Trauma Spring 2012 FINAL

Some Trauma Stats Most common cause of death for those 1-44 years of age Medical costs for trauma 200 billion annually Mostly results from MVA, unintentional accidents, gunshot wounds, stabbing, fights, domestic violence

Trimodal Distribution Immediate Early Late

Immediate Deaths Lacerations of the brain and spinal cord heart or great vessels

Early Deaths Within first 4 hours Intracranial hemorrhage Lacerations of liver or spleen Significant blood loss Liver laceration with extravasation. An enhanced axial CT scan of the upper abdomen shows a large laceration through the right lobe of the liver (blue arrow), blood in the peritoneal cavity (black arrows) and active extravasation of the intravenous contrast (red arrow). The stomach is labeled "S." Liver laceration with extravasation

Weeks after injury Infection and multiple organ failure Late Deaths

Level I, II & III Trauma Centers Usually in large metro areas and serve as both primary and tertiary care institutions Must be avail 24 hrs Must treat 1200 admissions or 240 major trauma patients per year Level II Can transport to level I when necessary Serve smaller cites and towns Must be avail 24 hrs Level III Remote and rural areas On call on nights and weekends

Skeletal Trauma

Fracture Classifications

FRACTURE TYPES

Closed reduction

Open Reduction

OPEN FRACTURES

Open Fracture Bone has penetrated skin May lead to infection Precautions must be taken to prevent infection from setting into the bone

Closed Fracture Skin is not penetrated Fractures can be classified by the mechanics of the stress that caused the break Torsion Transverse linear Spiral

Closed Fracture- Clavicle

Forearm Closed fracture

Impacted Fracture- Wrist When the fractured bone is jammed into the cancellous tissue of another fragment

Impacted Fracture- Hip

Fibular Impacted Fracture

Comminuted Fracture Do not represent the full thickness of the bone. Usually extensively shattered Particularly apt to be open fractures

Comminuted Fracture

Comminuted Fracture

Non-Comminuted Fracture

Non-Comminuted Fracture Complete fracture in which the bone is separated into to fragments Can be classified according to the direction of its fracture line Spiral or oblique Transverse

Avulsion Fracture Fragment of the bone is pulled away from the shaft Occur around the joints because of ligaments, tendons, muscles, associated with sprain or dislocation

Avulsion Fracture

Avulsion Fracture

Incomplete Fracture Part of bony structure gives way with little no displacement Common example is a greenstick fracture Torus fracture

Greenstick :Incomplete Fracture Cortex breaks on one side without separation or breaking of the opposite cortex Found almost exclusively in children under the age of 10

Incomplete Fracture

Greenstick Fracture

Greenstick Fracture

Greenstick Fracture

Torus: Incomplete Fracture AKA Buckle Fracture It is a greenstick fracture Cortex bulges outward producing a slight irregularity

Torus Fracture

Growth Plate Fracture Involve the end of the long bone Not visible unless displacement occurs Classified according to severity Salter-Harris System I-IV Based on degree of epiphysis involvement

Growth Plate Fracture

Growth Plate Fracture

Stress Fracture Results from an abnormal degree of repetition Generally found where muscle attachments are EX: runners at tib/fib Not always seen on plain x-ray

Stress Fracture

Stress Fracture

Occult Fracture Gives clinical symptoms without radiologic evidence 10 days later may show repairing itself or displacement

Occult Fracture

Occult Fracture

Colles Fracture Fracture through distal inch of the radius Distal fragment angled backward on the shaft Impaction along dorsal aspect Avulsion fx of the styloid process

Colles Fracture

Boxer’s Fracture

Monteggia’s Fracture Fx of the proximal 1/3 of the ulnar shaft

Galeazzi Fracture Occurs at proximal radius with a dislocation of the distal radial-ulnar Joint

Pott’s Fracture Both malleoli Dislocation of the ankle joint Trimalleolar fx Medial and post. malleoli of the tibia and lat. Malleolus of the fibula

Pott’s Fracture

Maisonneuve Fracture Severe ankle sprain Disruption of the syndemosis between the distal tibia & fibula Fracture at prox third of the fibula, often missed

Maisonneuve Fracture

Fat Pad Sign No definitive fx is seen but the fat pads indicate an underlying fracture

Dislocations

Dislocations

Subluxation

Subluxation

Skeletal Trauma Suspicious for Child Abuse Distal femur, wrist, ankle Metaphyseal corner fractures Multiple Fx’s in different stages of healing Femur, humerus, tibia Spiral fx’s <1 year old Multiple skull fx’s Occipital bone Post ribs, avulsed spinous processes, metacarpal & metatarsal fx’s, sternal& scapular fx’s, vertebral body fx’x and subluxation Unusually naturally occurring fx’s <5 years old Fx’s with abundant callous formations Implies repeated trauma with no immobilization

Battered Child Syndrome Frontal radiograph of the chest demonstrates multiple rib fractures with callous formation, including a fracture of the left 2nd and 6th ribs posteriorly. Posterior rib fractures are highly suggestive of child abuse (from forceful squeezing)

Battered Child Syndrome

Battered Child Syndrome

Battered Child Syndrome

Trauma of Chest and Thorax

PNEUMOTHORAX Common causes include a penetrating would such as: gun shot stabbing fractured ribs, thoracentesis

Atelectasis Refers to a condition with diminished air within lungs associated with reduced air volume. Most commonly this results fro a bronchial obstruction. Air cannot enter that part of the lung supplied by the obstructed bronchus. X-ray commonly demonstrates local increase in density caused by airless lung. Thin plate like streaks to lobar collapse. Refers to a condition with diminished air within lungs associated with reduced air volume Incomplete expansion of the lung caused by a partial or total collapse Often occurs from a penetrating wound in the chest

Abdominal Trauma

Abdominal Trauma Can include GI tract, liver, spleen, kidneys, pancreas, aorta and pelvic organs. Initially may show minimal symptoms LLD is best for demonstrating small amounts of air fluid levels Lay on side 10 minutes CT very valuable to catch subtle abnormalities not detected with x-ray

Pneumoperitoneum Presence of air in the peritoneum LG amounts indicate a colon perforation SM amounts indicate a duodenal perforation Can be from trauma rupture or nontraumatic bowel perforation Has a football sign

Pneumoperitoneum

Imaging Considerations Radiography First imaging modality for trauma Portables often used Primary means of evaluating skeletal trauma MRI For muscle, tendons, ligaments and soft tissue

Imaging Considerations CT Is excellent form imaging acute cerebral hemorrhage & fx's of the skull & facial bones Quickly replacing x-ray as the standard for evaluating C-spine trauma Better to visualize transverse processes of L-spine Blunt trauma to abdomen can use CT or US CT preferred for urinary trauma Sometimes angio is used