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Author:  Dr. Dylan Goveas, MS (Ortho)

Introduction:

More than 60 percent of injuries involve the musculoskeletal system, and more than half of hospitalized trauma patients have at least one musculoskeletal injury that could be life threatening, limb threatening, or result in significant functional impairment. These orthopaedic injuries are often associated with significant health care costs, decreased  productivity  in  the  workplace,  and,  in some cases, long-term disability. The optimal

Management of trauma patients with orthopaedic injuries requires significant physician and institutional commitment

Basics:

As soon as the patient self presents or is brought by relatives the following information is expected:

  • Age.
  • Gender.
  • Mechanism and type of injury.
  • Heart rate.
  • Blood pressure.
  • Glasgow Coma Scale (GCS)
  • Respiratory rate.
  • Oxygen saturation.
  • Any treatment given.

Before the patient arrives, all members of the trauma team should take steps to reduce the risk of occupational exposure to blood borne diseases such as HIV and hepatitis viruses. This means that, in addition to anti hepatitis immunisation for all trauma team staff, all blood and body fluids should be assumed to be a potential risk. Therefore, gloves, aprons/protective   gowns   and   goggles   should   be worn by each team member during the assessment and treatment of the trauma patient.

Primary Survey:

The objectives of the primary survey, that is, the initial assessment and resuscitation phase, are to identify and correct any life-threatening injuries quickly and efficiently. This will be achieved by following systematic assessment and management of

  • Airway with cervical spine control
  • Breathing and ventilation.
  • Circulation and haemorrhage control.
  • Disability and dysfunction.
  • Exposure and environment control

In addition to this, it should be remembered that, at this stage, actions by the team may have a potential impact on the patient’s later survival

Poor  infection  control  procedures  at  this  stage may lead to the patient developing a potentially life- threatening  sepsis.  The  trauma  team  must  be  aware that initial interventions may affect the whole patient journey.

If the patient is conscious and oriented on arrival, psychological support, including an explanation of what is going to happen, is essential. In addition to the rapid assessment of A, B, C, D, E, a brief history should be obtained using the AMPLE mnemonic:

A = allergies
M = medications
P = past medical history
L = last food/drink
E = events leading to the injury

Airway with cervical spine control:

The airway must be assessed and maintained while the cervical spine is immobilised. It should be assumed that any patient who has suffered a blunt trauma injury may have a cervical spine injury. Therefore, manual in-line immobilisation or full immobilisation using a semi- rigid collar, head blocks and tape is essential. The only exception to this is the combative or restless patient where forceful immobilisation may result in further spinal damage.

A sequential approach to airway assessment is needed:

Talk: Initially the patient should be spoken to, to elicit a response. If the patient can talk it demonstrates that he or she has a patent airway

Look: The doctor should open the patient’s mouth, looking for foreign objects that may be restricting a verbal response Breathing and ventilation:  All trauma patients should be given 100 per cent oxygen (15 litres via an oxygen mask with a reservoir bag) because of the risk of hypoxia caused by chest injury or hypovolaemia. A careful assessment of the chest should be made to detect any potential  or  actual  life-threatening  thoracic  problems that  may  need  urgent  intervention  by  medical  staff, such as insertion of a chest drain for a pneumothorax

The doctor should assess:

  • Respiratory rate  – rapid respirations indicate that a patient who is shocked or in pain. Extremely slow or absent respirations may indicate the need to start artificial ventilation using a bag, valve mask device.
  • Respiratory  depth   –  shallow  breaths  may  be indicative of an injury that is causing pain or a restriction in lung or chest movement.
  • Respiratory symmetry  – breathing that is unequal or asymmetrical may indicate bony rib injury or an underlying pneumothorax.
  • Observe  the  chest  – for any wounds,  bruises or other signs of injury.

Circulation with haemorrhage  control:

The priority here is the assessment of the patient’s circulation and control of haemorrhage.

The doctor should assess:

  • Heart rate – this is an early indicator of the shocked patient. A pulse of more than 100 beats per minute in an adult (or an equivalent tachycardia in a child
  • Blood pressure  a low blood pressure, for example, a systolic blood pressure of less than 100 mmHg in an adult patient, should be viewed as significant until hypovolemic shock can be ruled out or treated.
  • Capillary  refill  time  –  delayed  capillary  refill time of more than two seconds is indicative of hypovolemic shock in the trauma patient.
  • Level   of  consciousness   –  the  patient  who  is anxious, confused or drowsy may be hypoxic and/ or hypovolemic.
  • Disability:  The level of consciousness in a head injured patient should be formally re-assessed using the GCS. If an altered neurological state is identified with a GCS of less than 15, this may be indicative of brain injury.

Exposure    and    environmental   control:     The patient   should   be   fully   undressed   to   allow   a detailed examination. During the primary survey, examination of the anterior and posterior surfaces of the patient should be carried  out to assess for life threatening conditions. To examine the back the patient needs to be log rolled.

ORTHOPAEDIC INJURIES

After the initial examination as above, the local examination is carried out keeping in mind Inspection, Palpation, Movements and Measurements.

Once a clinical diagnosis is made, X rays are asked for besides the other investigations.

X ray Views:

Usually the requested X rays should have the joint above and joint below included.

The following are the X ray views for the upper and lower limbs.

