Trauma muskuloskeletal

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Brittany Wright
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1 Trauma muskuloskeletal

2 Arterial injuries associated with fractures or dislocations Clavicle fracture Shoulder fx/dislocation Supracondylar humerus fx Elbow dislocation Pelvic fracture Femoral shaft fx Distal femur fracture Knee dislocation Tibial shaft fx subclavian artery axillary artery brachial artery brachial artery gluteal arteries femoral artery popliteal artery popliteal artery tibial arteries

$Incidence Overall uncommon 3% of long bone fractures Specific$

3 Incidence Overall uncommon 3% of long bone fractures Specific circumstances Fractures with GSW (up to 38%) Knee dislocations (16-40%)

4 Mechanism of Injury Penetrating trauma GSW Stab Blunt trauma High energy Low energy iatrogenic

5 Consequences of vascular injury Blood loss Ischemia Compartment syndrome Tissue necrosis Amputation Death

6 Prognostic factors Level and type of vascular injury Collateral circulation Shock/hypotension Tissue damage (crush injury) Warm ischemia time Patient factors/medical conditions

7 Speed is crucial Rapid resuscitation Complete, rapid evaluation Urgent surgical treatment PROTOCOL IS ESSENTIAL!

$Cover wounds Reduce fractures/dislocations Splint$

8 Immediate treatment Control bleeding Replace volume loss Cover wounds Reduce fractures/dislocations Splint Re-evaluate

9 Diagnosis Physical exam Doppler pressure (Ankle/brachial systolic pressure index) Duplex scanning Arteriogram Exploration

10 Diagnosis Physical exam Doppler pressure (Ankle/brachial systolic pressure index) Duplex scanning Arteriogram Exploration Careful physical exam and high index of suspicion are most important!

11 Physical exam Major hemorrhage/hypotension Arterial bleeding Expanding hematoma Altered distal pulses Pallor Temperature differential between extremities Injury to anatomically-related nerve

12 Asymmetric pulses warrant doppler examination (determine ABI) Absent pulses warrant emergent vascular consultation/surgical exploration

13 Doppler ultrasound Determine presence/absence of arterial supply Assess adequacy of flow PRESENCE OF SIGNAL DOES NOT EXCLUDE ARTERIAL INJURY!

14 Angiography Locates site of injury Characterizes injury Defines status of vessels proximal and distal May afford therapeutic intervention

15 Identify and control bleeding from pelvic fractures Angiography

16 Surgical exploration Immediate exploration is indicated for: Obvious arterial injury on exam No doppler signal Site of injury is apparent Prolonged warm ischemia time

17 Crush syndrome Crush Syndrome is a reperfusion injury as a result of traumatic rhabdomyolysis! Building collapse Earthquakes Landslides Bombings Construction accidents Heavy snow on roof Mine or trench collapse

18 Spitak earthquake in Armenia in 1988

19 Great Hanshin earthquake in Japan in 1995

20 Marmara earthquake in Turkey in 1999

26 First described in the English language literature by Bywaters and Beal (1941) Several patients who had been trapped under rubble of buildings bombed subsequently died of acute renal failure A severe, often fatal condition that follows a severe crushing injury, particularly involving large muscle masses Characterized by fluid and blood loss, shock, hematuria, and renal failure.

27 Crush Syndrome Building collapse Earthquakes Landslides Bombings Construction accidents Heavy snow on roof Mine or trench collapse

28 Signs and Symptoms of Crush Injury Skin injury Swelling Paralysis may cause to be mistaken as a spinal cord injury. Paresthesias, numbness may mask the degree of damage. Pain Pulses distal pulses may or may not be present. Myoglobinuria the urine may become dark red or brown, indicating the presence of myoglobin.

30 Compartment Syndrome Severe pain in the involved extremity. Pain on passive stretching of the muscles involved. Decreased sensation in branches of the involved peripheral nerves. Elevated intracompartmental pressures on direct manometry.

31 Treatment The airway must be secured and protected from dust impaction. Adequate ventilation must be ensured and maintained along with adequate oxygenation Intravenous Fluid preexisting dehydration or fluid loss should be corrected

32 Intravenous (IV) fluids containing potassium (e.g., lactated Ringer's solution) should be avoided. Normal saline is a good initial choice

33 formula that can be used to maintain an alkaline urine output of 8 L/d is the infusion of 12 L/d of Normal Saline Solution (NSS) with 50 meq of sodium bicarbonate per liter of fluid, plus 120 grams of mannitol daily to maintain this urine output

34 Sodium Bicarbonate reverse the preexisting acidosis first steps in treating hyperkalemia. increase the urine ph, to decrease the amount of myoglobin precipitated in the kidneys.

