Trauma Principles

Amputations

Amputations about the Knee

BKA / Below Knee Amputation / Transtibial

 

Best results

- long posterior musculocutaneous flap 

- well cushioned mobile muscle mass

- full thickness skin

- very anterior scar

 

Contraindication

- non-ambulator

- get FFD

- better with through knee amputation

 

Advantages over AKA 

 

1.  Good Healing 

- > 90% in DM with BKA

 

2.  Higher prosthesis wearing rates 

- 74% vs 26% for AKA

 

3.  Reduced energy required for walking

- 74% BKA < 45 year old walk > 1 mile

 

4.  Reduced mortality 

- 10% vs 30%

 

Technique 

 

Tourniquet

- no tourniquet if PVD

- tourniquet in trauma (patients can bleed to death)

 

Posterior flap

- mark long posterior flap

- avoid suture line over anterior aspect of tibia / problems frequent here

 

Anterior flap

- short anterior flap at level of tibia cut

- want to extend posterior flap over distal tibia

 

Anterior Dissection

- find anterior NV bundle between T anterior and EHL

- deep peroneal nerve on interossesous bundle

- divide anterolateral muscles at tibial level to avoid bulbous stump

 

Tibial resection

- 15cm stump from joint

- no advantage in > 15cm as skinny poor stump

- < 3cm stump worse than through knee

- sharp dissect periosteum 2 cm above

- leave periosteal flap so can suture muscle flap to it

- bevel sharp edges

 

Fibula resection

- divide fibula 2cm above this

- need to ensure is stable (well connected to tibia via interosseous membrane)

- if not may need to create arthrodesis in young active patient

 

Fibular arthrodesis / unstabile fibula

- create wedge in tibia

- elevate periosteal sleeve to place over top of graft

- use 1 cm of fibula

- can get pain for 6-9 months as the graft unites

 

Posterior dissection

- find posterior tibial artery and tibial nerve

- on tibialis posterior between FDL and FHL

- divide deep muscles and allow to retract

- remove soleus leaving only gastrocnemius flap

- ensure vascularity flap

 

Myodesis gastrocnemius

- through drill holes in tibia and to periosteum of tibia

- fascial repair over muscle bellies

 

Closure

- over drain

- DPC if trauma or infection

- careful pressure dressings with tape to ensure good shaping

 

Through Knee

 

Indications

 

1.  Non ambulators

- aids sitting balance

- avoids FFD and subsequent problems

 

2.  < 3-5 cm tibia

 

3.  ST tissue loss means BKA not possible

 

Advantage over AKA

- improved socket suspension

- longer lever arm 

- muscle balanced amputation

- end-bearing potential

- less volume changes

 

Disadvantage

- asymmetrical knee joint

- bulky prosthesis

- overcome by newer prosthetic techniques

 

Technique

 

Tourniquet 

- patients can bleed to death

 

Flaps

- equal anterior / posterior flaps

- 5cm distal to knee joint

- fish mouth

- can make posterior flap slightly longer

 

Patella 

- depends on technique 

- original method is to retain patella

- Mazet & Hennessy excise patella from tendon

 

Knee dissection

- divide PT off tibial tuberosity

- cruciates and collaterals divided at level of below meniscus

- aim to keep them long

- this preserves the rich proprioceptive function of the capsule

 

Deep dissection

- divide posterior capsule

- find and ligate popliteal artery and vein

- finding tibial nerve, tension, sharp divide, diathermy

 

Myodesis

- PT sutured to cruciate stumps

- biceps tendon sutured to PT

- gastrocnemius to anterior capsule

 

AKA / Transfemoral

 

Issues

- energy expenditure increased by 65%

- residual abduction as A Magnus released from adductor tubercle

- myodesis in 10o adduction maintains abductor strength and prevents abductor lurch

- residual flexion due to quads / hamstring inbalance

 

Technique

 

Position

- sandbag under buttock

- avoid having leg in flexed position

 

Tourniquet 

- if able 

- can bleed to death

 

Flaps

- actually want scar slightly posterior, with larger anterior muscle flap

- fish mouth

- larger anterior flap skin and muscle 

 

Dissection

- cut quadriceps tendon above patella

- detach sartorius / gracilis / hamstrings 2 cm longer for myodesis

- detach A Magnus

 

Vessels

- SFA below vas medialis in Hunter's canal / subsartorial canal

- profunda femoris posterior to femur

- can cut femur first to give access to NV bundles

 

Femoral transection

- save all possible femoral length

- increasing length increases muscle strength

- minimum 12 cm above knee to fit in prosthetic knee joint

- has to be >18 cm from GT or fixation difficult

- if stump < 5 cm below lesser trochanter then fitted as hip disarticulation

 

Adductor myodesis

- maintain stump in 10° adduction

- anatomical position

- suture through drill holes in lateral femoral cortex

 

Anterior musculature

- myodesis of quadriceps to posterior femur avoids FFD

- through anterior drill holes

 

Posterior musculature

- myoplasty to A Magnus or quads

 

Soft spica

- suspend dressing from waist

- support medial thigh

 

Post-op

- positioning important to prevent contractures

- stump flat on bed

- intermittent prone positioning

 

 

 

Foot and Ankle Amputations

Level

 

Level not predicated by angiography

- best is appearance of ST at time of surgery as judged by experienced surgeon

 

Toe

 

Technique

- dorsal-plantar or side-to-side flap

- tension free closure

- high reamputation rate in PVD / DM

 

Hallux

 

Technique

- stabilise sesamoids in hallux amputation

- leave base of P1 to prevent adjacent toes falling into gap

- this also preserves plantar fascia

- tenodesis of FHB

 

Second Toe

- beware of HV postoperatively

- can use insert

- may need to fuse 1st MTPJ

 

Ray 

 

Indications

- single medial or lateral ray that has an infected ulcer

- multiple resections may excessively narrow foot

- central ray amputations are inferior to Lis Franc amputation

 

Technique

- racquet shaped incision based on involved MT to avoid NV bundles

- most are partial ray resections

- leave base

 

Prosthesis

- Oxford extra-depth shoes with custom insoles

 

Lisfranc

 

Technique

- at TMT

- create long plantar flap

- smooth curve fashioned 

 

Precautions

- muscle balance

- Tendo achilles lengthening may be required to avoid later equinus

- muscle reattachment especially Peroneus brevis (try to preserve base fifth MT)

 

Prosthesis

- may initially require AFO

- usually shoe filler eventually

 

Chopart 

 

Concept

- excellent amputation

- through midfoot leaving only talus and calcaneum

 

Advantage over Symes

- no problems with heel pad migration

- functional end bearing stump

- no LLD

 

Technique

- original procedure without transfer had problems with late equinus & varus

- reattach to talus neck T. Ant / T Post / EHL / EDL

- Tendo achilles lengthening

 

Prosthesis

- AFO with foot plate & filler

- slipper style prosthesis

 

Boyd

 

Concept

- talectomy / forward shift of calcaneum / calcaneotibial arthrodesis

 

Advantage over Symes

- preserves length & growth centres

- no heel pad migration

 

Disadvantage

- bulky stump

- poorer cosmesis

 

Technique

- dorsal incision from tip LM to 1 inch below MM

- planter incision transversely across sole at level MT bases

- amputate forefoot through Chopart joint

- excise talus

- anterior calcaneal osteotomy transversely across calcaneum at level of peroneal tubercle

- shift calcaneum anteriorly

- excise cartilage of distal tibia / fibula & superior calcaneum

- calcaneo / tibial arthrodesis

- steinman pin through calcaneum and tibia 

- close over drains

 

Pirigoff 

 

Concept

- talectomy 

- anterior 1/2 calcaneum excised 

- rotated 90°

- calcaneo-tibial arthrodesis

- used in children to preserve length & growth centres

 

