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1 Program Information

2 Shannon Carroll, MD Suresh Agarwal, MD
Skeletal System Shannon Carroll, MD Suresh Agarwal, MD

3 Skeletal System Common Skeletal System Pathology encountered in Critical Care Complications of Skeletal Injury The two main goals of this presentation are to review skeletal system pathology often seen in the ICU and to discuss some common complications of skeletal injuries.

4 Skull
Head injuries are often seen in trauma patients, frequently involving fractures of the skull.

5 Skull Fractures 4 Major Types Linear Depressed Diastatic Basilar
There are 4 main types of skull fractures: linear, depressed, diastatic, and basilar.

6 Linear Skull Fracture Most common type Over Lateral Convexities
Over squamous area of temporal bone Damage to middle meningeal artery Epidural Hematoma The most common type of skull fractures are linear skull fractures. They are most frequently seen over the lateral convexities of the skull. If the fracture occurs over the squamous portion of the temporal bone, it often results in damage to the middle meningeal artery, leading to an epidural hematoma.

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 Depressed skull fractures occur when fragments of bone are displaced into the cranial vault. These fractures most often occur with blunt force by an object with a small surface area, such as a rock or hammer. The underlying brain tissue is often damaged. A depressed skull fracture is termed “complex” if the associated dura mater is torn. Depressed skull fractures are prone to contamination and infection. They often require surgery to decompress the brain, replace the displaced fragments of bone, and debride devitalized and contaminated scalp, skull, and brain tissue. If torn, the dura should be surgically repaired. jpg

8 Diastatic Skull Fracture
Fracture causes widening of suture Most commonly seen in infants and small children Seen in adults along the lambdoid suture The third type of fractures, diastatic skull fractures, are caused by widening of the skull at the anatomical sutures. They are most often seen in infants and small children. They can occur in adults, usually associated with the lambdoid suture, which does not usually fuse until the seventh decade of life. This suture is located on the posterior skull, dividing the occiput from the surrounding temporal and parietal bones. Pirouzmand F, Muhajarine N. Craniofac Surg Jan;19(1): Definition of topographic organization of skull profile in normal population and its implications on the role of sutures in skull morphology. jpg

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 The fourth type of skull fractures, basilar skull fractures, commonly arise from blunt trauma to the forehead or occiput. They usually occur anteriorly, causing disruption of the associated dura. It also often involves the cribriform plate The olfactory nerve is at risk of damage with these fractures. Difficult to appreciate on CT scan, they are often detected after the finding of fluid in the sphenoid sinus. Basilar skull fractures can occur posteriorly, often extending through the petrous portion of the temporal bone, putting the vestibulocochlear facial nerves at risk of damage. One of the major complications of basilar skull fractures is an associated injury to the dura, resulting in a cerebrospinal fluid fistula. This communication can cause CSF otorrhea or rhinorrhea and put the patient at significant risk of infection. If persistent, surgical repair may be necessary. jpg

10 Basilar Skull Fracture
Raccoon Eyes Battle’s Sign Two of the stereotypical clinical findings associated with basilar skull fractures are raccoon eyes and battle’s sign.

11 Vertebral Injuries Vertebral Column forms the Axial Skeleton
Among All Trauma Patients 4.3% Cervical Spine Injury 6.3% Thoracolumbar Spine Injury 1.3% Spinal Cord Injury Injuries to the vertebral column comprise another set of commonly encountered injuries in the critical care unit. The vertebral column composes the axial skeleton. Among all trauma patients, 4.3% have cervical spine injuries, 6.3% have thoracolumbar spine injuries, and 1.3% incur spinal cord injury.

12 Vertebral Injuries 7 Mechanisms of Injury Flexion – compression
Axial compression Flexion – distraction Hyperextension Rotation Shear Avulsion There are seven major mechanisms of spinal injury base on the direction and magnitude of force applied to the spine. Flexion-compression fractures are exemplified by a simple anterior wedge fracture with disruption of the posterior ligamentous elements. Axial compression fractures are a result of force from an axial load. Burst fractures with instability of the anterior and middle columns often occur. A Jefferson fracture is a compression fracture of the axis. Flexion-extension fractures are very unstable injuries with disruption of the posterior stabilizing element and interruption of the middle and anterior columns. An example is a Chance fracture. Hyperextension fractures result in damage to the anterior and middle columns and frequently include subluxation or dislocation. An example of this type of injury is the Hangman’s fracture of C2. Rotation injuries involve subluxation, dislocation, and fracture-dislocation of the spinal facets. These are very unstable injuries. Shear injuries usually result in three column injuries and often involve facet dislocation. Avulsion injuries are exemplified by type 1 odontoid fractures and “clay-shovelers fracture” of C7.

13 Cervical Spine Injuries
The cervical spine is the most mobile segment of the spine and is therefore most susceptible to injury.

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 Cervical spine injuries occur between the occiput and C2 in approximately 25% of cases. They occur in the subaxial region, C3 to C7, in the other 75% of cases. A rare and usually fatal injury is an occipito-cervical subluxation, often involving fractures of the occipital condyles. Fractures of the atlas rarely cause neurologic deficits but may result in severe, persistent pain and decreased neck mobility. Atlanto-axial dislocations occur when the transverse ligament is disrupted but C1 is not fractured. This is an extremely unstable injury with a high risk of resulting neurologic deficit.

