dr.

Widiyatmiko Arifin Putro, SpOT

Faculty of Medicine
Universitas Swadaya Gunung Jati
Cirebon
Scope : Subdivision :
 Congenital & developmental  Traumatology
abnormalities
 Infection & inflammation  Orthopaedi :
 Arthritis & rheumatic disorders 1. Adult Reconstruction
 Metabolic & endocrine 2. Oncology Orthopaedic
disorders 3. Pediatric Orthopaedic
 Tumours 4. Spine
 Sensory disturbance & muscle
5. Hand & Microsurgery
weakness
 Injury & mechanical 6. Sports Injury
derangement 7. Ankle and Foot
 Trauma  commonest cause of death in people
from 1–44 years
 1.2 million per year road accidents.
 WHO predicts that by 2020 road traffic injuries
will rank third in the causes of premature death
and loss of health from disability
 In the UK vehicular accidents causing death or
serious
 injury are usually motorcycle and car related
Global Percentage of Deaths due Proportion of casualties by road
to Injury (1999) user type
 major trauma mortality in a high-income
country hospital (6 %) and in a rural area of a
low-income country (36 %)
 Deaths as a result of trauma classically follow
a trimodal pattern
 50% < 60 minutes
 30%  1-3 hours(Gold)
 20%  6 weeks
• Early phase-immediate death
 severe brain injury, disruption of great vessels, cardiac
disruption
• Second phase-minutes to hours
 subdural, epidural hematomas, hemopneumothoraces,
severe abdominal injuries, multiple extremity injuries
(bleeding)
• Third phase-delayed
 multisystem organ failure
 sepsis
 effective EMS is available to initiate
management at the scene of the injury and
transfer the casualty rapidly to hospital
 Treatment is centred on
 Evaluation
 resuscitation
 stabilization
• One per population of 5 million or less
• Studies demonstrate a 30-40% preventable
death rate due to inadequate trauma systems
• Trauma Surgeon TEAM • Interventional radiology
LEADER • Intensivist
• Anesthesia • Hospital Staff-Nursing,
• Musculoskeletal • Speech, Admin.
traumatologist • Legal/Security
• Neurosurgeon • Social work
• Vascular/CT surgeon • Ministry
• Urology, Gynecology
• Europe - General Surgeon
Traumatologists
 treat all injuries
• North America -
Multidisciplinary team
 Orthopaedic Traumatologist-
broad knowledge of treatment of
injuries involving other organ
systems to coordinate care
optimally with colleagues
• General resuscitation / ICU
care
• Advantages / disadvantages
of early stabilization of long
bone fractures
• Skilled sufficiently to do a
procedure expeditiously with
minimal risk of complications
• Understands impact of
treatment on multisystem
injury
• Injury Severity Score >15
• Hemodynamic instability
• Coagulopathy
• Closed head injury
• Pulmonary injury
• Abdominal injury
 Def.: scale of anatomic injury
 ISS is the sum of the squares of the three
highest AIS categories
 AIS (Abbreviated Injury Scale) – looks at five
categories: general, head and neck, chest,
abdominal, and extremities
 Maximum ISS is 75
• Phases of management • Priorities in treatment
 Primary Survey  Airway + Cspine control
 Resuscitation  Breathing
 Secondary Survey  Circulation/CNS
 Definitive care  Digestive system
 Excretory Tracts
 Fractures
• Establish an appropriate airway
 obtain patency-jaw lift
 oral or nasal airway
 surgical airway
• Control of the cervical spine
• Lateral C-spine radiograph
 not included in the initial radiographic evaluation
in the revised ATLS protocol
• Assess breathing and oxygenation
• Evaluation with Arterial Blood Gas (ABG)
• Etiology of decreased oxygenation has to be
determined
 Tension pneumothorax-decompress
 Open pneumothorax-seal and chest tube
 Flail chest, pulmonary contusion-chest tube
• Control of airway
• Prevent aspiration in unconscious patient
• Hyperventilation for increased intracranial
pressure
• Obstruction from facial trauma and edema
• Identifiable bleeding controlled with direct
pressure
• Always try direct pressure first
• Avoid blind use of vascular clamps
• Tourniquets are rarely indicated except for
traumatic amputations
Peripheral Pulse Systolic Blood Pressure
radial 80 mm Hg
femoral 70 mm Hg
carotid 60 mm Hg

