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Skeletal System Shannon Carroll, MD Suresh Agarwal, MD.

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2 Skeletal System Shannon Carroll, MD Suresh Agarwal, MD

3 Slide 3 Skeletal System Common Skeletal System Pathology encountered in Critical Care Complications of Skeletal Injury

4 Slide 4 Skull

5 Slide 5 Skull Fractures 4 Major Types Linear Depressed Diastatic Basilar

6 Slide 6 Linear Skull Fracture Most common type Over Lateral Convexities Over squamous area of temporal bone –Damage to middle meningeal artery –Epidural Hematoma mxray/v5c09h2.jpg

7 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/minDsc jpg

8 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 Jan;19(1): 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/ jpg

9 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/ jpg

10 Slide 10 Basilar Skull Fracture Raccoon Eyes image.absoluteastronomy.com/im ages/encyclopediaimages/b/bl/bla ckeye_pigmentation.jpg tle_Sign_s.jpg Battle’s Sign

11 Slide 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 ne/spine_thoracic/anatomy/thoracic_spine_anat omy01.jpg

12 Slide 12 Vertebral Injuries 7 Mechanisms of Injury Flexion – compression Axial compression Flexion – distraction Hyperextension Rotation Shear Avulsion

13 Slide 13 Cervical Spine Injuries treatment.com/images/human-lateral- cervical-spine.jpg

14 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

15 Slide 15 Fractures of the Odontoid Apical ligament avulsion fracture Stable Minimal if any external support img.medscape.com/pi/emed/ckb/orthopedic _surgery/ jpg

16 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/ jpg

17 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/ jpg

18 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 ar_spondylolisthesis_grades.jpg

19 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 content/uploads/2009/11/three-column- concept-2.jpg

20 Slide 20 Spinal Instability content/uploads/2009/11/three-column- concept-2.jpg 50% Loss of Vertebral Body Height Angulation > 20% Compression Fractures Burst Fractures

21 Slide 21 Non-operative Management of Spinal Injuries Stable injuries No neurologic deficits Immobilization

22 Slide 22 Spinal Immobilization C– spine –Head halter –Tongs –Halo images.allegrocentral.com/9E/75/J-Tongs- Traction-Tongs PRODUCT- MEDIUM_IMAGE.jpg mid=15083&proc=3

23 Slide 23 Spinal Immobilization T– and L– spine –Bedrest –Log rolling –Rigid brace ache/product_list/products_01_B09.jpg

24 Slide 24 Operative Management of Spinal Injuries Spinal Fusion –Pedicle screws and rods Vertebroplasty Kyphoplasty guide.com/Chapter_Fig_folders/C h15_Carpentry_Folder/Ch15_Imag es/15_3_Pedicle_Screws.jpg eldoradopainmanagement.net/mediac/450_ 0/media/Compression_Render_Final.jpg es/balloon_kyphoplasty.jpg

25 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.

26 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

27 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

28 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

29 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

30 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

31 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

32 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

33 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

34 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

35 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

36 Slide 36 Chest Wall ditional/Rib_cage.jpg

37 Slide 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 image.wetpaint.com/image/1/XO MgDfktBYZImgBWx3Xc2g /GW537H600

38 Slide 38 Rib Fractures Treatment = Analgesia –PCA –Rib Blocks –Epidural –Intercostal/ Intrapleural Catheter /cow353-1lg.jpg

39 Slide 39 Flail Chest 2 ribs fractured in 2 locations Significant morbidity from underlying pulmonary contusions “Pendelluft” Treatment: –Supplemental O2 –Analgesia –Pulmonary Toilet –?Endotracheal Intubation –?Surgical Stabilization upload.wikimedia.org/wikipedia/commons /3/39/Flail_chest_mechaincs.jpg Paradoxical Motion

40 Slide 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 bloc-overview jpg Gasparri MG, Almassi GH, Haasler GB (2003) Surgical management of multiple rib fractures. Chest 124:295S

41 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

42 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

43 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 adult_shoulder_fx_type_scapular_blade.jpg

44 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 ?book=physmedrehab&part=A3412&blobname =ch4f4-30.jpg

45 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 ges/clavicle-side.jpg

46 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/ /clavicle_fracture_surgery_pho to.gif images.google.com/imgres?img url=http://assets.sbnation.com/a ssets/161691

47 Slide 47 Pelvis aff973/Pelvis///Pelvis_thumb01.jpg

48 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

49 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/ _13.jpg

50 Slide 50 Pelvic Compression Fracture Vectors Lateral Compression Anterior-Posterior Compression Vertical Shear images.google.com/imgres?imgurl=http://www.aofo undation.org/AOFileServerSurgery/MyPortalFiles% 3FFilePath%3D/Surgery/en/_img/surgery/01- Diagnosis/61/62-A1-xrays-

51 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 pelvis-fractures-types

52 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 adult_pelvis_fx_causes06.jpg

53 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 -pelvis-fractures-types

54 Slide 54 Upper Extremity

55 Slide 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 _acromioclavicular_separation_intr o01.jpg

56 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):

57 Slide 57 Shoulder dislocation Anterior (85-95%) –Risk of axillary nerve injury –Treatment: Closed Reduction Posterior –Mechanisms: Seizures, Electrocution –Risk of axillary artery injury –Treatment: Closed Reduction dislocation.jpg der_dislocation/shoulder_dislocation_anatomy12.jpg

58 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 s/4_parts_prox_humerus.jpg

59 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 /adult_humeral_fx_brace.jpg

60 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 om/wp-content/Volkman.jpg

61 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/ Nursemaids-Elbow.jpg

62 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 ont1.jpg /caseoftheweekpix2/cow157lg.jpg