15 Fractures of the Odontoid
Apical ligament avulsion fracture Stable Minimal if any external support C2 odontoid fractures are common and can be divided into three different types: A type 1 fracture is an apical avulsion fracture. This simple fracture at the tip of the odontoid is fairly stable and requires very little, if any, external support for treatment. jpg

16 Fractures of the Odontoid
Waist of the odontoid Unstable Requires reduction or translation and angulation Requires stabilization Surgical Halo vest C2 odontoid fractures are common and can be divided into three different types: A type 1 fracture is an apical avulsion fracture. This simple fracture at the tip of the odontoid is fairly stable and requires very little, if any, external support for treatment. A type 2 fracture spans across the waist of the odontoid. This is an unstable type of fracture. Treatment involves reducing the fracture and maintaining alignment with operative fixation or a halo vest. A type 3 fracture crosses below the waist and into the C2 vertebral body. It is best treated with a halo vest. There is a 15% incidence of nonunion with this fracture and may require surgical stabilization. jpg 16

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 C2 odontoid fractures are common and can be divided into three different types: A type 1 fracture is an apical avulsion fracture. This simple fracture at the tip of the odontoid is fairly stable and requires very little, if any, external support for treatment. A type 2 fracture spans across the waist of the odontoid. This is an unstable type of fracture. Treatment involves reducing the fracture and maintaining alignment with operative fixation or a halo vest. A type 3 fracture crosses below the waist and into the C2 vertebral body. It is best treated with a halo vest. There is a 15% incidence of nonunion with this fracture and may require surgical stabilization. jpg 17

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 The thoracolumbar spine is more mobile than the adjacent thoracic spine and sacrum and is therefore prone to injury. Injury to the thoracolumbar spine is most common around the thoraco-lumbar junction. L1 is the most commonly injured vertebra. Compression fractures are the most common type of injury to the thoracolumbar spine. Spondylolisthesis, defined as subluxation or a slip of one vertebral body on another, is most commonly seen in the lumbar spine. Treatment may involve conservative treatment with a brace. Surgical reduction and fixation may be required.

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 Spinal instability is caused by disruption of the anatomic components, motion or supportive elements. The spine is then able to move outside of its normal range of motion, resulting in excessive or abnormal motion. Spinal stability in the thoracolumbar spine is best understood with the three column model. The spine is divided into anterior, middle, and posterior elements. Injury to two or more of the columns results in instability.

20 Spinal Instability 50% Loss of Vertebral Body Height
Angulation > 20% Compression Fractures Burst Fractures Other findings consistent with unstable spine injuries include greater than or equal to 50% loss of vertebral body height, angulation of greater than 20%, compression fractures, and burst fractures. 20

21 Non-operative Management of Spinal Injuries
Stable injuries No neurologic deficits Immobilization Spinal injuries amenable to nonoperative management must be stable and the patient must not demonstrate any neurologic deficits. The ability to maintain immobilization must be present. This is an example of a cervical orthosis used to maintain immobilization in patients with a stable C-spine fracture.

22 Spinal Immobilization
C– spine Head halter Tongs Halo Conservative management of unstable spinal injuries involves reduction of deformity, decompression of neural elements, and stabilization. Conservative management of cervical spine injuries includes axial traction with a head halter, tongs, or a halo. Ten to fifteen pounds are initially applied. Head halters, that attach at the chin and occiput are limited to twenty pounds of traction. Other disadvantages are their ability to provide axial traction only and their propensity to create decubitus wounds of the occiput and chin. Tongs are ideal for longitudinal, temporary traction. Disadvantages of tongs include their limitation to longitudinal traction only. They also can be more painful and pins are prone to loosening over time. The halo has the advantage of stabilizing the spine in many planes. It can also withstand greater weights for longer periods. Pins are less likely to loosen. The halo ring is applied with either a cast or vest. PRODUCT-MEDIUM_IMAGE.jpg

23 Spinal Immobilization
T– and L– spine Bedrest Log rolling Rigid brace Thoracic and lumbar spine injuries are conservatively treated with bedrest, log rolling, and a rigid brace. Thoracolumbar orthosis function in four ways: they restrict movement of the spine, maintain alignment of the spine, reduce pain, and provide additional support to the muscles of the trunk. 23

24 Operative Management of Spinal Injuries
Spinal Fusion Pedicle screws and rods Vertebroplasty Kyphoplasty Goals of operative management of spinal injuries are the same as goals of conservative management: restore alignment, restore and maintain stability, and provide for decompression of neural elements. Posterolateral spinal fusion involves crew and rod fixation through the pedicles of adjacent vertebrae. Interbody spinal fusion involves anterior, posterior, or transforaminal fixation with screws and rods with replacement of intervertebral discs with bone grafts. Vertebroplasty is a procedure in which bone cement is injected percutaneously into the vertebra. It is employed to treat compression fractures. Kyphoplasty is a procedure in which a balloon is introduced percutaneously into a fractured vertebra and inflated to restore vertebral body height and correct angulation. Bone cement is then injected into the void created by the balloon.

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% Cervical spine clearance in the awake patient who has experience a significant mechanism of injury may be accomplished using the Nexus Criteria. These criteria include absence of all of the following: tenderness in the posterior midline of the cervical spine, focal neurologic deficit, decreased level of alertness, evidence of intoxication, and distracting pain. If all of the above are absent, the C-spine can be safely cleared. This screening tool has a sensitivity of 99.6% and a negative predictive value of 99.9%. 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.

26 Cervical Spine Clearance Algorithm
Como JJ, Diaz JJ, Dunham CM, et al. EAST practice management guidelines for identifying cervical spine injuries following trauma Cervical spine clearance in an trauma patient with altered level of alertness or patients with one or more of the preceding Nexus criteria is more complicated. The Eastern Association for the Surgery of Trauma has established this algorithm in 2009 for the C-spine clearance of such patients.

27 Cervical Spine Clearance Algorithm
Como JJ, Diaz JJ, Dunham CM, et al. EAST practice management guidelines for identifying cervical spine injuries following trauma -If the C-spine cannot be cleared clinically, a CT scan of the cervical spine is indicated.

28 Cervical Spine Clearance Algorithm
Como JJ, Diaz JJ, Dunham CM, et al. EAST practice management guidelines for identifying cervical spine injuries following trauma -If no C-spine injury is identified, the patient is assessed for neck pain.

29 Cervical Spine Clearance Algorithm
Como JJ, Diaz JJ, Dunham CM, et al. EAST practice management guidelines for identifying cervical spine injuries following trauma -If neck pain is present, an MRI of the cervical spine is indicated.

