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

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Presentation on theme: "Musculoskeletal Trauma Cambridge Trauma weekend 2011 Mr Lee Van Rensburg www.easytrauma.co.uk."— Presentation transcript:

1 Musculoskeletal Trauma Cambridge Trauma weekend 2011 Mr Lee Van Rensburg

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4 Fatal accident deaths England and Wales ~ 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

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25 Emergency

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27 Binder and traction limb

28 C Clamp

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33 Angiography

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35 Pelvic packing

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39 Complex/ combination

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

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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

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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

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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

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

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

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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

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

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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/ H50 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

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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

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

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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

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89 Questions


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