Symes

 

Principle

- through ankle joint

- may allow ambulation with out prosthesis in emergencies 

- end-bearing with stable gait pattern

- can still fit ankle prothesis

- women can be unhappy with cosmesis

 

Technique

- from tip of LM to 1 inch below tip MM across front of ankle

- then continue plantarward under sole between same points / MT bases

- need to preserve large post heel pad

- excise talus & calcaneus

- remove malleoli at level of joint & contour 

- divide arteries / veins / nerves above levels of flaps

- anchor heel pad to anterior tibia via intra-osseous sutures 

 

Problems

- heel pad migration is biggest complication

- don't trim dog ears or can get skin slough

 

 

 

 

 

 

Hip Amputation

Hip Disarticulation / Boyd Technique 

 

Anterior Racquet shaped incision

- begins just inferior to ASIS

- curves medially to under inguinal ligament

- 5 cm distal to adductor origin

 

Identify and ligate femoral artery and vein

 

Posterior incision

- 5 cm beneath ischial tuberosity

- laterally 8 cm below greater trochanter 

- then curve back to ASIS

 

Superficial Dissection

- detach sartorius & rectus femoris proximal

- divide pectineus 1/2 inch from the pubis

- avoid division of obturator vessels from where exit pelvis

 

Anterior Deep Dissection

- ER leg

- divide iliopsoas tendon at LT

- detach adductors & gracilis at ischium

- expose and ligate obturator artery / nerve between pectineus & obturator externus at femur

 

Posterior Deep Dissection

- IR leg

- divide obturator externus / short external rotators at femur

- detach G max & G med from femur

- divide G max in line of skin incision

 

Hip

- disarticulation

- divide capsule & L Teres

- divide hamstrings at ischium

 

Muscle flaps

- suture gluteal flap to pectineus & adductor muscles 

- approximate skin edges

 

Hindquarter Amputation

 

AKA

- hemipelvectomy

- trans-iliac /trans-pelvic amputation

 

Set Up

- two surgeons 

- colostomy & stitch anus closed

- eschmarc to express limb of blood to prevent shock

- cross match 3 L of blood

- prepped from chest to below knees

- tape scrotum to opposite leg

- special frame to hold leg 

- lateral with amputated limb up

 

3 Part Technique King & Steelquist

 

Anterior Part

- begin incision at pubic tubercle

- extend along inguinal ligament to ASIS

- extend along crest to PSIS 

- detach abdominal muscles & inguinal ligament from the crest 

- open iliac fossae between peritoneum & iliacus

- at the pubis severe the inguinal ligament & the rectus abdominis & retract the cord medially

- open the space of retzius & retract the bladder into the pelvis

- divide external iliac artery and vein & femoral nerve

 

Perineal Part

- widely abduct the leg

- extend the incision from the pubic tubercle, along the pubic & ischial rami to the ischial tuberosity

- expose the subcutaneous rami

- elevate the ischiocavernosus & transversus perinei subperiosteally from the rami inferior surfaces

- divide symphysis pubis with osteotome

 

Posterior Part

- carry incision from PSIS to GT then along gluteal crease to ischial tuberosity 

- expose G max aponeurosis in line with the skin incision 

- elevate G max, forming a large flap of skin, fat & muscle

- expose G medius & short rotators into view 

- sever piriformis & sciatic nerve

- pass gigli saw through greater sciatic notch & bring it out over iliac crest just anterior to SIJ

- divide ilium, sacrotuberous & sacrospinous ligaments

- rotate inominate bone with leg to expose pelvic contents

- divide obturator artery and vein

- divide psoas at SIJ

- divide levator ani off pelvic wall

- hemipelvis now free

 

Closure

- suture G max flap to rectus abdominus / lateral abdominal wall / quadratus lumborum / psoas

- close skin over drains

- firm dressing

 

 

 

 

LEAP Study

Lower Extremity Assessment Project

 

Set up

 

Multicentre Prospective Outcome Study

- 601 patients

- severe, limb threatening lower extremity injuries

- 8 level 1 trauma centres

 

Inclusions

 

IIIC / IIIB / selected IIIA

- knee dislocations or closed tibial fractures associated with vascular injuries

- major ST injuries

- severe foot / ankle injuries (open pilon, type IIIB ankle)

 

Exclusions

 

GCS < 15 day 21

Third degree burns

Spinal cord deficit

 

Sensate sole

 

Bosse et al JBJS Am Dec 2005

 

3 groups of patients

1.  26 patients with insensate sole at time of admission who underwent amputation

2.  29 patients with insensate sole at time of admission who underwent limb salvage

3.  Case matched group with sensate sole who underwent limb salvage

 

Assessed at 12 and 24 months

- orthopaedic surgeon

- occupational therapist

- VAS

- sensation assessed

 

Sensate v insensate salvage groups

- no difference late amputation

- no functional difference

- similar sensory examinations at 24 months

 

Insensate salvage v insensate amputation

- amputation more likely to use walking aid

- amputation more likely to have difficulty with stairs

 

Impression

- insensate sole is a poor predictor of eventual function and poor guide to amputation

- a large number have reversible ischaemia or neuropraxia

 

Outcomes of Reconstruction or Amputation

 

Bosse et al N Eng J Medicine Dec 2002

 

Case matched

- functional outcome for amputation or reconstruction the same

 

 

 

 

 

Mangled Extremity Severity Score

Mangled Extremity Severity Score  

 

Johansen et al 1990        

- no score is an absolute predictor of need for amputation

- only acts as a guide

- better to use in conjunction with vascular / soft tissue / bony reconstruction  required

 

"VISA gives you double frequent flyer points after 6 hours"

 

Velocity

Ischaemia

Shock

Age

 

Velocity

 

Low Energy           1

Medium Energy     2

High Energy          3

Very High Energy   4

 

Ischemia

 

Poor pulse                 1

Pulseless & poor CR   2

Totally avascular         3

 

Score doubled for ischemia > 6/24

 

Shock

 

Systolic BP > 90 mm Hg 0

Hypotensive transiently     1

Persistent hypotension      2

 

Age (Years)

 

< 30 0

30-50    1

> 50     2

 

Max = 11 or 14 if > 6hrs

 

>7 = 100% chance of amputation

 

Results

 

Helfet Clin Orthop 1990

- objective criteria can predict amputation after lower-extremity trauma

- MESS was prospectively evaluated in 26 lower-extremity open fractures with vascular injury

- 4.00 for the 14 salvaged limbs 

- 8.83 for the 12 amputated limbs p < 0.01

- MESS > 7 100% predictive value for amputation

 

 

 

 

Principles

Epidemiology

 

2/3 PVD 

1/3 Trauma 

5% Tumour

1% Congenital

 

Indications

 

Dead / Dying / Dangerous / Damn nuisance

 

Indications for amputation in open tibial fracture

 

Lange et al J Trauma 1985

 

Absolute Indications (1 of 2)

1.  Complete tibial nerve disruption

2.  Crush injury with warm ischaemia time > 6 hours

 

Relative indications (2 of 3)

- serious associated polytrauma

- severe ipsilateral foot trauma

- projected long course to full recovery

 

MESS (Mangled Extremity Severity Score) guide only

- involve patient in decision

 

Aims

 

Aim

- maximum function

- minimum complication rate

 

Ambulatory

- most distal level that will achieve healing & provide functional stump

 

Non-ambulatory

- improve sitting balance, transfers & nursing care

- through knee best in non ambulatory

- balanced amputation

- no FFD of knee, which limits impinging on bed and development of sores

 

Principles of Good Outcome

 