Upper Limbs:

Shoulder: AP / Axial
Humerus: AP / Lat
Elbow: AP / Lat
Forearm: AP / Lat
Hand: AP / Oblique

Lower Limbs:

Hip: Pelvis  with  Both Hips  AP  with  15  degree internal rotation and the respected hip Lateral
Femur: AP / Lat
Knee: AP / Lat
Tibia: AP/ Lat
Ankle: AP/ Mortise / Lat
Foot: AP/ Oblique
Calcaneum: Lat/ Axial

Management of Common Closed Upper limb trauma before referral:

After  the  initial  assessment,  clinical  examination and x-rays the following can be done:

  1. Colles’ Fracture:
    Look  for  radial  artery  pulsation  and  if  possible  a peripheral nerve examination.
    When gross deformity is present, after the administration   of   analgesics,   traction   and   counter traction is given. With fracture reduction swelling gradually comes down. This is then followed by application of a POP splint from proximal to the proximal palmar crease to the elbow. Limb elevation is then advised.
  2. Forearm Fractures:
    Look for soft tissue tightness, Pulselessness, Paraesthesia and stretch pain in view of compartment syndrome. Apply a POP splint above the elbow starting from the MCP joints
  3. Elbow Fractures:
    As above
  4. Humerus fractures:
    U slab
  5. Shoulder fractures:
    Shoulder immobilizer
  6. Clavicle Fractures:
    Figure of 8 bandage

Management of Common Closed Lower limb trauma before referral:

  1. Phalangeal fractures:
    Strapping one toe with the other with a gauge in between for three weeks
  2. Foot fractures:
    Below knee slab
  3. Tibia fractures:
    Look for compartment syndrome and apply above knee POP splint
  4. Knee fractures:
    Look for compartment syndrome and apply above knee POP splint
  5. Femur fractures:
    Thomas Splint ideally or above knee POP splint
  6. Hip fractures:
    Skin Traction

OPEN FRACTURES

  • Open fractures occur when a fractured bone is exposed to contamination from the external environment through a disruption of the skin and subcutaneous tissues and are susceptible to infection
  • Patients with open fractures should receive intravenous   antimicrobials   within  one  hour   of presentation to reduce the risk of infection
  • Patients with Gustilo type 1 or  2 open fractures should receive a first-generation cephalosporin (for example, cefazolin)
  • Gram  negative coverage should be considered in patients with Gustilo type 3 fractures for example, gentamicin
  • Antibiotics should be administered for  no longer than 24 hours after a surgical procedure.
  • In cases of severe contamination, antibiotics may be continued for as long as 72 hours after a surgical procedure.
  • Tetanus toxoid should be administered if the patient had an incomplete primary immunization, if it has been >10 years since his or her last booster dose, or if the immunization history is unknown or un- clear.Tetanus immunoglobulin should be administered if it has been >10 years  since the patient’s last booster dose or if he or she has a history of incomplete primary immunization.
  • Patients  with  open  fractures  should  be  taken  to the operating room for irrigation and debridement within 24 hours of initial presentation whenever possible. Patients with severe fractures associated with gross wound contamination should be brought to the operating room more quickly, and as soon as clinically feasible, based on the patient’s condition and resources available.
  • Whenever  possible,  skin  defects  overlying  open fractures should be closed at the time of initial debridement.
  • When a patient with an open fracture presents to the emergency department, a sterile dressing should be placed over the wound to minimize ongoing wound contamination. Patients with open fractures receive broad-spectrum intravenous antibiotics within one hour of presentation.
  • Open   fractures   with   a   clean   or   moderately contaminated wound less than 10 cm in length without extensive soft-tissue damage, flaps, or avulsions (Gustilo type I and II), a first generation cephalosporin (cefazolin) is recommended.
  • Open fractures associated with wounds greater than 10 cm in length, significant contamination, extensive soft  tissue  damage,  or  significantly comminuted fractures (Gustilo type III), a first generation cephalosporin and another antimicrobial with gram- negative coverage (for example, gentamicin).
  • A minimum of 24 hours of antibiotics should be administered from the start of the surgical procedure. Generally, antimicrobials are discontinued 24 hours after the procedure.
  • Continuation for up to 72 hours may be appropriate for highly contaminated wounds. Antibiotics should not  be  administered  beyond  72  hours  unless  a second  operative  intervention  occurs  within  that time period.
  • Historically, dogma has led orthopedists to treat open fractures with surgical irrigation and debridement within six hours of the injury or risk increased rates of infection.
  • This practice has come to be known as the “six hour rule” in orthopedic surgery.

Compartment Syndrome:

  • Compartment syndrome can result in irreversible tissue damage within six hours of impaired perfusion
  • The   most   reliable   early   clinical   findings   of compartment syndrome are:
  • Pain out of proportion
  • Pain with passive stretch
  • Paresthesia
  • When a compartment syndrome is suspected, early fasciotomies should be performed using long, generous skin and fascial incisions to release all the compartments of the involved limb, and those incisions should be left open at the conclusion of the procedure.
  • Compartment syndrome results in tissue ischemia that worsens with passing time and/or increasing intra compartmental pressure.
  • It is also important to consider that damaged tissue is more vulnerable to increases in intra compartmental pressure

Stages in fracture  management:

  • Initial assessment & first aid
  • X-ray assessment
  • Fracture reduction
  • Stabilization –  Cast immobilization
    Internal fixation
    External fixation
  • Rehabilitation