63 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 z.about.com/d/orthopedics/1/0/2/1/fxapcolles.jpg ar fig10.jpg

64 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

65 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

66 Slide 66 Lower Extremity files.turbosquid.com/Preview/Content _2009_07_13__17_30_11/leg_bones. jpgf1dbe04a-ce4d fc1- 0fb1043c8a87Large.jpg

67 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

68 Slide 68 Hip Fractures 50% over 85years –6 month mortality of 20% Preoperative Management of Unstable Fxs –Buck’s Traction –Skeletal Traction mt/images/College/conferences/Ortho_Traction_in_Orthope dicCare.pdf

69 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 ichipscrew.jpg

70 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

71 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

72 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

73 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 %20Images/fracture_of_patella_2.JPG Surgery/MyPortalFiles? FilePath=/Surgery/en/_img/surgery/05-RedFix/34/P90- tension-band-wiring/33_P90_i480L_C11_patella.jpg

74 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 large/00_04_0756_04b_cmyk.jpeg

75 Slide 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 sections/msk/teaching-materials/sundry-msk- computer-programs/sundry-images-for- programs/3DCTS1_3DAP.jpg/image

76 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 xray5.jpg p%20A.jpg

77 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 tTrauma/FxTalusNeck.gif content/obj/0802/salem_fig1b.jpg

78 Slide 78 Metatarsal Fractures Jones Fracture –Mechanism: Inversion of Foot –5th Metatarsal –At risk for nonunion fractures-types

79 Slide 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

80 Slide 80 Complications of Extremity Fractures Gas Gangrene Necrotizing fasciitis Treatment: –Early wide debridement –Antibiotics (PCN) Tetanus –Highest risk w/ farming accidents –Treatment: Supportive Debridement Immunization Antibiotics amog.com/wp- content/uploads/2009 /03/fasciitis.jpg en/MedEd/mech/cases/Gra m_Positive/slide1.jpg www2.cedarcrest.edu/academic/ bio/hale/bioT_EID/lectures/tetan us-pathogen2.jpg

81 Slide 81 Osteomyelitis Acute Osteomyelitis –Hematogenous Spread –Contiguous Spread Subacute Osteomyelitis Chronic Osteomyelitis ssl.gstatic.com/health/33576cb3c325418b 82afc d485/ref/graphics/9712.jpg

82 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 look.com/diseases_images/osteomyelitis.jpg

83 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

84 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

85 Slide 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 img.medscape.com/pi/emed/ckb/vascul ar_surgery/ tn.jpg /dlpdict/petechiae.jpg

86 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

87 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

88 Slide 88 Complications of Extremity Fractures Rhabdomyolysis –Treatment = aggressive IVF Avoid buildup of myoglobin in renal tubules Prevent hyperkalemia

89 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/minDsc 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 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 fc1-0fb1043c8a87Large.jpg Gasparri MG, Almassi GH, Haasler GB (2003) Surgical management of multiple rib fractures. Chest 124:295S

90 Slide 90 Image Sources georgiahealthinfo.gov/cms/files/global/images/image_popup/fsm7_compartmenttestin g.jpg herkules.oulu.fi/isbn /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 PRODUCT- MEDIUM_IMAGE.jpg images.google.com/imgres?imgurl=http://assets.sbnation.com/assets/ images.google.com/imgres?imgurl=http://www.aofoundation.org/AOFileServerSurger y/

91 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/ jpg img.medscape.com/pi/emed/ckb/radiology/ jpg img.medscape.com/pi/emed/ckb/vascular_surgery/ tn.jpg Kindwall EP. Uses of hyperbaric oxygen therapy in the 1990s. Cleve Clin J Med. Sep- Oct 1992;59(5): Low CK, Lam AWM. Results of fixation of clavicle alone in managing floating shoulder. Singapore Med. 2000;4(19): 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 Jan;19(1): 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/ _13.jpg _ skeleton-with-edge-of-blank-sign-includes-clipping-path.jpg

92 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): s3.beckshome.com/ Nursemaids-Elbow.jpg ssl.gstatic.com/health/33576cb3c325418b82afc d485/ref/graphics/9712.jpg t0.gstatic.com/images?q=tbn:TuEw6pvP4iIG5M:http://img.medscape.com/pi/emed/ck b/neurosurgery/ 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

93 Slide 93 Image Sources upload.wikimedia.org/wikipedia/commons/6/61/Pulmonary_embolism.jpg upload.wikimedia.org/wikipedia/commons/3/39/Flail_chest_mechaincs.jpg upload.wikimedia.org/wikipedia/commons/5/59/Ostermyelitis_Tibia.jpg www2.cedarcrest.edu/academic/bio/hale/bioT_EID/lectures/tetanus- pathogen2.jpg myk.jpeg ery/en/_img/surgery/05-RedFix/34/P90-tension-band- wiring/33_P90_i480L_C11_patella.jpg 5_Images/15_3_Pedicle_Screws.jpg

94 Slide 94 Image Sources G dislocation_anatomy12.jpg spine_anatomy01.jpg e.jpg

95 Slide 95 Image Sources skeleton-with-edge-of-blank-sign-includes-clipping-path.jpg g e/conferences/Ortho_Traction_in_OrthopedicCare.pdf 340/cow353-1lg.jpg

96 Slide 96 Image Sources A3412&blobname=ch4f4-30.jpg B09.jpg

97 Slide 97 Image Sources materials/sundry-msk-computer-programs/sundry-images-for- programs/3DCTS1_3DAP.jpg/image z.about.com/d/orthopedics/1/0/2/1/fxapcolles.jpg


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