Slide 5 Skull Fractures 4 Major Types Linear Depressed Diastatic Basilar
Slide 6 Linear Skull Fracture Most common type Over Lateral Convexities Over squamous area of temporal bone –Damage to middle meningeal artery –Epidural Hematoma www.hawaii.edu/medicine/pediatrics/pe mxray/v5c09h2.jpg
Slide 7 Depressed Skull Fracture Displaced bone fragments pushed into the cranial vault From blunt force by object with small surface area Often damages underlying brain tissue Complex = dura mater torn Contamination/Infection Often require surgery anatpat.unicamp.br/minDsc35446+.jpg
Slide 8 Diastatic Skull Fracture Fracture causes widening of suture Most commonly seen in infants and small children Seen in adults along the lambdoid suture Pirouzmand F, Muhajarine N. Craniofac Surg. 2008 Jan;19(1):27-36. Definition of topographic organization of skull profile in normal population and its implications on the role of sutures in skull morphology. img.medscape.com/pi/emed/ckb/radiology/336139-343764- 9928.jpg
Slide 9 Basilar Skull Fracture From blunt force to the forehead or occiput Usually anterior –Often involves cribriform plate –Disruption of olfactory nerves Posterior –Through petrous bone and internal auditory canal –Disruption of the vestibulocochlear nerve and facial nerves CSF otorrhea/rhinorrhea t0.gstatic.com/images?q=tbn:TuEw6pvP4iIG5M:http://i mg.medscape.com/pi/emed/ckb/neurosurgery/247017- 248108-4155.jpg
Slide 14 Cervical Spine Injuries 25% Occiput to C2 75% C3 to C7 Occipto-cervical subluxation –Rare –Usually fatal Fractures of the Atlas –Pain –Decreased mobility Atlanto-axial dislocation –High risk of neurologic deficit www.springerlink.com/content/26ghau7p5nmpcjle/
Slide 15 Fractures of the Odontoid Apical ligament avulsion fracture Stable Minimal if any external support img.medscape.com/pi/emed/ckb/orthopedic _surgery/1230552-1267150-1299.jpg
Slide 16 Fractures of the Odontoid Waist of the odontoid Unstable Requires reduction or translation and angulation Requires stabilization –Surgical –Halo vest img.medscape.com/pi/emed/ckb/orthope dic_surgery/1230552-1267150-1299.jpg
Slide 17 Fractures of the Odontoid Extends below the waist into the body of C2 Best treated with a halo vest 15% incidence of nonunion with other immobilization img.medscape.com/pi/emed/ckb/orthopedic _surgery/1230552-1267150-1299.jpg
Slide 18 Thoracolumbar Spine Injuries L1 fracture 16% Spondylolisthesis –Subluxation or Slip of one vertebral body on another –Most common in lumbar spine –Treatment Conservative management Fusion www.webinique.com/images/lumb ar_spondylolisthesis_grades.jpg
Slide 19 Spinal Instability Disruption of anatomic components, motion or supportive elements Excessive or abnormal spinal motion 3 Column Model –In thoracolumbar spine –Instability = Injury to 2 or 3 columns www.pgblazer.com/wp- content/uploads/2009/11/three-column- concept-2.jpg
Slide 20 Spinal Instability www.pgblazer.com/wp- content/uploads/2009/11/three-column- concept-2.jpg 50% Loss of Vertebral Body Height Angulation > 20% Compression Fractures Burst Fractures
Slide 21 Non-operative Management of Spinal Injuries Stable injuries No neurologic deficits Immobilization www.alsab.ca/images/collar2.jpg
Slide 25 Cervical Spine Clearance The NEXUS Clinical Criteria 1. Tenderness at the posterior midline of the cervical spine 2. Focal neurologic deficit 3. Decreased level of alertness 4. Evidence of intoxication 5. Clinically apparent pain that might distract the patient from the pain of a cervical spine injury –Any of the above -> increased risk for cervical spine injury -> requires radiographic evaluation –Sensitivity: 99.6% –NPV: 99.9% –Specificity: 12.9% –PPV: 2.7% Hoffman JR, Mower WR, Wolfson AB, et al. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. National Emergency X-Radiography Utilization Study Group. N Engl J Med. 2000;343:94 –99.
Slide 26 Cervical Spine Clearance Algorithm Como JJ, Diaz JJ, Dunham CM, et al. EAST practice management guidelines for identifying cervical spine injuries following trauma. 2009.