30 Cervical Spine Clearance Algorithm
Como JJ, Diaz JJ, Dunham CM, et al. EAST practice management guidelines for identifying cervical spine injuries following trauma -If the MRI is negative, flexion/extension Xrays are indicated.

31 Cervical Spine Clearance Algorithm
Como JJ, Diaz JJ, Dunham CM, et al. EAST practice management guidelines for identifying cervical spine injuries following trauma -If, after a negative C-spine CT scan, the patient has no pain or is unable to be assessed for pain, the patient is examined for evidence of neurologic deficit that could be attributed to a C-spine injury.

32 Cervical Spine Clearance Algorithm
Como JJ, Diaz JJ, Dunham CM, et al. EAST practice management guidelines for identifying cervical spine injuries following trauma -If neurologic deficit is present, MRI is indicated, followed by continuation of the cervical collar and Spine consultation.

33 Cervical Spine Clearance Algorithm
Como JJ, Diaz JJ, Dunham CM, et al. EAST practice management guidelines for identifying cervical spine injuries following trauma -If, at any point, C-spine injury is identified…

34 Cervical Spine Clearance Algorithm
Como JJ, Diaz JJ, Dunham CM, et al. EAST practice management guidelines for identifying cervical spine injuries following trauma …the cervical collar should be continued and Spine consult should be obtained.

35 Cervical Spine Clearance Algorithm
Como JJ, Diaz JJ, Dunham CM, et al. EAST practice management guidelines for identifying cervical spine injuries following trauma -If the C-spine CT is negative, the patient has no pain or is unable to be assessed for pain, and if there are no neurologic deficits attributable to the C-spine, the cervical collar can be removed. -Additionally, if C-spine CT is negative, C-spine MRI is negative, and flexion/extension Xrays are negative, the cervical collar can be removed.

36 Chest Wall Chest wall injuries are common in both penetrating and blunt trauma and are often dealt with in the critical care setting. These injuries can result in pain, hemorrhage, and chest wall instability, and significantly contribute to a patients pulmonary dysfunction and pneumonia.

37 Rib Fractures Overall mortality = 12% High-Energy Injuries:
1st or 2nd rib fractures Multiple rib fractures Scapula Fracture Rib Fractures in the Elderly (>65) 2 – 5 x greater risk of morbidity/mortality 19% Increase in mortality per rib fx 27% Increase in pneumonia Rib fractures are extremely common and have an overall mortality of 12%. Injuries associated with a high-energy mechanism include first or second rib fractures, multiple rib fractures, and scapula fractures. Rib fractures can have significant associated morbidity, especially for the elderly. Patients greater than 65 years old with rib fractures have a two to five times greater risk of morbidity and mortality than the rest of the population. Each rib fracture increases the risk of mortality by nineteen percent in the elderly. They also have a twenty seven percent greater risk of developing pneumonia.

38 Rib Fractures Treatment = Analgesia PCA Rib Blocks Epidural
Intercostal/ Intrapleural Catheter The treatment of rib fractures is primarily conservative. Adequate analgesia is paramount in preventing respiratory dysfunction. This can be accomplished in several different ways. Patient-controlled analgesia is often effective in relieving the pain of rib fractures. Parenteral narcotics and NSAIDs may be added for increased control. Rib blocks with lidocaine and bupivicaine may be effective in relieving pain from rib fractures but are of limited benefit due to the fact that they are short-acting and must be repeated in approximately six hours for ongoing pain relief. There is also a risk of pneumothorax. Epidural catheters with infusions of local anesthetics and narcotics have demonstrated the greatest benefit in regard to the improvement of pulmonary function after moderate to severe trauma with rib fractures, especially when the rib fractures are bilateral. Epidural catheters are contraindicated if a spinal injury cannot be excluded or if the patient has been on low molecular weight heparin in the previous 24 hours. They also have several side effects, including hypotension, urinary retention, pruritus, and ileus that are undesirable. The epidural catheter should only be left in place for 7 to 10 days. Intrapleural and intercostal have been attempted for pain control with rib fractures, but they have had limited success. This method entails infusion of local anesthetic intrapleurally through a chest tube or extrapleurally through a small subpleural or paravertebral catheter.

39 Flail Chest 2 ribs fractured in 2 locations
Paradoxical Motion 2 ribs fractured in 2 locations Significant morbidity from underlying pulmonary contusions “Pendelluft” Treatment: Supplemental O2 Analgesia Pulmonary Toilet ?Endotracheal Intubation ?Surgical Stabilization Flail chest results when 2 ribs are fractured in 2 locations. Flail segments most commonly occur anteriorly or antero-laterally in the middle or lower chest. The morbidity associated with flail segments, particularly respiratory compromise, is strongly associated with the pulmonary contusions underlying the flail segment. The paradoxical motion of the flail segment was previously thought to effect gas exchange due to a back-and-forth movement of the same air, functionally increasing the dead space, in a phenomenon termed “pendelluft.” It is now believed that this increase in dead space is the result of alterations in compliance and resistance and is often seen in many types of acute lung injury, even when chest wall instability is not present. The treatment of flail chest is similar to that of other rib fractures in that analgesia is the mainstay. Supplemental oxygen and pulmonary toilet should also be employed. Difficulty with adequate ventilation and oxygenation may demand endotracheal intubation. Surgical chest wall stabilization may also be indicated.

40 Surgical Stabilization
Studies suggest Quickly restores normal chest wall mechanics Less pain Decreased mortality Decreased mechanical ventilation needs Shorter hospital stays Decreased long term morbidity Gasparri MG, Almassi GH, Haasler GB (2003) Surgical management of multiple rib fractures. Chest 124:295S There is a recurring interest in surgical chest wall stabilization for the treatment of flail chest. There is little evidence to support its efficacy. Still, a few small retrospective series assert the following benefits of the procedure: It quickly restores normal chest wall mechanics improving pulmonary function. It decreases the pain associated with rib fractures. There may be decreased mortality and need for mechanical ventilation versus patients who undergo conservative management. Hospital stays may be shorter. And lastly, long-term morbidity might be decreased.