1.  Reconstructive approach 

- not considered as a failure

2.  Team approach

- early involvement of rehab / prosthetist

3.  Pre-op assessment & planning

4.  Patient explanation & involvement

5.  Good surgical technique

- optimal limb length

- good residual joint

- excellent ST (non adherent and durable) with muscle cushioning

6.  Early prosthetic fitting

7.  Amputee rehabilitation

8.  Appropriate prosthesis prescription

 

Energy Cost of Level

 

O2 Consumption inversely proportional to

- length of residual limb

- number of joints preserved

 

Increase over baseline

- long BKA 10%

- medium BKA 20%

- short BKA 40%

- medium AKA 60%

- hindquarter 100% +

- wheelchair ~ 0%

 

Maximum walking speeds

- normal = 82 m /min

- BKA = 50-70 m /min

- AKA = 40-55 m /min

 

Geriatric with PVD & AKA is virtually at maximum energy expenditure

 

End Bearing Vs Non- End Bearing

 

End Bearing / disarticulation 

 

Weight taken through end of stump

- scar non-terminal

- bone end metaphyseal, not hollow diaphyseal

- usually joint disarticulation

- end bearing prosthesis used

 

Non End Bearing / transosseous

 

Commonest

- intimate fit needed to distribute load over as wide a load as possible

- load transfer usually over the entire residual limb

- scar can be terminal

- usually trans-osseous amputations where end bearing would be too painful

 

Surgery

 

Planning

 

Maximise length & joints

Vascularity

Skin cover

Infection

Prosthetic

 

Skin Flaps

- careful planning

- Atraumatic ST handling

- keep skin flaps thick

- avoid unnecessary dissection between tissue planes

- Non-terminal if end bearing

- Terminal if °End bearing

- Full thickness skin 

- Avoid SSG

 

Bone

- leave long

- Bevelled bone end

- Min Periosteal strip in adults

- strip 0.5 cm in kids to prevent terminal overgrowth

 

Muscles

 

Aim

- Mobile non-adherent muscle mass

 

Stabilisation of distal ends

- provides padding over bone

- prevents atrophy

- avoids FFD by balancing deforming forces

- improves lever arm length i.e. avoid trendelenberg in AKA

 

Techniques

- suture at functional length

- Myodesis - suture to bone

- Myoplasty - suture to muscle or ST

 

Nerve

- Sharp division of nerve under gentle non-crushing retraction

- Allows cut end to retract into ST

- inevitable neuroma cushioned by muscle

- Clamping increases CRPS II

- Ligature / Diathermy has no effect

 

Closure

- Excellent haemostasis

- Delayed closure as needed

 

IPSF vs EPSF

 

Immediate Post surgical Prosthesis Limb Fitting IPSF

- Rapid application of limb < 5/7

- Early Weight bearing

- Suitable for traumatic amputee's 

- Increased wound complications due to rapid stump shrinkage in first 2weeks

 

Early Post surgical Prosthesis Limb Fitting

- Better as most rapid stump shrinkage has occurred 

- 14-21 days

- Less wound complications

 

Complications

 

Pain

 

1. Phantom Sensation

- Sensation that limb still present

- Occurs in most patients

- Usually diminishes over time

 

2. Phantom Pain

 

Burning pain in Phantom limb

- Occurs in ~10% of pts

- usually settles 4- 6 weeks

 

Treatment

- Increase prosthetic use

- Physio

- TENS

 

3.  Causalgia / RSD 

 

Pain in stum - Burning / throbbing etc

 

Non-op Treatment

- Massage, Compression, TENS

- Varied success

 

Operative Treatment

- Limited success

 

Prevention

- Effective

- Peri-op Epidural

- Post-op intraneural anaesthesia

 

4. Mechanical Causes 

- Sharp bone end

- Poor ST envelope

- Unstable skin 

- Ill fitting prosthesis

 

5. Other Causes

- Radicular pain

- Proximal OA

- Ischaemic pain

- Neuroma not uncommon cause consider LA injection for Dx

 

Oedema 

 

Common

- Minimise with rigid dressings

- If soft dressings used, stump wrapping important

 

Excessive proximal tightness results in

- Proximal narrowing

- Increased distal oedema

- Dumb Bell stump

 

Contractures 

 

Usually occur between amputation & prosthetic fitting

 

Hip In AKA

 

Deformities

- FFD

- abduction

 

Minimised by

- Adductor Magnus / Hamstring stabilisation 

- Quads myodesis to posterior femur

- Avoidance of stump on pillow

- Early active & passive exercises

- Prone lying

 

Knee in BKA

 

Deformity

- FFD

 

Minimised by

- LL rigid dressings

- EPLF

- Quads strengthening

- HS stretching

- Difficult to treat once established because of short lever arm

 

Wound 

 

Breakdown not uncommon

- Especially in PVD & DM

 

Dermatological 

 

Numerous problems

- Epidermoid cysts

- Contact dermatitis

- Superficial skin infections

 

 

 

Prosthetics

Contraindications

 

No ambulation potential

Severe cardiac disease 

Poor vision

Poor motivation or compliance

Poor stump - infected, ulceration, poor skin

FFD knee or hip

 

Indications

 

Young traumatic or neoplastic amputee

Motivated PVD / neuropathy amputee with cardiac reserves

 

Timing

 

Best to fit prothesis ~ day 14 

- allows most stump shrinkage to occur

- IPOP tends to cause high complication rate especially with PVD

 

Elements of a Prosthesis

 

1. Socket

- transmits forces between the stump & the prosthesis in all planes 

- may be proximal, distal or total bearing 

 

2. Means of Suspension

- suction socket 

- suspension belts 

- neoprene sleeve 

- elastic stocking 

- silicone sleeve 

 

3. Joint mechanism (knee)

 

A.  Stance phase control 

 

Simple 

- aligns the prosthesis so the ground reaction force passes in front of the knee 

- locks in hyperextension; 2 drums lock at 0-15o

- for elderly 

 

Mechanical stabilisers 

- braking mechanism activated by the weight bearing load or hydraulics

 

B.  Swing phase control 

- pneumatic cylinder 

- hydraulic cylinder 

- intelligent prosthesis - computer adjusts rate of swing to cadence (steps/min) 

 

4. Terminal device / Foot 

 

A.  SACH 

- Solid Ankle Cushioned Heel

- wood keel / heel cushion / rubber foot

- use for BKA

 

B.  Single axis

- some DF/ PF possible

- makes knee stable

- use if knee stiff ie AKA or through knee

 

C.   Multi - Axis Foot

- hindfoot eversion / inversion + DF / PF

- better for active patient

 

D.   Dynamic Response

- "Ryan's Superfoot"

- flexible keel allows smoother roll over

- store energy via carbon fibre foot plate

- Aid toe off / more natural gait / save energy

- expensive

- not used in children as turnover too high

 

BKA Prosthesis

 

Socket

 

Usually firm PTB design

- can add liner for increased comfort

- definitive socket fitted 1 year (size stabilised by then)

- load patella tendon & medial / lateral flares

- most weight actually borne on medial tibial flare

- extend flares higher if unstable knee

 

Suspension 

 

Suprapatellar cuff

- simplest & most common

- dacron & leather

- grips condyles

- advantage is transfers all force to residual leg below knee

 

Supracondylar mould

- grips above femoral condyles

- young patient or < 5cm residual tibia

 

Neoprene 5mm liner

- rolled over distal thigh

- frictional fit ± suction

- negative pressures in swing

 

AKA Prosthesis 

 

Suspension

 

Difficult

- lack of bony contours

- not truly end bearing

- usually ischial bearing

 

Options

1. Suction with valve hole

2. Waist or hip belts - if femur too short

 

Requires

- surface tension

- negative pressure

- active muscles

- stable body weight / socket fits

 

