Musculoskeletal Trauma Cambridge Trauma weekend 2011 Mr Lee Van Rensburg

Fatal accident deaths England and Wales ~ 5 years  Swimming 191  Boating/sailing 69  Motor sports 65  Horse riding 62  Air sports 51  Mountaineering 51  Fishing 50  Soccer 14  Running/jogging 9  Badminton 3  Cricket 2  Hockey 2  Rugby 2  Golf 1  Gymnastics 1  Tennis 1

Musculoskeletal Trauma Life threatening Limb threatening

Musculoskeletal Trauma Life threatening Major pelvic disruption with haemorrhage Major arterial haemorrhage Crush syndrome (rhabdomyolysis) Limb threatening

Musculoskeletal Trauma Life threatening Limb threatening Open Fractures, joint injuries Vascular injuries Compartment syndrome Neurologic injury

Life Threatening Injuries Major pelvic disruption with haemorrhage Major arterial haemorrhage Crush syndrome (rhabdomyolysis)

Anatomy

Binding of book

Pelvis

Pelvic injury 3 patterns Anterior posterior compression (APC) Lateral compression Vertical shear

APC

Lateral Compression

Vertical shear

3 pelvic injuries

Treatment Emergency Definitive

Treatment Emergency Resuscitation ATLS Fracture pattern –Pelvic binder –External fixation - anterior –C Clamp - posterior –Traction Angiography - embolisation Pelvic packing Definitive

Treatment Emergency Resuscitation ATLS Fracture pattern –Pelvic binder –External fixation - anterior –C Clamp - posterior –Traction Angiography - embolisation Pelvic packing

Emergency

At level of greater trochanters and the symphysis pubis Pelvic binder

Splinting Lower Limbs

54 hours in binder

Emergency

Binder and traction limb

C Clamp

Angiography

Pelvic packing

Complex/ combination

Urethral injury Blood at meatus Frank haematuria Perineal haematoma Scrotal/ penile haematoma High riding prostate

Complications

Life Threatening Injuries Major pelvic disruption with haemorrhage Major arterial haemorrhage Crush syndrome (rhabdomyolysis)

Major Arterial Haemorrhage Penetrating / blunt injury in close proximity to artery Haemorrhage, haematoma, hypotension Ischaemic extremity Stop the bleeding!

NeurovascularNeurovascular

Crush Syndrome Myoglobinuria Metabolic acidosis,  K +,  Ca ++ and coagulopathy IV fluids, alkalisation of urine

Limb-Threatening Injuries Open Fractures, joint injuries Vascular injuries Compartment syndrome Neurologic injury

Open Fractures, Joint Injuries Wide spectrum of soft-tissue injury Open wound = Open fracture

Open Fractures, Joint Injuries Treatment –Antibiotics? –Wound swab ???? –Photograph –Sterile dressings (betadine or saline) –Splint – REDUCE YES, DOCUMENT –Tetanus prophylaxis –Surgical debridement Co-amoxiclav 1.2g, 8 hrly Or Cefuroxime 1.5g, 8 hrly Penicillin allergy Clindamycin 600mg, 6 hrly

Vascular Injury, Amputation Variable presentation: Assess pulses Associated with fractures / dislocations Realign Check pulses after splinting Immediate surgical consult

Keep moist Keep cool Don’t freeze Don’t macerate

Compartment Syndrome

 Compartment pressure Nerve / muscle ischaemia  necrosis NO 5 P’s Pain, Pain passive stretch Elevate (level of heart) Release constricting devices (keep splint) Suspect tibial, forearm fractures after revascularisation in unconscious patient Early surgical consult

Compartment syndrome Pitfalls Simple transverse tibial fracture Open fractures Depressed level of consciousness Pressure 30mmHg ΔP (Diastolic – compartment) > 30mmHg

Neurologic Injury Due to fracture / dislocation –Anterior shoulder: Axillary nerve –Posterior hip: Sciatic nerve Recognise injury and immobilise Early surgical consult Careful reduction, if possible,  reassess and splint