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 Currently, chest wall stabilization with rib fixation, using either wires or small plates, is not recommended for patients with rib fractures and flail segments that do not require intubation and mechanical ventilation. The current suggested indications for rib fixation are: flail chest requiring mechanical ventilation, persistent or refractory pain and disability associated with rib fractures, chest wall deformity, symptomatic rib non-union, and for patients undergoing a thoracotomy for other indications upon closing. 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

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 Sternal fractures are uncommonly seen in blunt trauma. Classically, they have been due to a deceleration impact of an unrestrained driver against the steering wheel of the car. They are regarded as a hallmark for more serious injury. The most common associated injuries are rib fractures, long bone fractures, and head injuries. Cardiac contusions have been associated with sternal fractures, but the relationship is inconsistent. Patients with sternal fractures should be monitored for arrhythmias and an electrocardiogram should be performed to assess for blunt cardiac injury. The treatment of sternal fractures is conservative. Rest and analgesia are employed. The patient may be monitored for EKG changes. Rarely, sternal fractures may require open reduction and internal fixation for persistent pain or considerable gross displacement.

43 Scapula Fractures From high energy trauma
Rarely occur as an isolated injury Management: Sling Pendulum exercises at 3 weeks Strengthening at 6 weeks Scapula fractures result from high energy trauma and are also considered a hallmark of more serious associated injuries. Management includes a sling for support and comfort, early pendulum exercises at 3 weeks, and strengthening at 6 weeks.

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 Scapula fractures also rarely require surgical repair. There are 4 main indications for operative management: If the scapula fracture is one of multiple fractures to the shoulder. If it involves a displaced fracture of the glenoid neck. If it involves a displaced fracture of the glenoid fossa. And if there is significant disruption of the superior shoulder supensory complex.

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 Clavicle fractures, unlike sternal and scapula fractures, often occur as an isolated injury. The most common mechanism of clavicle fracture is a fall or blow with a lateral force to the shoulder. The first third of the clavicle is rarely fractured. The middle one third of the clavicle is the most common location for fracture, seen in approximately 80% of clavicle fractures. The distal one third of the clavicle is also infrequently fractured. There is a considerable risk of nonunion with clavicle fractures, especially when they occur in the distal portion. Nonunion is estimated to occur in approximately 20% of clavicle fractures. The treatment of clavicle fractures is initially nonoperative, consisting of a sling for support and comfort, pendulum exercises at 2 to 3 weeks and avoidance of heavy activity for approximately 8 weeks.

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 Rarely, operative fixation of clavicle fractures may be warranted. Indications for surgical repair are: some fractures of the distal clavicle, middle clavicle fractures with greater than 2 centimeters of shortening, open clavicle fractures, symptomatic nonunions, associated neurovascular injury, and when the clavicle fracture is one of several fractures involving the shoulder. Surgical treatement usually consists of screw and plate fixation. Intramedullary implants are occasionally employed for clavicle fixation.

47 Pelvis Pelvic fractures are often encountered the ICU, especially in patients who are victims of major trauma. Management may be multifaceted and complicated by associated injuries involving the many structures housed within the pelvis.

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 The most common mechanisms of injury resulting in pelvic fractures are motorcycle collisions, pedestrians struck by motor vehicles, a fall from greater than 15 feet, and motor vehicle collisions. The mortality associated with pelvic fractures is substantial, ranging from 7 to 14%. Approximately 30% of these deaths are in patients with severe or open pelvic fractures. However, most of the deaths are not due the pelvic fracture itself, but to other concurrent injuries. Greater than 90% of patients with pelvic fractures have other injuries. The most common concomitant injuries that result in death in patients with pelvic fractures are head injuries, non-pelvic hemorrhage, lung injury, thromboembolic events, and multiple-system organ failure.

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% Still, pelvic fractures can pose a very real risk of hemorrhage. The mean transfusion requirement of a patient with a traumatic pelvic injury is 8 units. Blood loss from pelvic fractures can be minimized with early intervention. When a pelvic fracture is identified as one with potential for significant hemorrhage, several different methods can be employed to re-approximate the pelvis and provide temporary stabilization. A bed sheet can be used for pelvic compression. It is tied around the pelvis at the level of the greater trochanter while a person on each side of the patient applies lateral pressure to the greater trochanters. Multiple splints and pelvic binders have been designed for pelvic compression in the acute setting and are very effective. Pelvic clamps can be applied quickly and are effective at achieving pelvic compression, resulting in control of hemorrhage. They are usually, however, usually applied in the operating room with flouroscopic guidance to avoid damage to neurovascular structures. Similarly, external fixation can be applied as a “damage control” maneuver. It is also fast and effective and allows for attention to be turned to other life-threatening injuries. It can be used a definitive treatment or as a bridge to internal fixation. Angiography can be diagnostic and therapeutic in trauma patients with pelvic fractures and hemorrhage despite external fixation. Pelvic arterial disruption is the source of hemorrhage in somewhere between 3 and 20% of patients with pelvic fractures and intractable hemorrhage. At the time of angiography, additional traumatic sources of hemorrhage may be identified and embolized. _13.jpg

50 Pelvic Compression Fracture Vectors
Lateral Compression Anterior-Posterior Compression Vertical Shear Pelvic compression fractures generally occur as a result of force applied to the body in 3 different vectors. They are classified accordingly as lateral compression, anterior-posterior compression, and vertical shear fractures.

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 Lateral compression fractures generally occur after significant force has been transmitted through the lateral side of the pelvic ring, such as would occur in a side-impact motor vehicle collision. The diameter across the pelvis is shortened and the volume of the pelvis is therefore decreased. There is little risk of vascular or ligamentous pelvic injuries with this type of fracture. This type of fracture is, however, frequently associated with lethal torso injuries. There is no benefit nor harm to applying early compressive devices with this type of fracture.