Socket 

 

1. Quadrilateral

- traditional socket with narrow AP diameter

- weight bear on ischium / not in socket

- difficult for the femur to sit in adduction

 

2. CAT - CAM

- narrow medial - lateral diameter

- femur sits in adduction 

- more ovoid

- incorporate ischium into socket via flare

- more comfortable

- better femoral stability in socket

 

Knee Design Options

 

1. Single axis

- simple hinge

 

2.  Polycentric axis 

- 4 bar linkage device

- more natural

- expensive and heavy

 

3. Friction

- limits knee flexion

 

A.  Constant

- cheaper

- limited to one walking speed

 

B.  Variable friction, including with extension

- hydraulic controlled

- resist flexion in extended knee

- easy flexion in flexed knee

- allows different speeds 

 

4.  Safety knees / Stance control knee

- lock when weight applied 

- good for elderly

 

Commonest

- Single Axis Safety Knee

 

Most expensive & heaviest

- Polycentric Hydraulic Controlled Knee

 

Through Knee Prosthesis

 

Socket

- endbearing socket

 

Suspension 

- via femoral condyle flares or strap

- 4 bar linkage knee overcomes previous problems with through knee

- folds away when sitting

- knees at same level

 

 

Upper Limb Amputations

General Principles

 

All possible length should be preserved consistent with clinical judgement

- function of amputated stumps decrease progressively with each higher level of amputation 

- prosthetic rejection by patient increases with the more proximal amputations

- most ADL'S can be performed adequately with one limb, so don't use prosthesis

- all nerves are drawn distally into wound & sectioned so they retract well proximally to bone level of amputation

 

Transcarpal

 

Concept

- can preserve flexion / extension of radiocarpal joint which transmitted partly to prosthesis

 

Technique

- fashion long palmar, short dorsal flaps in ratio (2:1)

- divide tendons under tension

- divide nerves well proximal to amputation

- divide vessels just proximal to amputation bony level

- divide bones and smooth / round edges

- anchor wrist flexor and extensor tendons to remaining carpal bones in line of pull to allow wrist flexion/extension

 

Wrist disarticulation

 

Technique

- fashion long palmar, short dorsal flaps (2:1)

- skin apices 1cm distal to ulnar and radial styloids

- divide vessels, nerves, tendons and open radiocarpal joint

- resect radial / ulnar styloid processes & smoothen bony processes to form a smooth rounded contour

- protect distal radioulnar joint including triangular ligament to preserve supination/ pronation

- insert suction drain and skin closure 

 

Forearm

 

Forearm amputationForearm amputation

 

Concept

- preserve as much length as possible (forearm rotation and strength proportional to length retained)

- if circulation compromised, amputation through distal 1/3 forearm are less likely to heal

- distally skin is thin and subcutaneous tissue scant

- junction mid and distal thirds good compromise for amputation level

- short 'below elbow stump' (up to 3.8-5cm long) preferable to through or above elbow

- important to preserve elbow joint

 

Distal

- skin incision apices at level of bone cut

- ligate radial / ulnar arteries and divide nerves under tension then transverse bone cuts and rasp edges

- fashion FDS flap long enough to be carried around bone ends 

- section rest of muscles at level of bone

- suture FDS flap over dorsal fascia

 

Proximal third

- fashion equal volar and dorsal flaps ideally

- divide muscle bellies distal to bone cuts to allow for retraction

- transverse bone cuts and rasp edges

- if stump is proximal to bicipital radial tuberosity, then resect distal 2.5cm of biceps tendon

- this lengthens stump functionally and enhances prosthetic fitting

- leaves brachialis as principle elbow flexor

 

Krukenburg's Amputation

- performed as a secondary procedure in 'below elbow' amputation

- converts forearm amputation into radial and ulnar pincers

- need at least 10 cm from olecranon tip & elbow flexion contracture <70o

- classically used in blind bilateral below elbow amputee

 

Elbow disarticulation

 

Concept

- good level for amputation due to easy fitting of prosthesis to distal humeral flare

- allows transmission of humeral rotation to the prosthesis (preferable to a more proximal humeral amputation)

- due to modern prosthesis techniques, disarticulation is preferred to proximal humeral amputation

 

Technique

- equal anterior and posterior flaps with apices at level  of humeral epicondyles

- posterior flap extents 2.5cm. distal to olecranon tip

- anterior flap extends just distal to biceps tendon insertion

- divide lacertus fibrosis

- reflect distally flexor origin off medial epicondyle

- expose neurovascular bundle on medial side of biceps tendon

- divide brachial artery, median and ulnar nerves proximal to elbow joint

- free the insertions of biceps and brachialis from radius / ulna

- divide radial nerve as lies between brachialis and BR

- divide transversely extensor mass 6 cm distal to joint line

- divide posterior fascia and triceps tendon near tip of olecranon

- divide anterior joint capsule to complete the disarticulation & remove the forearm

- leave intact articular cartilage of humerus 

- suture triceps tendon anteriorly to biceps and brachialis

- suture extensor muscle mass medially to flexor origin muscle stump

 

Can add distal humeral osteotomy

- create anterior angulation 45o

- aids prosthesis fitting / reduces need for shoulder harness

 

Above Elbow

 

Concepts

- most important to preserve limb length

 

Above elbow prosthesis

- elbow-lock mechanism stabilises joint in full extension, flexion or in a position between

- lock mechanism extends 3.8 cm distally from the end of the prosthetic socket

- therefore most distal bone section should be 3.8cm from end of humerus to allow room for this mechanism

 

Supracondylar level

- equal anterior and posterior flaps at length 1/2 diameter of arm at that level

- artery and nerve divided proximal to level of resection

- divide anterior compartment muscle flaps 1.3cm distal to bone section level so they retract to this level

- free triceps insertion off olecranon & preserve as a long flap

- transverse bone cut 3.8 cm proximal to humerus end and rasp edges

- suture long flap of triceps anteriorly to the fascia over anterior muscles

 

Proximal to supracondylar level

- equal anterior and posterior flaps

- divide anterior compartment muscles 1cm distal to bone cut to allow retraction

- divide triceps 3.8-5cm distal to bone cut

- suture triceps anteriorly over bone end to anterior muscle fascia

 

Shoulder amputations

 

Concept

- shoulder amputation levels require fitting as if for joint disarticulation

- Prosthetic function is severely impaired at shoulder level 

- prostheses are used primarily as a holding device when performing activities with both hands

 

Through surgical neck

 

Position

- patient supine with sandbag beneath shoulder (patient's back 45 degrees to table)

 

Anterior incision

- incision from coracoid process, along anterior deltoid border to its insertion

 

Posterior incision

- along posterior deltoid border to posterior axillary fold

- connect the two limbs of incision by a second incision that passes through axilla then incise anteriorly through axilla

 

Superficial dissection

- ligate cephalic vein, separate deltoid and pectoralis major in deltopectoral groove

- reflect deltoid laterally

- divide pectoralis tendon at its insertion and reflect medially

 

Expose neurovascular bundle

- develop plane between pectoralis minor and coracobrachialis to expose neurovascular bundle

- divide axillary artery and vein inferior to pectoralis minor

- divide nerves on stretch so they retract proximal to pectoralis minor

 

Deep dissection

- divide deltoid insertion and reflect deltoid / lateral skin flap superiorly

- divide teres major and latissimus dorsi at bicipital groove

- divide short and long heads of biceps, triceps and coracobrachialis 2 cm distal to bone cut

- section bone at surgical NOH

 

Closure

- suture long head triceps, both heads biceps and coracobrachialis over end of humerus

- suture pectoralis major tendon to bone end

- bevel deltoid to allow skin closure

 

Shoulder disarticulation

 