capillary refill > 2 secs Hypotensive

Class Percent Blood Blood Urinary Treatment
Blood Loss (cc) pressure output
Volume change
I 15 < 800 None None Crystalloid

II 15-30 800-1500 Min 20-30cc/hr Crystalloid

III 30-40 2000 Hypotension 10-20cc/hr Cryst/

blood
IV > 40 > 2000 significant Min Blood
• Two peripheral large bore
Ivs (16)
• Two liters of Ringers
Lactate
 If no response then severe
hemorrhage has occurred
 immediate blood is needed
• Monitor
 Blood pressure
 Urinary output
 Base deficit
 Initial
Hematocrit/Hemoglobin -
unreliable
• Hemorrhagic
• Cardiogenic-pericardial tamponade
• Neurogenic-CHI, spinal cord injury
 hypotension without tachycardia
 Vasoconstrictive meds not administered until
volume is restored
• Septic-late sequela
• Crossed Matched • Blood warmer-prevents
hypothermia, arrhythmias
 1 hour
• Blood filters-160 u
• Type Specific
macropore
 10 minutes • Coagulation status-
• Type O Rh neg Platelets monitored every 10
 immediately units
 Platelets < 100,000-replace
• Labile factors (fibrinogen)-
replace with FFP
• Direct control of bleeding sources
• Large bore IV access-Fluid replacement
• Monitor-urine output, CVP, pH, lactate level
• Blood replacement-indicated by clinical
response
• Head
 skull trauma
 reevaluate pupillary size and reaction
 blood/fluid at tympanic membranes and nares
 facial and ethmoid fractures
• Cervical spine
 swelling, crepitus, expanding hematoma
• Glascow Coma Score-
GCS
• Pupil exam-intracranial
pressure
• Motor and Sensory - all
extremities in alert
patient
• Chest-reevaluate for
crepitus, fractures, flail
segments,open wounds
• Abdomen-inspect,
auscultate, palpate
 seat belt injury-spinal or
intraabodominal injury
• Pelvis-exam for
tenderness, instability
• Rectal exam
 tone, sensory, prostate injury
 if abnormal, do not pass foley-consult Urology
• Extremity exam
 palpate for crepitus, swelling, pain, instability,
range of motion
• Neurological exam-document all findings
• Oxygenation and cerebral circulation
• Loss of consciousness (LOC) > 5 mins
 observation for 24 hours
 potential for seizures
• CT scan of head
• Meningeal
• Brain tissue
• Suspect in unconsciousness patient or
lateralizing signs
 fixed pupil
• Patient positioning
• Fluid restriction
• Hyperosmotic diuretics-mannitol
• Deliberate hypocapnia
 controlled hyperventilation
 maintain pCO2 at 25-30 mm Hg
• Avoidance of stimuli
• Accounts for 50-75 %
 of fatalities in blunt trauma
• 15% of injuries require
 surgical intervention
• Second leading cause of death
• Life saving procedures performed during
the primary survey
• Secondary survey-
 pulmonary contusion, aortic disruption, airway
disruption, traumatic diaphragmatic
disruption, myocardial contusion
• CXR-aortic disruption
 widened mediastinum, fracture of 1st and 2nd
ribs, sternum fracture,loss of aortic knob,
trachea and esophageal deviation
• Aortagram of the aortic arch
• Failure of resuscitation
• Penetrating injury to the mediastinum
• Continued thoracic hemorrhage
• Failed pericardiocentesis
• Tracheal, bronchial, esophageal rupture
• Most common site for occult hemorrhage
 liver, spleen, kidney, pancreas, bowel
 No peritoneal signs in 40% of hemoperitoneum
• NG tube to decompress gastric contents
• Foley to decompress bladder
 Contraindications
▪ blood at the meatus, scrotal or perineal hematoma, high
riding prostate
• Blunt traumawhen PE is not
adequate to assess- altered mental
status
• Unexplained hypotension
 pelvis, lumbar spine, lower ribs fractures
• Polytrauma patient lost to
continual monitoring- General
Anesthesia
• Contraindications-multiple
abdominal operations, obvious
need for operation
• Frank blood
• Fluid aspirate-unspun
 > 100,000 RBC/mm3
 > 500 WBC/ mm3
 hematocrit > 2%
 presence of bile, bacteria, fecal material
• Ultrasound
• CT scan
• Method used for abdominal evaluation is
often institutionally dependent
• Seen in 15% of blunt
abdominal injuries
• Clinical signs
 lower rib fracture, flank
discoloration, lower
abdominal mass, genitalia
discoloration, inability to
void, blood at the meatus,
hematuria
• Evaluation
 Retrograde urethrogram-
before foley is placed
 Hematuria-IVP, cystogram,
excretory urethrogram
• Physiologic
 Trauma Index-Kirkpatrick
and Youman
 Glascow Coma Scale
• Anatomic Damage
 Abbreviated Injury Scale
(AIS)
 Injury Severity Score (ISS)
• Biochemical Indices
• Experienced and familiar with a number of
acceptable procedures
• Some more demanding in terms of EBL,
duration, equipment required
• Potential EBL
 pelvis/acetabulum - 8-10 units
 IM nail femur - 2-3 units
 Tibia - 1-2 units
• Open fractures
• Dislocations (hip and
spine)
• Compartment
syndromes
• Cauda equina
syndrome
• Extremities with
neurological or vascular
compromise
 Bone Density
 Subtle density changes
Cortical Bone
greatly changes
strength and elastic
modulus
 Density changes Trabecular Bone
 Normal aging
 Disease
 Use
 Disuse
Figure from: Browner et al: Skeletal Trauma
2nd Ed. Saunders, 1998.
  Bending
 Axial Loading
 Tension
 Compression
 Torsion

