Principle Management of Wound and Fracture in Emergency Department

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Marcus Richard
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1 Principle Management of Wound and Fracture in Emergency Department Presented in Clinical Update Seminar January 15 th 2011 dr. Tedjo Rukmoyo, SpOT (K) Spine

2 Initial Management ATLS Procedure A : airway B : breathing C : circulation D : disabilities E : exposure Compressive dressings for hemorrhage Check Cervical Chest Abdoment X ray Head Pelvis Neurovascular

3 Wound Inspection & Palpation Concentrate on Hemorrhage Location Size Border Wound type Exudate Infection Dressed or undressed

4 Wound management Evaluate the wound NeuroVasc status Joint Movement X-RAY! Sterile saline dressing Irrigate with NS 1 or 2 litres Tetanus status immunity IV antibiotics Prepare minor set Needle Suture material instruments

5 Wound irrigation Irrigate with NaCl 0,9 % 1 2 litre Brush, evacuate foreign body Use : Povidon iodine Savlon Perhidrol (hidrogen peroxide) Irrigate with NaCl to cleanse

6 Debridement Excision: Wound Edge Skin Abrasion Dead Tissue Dirty Bone Evacuate: Foreign body Re-Irrigation / Spoel Irrigation Temporary

7 Primary Closure

8 Secondary closure & Packing

9 Dressing Types and Assistive Devices Dry Dressings dry wound Wet-to-Dry Dressings wet wound Packing deep wound Vacuum Assisted Closure Compression Elastic Bandage

10 Principle Wound and Skin coverage Without skin loss Primary clossure Contraindication : 1. Contamination 2. NV injury 3. Tension

11 Principle Wound and Skin coverage With skin loss : Secondary intention Release / counter incision STSG, FTSG Flap fasciocutaneus, rotational

12 Fracture Classification Close (simple) Open Gustillo Anderson Grade I Grade II Grade III a Grade IIIb Grade IIIc

13 Gustillo Anderson

14 > Grade III B Vascular disruption Arteriography If can be repaired? Possible Limb salvage Failed? amputation?

15 Debridement and Irrigation As soon as possible Scrub and brush wound dirt Superficial debridement: Identify and explore -> extend wound Excised non viable tissue

16 Debridement and Irrigation Deep debridement : When in doubt take it out Check muscle : 4 c Color Capacity to bleed Contractility Consistency Cover by tissue or moist dressing Remove Foreign body

17 Debridement Procedure

18 Irrigation Use NS, high volume low pressure lavage For grade II-III : 6 10 l Use antiseptics, perhidrol, antibiotic, etc

19 Upper extremity Immobilization On Accidental Site At the primary health care (puskesmas or clinics)

20 Lower extremity Immobilization On Accidental Site At the primary health care (puskesmas or clinics)

21 Skeletal Stabilisation Evaluate vascular status, limb salvage, debridement and irrigation Stabilize the bone : Restore length Angular alignment Rotation Will promote healing Decrease pain and further damage

22 Method Skeletal stabilisation Cast : splint, circular cast Traction : skin, skeletal External fixation : steinman or K wire

23 Internal Fixation Plate and screw Accurate anatomical Mantain /w plate Various types IM nails Restore alignment Callus healing Minimize soft tissue damage

24 Compartment syndrome

25 Rehabilitation Early Range of Motion Isometric, isotonic, isokinetic excercise Motor Power excercise Non weight bearing Partial weight bearing Full weight bearing Return to normal activity

INJURIES AND THEIR MANAGEMENT

INJURIES AND THEIR MANAGEMENT INJURIES AND THEIR MANAGEMENT An injury is damage to the body caused by external forces, which may be physical or chemical. 1) Incisions 2) Types of wounds and their closure