Position and incision

- as above

 

Superficial dissection

- ligate cephalic vein

- separate deltoid and pectoralis major

- retract deltoid laterally and divide insertion

- divide pectoralis major tendon at insertion and reflect medially

 

Neurovascular bundle

- divide conjoint tendon and P minor on coracoid

- expose neurovascular bundle

- ligate axillary artery and vein and thoracoacromial artery

- divide nerves on stretch so they retract proximal to pectoralis minor

 

Deep dissection

- reflect deltoid insertion superiorly to expose shoulder joint capsule

- divide teres major and latissimus dorsi at insertions

- after internally rotating arm divide posterior rotator muscles at insertion & posterior capsule 

- place arm in extreme external rotation & divide subscapularis anterior joint capsule

- divide triceps at infraglenoid tubercle insertion & divide inferior capsule to severe the limb

 

Closure

- suture all muscles across glenoid to fill the hollow out (deltoid to inferior glenoid)

- may need to trim prominent anterior acromion to produce smoothly rounded contour

- drain deep to deltoid

 

Forequarter

 

Concept

- shoulder girdle amputation

- consists of removal entire shoulder girdle / upper limb in interval between scapula and thoracic wall

- indicated for malignant tumour involving upper humerus or shoulder joint

- atypical skin flaps often used, may require axillary skin grafts

 

Anterior Approach

 

Incision

 

Upper limb of incision

- begins at lateral border sternocleidomastoid

- extends laterally along anterior aspect clavicle

- back across AC joint

- over superior aspect shoulder to scapular spine

- inferiorly along vertebral border of scapula to inferior angle

 

Lower limb

- starts at mid 1/3 clavicle

- runs inferiorly in deltopectoral groove 

- runs posteriorly through axilla to join upper limb incision at inferior scapular angle

 

Superficial Dissection

- subperiosteally dissect out clavicle 

- cut at lateral border sternocleidomastoid and through AC joint

- external jugular divided or retracted

 

Deep Dissection

- release pectoralis major off humerus and pectoralis minor off coracoid to expose neurovascular structures

- ligate subclavian artery and vein, divide brachial plexus under stretch

- release Lat dorsi & remaining soft tissues that bind shoulder girdle to anterior chest wall and allow limb to fall posteriorly and down 

- while holding arm across the chest divide posterior rotator cuff

- divide anterior and posterior muscles holding scapula to thoracic wall 

- trapezius / omohyoid / L scapulae / rhomboids / serratus anterior 

- suture pectoralis major and trapezius over lateral chest wall

- trim flaps and primary suture

 

Posterior Approach

 

Position

- lateral decubitus position near edge of operation table

 

Incisions

 

Posterior

- make posterior incision first

- begin at medial end of clavicle, extending laterally along clavicle over acromion process to posterior axillary fold

- along axillary border of scapula to a point inferior to scapular angle

- curve incision medially to end 5cm from midline of the back

- same incision as for anterior approach except posterior limb runs along axillary border of scapula

 

Anterior

- as above

- starts at mid 1/3 clavicle and runs inferiorly just lateral and parallel to deltopectoral groove

- then runs posteriorly through axilla to join posterior axillary incision at lower 1/3 of axillary border of scapula

 

Superficial Dissection

- elevate full-thickness skin flaps and subcutaneous tissue to medial border of scapula

- trapezius / lat dorsi divided parallel to medial border of scapula

- divide Levator scap / rhomboids / serratus anterior / omohyoid from scapula

- ligate vessels especially transverse Cervical artery and Transverse scapular artery

- free clavicle and divide at medial end with subclavius

- shoulder falls anteriorly

 

Deep dissection

- subclavian artery & vein / brachial plexus on stretch (divided close to spine)

- divide P major and minor & remove limb

 

 

Clearance Cervical Spine

Issue

 

Ventilated trauma patient

- most will have CT scan

- doesn't exclude ligamentous injury

 

Hard collar

- will cause neck ulcers if left on indefinitely (occiput and jaw)

- raises the ICP / issue in head injured patient

 

Options

 

1.  MRI

- sensitive but difficult especially in unwell, ventilated patient

- patients become more unstable being take to MRI

- ICP tend to rise (problem in head injuries)

- may increase time that cervical collar is left on

 

2.  Flexion / extension views of unconscious patient

- under fluroscopy

- is this safe in the ventilated patient?

- has been shown to be very safe

- only very occasionally detects unstable injury missed by CT

- however, difficult to defend if patient wakes up with neurology

 

3.  CT scan alone

- reported incidence of missed unstable C spine injury is 2.5%

 

Evidence

 

Spiteri et al J Trauma Infection and Critical Care 2006

- 839 ventilated trauma patients

- protocol of radiographs, helical CT and dynamic screening

- 87 unstable C spine injuries

- helical CT picked up 85

- dynamic screening picked up 1

- dynamic screening missed one atlanto-occipital dislocation

- a powers ratio on the CT would have detected this

- their conclusion was that helical CT was sufficient

 

Stelfox et al J Trauma Infection and Critical Care 2007

- 140 patients

- cervical collar removed if MRI or helical CT C0 - T1 normal

- policy changed to CT only

- no report of missed injury

- MRI patients waited longer, more likely to get ulcers, were ventilated longer

 

 

 

 

 

 

Compartment Syndrome

Definition

 

Circulation of tissues within a closed osteofascial space are compromised by increased pressure within that space

 

Most common 

- anterior leg compartment

- flexor compartment forearm

- deep posterior leg compartment

 

Aetiology

 

Prerequisite is volume restricting envelope 

- fascia & skin

- POP

- dressings

 

1.  Increased contents

 

Bleeding / edema 

- fracture

- osteotomies 

- crush injuries

- post - ischaemic swelling

 

2.  Decreased size

 

Tight casts & dressings

Tight closure of fascial defects

Fracture reduction 

 

Pathogenesis

 

Increased local tissue pressure increases pressure within intracompartmental veins

- local AV gradient is reduced

- causes decreased local perfusion secondary to Starling Forces

 

Metabolic tissues demands not met

- loss of tissue function & viability

- distal pulses remain as ICP < SBP 

- digit capillary refill remains as venous return extracompartmental 

 

Symptoms

 

1. Pain

- most important sign

- much great than expected 

- masked by coma / neural injury 

- unrelieved by opiates

 

2. Paraesthesia

- often early

- pins & needles or decreased sensation to light touch

- distribution important

- nerve of that compartment will be affected

 

Signs

 

3. Palpation

- swollen, tense compartment

 

4. Passive Stretch

- pain on passive stretch 

- subjective

- complicated by underlying trauma

 

5. Paresis

- may be due to proximal nerve injury or guarding 2° to pain

 

6. Pulses

- pulse & capillary refill are normally present

 

Diagnosis

 

Clinical Diagnosis

 

Tense compartment with pain +++

Pain on passive stretch

 

Intramuscular Pressure Measurement

 

Pressure Measurement

 

Indications

 

1. Unresponsive 

- head injury

- ventilated

2. Uncooperative 

- children, drug abusers

3. Underlying peripheral nerve deficit 

- tibial fracture with CPN nerve deficit

 

Techniques

 

1. Needle - Manometer Method (Whitesides)

- 18G needle is connected via a 3 way stop cock to an air filled 20 ml syringe

- air filled tubing which is connected to a Hg Manometer 

- a small amount of saline sits in tube connected to needle 

- compression of the syringe raises the pressure till saline flows into the compartment

- this is indicated by the meniscus moving

 

2.  Arterial Pressure Transducer

- i.e. devices used in ICU to measure arterial blood pressure and CVP

- no need to inject fluid

- pressure in saline tube equalizes with compartment

- connect to Wick or Slit catheter

- slits have many longitudinal slits to equalize pressure in tube with compartment