Slide 27 Cervical Spine Clearance Algorithm Como JJ, Diaz JJ, Dunham CM, et al. EAST practice management guidelines for identifying cervical spine injuries following trauma. 2009.
Slide 28 Cervical Spine Clearance Algorithm Como JJ, Diaz JJ, Dunham CM, et al. EAST practice management guidelines for identifying cervical spine injuries following trauma. 2009.
Slide 29 Cervical Spine Clearance Algorithm Como JJ, Diaz JJ, Dunham CM, et al. EAST practice management guidelines for identifying cervical spine injuries following trauma. 2009.
Slide 30 Cervical Spine Clearance Algorithm Como JJ, Diaz JJ, Dunham CM, et al. EAST practice management guidelines for identifying cervical spine injuries following trauma. 2009.
Slide 31 Cervical Spine Clearance Algorithm Como JJ, Diaz JJ, Dunham CM, et al. EAST practice management guidelines for identifying cervical spine injuries following trauma. 2009.
Slide 32 Cervical Spine Clearance Algorithm Como JJ, Diaz JJ, Dunham CM, et al. EAST practice management guidelines for identifying cervical spine injuries following trauma. 2009.
Slide 33 Cervical Spine Clearance Algorithm Como JJ, Diaz JJ, Dunham CM, et al. EAST practice management guidelines for identifying cervical spine injuries following trauma. 2009.
Slide 34 Cervical Spine Clearance Algorithm Como JJ, Diaz JJ, Dunham CM, et al. EAST practice management guidelines for identifying cervical spine injuries following trauma. 2009.
Slide 35 Cervical Spine Clearance Algorithm Como JJ, Diaz JJ, Dunham CM, et al. EAST practice management guidelines for identifying cervical spine injuries following trauma. 2009.
Slide 41 Suggested Indication for Surgical Treatment of Rib Fractures Flail chest Reduction of pain and disability Chest wall deformity/defect Symptomatic rib fracture non-union Thoracotomy for other indications Raminder Nirula1, Jose J. Diaz Jr.2, Donald D. Trunkey3 and John C. Mayberry3. Rib Fracture Repair: Indications, Technical Issues, and Future Directions. World Journal of Surgery 2009; 33(1): 14-22
Slide 42 Sternal Fractures “Steering Wheel Syndrome” Possible Associated Injury = Blunt Cardiac Injury Most Common Associated Injuries: –Rib fractures –Long bone fractures –Head injuries Treatment: –Rest –Analgesia –Monitor for EKG changes radiographics.rsna.org/content/21/5/ 1257/F42.medium.gif
Slide 43 Scapula Fractures From high energy trauma Rarely occur as an isolated injury Management: –Sling –Pendulum exercises at 3 weeks –Strengthening at 6 weeks www.eorthopod.com/sites/default/files/images/ adult_shoulder_fx_type_scapular_blade.jpg
Slide 44 Indications for Surgical Repair of Scapula Fractures If it is one of multiple shoulder fractures Displaced fracture of the glenoid neck Displaced fracture of the glenoid fossa Significant disruption of superior shoulder suspensory complex www.ncbi.nlm.nih.gov/bookshelf/picrender.fcgi ?book=physmedrehab&part=A3412&blobname =ch4f4-30.jpg
Slide 45 Clavicle Fracture Classification –Proximal (rare) –Central (80%) –Distal Risk of Nonunion (highest in distal fractures) Treatment: –Sling –Pendulum exercises at 2 to 3 weeks –Avoidance of heavy activity x 8 weeks www.drdavidduckworth.com.au/css/ima ges/clavicle-side.jpg
Slide 46 Clavicle Fractures Indications for surgical fixation: –Distal clavicle –Middle clavicle with >2cm of shortening –Open –Symptomatic Nonunions –Associated neurovascular injury –Complex injuries of the shoulder Surgical Procedure –Screw and Plate Fixation –Intramedullary implants assets.sbnation.com/assets/1616 91/clavicle_fracture_surgery_pho to.gif images.google.com/imgres?img url=http://assets.sbnation.com/a ssets/161691