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 An anterior-posterior compression fracture occurs when force is transmitted through the anterior pelvis, either directly through impact with the iliac spines or indirectly through the femurs. This type of fracture is often referred to as an “open book” pelvic fracture. Pubic symphysis diastasis and sacroiliac joint widening are common characteristics of this injury. It can occur as a constellation of ligamentous injuries without fracture, but most frequently occurs with fractures. This type of injury causes an increase in the diameter and volume of the pelvis. Patients who incur this unstable injury are at signficant risk of life-threatening bleeding. It would, therefore, be beneficial to apply early compression and stabilization when this injury is present.

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 Pelvic fractures resulting from vertical shear forces are the third type. Common mechanisms of injury include falling or jumping from a considerable height and landing on a straight leg. This type of fracture also results in significant ligamentous injury with frequent disruption of the symphyseal, sacrospinous, sacrotuberous, and sacroiliac ligaments. As with anterior-posterior compression fractures, the diameter and volume of the pelvis are increased. Although there is less bleeding associated with this fracture compared to anterior-posterior compression fractures, there is still a real risk of dangerous hemorrhage. Early pelvic compression is beneficial when this type of injury is present.

54 Upper Extremity
Critical care often involves the care of patients with upper extremity injuries, usually as a component of multiple injuries in polytrauma patients. Critical attention must be given to detecting any compromise in neurologic or vascular function.

55 Shoulder Fractures/Dislocations
Acromioclavicular dislocation “Shoulder Separation” Mechanism: fall onto acromion Involved ligaments: Acromioclavicular ligament Coracoclavicular ligament Complications: Risk of Brachial Plexus Injury Risk of Subclavian Vessel Injury Treatment: Sling Aromioclavicular dislocations and associated fractures are frequently referred to as “shoulder separations” and are often the result of falling onto the acromion. Damage occurs to the acomioclavicular ligament and coracoclavicular ligament. This injury may be complicated by damage to the brachial plexus or the subclavian vessels. Treatment is non-operative, involving a sling except in rare cases of considerable bone displacement.

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) A shoulder fracture frequently referred to as a “floating shoulder” results from fracture of the glenoid neck of the scapula and the clavicle, where the glenohumeral joint no longer retains a bony connection to the rest of the skeleton. Treatment includes surgical fixation of one of the two fractured elements, most commonly the clavicle. Low CK, Lam AWM. Results of fixation of clavicle alone in managing floating shoulder. Singapore Med ;4(19):

57 Shoulder dislocation Anterior (85-95%) Risk of axillary nerve injury
Treatment: Closed Reduction Posterior Mechanisms: Seizures, Electrocution Risk of axillary artery injury Glenohumeral dislocation is a common dislocation, occurring in 2% of the general population and 7% of athletes. It usually occurs anteriorly, comprising approximately 85 to 95% of shoulder dislocations. With this dislocation, the axillary nerve is at risk of injury. The treatment is urgent closed reduction, followed by a period of immobilization. Much less commonly, the shoulder can become dislocated posteriorly. This type is more difficult to detect on physical exam, presenting with less gross deformity, but an inability to externally rotate the upper arm. This is most often the result of seizures or electrocution. With this dislocation, the axillary artery is at risk for injury. Again, the treatment is closed reduction followed by a period of immobilization.

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 Proximal humerus fractures commonly occur with rotator cuff injuries or shoulder dislocations. They pose a risk of injury to peripheral nerves. The axillary artery is also at risk of damage. The treatment for nondisplaced fractures is a sling for a short period of time with early range of motion. There are 3 strategies for treatment of displaced humerus fractures. If the proximal humerus is fractured and displaced with impaction of the humeral head, the treatment is non-operative. If the proximal humerus fracture is displaced and in 2 parts, it can usually be treated with closed reduction and percutaneous fixation. If the humerus is in 3 parts, it will most likely require open reduction and internal fixation.

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 Midshaft humerus fractures are common and usually obvious. The radial nerve is at the greatest risk of damage with this injury and occurs approximately 12% of the time. Radial nerve injury is most common with fractures at the distal 1/3 of the humerus where it is closely associated with the humerus and runs in the spiral groove. Seventy percent of radial nerve injuries resolve with conservative management including spinting of the wrist and digits. Treatment of the humerus consists of a sling for conservative management if it is not displaced. If it is displaced, it may be reduced with gravity traction from a long arm cast for a short period of time. It then may be immobilized with a fracture brace. Severely comminuted or displaced fractures require operative fixation with either plate and screw fixation or intramedullary nailing.

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 Supracondylar fractures are common, especially in children age 5 to 7. They almost always require open reduction and internal fixation. A complication associated with supracondylar humerus fractures is Volkmann’s contracture. This occurs when the fracture causes occlusion of the anterior interosseus artery and reduction restores perfussion. This may lead to a reperfussion injury resulting in a flexor compartment syndrome.

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 One infamous elbow fracture-dislocation injury is known as the “terrible triad of the elbow.” This injury involves an elbow dislocation, radial head fracture, and coranoid process of the ulna fracture. This injury always requires surgery with repair or reconstruction. It is difficult to restore the functional capacity of the elbow, even with surgery. A common dislocation of the elbow is known as “nursemaid’s elbow.” It involves subluxation of the radius at the elbow. It is usually caused by traction to an extended pronated forearm. The treatment for this injury is closed reduction. Nursemaids-Elbow.jpg

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 There are several commonly encountered forearm fractures. These are 2 of the most severe, Monteggia and Galezzi fractures. A Monteggia fracture involves a proximal ulna fracture and radial head dislocation. This injury usually requires open surgical exploration with careful reduction of the radio-capitellar joint, followed by fixation. A Galezzi fracture is similar but occurs at the opposite end of the forearm. It involves an unstable radius fracture and a complex disruption of the radioulnar joint. This injury almost always requires operative repair, often with wire fixation of the radioulnar joint and possible repair of the ligament and styloid process. An above the elbow cast is then applied for 6 weeks.