35 50 to 100 meq of bicarbonate, depending on severity of injury, to be given prior to release from compression

36 Treatment of Hyperkalemia Insulin and glucose. Calcium intravenously for life-threatening dysrhythmias. Beta-2 agonists albuterol, metaproterenol sulfate (Alupent), etc. Potassium-binding resins such as sodium polystyrene sulfonate (Kayexalate). Dialysis, especially in patients with acute renal failure

37 Alkaline Diuresis maintain a urine output of at least 300 ml/h with a ph higher than 6.5 intravenous fluids, mannitol, and sodium bicarbonate (44 to 50 meq/liter)

38 Intravenous Mannitol protects the kidneys from the effects of rhabdomyolysis increases extracellular fluid volume increases cardiac contractility relief symptoms and reduction of swelling of compartment syndrome

39 Mannitol can be given in doses of 1 gm/kg or added to the patient's intravenous fluid as a continuous infusion. The maximum dose is 200 gm/d Mannitol should be given only after good urine flow has been established

40 Wounds should be cleaned, débrided, and covered with sterile dressings Splinting and elevation of the limb will help to limit edema and maintain perfusion. Intravenous antibiotics Medications for pain control can be given as appropriate. Tourniquets are controversial and usually not necessary

41 Amputation should be used only as a last resort Fasciotomy

42 CONCLUSIONS The development of Crush injury syndrome is preventable and treatable. The mainstay of treatment is the prevention of renal failure by adequate rehydration and alkalinization of urine. The traditional treatment of compartment syndrome is fasciotomy. The complication rate is high, with the most serious hemorrhage and sepsis.

43 Amputations Amputations are classified at the level where the amputation takes place

44 Types and levels congenital Acquired lower extremity upper extremity Forequarter Intrascapulothorasic shoulder disarticulation Transhumeral above elbow Elbow Disarticulation Transradial below elbow wrist disarticulation Transcarpal Metacarpal phalangeal Transphalangeal partial hand

45 1. Flap amputations: Types of Amputations (according to soft tissues cutting) - single-flap amputation - double-flap amputation 2. Circular amputations: - one-step (guillotine) amputation - two-step amputation (variety cuff method of forearm amputation) - three-step (conical-circular) amputation

47 Sites of Election for Amputations of Upper Extremity

48 Finger Amputation

49 Osteo-plastic Amputations (Gritti-Stokes and Sabanajeff amputations)

50 Pirogoff Amputation

51 Callander Amputation (this gives an excellent end-bearing stump)

52 Below-knee Amputation

53 Amputation in Middle Third of Leg

54 Schemes of Foot Amputations

55 Syme Amputation

56 Phantom limb sensation/pain The sensation that the amputated extremity is still there Pain treated with TENS, desensitization, fluidotherapy, US, nerve blocks or surgery

57 Other complications S/P amputation Depression is common Falls stand on side of LE amputation balance is greatly disturbed body center of gravity is changed balance must be relearned protective reactions must be changed

58 Stump Management Shape residual limb so it is tapered at the distal end to allow for prosthetic fit Figure 8 ace bandage wrap wrapped distal to proximal more pressure distally never wrap circular direction because of tourniquet effect pt wears wrap continually check skin 3-4 times each day

59 Common Traumatic Injuries of the Hand Bone and Soft Tissue

60 Applied Anatomy Extensor and flexor tendons insert into the base of the distal phalanx Routinely not a deforming fracture

61 Nailbed Injury Nailbed lacerations need to be repaired Use 6-0 absorbable to repair matrix Prevents nail growth problems Reinsert nail and secure

62 Subungual Hematoma Results from blunt trauma to nail Very painful Relieved by Cautery Heated paperclip 18g needle

63 Subungual Hematoma Clean with alcohol Instrument of choice Pierce nail Gauze for 24 hours

64 Mallet Fingers (soft tissue and bony) Applied Anatomy Terminal extensor tendon inserts into the dorsum of the distal phalanx Mechanism of injury Occurs with a sudden flexion force against an extended digit Results in flexion deformity of the DIP joint

65 Mallet Fingers (soft tissue and bony) History and Physical Exam Pain and deformity of the DIP joint after bumping the end of the finger Inability to straighten the end joint Test for tendon function

66 Mallet Fingers (soft tissue and bony) Radiographs 2 views looking for dorsal avulsion fragment May be negative Classification Soft tissue (- x-ray) Bony (+ x-ray) Fleck Dorsal articular piece Subluxation of DIP joint

67 Mallet Fingers (soft tissue and bony) Treatment Closed reduction Continuously splint DIP in full extension for 6 to 10 weeks Only immobilize the DIP Acceptable results may still be obtained with continuous extension splinting if it is as long as 2-3 months after initial trauma

68 Flexor Tendon Avulsion Applied Anatomy Flexor digitorum profundus tendon inserts into the base of the distal phalanx

69 Flexor Tendon Avulsion Mechanism of Injury Hyperextension against a flexed DIP joint Relatively uncommon, but devastating is missed Ring finger most commonly involved

70 Flexor Tendon Avulsion Associated injuries None History and Physical Exam Pain on volar surface of digit May extend into palm with eccymosis Cannot flex tip Resting hand has extension of DIP joint No active flexion

71 Flexor Tendon Avulsion Radiographs DIP to look for avulsion, but also hand to look for retracted segment Most are normal Classification Pure tendon avulsion Bony avulsion