Slide 48 Pelvic Fractures Most Common Etiologies –Motorcycle collisions –Pedestrian v. Motor vehicle –Fall > 15 feet –Motor vehicle collision Mortality –7-14% –30% w/ severe or open fractures –Most deaths due to other traumatic causes Concomitant Injuries in >90% of patients with pelvic fractures Most deaths due to: –Head Injury –Non-pelvic hemorrhage –Lung Injury –Thromboembolic Events –MSOF
Slide 49 Pelvic Fractures Mean transfusion requirement = 8 units of packed red blood cells Minimize blood loss from pelvic fractures –Early re-approximation and stabilization Bed Sheet Splint Clamp External Fixation –Angiography Pelvic arterial disruption is source of hemorrhage 3 – 20% t3.gstatic.com/images?q=tbn:oc6jX5VKvtYoDM:http ://www.vygia.com.vn/image/C-Clamp_02.jpg publicsafety.com/article/photos/11297429117 46_13.jpg
Slide 51 Lateral Compression Fracture Impact to lateral side of pelvic ring Shortens diameter across pelvis/decreases volume of pelvis Little risk of vascular or ligamentous injury www.eorthopod.com/content/adult- pelvis-fractures-types
Slide 52 Anterior-Posterior Compression Fractures “Open Book” Mechanisms: –Direct Impact to the Iliac Spines –Transmitted through the femurs Can have ligamentous injury without fracture Increases diameter/volume of pelvis Significant risk of bleeding Unstable www.eorthopod.com/sites/default/files/images/ adult_pelvis_fx_causes06.jpg
Slide 53 Vertical Shear Pelvic Fractures Mechanism: Fall/Jump landing on straight leg Disruption of ligaments: –Symphyseal –Sacrospinous –Sacrotuberous –SI –Increases Diameter/Volume of Pelvis Less bleeding than A-P fractures, but still significant risk www.eorthopod.com/content/adult -pelvis-fractures-types
Slide 56 Shoulder Fractures/Dislocations Floating Shoulder –Glenoid neck fracture + Clavicle fracture –Glenohumeral joint without attachment to the rest of the skeleton –Usually requires surgical fixation of one of the elements (clavicle) Low CK, Lam AWM. Results of fixation of clavicle alone in managing floating shoulder. Singapore Med. 2000;4(19):452-453.
Slide 58 Humerus Fractures Proximal Humerus Fractures Concomitant injuries: –Rotator cuff injuries –Shoulder dislocation Risk of peripheral nerve injuries Risk of axillary artery injury Nondisplaced Fractures –Sling for a short period –Early Range Of Motion Displaced Fractures –With impaction of humeral head: Nonop –Most 2 Part Fractures: Closed reduction w/ percutaneous fixation –Most 3 Part Fractures: ORIF www.shouldersurgeon.com/graphic s/4_parts_prox_humerus.jpg
Slide 59 Humerus Fractures Midshaft Humerus Fractures –Radial Nerve Injury 12% of Humeral Shaft Fractures with fractures of the distal 1/3 of the Humerus Runs in the spiral groove 70% resolve w/ conservative management Splint wrist and digits –Nondisplaced: Sling –Displaced: Reduction with long arm cast for gravity traction Fracture Brace Plate and Screw Fixation Intramedullary Nailing www.eorthopod.com/sites/default/files/images /adult_humeral_fx_brace.jpg
Slide 60 Humerus Fractures Supracondylar Humerus Fractures Almost always require ORIF Volkmann’s Contracture –Supracondylar Humerus Fracture –Anterior interosseus artery is occluded –After reduction, perfussion is restored –Reperfussion injury leads to Flexor Compartment Syndrome www.unboundedmedicine.c om/wp-content/Volkman.jpg
Slide 61 Elbow Fractures/Dislocations “Terrible Triad of the Elbow” –Elbow dislocation + Radial Head Fx + Coranoid Process of the Ulna Fx –Requires surgery with repair or reconstruction Nursemaid’s Elbow –Subluxation of Radius at Elbow –Cause: Traction to an extended, pronated arm –Tx: Closed Reduction s3.beckshome.com/20060625- Nursemaids-Elbow.jpg
Slide 62 Forearm Fractures Monteggia Fracture –Proximal Ulna Fracture + Radial Head Dislocation –Treatment ORIF Galezzi Fracture-Dislocation –Complex disruption of the distal radioulnar joint + Unstable radius fracture –Surgical repair is almost always necessary www.wheelessonline.com/images/i1/m ont1.jpg www.learningradiology.com/caseofweek /caseoftheweekpix2/cow157lg.jpg