 

3.  Stryker Device 

- Variation on 2

 

Interpretation

 

Matsen > 45 mmHg

Mubarek & Rorabeck > 30 mmHg

Whitesides - within 30mmHg of DBP

 

Management

 

Prevention 

 

Remove all tight dressings

- splitting POP decreases pressure by 30%

- bivalving & cutting padding reduces pressure by another 55%

- elevate limb 

 

Avoid hypotension 

 

Ream without tourniquet

 

Early fasciotomy 

 

Compartment Release

 

Full-length skin incision

Complete fasciotomy of all compartments

Assessment of muscle (colour / consistancy / contraction / bleeding)

Debridement dead muscle

Delayed DPC / graft 

 

2 Incision Technique Leg

 

Anterolateral compartments

- incision halfway between crest of tibia & fibula

- identify and protect SPN

- expose lateral intermuscular septum (transverse cut)

- release Anterior & Lateral compartments

 

Posterior compartments

- incision 2 cm posterior to posterior margin of tibia

- identify and protect saphenous vein / nerve anteriorly

- identify septum between superficial & deep compartments

- release fascia over Gastro-Soleus (superficial posterior compartment)

- release deep posterior compartment which is located behind the tibia / FDL

 

Perifibular Approach / Single incision Technique

 

Lateral incision beginning just posterior to fibula

- expose & protect CPN

- posteriorly release superficial posterior compartment

- release FHL (deep posterior compartment

- anteriorly expose and release anterolateral compartments after identifying SPN

 

Compartment Release Forearm

 

4 interconnected compartments

- volar superficial

- volar deep (FDP / FPL / pronator quadratus)

- mobile wad (BR, ECRL, ECRB)

- extensor

 

Volar

- incision from medial elbow to carpal tunnel

- must release lacertus fibrosis and carpal tunnel

- divide fascia

- this will release superficial flexor muscles

- ensure release mobile wad

- ensure release FDP

 

Dorsal

- often volar release wil decompress dorsal compartment

- usually ulnar sided incision

- proximal over muscle belly

- distally is mostly tendons

 

Compartment Release Hand

 

Two dorsal incisions

- over MT 2 and MT 4

- release interossei compartments

 

Carpal tunnel incision

- release thenar / hypothenar / adductor

- release carpal tunnel

 

Compartment Release Foot

 

2 dorsal incisions

- over MT 2 and MT 4

- release 4 interossei compartments

 

Medial incision

- release medial / central and lateral compartments

 

Complication

 

Volkmann's contracture

- ischaemic muscles fibrose & contract

- causes deformity & stiffness

- nerves damaged with variable numbness

 

 

 

Compound Fractures

Definition

 

Fracture with break in skin communicating with fracture haematoma or fracture

- contamination with micro-organisms

- coupled with damage to ST and vascular supply

- leads to increased risk in infection and healing problems

 

Gustillo Classification

 

Grade I

- low velocity / wound < 1cm

- minimal contamination & minimal tissue injury

 

Grade II

- wound > 1cm

- moderate contamination / moderate tissue Injury

 

Grade IIIA

 

High velocity injury

- segmental

- comminuted

- suggests extensive injury or loss of soft tissue

- damage to periosteum

 

DPC possible

 

Automatic Grade III

- shotgun wound

- high velocity gunshot wound

- segmental fracture with displacement

- diaphyseal segmental loss

- wound occurring in a farmyard / highly contaminated environment

- crushing force from a fast-moving vehicle

 

Grade IIIB

 

High velocity injury

After debridement needs skin flap / graft

 

Grade IIIC

 

Needed vascular repair to save limb

 

Infection Rate

 

I:      0-2%

II:     2-7%

IIIA:  7%

IIIB:  10-50%

IIIC:  25-50% with 50% or more amputation

 

Management

 

Goals

 

Prevent infection

Manage the wound

Stabilise the fracture

Enable healing

 

Immediate

 

EMST / ATLS Principles

 

Assess Limb

- vascular

- neurology

- skin defect / contamination

- photos

 

Treatment

- irrigate wound

- apply betadine dressing

- stabilise with POP if possible

- appropriate antibiotics / tetanus

- early OT for irrigation / debridement / stabilisation

 

Antibiotics

 

Guidelines

- grade 1: first generation cephalosporin

- grade 2: add gentamicin

- farmyard / heavily contaminate add penicillin (clostridium / gas gangrene)

 

Patzakis JBJS Am 1974

- prospective, randomised controlled trial

- infection with preoperative cephalothin was 2.3% 

- infection 13.9% without antibiotic

 

Swabs

- studies finding of initial swab correlating with infecting organism has been discredited

- no real correlation between road-side organisms & subsequent infection

- subsequent infection are typically hospital acquired

 

Gustilo

- increased rate of gram negative infection in Grade II

- hence add aminoglycoside if Grade II

- add penicillin if soil contamination

- no evidence any other combination is better

 

Timing

- delay > 3 hours increases infection risk

- 48 - 72 hours post injury

- 48 - 72 hours post each procedure

 

Wound Management

 

Irrigation

 

Gustilo JBJSA 1987

- infection higher if < 10L washout

 

Anglen 1984

- pulse lavage 100 x effective than bulb

 

Debridement

 

Must remove all non viable tissue

- remove cortical bone with no ST covering

 

Timing of wound closure

 

Do so when wound is clean

 

No evidence of increased infection with primary closure

- may prevent secondary contamination

- risk of clostridial myonecrosis

 

DPC (delayed primary closure)

- prevent anaerobic conditions in wound

- facilitates drainage

- allows second debridement

- can seal the wound via vacuum dressing

 

Fracture Stabilisation

 

Advantage

- prevent soft tissue from further injury

- facilitates host response to bacteria despite presence of implants

- allows mobilisation and functional rehab

 

Femur

- IMN best for I, II, IIIA and B

- 10% deep infection in type III B

- best to plate in type IIIC before revascularisation

 

Tibia

 

Reamed v unreamed

- no difference in infection rate

 

IMN v External fixator

- reduced risk of revision surgery, malunion and superficial infection with IM nail

- no difference in infection rate or union

 

External fixator

- heavily contaminated wound

- non amenable to nail (i.e. very distal)

- vascular injury

 

Soft Tissue Reconstruction

 

Options

 

Proximal tibia - local pedicle gastrocnemius flap

Middle third - soleus flap

Distal third - free muscle flap (rectus / gracilis / lat dorsi)

 

Timing

 

Gopal et al JBJS Br 2000

- early < 72 hours v late > 72 hours

- 6% v 29% deep infection

- did not use antibiotic beads

 

 

 

 

 

Concussion

Definition

 

Disturbance in brain function caused by direct or indirect injury to head

- no pathology seen on standard neuorological imaging

 

Pathophysiology

 

Disruption of mitachondria

- inability to produce energy

- accounts for symptoms such as lethargy etc

 

Headache

- ? due to ligament injury at cranio-cervical junction

 

Symptoms

 

Confusion

Tiredness

Lethargy

Inability to concentrate

Headache

Sleep impairment

Slowed reaction times

 

Symptoms worsen with

- concentration

- physical exertion

 

80 - 90% resolve within 1 week

- some patients suffer prolonged post concussion syndrome

 

NHx

 

2 x grade 3 concussions in career

- risk of permanent damage < 10%

- amateur sportsman should cease sports after 2 x Grade 3 concussions

 

3 x grade 3 concussions in career

- risk of permanent damage 60%

 

Adolescent

- studies have shown that after a grade 3 concussion in the next year

- A grade students show little effect to their grades

- average students have significant risk of failing grades

 

Management

 