Damage Control Orthopaedics Beyond ATLS

SR 21 YO, Male 13/05/ H50 ISS 57ISS 57 SAH, DAISAH, DAI R HaemothoraxR Haemothorax Pelvic ring fracturePelvic ring fracture –(Dissociation R hemipelvis) # L Acetabulum# L Acetabulum # L Femur# L Femur Compartment syndrome both lower legs and thighsCompartment syndrome both lower legs and thighs

Theatre - 1 hr arrival LaparotomyLaparotomy –Pelvis packed, Vac dressing C clamp and pelvic ex fixC clamp and pelvic ex fix AngiogramAngiogram EmbolisationEmbolisation

EVD 14/05/06 – 20:45

Theatre 14/05 08h20 Retrograde femoral nailRetrograde femoral nail FasciotomyFasciotomy Both thighs both calvesBoth thighs both calves

15/05/06 AngiogramAngiogram IVC filterIVC filter Repeat bleedingRepeat bleeding Laparotomy change of packsLaparotomy change of packs Bladder repairBladder repair Pubic symphysis ORIFPubic symphysis ORIF

Theatre 15/05/06 AngiogramAngiogram IVC filterIVC filter Repeat bleedingRepeat bleeding Laparotomy change of packsLaparotomy change of packs Bladder repairBladder repair Pubic symphysis ORIFPubic symphysis ORIF 2 hour rewarming on table2 hour rewarming on table

Theatre 15/05/06 Removal of C clampRemoval of C clamp Anterior platingAnterior plating R Sacroiliac jointR Sacroiliac joint Debridement washout closure C clamp and Ex fix woundsDebridement washout closure C clamp and Ex fix wounds

Theatre Vac dressing change 17/05/06Vac dressing change 17/05/06 Closure of thigh woundsClosure of thigh wounds Vac dressing change 23/05/06Vac dressing change 23/05/06 Closure of L lower leg woundClosure of L lower leg wound Vac dressing change 28/05/06Vac dressing change 28/05/06 Closure R lower leg woundClosure R lower leg wound

Theatre 30/05/06 Planned ORIF acetabulumPlanned ORIF acetabulum Wound breakdownWound breakdown L iliac crestL iliac crest Both thighsBoth thighs Washout and vac dressingsWashout and vac dressings

JM 20 YO, Male 27/02/06 – 15:48 #BOS#BOS #Nasal bone#Nasal bone APC pelvic injuryAPC pelvic injury # R Supracondylar femur# R Supracondylar femur # R Tibia shaft (open)# R Tibia shaft (open) # L Tibial plateau (open)# L Tibial plateau (open) # Bimalleolar L ankle# Bimalleolar L ankle

Pre hospital Intubated through windowIntubated through window Pre hospital arrestPre hospital arrest Hr 144, Systolic 60Hr 144, Systolic 60 GCS 3GCS 3

Pre theatre CT brainCT brain BOSBOS AngiogramAngiogram Very small bleeder embolisedVery small bleeder embolised

Theatre 27/05/06 External fixatorExternal fixator PelvisPelvis R legR leg L legL leg Debridement washout, fasciotomy and vac dressingDebridement washout, fasciotomy and vac dressing R thighR thigh R lower legR lower leg L lower legL lower leg LaparotomyLaparotomy EVDEVD

Theatre – 01/03/06 Plating pubic symphysisPlating pubic symphysis Intramedullary nailIntramedullary nail R femur retrogradeR femur retrograde R tibiaR tibia Change of VacsChange of Vacs

Theatre 05/03/06 ORIF L Tibial plateauORIF L Tibial plateau ORIF L fibulaORIF L fibula Free Flap R tibiaFree Flap R tibia Rotation flap L TibiaRotation flap L Tibia

Theatre 23/03/06 Debridement and SSG L AnkleDebridement and SSG L Ankle Medial sideMedial side

Questions