Slide 63 Forearm Fractures Night-stick Fracture –Isolated Ulnar Shaft Fracture –Nondisplaced: Long arm cast for short period, then functional bracing –Displaced: Compression Plating Colles Fracture –Fall on outstretched, extended wrist –Distal Radius Fracture –Treatment: Closed Reduction Greenstick fracture –Partially through bone –Opposite side of bone bent www.wheelessonline.com/image4/i1/nght1.jpg z.about.com/d/orthopedics/1/0/2/1/fxapcolles.jpg www.medscape.com/content/2002/00/44/65/446548/art- ar446548.fig10.jpg
Slide 64 Scaphoid Fracture ½ of all isolated carpal bone fractures Fracture locations: –Waist (75%) –Proximal Pole (20%) –Distal Pole (5%) –Blood supply from the ligaments at the distal pole Snuff Box tenderness Risk of Avascular Necrosis Operative Repair –Open Screw Placement –Percutaneous Screw Placement Cast to elbow patientsites.com/media/img/1225/wrist_scaphoid _fracture_intro01.jpg
Slide 65 Finger/Thumb Fractures Rolando fracture –T- or Y-shaped –Thumb metacarpal base –Difficult to manage Phalangeal fractures –Usual treatment: Buddy taping or splint immobilization –Intra-articular invovlement: Closed reduction Fixation with percutaneous screws Fixation with Kirschner wires radiographics.rsnajnls.org/content/ vol20/issue3/images/large/g00mc2 0l25x.jpeg
Slide 67 Femur Fracture Present in about 15% of seriously injured trauma patients 8-10% Bilateral Mortality –Unilateral = 10-12% 20% in patients > 65 years old –Bilateral = 26-33% –90% due to concomitant injuries Decreased complications with surgical fixation within 24 hours
Slide 68 Hip Fractures 50% over 85years –6 month mortality of 20% Preoperative Management of Unstable Fxs –Buck’s Traction –Skeletal Traction www.lancastergeneralcollege.edu/content/upload/AssetMg mt/images/College/conferences/Ortho_Traction_in_Orthope dicCare.pdf
Slide 69 Hip Fractures Femoral Neck Fractures Intracapsular –High risk of Avascular Necrosis and Nonunion –Intracapsular hematoma also may compromise perfusion –Surgical emergency in young people –Treatments: Internal fixation Hip arthroplasty Extracapsular –Dynamic Hip Screw (DHS) –Early weight bearing/Rehab www.orthomeditec.com/images/dynam ichipscrew.jpg
Slide 70 Hip Fractures Trochanteric Fractures –More stable than femoral neck fractures –Require ORIF Early Ambulation/Rehab Subtrochanteric Fractures –High risk of failure of surgical fixation –Treatments: ORIF Closed Reduction and Intramedullary Nailing Indirect reduction with blade-plate /screw-plate fixation
Slide 71 Hip Dislocations Reduction within 6 to 8 hours is crucial Posterior (85-95%) –Leg internally rotated and adducted –Risk of sciatic nerve injury –Treatment: Closed Reduction Anterior –Leg externally rotated and abducted –Risk of femoral artery injury –Treatment: Closed Reduction i21.photobucket.com/albums/b286/flagady15/ Bones/hip-fig1.jpg chestofbooks.com/health/anatomy/Human-Body- Construction/images/Fig-515-Posterior-luxation-of- the-hip-produced-by-rotati.jpg
Slide 72 Femoral Shaft Fractures Blood loss up to 1500 – 2000cc Important to reduce fracture and maintain alignment early Closed Reduction and Reamed, Interlocking Intramedullary Nail Ex-fix with Intramedullary Nail –Days 5 to 10 Associated Complications: –Fat Embolism Syndrome –Acute Lung Injury/ARDS nyic.stemlegal.com/wp- content/uploads/2009/01/femur-nailing.jpg
Slide 73 Patella Fractures Mechanism: Direct blow to flexed knee Nondisplaced: Long leg cast Comminuted: –Open reduction and internal fixation Lag screws Tension Banding –Partial or total Patellectomy www.cahnlitigation.com/toetheslab/images/Post %20Images/fracture_of_patella_2.JPG www.aofoundation.org/AOFileServer Surgery/MyPortalFiles? www.aofoundation.org/AOFileServerSurgery/MyPortalFiles? FilePath=/Surgery/en/_img/surgery/05-RedFix/34/P90- tension-band-wiring/33_P90_i480L_C11_patella.jpg
