Traumatic Brain Injuries Dr. Arif Baradia M. Med (Ortho) Supervisor: Professor Mwangombe

What is Traumatic Brain Injury?

PROCESS not EVENT PRIMARY and SECONDARY BRAIN INJURY Penetrating or Non-penetrating

Epidemiology 1.5 m per year MVA 45% Falls30% Occupational10% Recreational10% Assault 5% Role of Alcohol

Epidemiology 40-60% of head injured patients have extremity injury 32,000-48,000 head injury survivors with orthopaedic injuries annually

Pathophysiology of Head Injury Monroe - Kellie doctrine CSF 10% BRAIN 80% BLOOD 10% Rigid “Box” Aka The Skull

Cerebral Blood Flow 15% C.O 750ml/min CPP = MAP – ICP maintain above 70 mmHg

Mechanisms of Brain Injury 1.Brain Contusion 2.Raised ICP 3.Diffuse Axonal Injury 4.Stroke

1.Brain Contusion cell death + hemorrhage The contusion often occurs at a site distant from the point of impact

2.Raised ICP

Raised ICP Brain Oedema/Swelling Extra-dural Hematoma Sub-Dural Hematoma

Brain Oedema

Extra-dural Hematoma

Subdural Haematoma

3. Diffuse Axonal Injury

Secondary Brain Injury Excitatory Neurotransmitters Calcium/Sodium Influx Phospholipases Proteases Cell mb integrity Cell function Cell viability + water = cytotoxic edema Arachidonic Acid Prostaglandins Thromboxanes Leukotrienes

Overview Initial evaluation Prognosis Management of Head Injury Orthopaedic Issues – Operative vs. nonoperative treatment Timing of surgery methods – Fracture healing in head injury – Associated injuries – Complications

Initial Evaluation Pre-Hospital care Emergency Department ATLS protocol Primary Survey Secondary survey History Physical Exam – GCS 13, xT, xTP Imaging

ABCDE GCS < 9 – intubate Hyperventilation, 100% Oxy sat BP > 90mmHg Pupils GCS ICP monitoring

Hyperosmolar therapy – Mannitol 0.25 – 1 g/kg infusion – Hypertonic saline – Albumin HCT 30 – 33% PaCO2 – 35 +/- 2 mmHg CVP 8 – 14 mmHg Avoid dextrose IV Maintain euthermia or hypothermia

Role of Orthopedic Surgeon Resuscitation Treatment Methods/Timing Associated injuries Complications

1. Damage Control Surgery Goal – Limit ongoing hemorrhage, hypotension, and release of inflammatory factors – Limit stress on injured brain – Initial surgery <1-2 hrs limit surgical blood loss

Methods – Initial focus on stabilization External fixation Limited debridement Limited or no internal fixation or definitive care – Delayed definitive fixation (5-7 days)

2. Resuscitation: Role of Orthopaedics Goal: limit ongoing hemorrhage and hypotension – pelvic ring injury-- external fixation reduced mortality from 43% to 7% (Reimer, J Trauma, ‘93) – open injury--limit bleeding – long bone fracture--controversial

Long Bone Fracture in the Head Injured Patient Early fixation (<24 hours) well accepted in the polytrauma patient In the head injured patient early fixation may be associated with – hypotension– elevated ICP – blood loss/coagulopathy – Hypoxia – Fat embolism Advocates of early and delayed treatment

Early Osteosynthesis Hofman ‘91, Poole ’92, McKee ’97 – either no difference or lower mortality and GOS Bone ‘94, Starr ‘98 – delayed fixation worse mortality and 45X pulm complications

Delayed Osteosynthesis Reynolds ’95, Jaicks ’97, Townsend ‘98 – more hypotension i.e. more fluid resusc needed, lower discharge GCS

Fracture Care Decided on a case by case basis but surgery is often optimal – Alignment – Articular congruity – Early rehabilitation – Facilitated nursing care Non-operative fracture care

BUT Minimise – Hypotension – Hypoxia – Elevated ICP – Adequate fixation

3. Bone Healing ?enhanced bone healing? – Exuberant callus – Heterotopic ossification Humoral osteogenic factors released by the injured brain - Klein et al ‘99 ?prolactin – Wildburger et al ?Growth Factor – Bidner et al Union rates not significantly affected while malunion rates increased

Heterotopic Ossification

Formation of lamellar bone inside soft tissue structures where bone does not normally exist 1)inciting event 2)signal from the site of injury 3)supply of mesenchymal cells whose genetic machinery is not fully committed 4)environment which is conducive to the continued formation of new bone

Associated with ventilator dependency Avoid periarticular procedures Use approaches/techniques less associated with H.O. Prophylaxis RT – single dose within 48 hours of surgery Indomethacin – 25 mg tds for 6 weeks Excision

Occult Injuries Fractures, dislocations and peripheral nerve injuries may be “missed” – Up to 11% of orthopaedic injuries may be “missed” – Peripheral nerve injuries are particularly common (as high as 34%) – Occult fractures in children with head injury are also common (37-82%)

Occult Injuries Detailed physical exam with radiographs of any suspect area due to bruising, abrasion, deformity, loss of motion Consider EMG for unexplained neurologic deficits Bone scan advocated in children with severe head 72 hrs

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