1. Musculoskeletal Trauma Cambridge Trauma weekend 2011 Mr Lee Van Rensburg www.easytrauma.co.uk

4. Fatal accident deaths England and Wales 1988-92 ~ 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

5. Musculoskeletal Trauma Life threatening Limb threatening

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

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

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

9. Anatomy

10. Binding of book

11. Pelvis

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

13. APC

14. Lateral Compression

15. Vertical shear

16. 3 pelvic injuries

17. Treatment Emergency Definitive

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

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

20. Emergency

21. At level of greater trochanters and the symphysis pubis Pelvic binder

22. Splinting Lower Limbs

23. 54 hours in binder

25. Emergency

27. Binder and traction limb

28. C Clamp

33. Angiography

35. Pelvic packing

39. Complex/ combination

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

44. Complications

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

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

47. NeurovascularNeurovascular

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

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

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

53. 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

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

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

59. Compartment Syndrome

60.  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

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

64. 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

65. Damage Control Orthopaedics Beyond ATLS

66. SR 21 YO, Male 13/05/06 - 23H50 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

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

69. EVD 14/05/06 – 20:45

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

71. 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

72. 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

73. 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

74. 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

75. 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

76. 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

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

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

83. 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

84. 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

85. 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

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

89. Questions www.easytrauma.co.uk