Slide 74 Knee Dislocation May involve: –Patello-femoral joint –Tibio-femoral joint Usually Lateral –Hemarthrosis or Effusion develops –May be recurrent –Treatment: Closed Reduction Knee immobilization for 4 to 6 weeks Complete Knee Dislocation: –Anterior or Posterior –Need angiogram to assess for Popliteal Artery injury www.ajronline.org/content/vol186/issue3/images/ large/00_04_0756_04b_cmyk.jpeg
Slide 76 Calcaneus Fractures Require tremendous force to the heal Frequently occur w/ spine injuries Nondisplaced and extra-articular: nonoperative Displaced and intra-articular: ORIF 2-3 weeks after injury www.fighttimes.com/magazine/images/8/l-medcell- xray5.jpg www.mccainortho.com/Calcaneus%20Post%20O p%20A.jpg
Slide 77 Talus Fractures Risk of Avascular Necrosis (AVN) –Especially if fracture is at neck of talus –Dislocation is a surgical emergency Closed reduction for most Severely displaced: Precise reduction and fixation with Interfragmentary Screws www.foothyperbook.com/images/hindfoo tTrauma/FxTalusNeck.gif www.orthosupersite.com/images/ content/obj/0802/salem_fig1b.jpg
Slide 78 Metatarsal Fractures Jones Fracture –Mechanism: Inversion of Foot –5th Metatarsal –At risk for nonunion www.eorthopod.com/content/adult-foot- fractures-types
Slide 79 Complications of Extremity Fractures Infection –Findings often appear 10-21 days after infection –Most common organism = Staph. aureus –Also common = Pseudomonas aeruginosa and Enterobacteriaceae Diagnosis –Physical findings –Constitutional symptoms –Radiography CT MRI 3-phase bone scan Radiolabeled WBC scan
Slide 82 Diagnosis of Osteomyelitis Requires 2 of the 4 following criteria: Purulent material on aspiration of affected bone Bone tissue or blood culture positive Localized classic physical findings of bony tenderness, with overlying soft-tissue erythema or edema Positive radiological imaging study www.medical- look.com/diseases_images/osteomyelitis.jpg
Slide 83 Osteomyelitis Most Common Organisms Staphylococcus aureus Gram negative infections (vertebral bodies) Pseudomonas (IVDA) Fungal osteomyelitis (chronically ill/TPN) Salmonella osteomyelitis (Sickle Cell Disease) Group B streptococcus (Infants 2-4 weeks old) Haemophilus influenzae (6 months to 4 years old) upload.wikimedia.org/wikipedia/commons/5/59/Os termyelitis_Tibia.jpg
Slide 84 Osteomyelitis Treatment: Surgical Debridement ? Limb Loss Antibiotics –Broad Spectrum IV –Tissue cultures to narrow Hyperbaric Oxygen for Refractory Osteomyelitis radiographics.rsna.org/.../g07nv10c18x.jpeg Kindwall EP. Uses of hyperbaric oxygen therapy in the 1990s. Cleve Clin J Med. Sep-Oct 1992;59(5):517-28
Slide 85 Complications of Extremity Fractures Fat Embolism –Approx. 5000 deaths per year –Classic Triad: Respiratory Compromise Change in Mental Status Petechiae –Half of all cases present only with respiratory failure –Treatment: Supportive img.medscape.com/pi/emed/ckb/vascul ar_surgery/459840-459841-460524- 1723668tn.jpg www.futurehealth.rochester.edu/dlp2 /dlpdict/petechiae.jpg
Slide 86 Thromboembolism Virchow’s Triad: –Hypercoagulability –Endothelial Damage –Venous Stasis More than 60% of DVTs are Asymptomatic PEs are the 3rd most common cause of death in trauma patients who survive past the first day DVT Prophylaxis: SCDs Foot pumps –Heparin LMWH Coumadin
Slide 87 Complications of Extremity Fractures Compartment Syndrome Diagnosis primarily clinical –Pain –Parasthesias –Piokylothermia –Pulseless –Pain with passive range of motion Critical Pressures: –Compartment Pressure > 30mmHg –Diastolic BP – Compartment Pressure < 30mmHg
