL RESPONSE 5-ORIENTED 4-CONFUSE 3-INAPPROPRIATE WORDS 2-INCOMPREHENSIVE WORDS 1-NIL MOTOR RESPONSE 6-OBEY 5-LOCALIZED RESP TO PAIN 4-WITHDRAWAL FROM PAIN 3-FLEXION RESP. TO PAIN 2-EXTENSION RESP. TO PAIN 1-NIL

fractures CLOSE OPEN

 BUCKLE FX…..NO CORTICAL DISRUPTION

 One cortex disrupted

 Both cortexes disrupted

 Alignment of bone trabecular disrupted

 When FX site expose to outside  Type 1=puncture wound….. Primary ORIF  Type 2 =< 5 cm………………Primary ORIF  Type 3=>5 cm…………………Primary ORIF  Type 3 A>>> skin coverage ok…” “  Type 3 B >>>no coverage…EXT Fixation  Type 3 C>>> N/V Injury… IF or EF+Repair of N/V

 All Fx & DX that associated with N/V compromise are emergency  Dx of major joint,knee, hip, shoulder, elbow  FX with severe displacement that cause compression of N/V,fx of femoral neck in <30 YO due to risk of AVN should be fixed within h  Open Fx esp. if bone is exposed

TRUE ORTHOPEDIC EMERGENCY

 Compartment syn. is life & limb threatening condition  When perfusion pressure< tissue perfusion  VVVVVVVVVVVVVVVVVVV  reduce tissue perfusion  vvvvvvv  CELL DEATH

A-Increase compartment contents due to: 1.Trauma,FX, hemorrhage 2.Intensive muscle use such as (tetanus, vigorous exe., seizure) 3.Art/Ven obstruction 4.Intra /art injection 5.rabdomyolysis 6.envenomation 7.burns B-Increase Compartment size & pressure due to : 1.Burns(circumferential) 2.casts 3.Military anti shock trouser

Venus pressure If >capillar y perfusion CAPILLAR Y COLLAPSE TISSUE HYPOXIA -CELL DEATH -Deg. Of sacroplasm -release Na,K,Ca,myoglobin - cellular swelling -Capillary leakage

 Male =7.3/  Female=0.7/  Most common in tibial FX

If untreated  Tissue necrosis  Limb impairment If severe Renal failure Deatheath

Tissue perfusion Capillary perfusion Pressure 25mm/h g Interstitia l Fluid perssure 4- 6mm/hg If intra comp.pressure>30 cause comp.syn.

 >48mm/hg if head on arm  178 if forearm under ribcage  72 if legs folded & crossed

 P…….pain  P…….paresthesia  P…….pallor  P…….paralysis  P…….pulselessness

 Capillary filling decrease  PST..passive stretch test ++++

 Don’t elevate limb>>>>that decrease art. Blood flow  Irreversible nerve damage after 6H  Remove all ext.pressure,cast, bandage, cotton,dress,…  Anti inflamatory +CS

 Clinical finding  Pressure within mm/hg/D.B.P  Rising tissue pressure  Significant tissue injury or high risk patient  More than 6h total limb ischemia

 Missed compartment syndrom> h  Due to severe muscle necrosis risk of infection is too high

 Volkman contracture  Weak dorsiflexors  Claw toes  Sensory loss  Chronic pain  Amputation