Bending Compression Torsion

Figure from: Browner et al: Skeletal Trauma 2nd Ed, Saunders, 1998.
 Bending load:
 Compression strength
greater than
tensile strength
 Fails in tension

Figure from: Tencer. Biomechanics in Orthopaedic

Trauma, Lippincott, 1994.
 Combined bending &
axial load
 Oblique fracture
 Butterfly fragment

Figure from: Tencer. Biomechanics in Orthopaedic

Trauma, Lippincott, 1994.
• Reduce and stabilize
dislocations
• Fasciotomies in compromised
limbs
• Proper debridement and
irrigation of open injuries
• Stabilization of long bone
injuries
• Secure fixation of intra-
articular fractures
• Proper splinting of other
injuries
• Pelvic ring injuries
• Lower extremity –
 long bone fractures
• Fractures with
 vascular injuries
• Complex periarticular
 fractures
• Open fractures
Pelvic Trauma with Massive Bleeding
• Adequacy of resuscitation
 Vital signs of resuscitation
 Laboratory parameters—base deficit, lactic acidosis
• Anesthesia-agents-myocardial depressants
• Coagulopathy-dilution, DIC, thrombocytopenia
• As long as homeostasis is maintained no evidence of
duration of the procedure alone results in pulmonary
or other organ dysfunction or worsens the prognosis
of the patient
• Must be ready to change plan as the patient
status dictates
• Dynamic process
• Requires cooperation of entire team
• Doctor must:
 Appreciate the interrelationships between organ
system injuries to include musculoskeletal injury
 Understand
▪ options for treatment of orthopaedic injury
▪ impact on the polytrauma patient
 Provide timely and effective treatment