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 Some other common forearm fractures include a night-stick fracture which describes an isolated fracture of the ulna. Treatment for this injury is usually a short period in a long arm cast followed by functional bracing. If the ulnar fragments are severely displaced, compression plating may be necessary. Another common forearm fracture is a Colles fracture. This is a fracture that usually occurs due to a fall on an outstretched hand with wrist extended. It is a type of distal radius fracture. Treatment is usually closed reduction with casting. A greenstick fracture is a type of fracture that can occur with most of the bones of the arms or legs, but which frequently occurs with radius injuries. It is most common in children. It involves a fracture that extends partially through the bone, leaving the opposite side of the bone bent.

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 Fracture of the scaphoid bone is a significant fracture, constituting approximately half of all isolated carpal bone fractures. It often presents with snuff box tenderness. The most common location for fracture is the waist of the scaphoid, occurring about 75% of the time, followed by the proximal pole at 20% , and the distal pole at about 5%. This is significant because the blood supply to the scaphoid bone comes from its ligamentous attachments which are affixed to the distal pole of the scaphoid. This puts the scaphoid at risk of avascular necrosis when fracture occurs at the more common sites, proximal to the distal pole. Operative repair is frequently required, consisting either of open screw placement or percutaneous screw placement. A cast to the elbow is then necessary.

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 A Rolando fracture is a severe type of thumb fracture that occurs in a T- or Y-configuration extending down to the metacarpal base. It is a difficult injury to manage, always requires surgery or external fixation, and usually results in a poor functional outcome. Phalangeal fractures are common in all age groups. Most can be treated with buddy taping or splint fixation. If there is intraarticular involvement, operative repair may be necessary. This involves closed reduction and fixation with percutaneous screws or Kirschner wires

66 Lower Extremity Lower extremity injuries comprise many of the injuries dealt with in a trauma ICU. The management of these injuries may be very complex and many critical issues may arise from such injuries. fc1-0fb1043c8a87Large.jpg

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 Femur fractures are present in about 15% of seriously injured trauma patients. Eight to ten percent of these patients present with bilateral femur fractures. These can represent high-energy, serious injuries with high incidences of morbidity and mortality due to other injuries sustained. The incidence of death with traumatic injuries that include a unilateral femur fracture is between 10 and 12%. This is increased to 20% in those over 65 years of age. Traumatic injuries that include bilateral femur fractures carry a 26 to 33% risk of mortality. Approximately 90% of deaths occurring in trauma patients with femur fractures are due to concomitant injuries and not to the femur fractures themselves. Despite controversy over the optimal timing of surgical fixation of femur fractures in patients with multiple traumatic injuries, evidence has demonstrated that there is a decreased risk of complications if the patient undergoes surgical fixation within 24 hours of the trauma.

68 Hip Fractures 50% over 85years 6 month mortality of 20%
Preoperative Management of Unstable Fxs Buck’s Traction Skeletal Traction Hip fractures, fractures of the proximal femur, most commonly appear in the elderly with 50% occurring in patients over the age of 85. They most frequently result from a fall in a patient with osteoporosis. With younger people, hip fractures are usually due to high-energy trauma and often they have other associated injuries. Patients with proximal femur fractures present with gross deformity, with a shortened and externally rotated lower extremity. The pain is usually the greatest in the groin. When a traumatic proximal femur fracture is detected, the lower extremity should be placed in traction to keep it immobilized until surgery. Light skin traction, for example with a Buck’s traction boot, can be quickly and easily utilized. Skeletal traction should be used for less stable fractures. Traction is not necessary in elderly patients with a low-energy mechanism of injury.

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 Femoral neck fractures are classified as intracapsular or extracapsular. Intracapsular fractures involve the narrow part of the femoral neck just below the femoral head. They hold a high risk of avascular necrosis and nonunion. An intracapsular hematoma may develop, further compromising perfusion by compressing nutrient vessels. This type of fracture constitutes a surgical emergency in young people. Treatment for this type of fracture usually involves urgent reduction, a decompressive capsulotomy, and internal fixation. Alternatively, hip arthroplasty may be more beneficial to less active, elderly, osteoporotic patients. Extracapsular femoral neck fractures are less complicated, with minimal risk of avascular necrosis and nonunion. They are typically treated with dynamic hip screw, followed by early functional rehabilitation with full weight bearing.

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 Trochanteric proximal femur fractures are located just distal to the femoral neck. They are more stable than femoral neck fractures. These fractures all require early open reduction and internal fixation to ensure early ambulation and full return of functional status as well as to prevent a varus hip deformity. Subtrochanteric fractures often occurs in young people to a high-energy collision or fall and it usually extends into the femoral shaft. In older people, subtrochanteric may occur with low-energy trauma, such as a fall from standing, in a person with osteoporosis. These fractures are prone to failure of surgical fixation. With ORIF, the fracture is exposed and fully fixed, but the bone is devascularized in the process. Closed reduction and intramedullary nailing maintains the bone’s blood supply but often the fracture cannot be fully reduced. New techniques involving indirect reduction with a blade-plate or screw-plate device allow for adequate reduction of the fracture while maintaining periosteal vascularization. These techniques are, however, technically challenging

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 Ideally, all hip dislocations should be properly reduced within 6 to 8 hours of the injury. The most common type of hip dislocation, occurring approximately 85 to 95% of the time, posterior dislocation usually results from direct force to the knee or upper tibia in a seated patient, such as would occur with an unrestrained passenger in a motor vehicle collision. If the leg is abducted at the time of impact, a posterior acetabulum fracture is likely to occur. If the leg is adducted at the time of impact, a pure dislocation is usually the result. Patients with posterior hip dislocations typically present with an internally rotated and adducted lower extremity. This type of dislocation puts the sciatic nerve at risk of injury. The treatment involves closed reduction and evaluation for acetabulum and, occasionally, femoral head fractures. Rarely, about 5% of the time, a hip will become dislocated anteriorly, usually due to forced external rotation and abduction. The patient will present with an externally rotated and abducted lower extremity. This type of dislocation puts the femoral artery at risk of injury. Treatment is again closed reduction with careful assessment for femoral head and neck fractures.