Generally accepted that concussed athlete should not return to the game

 

Sideline assessment

 

SCAT2 / Sport Concussion Assessment Tool

- assess symptoms and GCS

- also tests memory / concentration / balance / co-ordination

 

Canadian CT Head Rules

 

Stiell et al Lancet 2001

 

1.  GCS < 15 2 hours post injury

2.  2 or more vomiting episodes

3.  Age > 65

4.  Signs basal skull fracture

5.  Signs skull fracture

6.  Dangerous mechanism - > 3 foot or > 5 stairs

7.  Amnesia before event > 30 minutes

 

Zurich Consensus Statement SAJSM 2009

 

Recommends use of SCAT2 and graduated return to play

 

Grading American Academy Neurology 1997

 

Grade 1

 

Definition

- no loss of consciousness

- head injury with confusion < 15 minutes

- full memory of the event

 

Action

- first concusion: return to sport within 15 minutes

- second concussion: 1 week

 

Grade 2

 

Definition

- no loss of consciousness

- confusion > 15 minutes

 

Action

- first concussion: 1 week

- second concussion: 2 weeks

 

Grade 3

 

Definition

- loss of consciousness

- 3A:  few seconds

- 3B:  minutes

 

Action

 

3A

- first concussion: 1 month

- second concussion: 6 months

 

3B

- first concussion: 6 months

- second concussion: 1 year

 

Neuropsychological testing

 

i.e. IMPACT

 

Performed as baseline for all collision athletes

- can then compare scores if concussed

- assess when return to normal / degree impairment

 

Online test availabe

- word remembering

- line drawing recognition

- coloured squares

- X & O

 

Return to sport

 

Stepwise symptom-limited program, with stages of progression

- 24 hours minimum for each step

- return to step 1 if symptoms recur


1. Rest until asymptomatic (physical and mental rest)

- recovery phase
2. Light aerobic exercise (e.g. stationary cycle)

- increase HR
3. Sport-specific exercise

- add movement
4. Non-contact training drills (start light resistance training)

- co-ordination and cognition
5. Full contact training after medical clearance

- functional skills assessed by coach and trainers
6. Return to competition (game play)

 

 

Damage Control Orthopaedics

Definition

 

Approach that contains and stabilises orthopaedic injuries

- so that the patient's overall physiology can improve

 

Aim to avoid second hit of a major orthopaedic procedure

- delay definitive fracture repair until a time when the overall condition of the patient is optimised

 

History

 

Damage control began in general surgery

 

Phase 1

- control bleeding with packs

Phase 2

- resuscitate patient

Phase 3

- definitive surgery

 

Pathogenesis

 

One hit

- initial massive injury and shock

- intense systemic inflammatory syndrome

- macrophages, leucocytes, NK cells, interleukin, complement

- can precipitate multiorgan damage and failure

- i.e. increase endothelial permeability in lungs and predispose to ARDS / MODS

 

Second hit

- restimulates / hyperstimulates inflammatory system

- i.e. prolonged surgical procedures

 

Injury severity markers

 

IL6

- correlates well with degree of injury

- now routine in large trauma centres

 

CRP, TNF, IL 1 and 8

- no correlation to injury severity

 

Genetic predisposition

- DLA-DRII

 

Indications for DCO

 

Unstable patients / patient in extremis

 

Bilateral lung contusions / thoracic trauma 

 

Abdominal / pelvic trauma and hemorrhagic shock

 

Bilateral femur fractures

 

Parameters

1.  Acidotic:  pH < 7.24, lactate > 2.5 mmol/l

2.  Hypothermia:  temperature < 35

3.  Transfusion: > 10 units of blood

4.  Coagulopathy:  platelets < 90 000

4.  Long operative times > 90 minutes

5.  > 65 / geriatric patient

 

Exaggerated inflammatory response

- IL 6 > 800 ug/ml

 

Injury Severity Score / ISS

- > 20 with chest trauma

- > 40

 

Injury Severity Score

 

Based on Injury Scale / AIS

- 9 body regions

- head / face / neck / chest / spine / abdomen / UL / LL / external

- rated in severity 1 - 6

- max of 75

- minor / moderate / serious / severe / critical / untreatable

- a score of 6 in any region indicates futility of medial care

 

ISS

- 6 body regions

- head and neck / face / thorax / abdomen / extremity / external

- top 3 scores in any region are squared

- major trauma > 15

 

Timing of secondary Orthopaedic Procedures

 

Inflammatory response not diminished until day 6

 

Probably once patient stable

 

 

 

 

 

 

EMST / ATLS

Background

 

Trauma is 3rd most common cause death in all age groups

- number one in young adults < 44 years


Death

 

Death occurs in 3 time periods

 

1.  First few minutes

- death secondary aortic rupture or severe head injury

- 50% die in this period

- only a few survive 

- only if rapid transport 

 

2. Golden Hour 

- major head injury (Haematoma)

- chest injury (Pneumothorax)

- abdominal injuries (Ruptured viscus)

- major fracture (Pelvis, Long bone)

- 35% of deaths

- high salvage rate

 

3. Late death

- days to weeks later 

- brain death / multiorgan failure / sepsis

 

Management priorities

 

1.  Life threatening injuries

2.  Limb threatening injuries

 

Assessment & Management

 

1. Preparation

A Pre-hospital

B In-hospital

2. Triage

3. 1° Survey

4. Resuscitation

5. 2° Survey

6. Continue post resuscitation monitoring & re-evaluation

7. Definitive Care

 

Can occur simultaneously or parallel

 

Preparation

 

A. Pre-hospital

 

Co-ordination between Ambulance & hospital

 

Aims

1. Airway control

2. Stop bleeding

3. Immobilize patient

4. Rapid transport to appropriate facility

5. Obtain history

 

B. In-hospital

 

1. Prepare trauma area

- 1 nurse to take observations on arrival and every 2 minutes

- 1 nurse to record

- cannulas / IDC / chest tube

- suction / intubation

 

2. Notify trauma team

- general surgery / cardiothoracic aware and available

- anaethetist aware and available

 

3. Notify lab

- O negative blood available

- ready to process emergency blood tests / cross match

 

4.  Radiology

- technician to take C spine / CXR / pelvis

 

Triage

 

Sorting of patients based on treatment needs

 

Two scenarios

 

Multiple

- patients don't exceed treatment maximum of hospital 

- treat life threatening pathology first

 

Mass

- patients exceed treatment maximum of hospital

- treat those who will survive if simple intervention

 

Primary survey

 

Life threatening conditions are diagnosed and treated simultaneously

 

A.  Airway Maintenance and Spinal Precautions   

 

A patient who can respond verbally to "How are you?" is conscious and has a clear airway

 

Assume spinal fracture

- hard cervical collar with sand bags and tape

- spinal board

- log roll

 

Monitoring / 2 x large bore 16G cannulas / bloods

- simultaneously attached

- 02 / ECG / blood pressure

- CBC / Renal and liver function / coags / Group and hold / cross match / BHCG

 

Immediate management

- jaw thrust and chin lift

- clear FB / blood etc

- apply oxygen

 

Indications intubation

- GCS < 8

- maxillofacial fractures

- laryngeal trauma / stridor

 

Intubation Adult

- guedel airway / preoxygenate 100% oxygen

- inline traction / protect spine at all times

- rapid sequence induction / cricoid pressure

- xylocaine spray 10%

- fetanyl (1 mcg / kg, 50 - 100 mcg)

- midazolam (0.05 - 0.1 mg / kg, 5 - 10 mg)

- avoid muscle relaxants if possible (succinylcholine 1 mg / kg, usually 100mg)

- avoid propofol if possible / causes hypotension (10mg / ml, give 2.5 mg / kg to maximum 250 mg)