Slide 88 Complications of Extremity Fractures Rhabdomyolysis –Treatment = aggressive IVF Avoid buildup of myoglobin in renal tubules Prevent hyperkalemia
Slide 89 Image Sources ajs.sagepub.com/content/32/4/1059/F1.large.jpg amog.com/wp-content/uploads/2009/03/fasciitis.jpg anatpat.unicamp.br/minDsc35446+.jpg assets.sbnation.com/assets/161691/clavicle_fracture_surgery_photo.gif chestofbooks.com/health/anatomy/Human-Body-Construction/images/Fig- 515-Posterior-luxation-of-the-hip-produced-by-rotati.jpg Como JJ, Diaz JJ, Dunham CM, et al. EAST practice management guidelines for identifying cervical spine injuries following trauma. 2009. eldoradopainmanagement.net/mediac/450_0/media/Compression_Render_ Final.jpg files.turbosquid.com/Preview/Content_2009_07_13__17_30_11/leg_bones.j pgf1dbe04a-ce4d-4150-9fc1-0fb1043c8a87Large.jpg Gasparri MG, Almassi GH, Haasler GB (2003) Surgical management of multiple rib fractures. Chest 124:295S
Slide 90 Image Sources georgiahealthinfo.gov/cms/files/global/images/image_popup/fsm7_compartmenttestin g.jpg herkules.oulu.fi/isbn9514270959/html/graphic33.png Hoffman JR, Mower WR, Wolfson AB, et al. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. National Emergency X- Radiography UtilizationStudy Group. N Engl J Med. 2000;343:94 –99. i21.photobucket.com/albums/b286/flagady15/Bones/hip-fig1.jpg image.absoluteastronomy.com/images/encyclopediaimages/b/bl/blackeye_pigmentati on.jpg image.wetpaint.com/image/1/XOMgDfktBYZImgBWx3Xc2g171569/GW537H600 images.allegrocentral.com/9E/75/J-Tongs-Traction-Tongs-557879-PRODUCT- MEDIUM_IMAGE.jpg images.google.com/imgres?imgurl=http://assets.sbnation.com/assets/161691 images.google.com/imgres?imgurl=http://www.aofoundation.org/AOFileServerSurger y/
Slide 91 Image Sources MyPortalFiles%3FFilePath%3D/Surgery/en/_img/surgery/01-Diagnosis/61/62-A1- xrays- img.medscape.com/pi/emed/ckb/orthopedic_surgery/1230552-1267150-1299.jpg img.medscape.com/pi/emed/ckb/radiology/336139-343764-9928.jpg img.medscape.com/pi/emed/ckb/vascular_surgery/459840-459841-460524- 1723668tn.jpg Kindwall EP. Uses of hyperbaric oxygen therapy in the 1990s. Cleve Clin J Med. Sep- Oct 1992;59(5):517-28 Low CK, Lam AWM. Results of fixation of clavicle alone in managing floating shoulder. Singapore Med. 2000;4(19):452-453. nyic.stemlegal.com/wp-content/uploads/2009/01/femur-nailing.jpg patientsites.com/media/img/1225/wrist_scaphoid_fracture_intro01.jpg Pirouzmand F, Muhajarine N. Craniofac Surg. 2008 Jan;19(1):27-36. Definition of topographic organization of skull profile in normal population and its implications on the role of sutures in skull morphology. publicsafety.com/article/photos/1129742911746_13.jpg www.istockphoto.com/file_thumbview_approve/843463/2/istockphoto _843463-skeleton-with-edge-of-blank-sign-includes-clipping-path.jpg
Slide 92 Image Sources radiographics.rsna.org/.../g07nv10c18x.jpeg radiographics.rsnajnls.org/content/vol20/issue3/images/large/g00mc20l25x.jpeg radiographics.rsna.org/content/21/5/1257/F42.medium.gif Raminder Nirula1, Jose J. Diaz Jr.2, Donald D. Trunkey3 and John C. Mayberry3. Rib Fracture Repair: Indications, Technical Issues, and Future Directions. World Journal of Surgery 2009; 33(1): 14-22 s3.beckshome.com/20060625-Nursemaids-Elbow.jpg ssl.gstatic.com/health/33576cb3c325418b82afc7245394d485/ref/graphics/9712.jpg t0.gstatic.com/images?q=tbn:TuEw6pvP4iIG5M:http://img.medscape.com/pi/emed/ck b/neurosurgery/247017-248108-4155.jpg t3.gstatic.com/images?q=tbn:oc6jX5VKvtYoDM:http://www.vygia.com.vn/image/C- Clamp_02.jpg Textbook of Critical Care. Fink MP, Abraham E, Vincent JL, Kochanek P (ed) 5th ed : Philadelphia : Elsevier Saunders, 2005 Trauma, 4th edMattox KL, Feliciano DV, Moore EE, eds. New York, NY: McGraw-Hill, 2000