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 Femoral shaft fractures are always due to a high-energy mechanism of energy and usually heralds the presence of other serious traumatic injuries. Femoral shaft fractures frequently result in up to 1500 to 2000cc of blood loss, with the potential to bring about hemorrhagic shock. Early reduction of the fracture and maintenance of alignment is important for preserving adequate perfusion to the distal leg and reducing the volume of blood loss. The current standard of care for femur fracture fixation involves closed reduction with intramedullary reaming and intramedullary nail placement. Controversy over reaming has existed due to concern for possible intravastion of fat, marrow, debris, and inflammatory mediators. Multiple studies have failed to demonstrate that reaming results in any type of pulmonary complications and is therefore routine practice. If multiple critical injuries are present, external fixation can be performed for “damage control” with conversion to intramedullary nail at 5 to 10 days post-trauma. Early fixation is important in reducing or avoiding the associated complications of fat embolism syndrome, acute lung injury, and acute respiratory distress syndrome.

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 Patella fractures are usually a consequence of a direct blow to a flexed knee. Nondisplaced fractures should be treated non-operatively in a long leg cast. Displaced fractures should be treated with open reduction and internal fixation with either lag screws or tension banding. Tension banding is depicted in the pictures to the right. If fracture is severely comminuted and displaced, partial or total patellectomy may be indicated. All operative repairs involve repair of the patellar retinacula. Early but limited range of motion should be performed. Touch-down weight-bearing only should be continued for at least 4 to 6 weeks.

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 Knee dislocation may involve either of 2 joints: the patello-femoral or the tibio-femoral joints. Knee dislocations are usually lateral. Hemarthrosis or an effusion quickly develops. They may be recurrent due to anatomic variations that predispose the person to dislocation. The knee may become relocated upon straightening the leg. The patella can sometimes be palpated laterally. Treatment entails closed reduction with subsequent knee immobilization for 4 to 6 weeks. Complete knee dislocation is less common and usually occurs either anteriorly or posteriorly. The popliteal artery is at extreme risk of injury with knee dislocations and should be very thoroughly assessed, usually with angiography. Popliteal artery injuries are often asymptomatic early in the injury course and may go unappreciated if not scrutinize carefully, potentially resulting in amputation.

75 Tibia-Fibula Fractures
Proximal and Midshaft Tibia Fractures High risk for compartment syndrome Tibial Plateau Fractures Nondisplaced proximal tibia fractures: hinged knee brace Displaced/Unstable patient: External fixator Deformity/Instability: Surgical Repair Proximal and midshaft tibia fractures pose a high risk for compartment syndrome. Treatment for nondisplaced tibial plateau fractures of the proximal tibia consists of a hinged knee brace. Treatment of a displaced tibial plateau fracture in an unstable patient mandates an external fixator. Significant deformity or instability demands surgical repair.

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 The calcaneus requires a tremendous force to the heal in order to fracture. It frequently occurs with spine compression injuries due to severe axial loading injuries. If the fracture is nondisplaced and is estra-articular, treatment is nonoperative. Displaced and intra-articular fractures of the calcaneous require open reduction and internal fixation approximately 2 to 3 weeks after the injury has occurred in order to allow for the resolution of swelling.

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 The talus is at risk of avascular necrosis secondary to fracture. Fracture of the neck of the talus is the talus fracture that results in the greatest risk of AVN and can result in a surgical emergency if displaced. Dislocation greatly amplifies the risk of AVN and is therefore, a surgical emergency. Most talus fractures can be treated with closed reduction and conservative management. Severely displaced talus fractures require precise reduction and fixation with interfragmentary screws.

78 Metatarsal Fractures Jones Fracture Mechanism: Inversion of Foot
5th Metatarsal At risk for nonunion Metatarsal fractures are often the result of stress fractures. The second and third metatarsals are fixed while walking and, for that reason, are common sites of stress fractures. Metatarsal fractures are usually treated nonoperatively if isolated, nondisplaced, or minimally displaced. A particular fracture of the 5th metatarsal is termed a “Jones fracture.” It usually results after excessive inversion of the foot. Because it resides in a watershed area, this fracture runs a substantial risk of nonunion (up to 25%), requiring surgical fixation.

79 Complications of Extremity Fractures
Infection Findings often appear 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 Extremity injuries, especially in critically ill patients, are more susceptible to infections. Wound infections usually become clinically apparent approximately 10 to 21 days after infection. The most common organism associated with wound infections is Staph. aureus. Other common pathogens in wound infections are Pseudomonas aeruginosa and Enterobacteriaceae. The diagnosis of a wound infection is primarily made clinically with signs of infection including warmth, erythema, pain, tenderness, palpable fluctuance, and presence of purulence. The infection may also result in constitutional signs and symptoms including fevers and chills, malaise, and leukocytosis. If the infection involves the bone, a CT scan, MRI, or 3-phase bone scan might show evidence of infection. A radiolabeled WBC scan could be used to assess for the site of infection if the etiology is unclear.

80 Complications of Extremity Fractures
Gas Gangrene Necrotizing fasciitis Treatment: Early wide debridement Antibiotics (PCN) Tetanus Highest risk w/ farming accidents Supportive Debridement Immunization Antibiotics A few extreme wound infections are gas gangrene, necrotizing fasciitis, and tetanus. Gas gangrene is a severe, rapidly progressive infection, usually caused by Clostridium perfringens. It is a medical and surgical emergency. It can result in myonecrosis, gas in the soft tissue, and sepsis. It may progress quickly to toxemia and shock due to the exotoxin. Surgical treatment is source control with wide local debridement, often resulting in amputation. Penicillin is a medical adjunct to debridement. Hyperbaric oxygen is sometimes employed as treatment as well. Necrotizing fasciitis is a severe, rapidly progressive infection, similar to gas gangrene, that spreads across fascial planes. It is usually caused by Strep. pyogenes, but may result from MRSA. The bacteria release the exotoxin superantigen which leads to toxemia and shock. Treatment is similar to that of gas gangrene with radical debridement and a broad-spectrum antibiotic regimen that includes Penicillin. A third extreme infection, tetanus, causes prolonged contraction of skeletal muscles. It is caused by Clostridium tetani, which produces tetanospasmin, a neurotoxin. C. tetani is present in soil and is therefore most common in farming injuries. The best approach to tetanus management is immunization with Tetanus toxoid every ten years. Patients presenting with dirty open wounds susceptible to tetanus infection should receive a tetanus booster. Tetanus is treated with supportive care. Administration of human anti-tetanospasmin immunoglobulin or tetanus immunoglobulin to provide passive immunization is essential. Tetanus, like the previous 2 infections mandates extensive tissue debridement. Metronidazole is also used as an adjunct.