72 Flexor Tendon Avulsion Treatment Should be splinted and referred in a semi-urgent fashion Surgery is required Outcomes Results correlate with delay in treatment Early do well Postoperative hand therapy is important

73 Boutonniere Applied Anatomy When the central slip insertion at the base of the middle phalanx is disrupted, active PIP joint extension may be limited

74 Boutonniere Applied Anatomy The flexed position of the PIP joint then allows the lateral bands to fall volar to the axis These lateral bands then act to flex the PIP joint further Tension pulls the DIP joint into extension

75 Boutonniere Mechanism of Injury Acute flexion force to PIP joint PIP does not immediately fall into a flexed position Several weeks after the injury the digit assumes a buttonhole posture. Other mechanism include PIP dislocation and central slip lacerations History and Physical Exam Pain and swelling about PIP Inability to fully extend PIP DIP flexion is limited Longstanding cases PIP flexion Passive extension not possible

76 Radiographs Most often negative Occasionally small fragments dorsally off middle phalanx Classifications Acute Chronic Stiff supple Boutonniere

77 Boutonniere Treatment If not sure of central slip, assume it is and splint the PIP in full extension Acute boutonnieres 4 weeks of full extension splinting of PIP with active DIP flexion exercises Occasionally need surgery Chronic boutonnieres Hand therapy Possible surgery

78 Proximal Interphalangeal Collateral Ligament Injuries and Dislocations Most common orthopedic hand injury that can result in long-term digital stiffness and impairment

79 Proximal Interphalangeal Collateral Ligament Injuries and Dislocations Applied Anatomy PIP is a hinge Ligaments along palmar aspect - volar plate Prevents hyperextension Related to volar plate are collateral ligaments

80 Proximal Interphalangeal Collateral Ligament Injuries and Dislocations Applied Anatomy Each PIP joint has a radial and ulnar collateral ligament Tethers the PIP joint in its side-to-side motion Ligaments fail when they are stretched past a certain point

81 Proximal Interphalangeal Collateral Ligament Injuries and Dislocations Mechanism of Injury Sudden force directed to tip of digit results in hyperextension Spectrum ranging from slight hyperextension grade I sprain to frank dislocation Associated Injury If the skin tears open, it is an open dislocation History and Physical Exam Joint swollen and tender Test collateral ligaments to ascertain partial vs complete

$Proximal Interphalangeal Collateral Ligament Injuries and Dislocations Radiographs 2 views to check for fractures Post-reduction films if done$

82 Proximal Interphalangeal Collateral Ligament Injuries and Dislocations Radiographs 2 views to check for fractures Post-reduction films if done Classifications I do not compromise stability II partial compromise, at risk for complete disruption III- complete disruption, can compromise stability

83 Proximal Interphalangeal Collateral Ligament Injuries and Dislocations Treatment Early mobilization after a few days of splinting Buddy tape for 4 weeks A rare volar PIP joint dislocation requires 3-4 weeks of splinting in extension Outcomes These injuries can heal with some permanent fusiform swelling from scar tissue. Long term problem is not recurrent instability, but stiffness For this reason, early range of motion program is most often recommended

84 Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeper s Thumb) The ulnar collateral ligament of the thumb is important for pinch strength and stability Because of its location, it is particularly vulnerable to injury

85 Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeper s Thumb) Mechanism of Injury Combination of hyperextension and a radially directed force at the thumb MP joint (fall with a pole in the hand while skiing) History and Physical Exam Moderate swelling and eccymosis over ulnar side of MP joint In complete tears stress testing of UCL shows a poor endpoint

86 Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeper s Thumb) Radiographs Typically negative Possible avulsion fragment off proximal phalanx or metacarpal Treatment Incomplete nonoperatively (splint) Complete - surgically

87 Bennett's Fracture Dislocation Most frequent of all thumb fracture Described in 1882 by Dr. Edward Bennet It is a fracture dislocation, intra-articular fracture at base of carpometacarpal (CMC) joint of the thumb

88 Bennett's Fracture Dislocation Mechanism of Injury Results from axial blow directed against the partially flexed metacarpal; (ie. from fist fights) History and Physical Exam Moderate swelling and eccymosis over the CMC joint Pain with ROM or palpation

$Bennett's Fracture Dislocation Radiographs Oblique fracture line with a triangluar fragment at ulnar base of metacarpal Triangular$

89 Bennett's Fracture Dislocation Radiographs Oblique fracture line with a triangluar fragment at ulnar base of metacarpal Triangular fragment remains attached to trapezium w/ proximal displacement of the metacarpal Treatment Immobilization Referral for surgical pinning

FINGER INJURIES. Chapter 24, pgs ,

FINGER INJURIES. Chapter 24, pgs , FINGER INJURIES Chapter 24, pgs 727 730, 741 743 1. Demonstrate mastery of anatomical references to the hand and fingers. 2. Compare and contrast Mallet Finger, Swan Neck Deformity and Boutonnière Deformity.