81 Osteomyelitis Acute Osteomyelitis Hematogenous Spread
Contiguous Spread Subacute Osteomyelitis Chronic Osteomyelitis Osteomyelitis, an infection of the bone or bone marrow, can be classified by acuity. The 3 main divisions are acute, subacute, and chronic. Acute osteomyelitis can be subdivided by the route of contamination: hematogenous spread or contiguous spread with direct extension to the bone. d485/ref/graphics/9712.jpg

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 A diagnosis of osteomyelitis requires that at least 2 of the following 4 criteria be met: -purulent material on aspiration of the affected bone -positive blood culture or tissue culture -localized classic findings of bony tenderness with overlying soft-tissue erythema or edema -positive radiological study

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) The most common pathogens implicated in ostemyelitis are listed. Overall, the most common organism is Staph. aureus. Common bacteria involved in osteomyelitis of the vertebral bodies are Gram negative infections. IV drug abusers frequently contract osteomyelitis caused by Pseudomonas. Chronically ill patients, especially patients on chronic TPN are susceptible to fungal osteomyelitis. Patients with sickle cell disease may suffer from Salmonella osteomyelitis. Infants ages 2 to 4 weeks are susceptible to osteomyelitis caused by Group B Streptococcus. Children ages 6 months to 4 year are the most likely to get Haemophilus influenzae.

84 Osteomyelitis Treatment: Surgical Debridement ? Limb Loss Antibiotics
Broad Spectrum IV Tissue cultures to narrow Hyperbaric Oxygen for Refractory Osteomyelitis Treatment of osteomyelitis requires surgical debridement, possibly necessitating amputation. Broad-spectrum antibiotics should be initiated when osteomyelitis is suspected and tapered to pathogen-specific antibiotics after tissue or blood cultures yield a causative organism. Some studies have found that hyperbaric oxygen may be a beneficial adjuvant to the treatment of refractory osteomyelitis. Kindwall EP. Uses of hyperbaric oxygen therapy in the 1990s. Cleve Clin J Med. Sep-Oct 1992;59(5):517-28

85 Complications of Extremity Fractures
Fat Embolism Approx deaths per year Classic Triad: Respiratory Compromise Change in Mental Status Petechiae Half of all cases present only with respiratory failure Treatment: Supportive tn.jpg Fat embolism syndrome is usually associated with long bone fractures. Fat emboli are widely disseminated from bone fractures, causing a direct embolic effect and activation of the inflammatory cascade. If severe, it can result in multiple organ system failure. Fat emboli are reported to be the cause of approximately 5000 deaths per year, with a mortality rate of 5 to 15%. The classic triad of symptoms are: respiratory compromise, a change in mental status and petechiae. Half of all cases, however, present only with acute respiratory failure. Treatment is supportive.

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 Venous thromboembolism is a significant source of morbidity and mortality in all hospitalized patients, but particularly in trauma patients. All 3 factors in Virchow’s triad, hypercoagulability, endothelial damage, and venous stasis, are precipitated by trauma involving bone fractures. At least 60% of DVTs are asymptomatic. Pulmonary emboli are the 3rd most common cause of death in trauma patients who survive past the first day. Trauma patients who receive no chemical DVT prophylaxis have demonstrated a 58% incidence of DVT. In some studies, the use of unfractionated heparin as DVT prophylaxis has demonstrated no reduction in the incidence of DVTs. Current evidence suggests that prophylactic doses of low molecular weight heparin for DVT prophylaxis in trauma patients may decrease the incidence of DVTs by half with no significant bleeding complications.

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 Compartment syndrome is a potentially devastating complication that may result from a variety of causes including bone fractures, crush injury, burns, and reperfusion injury. It becomes critical when the resting pressure inside the compartment exceeds 30mm of mercury or the difference between the diastolic blood pressure and compartment pressure is less than 30mm of Mercury. Either of these scenarios results in pressure that is greater that which can be exceeded by the microvasculature. It therefore results in tissue ischemia that is capable of progressing to myonecrosis and limb loss. The treatment for compartment syndromes are to completely release all of the pressure by opening the fascia from one end of the compartment to the other.

88 Complications of Extremity Fractures
Rhabdomyolysis Treatment = aggressive IVF Avoid buildup of myoglobin in renal tubules Prevent hyperkalemia Rhabdomyolysis is a complication associated with compartment syndrome in that they share common mechanisms and compartment syndrome may lead to rhabdomyolysis. Treatment involves aggressive intravenous fluid hydration with close monitoring of urine output and labs to ensure that myoglobin does not build up in the renal tubules and to prevent the patient from developing hyperkalemia from muscle breakdown and renal failure. 88

89 Image Sources jpg Como JJ, Diaz JJ, Dunham CM, et al. EAST practice management guidelines for identifying cervical spine injuries following trauma fc1-0fb1043c8a87Large.jpg Gasparri MG, Almassi GH, Haasler GB (2003) Surgical management of multiple rib fractures. Chest 124:295S

90 Image Sources /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. PRODUCT-MEDIUM_IMAGE.jpg 90

91 Image Sources MyPortalFiles%3FFilePath%3D/Surgery/en/_img/surgery/01-Diagnosis/61/62-A1-xrays- jpg jpg tn.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 ;4(19): Pirouzmand F, Muhajarine N. Craniofac Surg Jan;19(1): Definition of topographic organization of skull profile in normal population and its implications on the role of sutures in skull morphology. _13.jpg

92 Image Sources 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 Nursemaids-Elbow.jpg d485/ref/graphics/9712.jpg 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 92

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