 

Intubation Paediatric Patient

- use Broselow Paediatic Emergency Tape for weight and medications based on heights

- preoxygenate

- atropine 0.02mg / kg or 0.1 to 1 mg given 2 minutes before intubation

- this prevents excessive vagal response and dries secretion

- sedate midazolam 0.1 - 0.3 mg / kg

- cricoid pressure

- paralyse succinylcholine 2mg / kg < 10 or 1 mg / kg > 10

- ETT based on size little finger

- trachea short (5 - 7cm in infant) and very anterior

- set tidal volumes at 6 - 8 ml / kg and RR 40/min infant and 20/min older child

 

Unable to intubate

 

1.  Jet insufflation cricothyroidotomy

- prep / LA

- small incision often required

- insert 12 or 14 G plastic cannula through cricothyroid membrane

- attach to syringe / angle 45o caudal

- aspirate as insert / stop when aspirate air / advance cannula over needle

- connect to 15 L minute oxygen

- have Y connector or cut side hole in tubing

- intermittitent insufflation 1 second on and 4 seconds off with thumb over hole

- suitable for 30 minutes

 

2.  Surgical cricothyroidotomy

- prep / LA

- horizontal incision between thyroid and cricoid cartilage

- horizontal incision between thyroid and cricoid / don't cut either cartilage

- open with artery forceps

- insert size 5, 6 or ETT, inflate and secure

- not suitable in children under 12 as cricoid is very important

 

Gastric distention / NGT

- can cause hypotension or aspiration

- very common in trauma / children / forced ventilate with bag and mask

- insert NGT as soon as able

- insert through mouth if facial trauma / avoids intracranial penetration

 

B.  Breathing  

 

Immediate management

 

Apply oxygen

- 12 L/min

- check RR (> 20 / minute worrying)

- check oxygen saturations

- apply ECG monitoring

 

Examination

 

Expose chest

- look / feel for flail segment

- symmetrical motion

 

Auscultate

- symmetrical breath sounds

- hear sounds

 

Palpate

- trachea midline

- heart apex

- rib fractures

 

Diagnosis

 

Pneumothorax / haemothorax

- decreased breath sounds

 

Hemothorax

 

Tension pneumothorax

- heart apex and trachea displaced

- heart sounds (muffled + distended neck veins = cardiac tamponade)

 

Tension Pneumothorax / Needle thoracostomy

- second intercostal space in midclavicular line

- large gauge needle / 16G

- will hear hiss if tension

- need to place ICC

 

Pneumothorax / Hemothorax / Intercostal Catheter

- 5th intercostal space just anterior to midaxillary line

- need to avoid spleen / liver

- level with nipple

- use larger tube if for haemothorax

- gown and glove, prep, LA down to pleura

- scapel incision, artery forcep down through pleura

- blunt dissection

- insert 32 F gauge tube without stylet aiming posteriorly and superiorly

- connect to underwater suction drain at -20 cm H2O

- suture and tape in (no 1 suture purse string, standard dressing, sleek)

- ensure drain is swinging

 

PneumothoraxPneumothorax Post ICC

 

Open chest wound

- taped on 3 side flutter dressing intially

- allows air out with expiration

- convert to occlusive dressing only after insertion of ICC

- ICC in 5th intercostal space

- otherwise risk tension pneumothorax

 

Cardiac Tamponade / Pericardiocentesis

- 20 ml syringe and 18G spinal needle

- aseptic technique

- insertion point between xiphisternum and left sternocostal margin

- can fill with some saline and inject 1ml periodically to prevent blockage of tip

- angle 45o to abdominal wall, 45o to sagittal plane

- aim for tip of left scapula

- insert up to 5 cm watching for ECG changes, aspirating as advance

- if patient truly has cardiac tamponage, insert drainage catheter using seldinger technique

- best done under echo guidance if possible

 

Hemothorax / Indications for thoracotomy

- > 1500 mls blood

- > 250 mls per hour for 4 hours

 

Flail chest

- no specific management required

- management of underlying lung injury

- may require mechanical ventilation / epidural

 

C. Circulation

 

Stages of Shock

 

  Stage I Stage II Stage III Stage III
Blood loss < 750 750 - 2000 1500  - 2000 > 2000
% blood volume 15% 30% 40% > 40%
PR < 100 > 100 > 120 > 140
BP Normal Decreased < 90 < 70
Pulse Pressure Normal Decreased    
RR Normal   30 - 40 > 35
Urine output > 30 Slightly reduced   Negligible
GCS Anxious Anxious Confused Lethargic

 

Immediate Management

 

Stop external bleeding / pressure

IV cannulas x2 16G         

Send off FBC / ELFT / glucose / Toxicology / Xmatch / pregnancy test

 

Resuscitate with isotonic crystalloid

- 2 litres then

- blood (O negative / type specific / cross matched)

 

Children 20 mls / kg bolus

- repeat x 3 then consider blood

- blood 10mls / kg type specific or O negative

- any hypotension in child indicates severe blood loss / > 45%

- can provide via intraosseous tibial infusion in < 6 hours

- anteromedial tibia below tibial tubercule / aim away from knee

- maintenance 4 / 2 / 1 rule per hour

 

Burns

- rule of 9's to calculate % BSA

- 2 - 4 mls RL per kg per % BSA first 24 hours

- half in first 8 hours, remainder in last 16 hours

 

Pelvic immobiliser / strap / sheet if any signs pelvic injury

 

ECG

- premature ventricular contractures

- lidocaine 1 mg / kg

 

Causes

 

Lung - tension pneumothorax / hemothorax

Heart - cardiac tamponade / aortic dissection

Abdomen - intra-abdominal bleeding

Pelvis - pelvic fractures

Long bone fracture

Spinal injury

External bleeding

Corticosteroid deficiency

 

Examine

- signs chest trauma / reduced breath sounds

- muffled heart sounds / distended neck veins

- abdomen exam - tenderness / rigidity

- pelvis - tender / mobile

- femoral deformity / long bone fracture

- external bleeding / scalp laceration

 

Investigations

- abdomen (Fast scan / DPL / CT scan) 

- pelvis (Xray)

- CXR (hemothorax / widened mediastinum)

- echo / CT chest

 

DPL

 

Technique

- LA

- decompress bladder with IDC

- decompress stomach with NGT

- incision supraumbilical if pelvic fracture / infraumbilical otherwise

- dissect down to peritoneum

- insert peritoneal dialysis catheter and aspirate

- if aspirate negative, infuse 1L crystalloid

- lavage , then aspirate 250 mls

- send to lab for analysis

 

Results

1.  Initial aspiration

- > 10 mls frank blood or obvious bowel contents

2.  Post lavage

- labs analysis: > 100 000 RBCs or > 500 WBC / ml, or positive gram stain

 

Hypotensive / Bradycardia

- suspect spinal injury

- trial 2L fluid

- atropine: 0.5 - 1 mg IV as push / maximum 3 mg

- noradrenalin: 0.1 - 2 mcg / kg / min up to maximum 30 mcg/min

- dopamine: 10 mcg / kg / min

 

IDC
- as soon as patient stable enough

- enables monitoring of resuscitation

- adults 0.5 mls / kg / hour

- paeds 1 ml / kg / hr (2mls if < 1 year)

 

D.  Disability 

 

GCS / Pupils

 

GCS = MVE

Severe HI <9

Moderate HI 9-12

Minor 13-15

 

Best eye response (E)

1. No eye opening 

2. Eye opening in response to pain

3. Eye opening to speech

4. Eyes opening spontaneously 

 

Best verbal response (V)

1. No verbal response 

2. Incomprehensible sounds

3. Inappropriate words

4. Confused

5. Oriented

 

Best motor response (M)

1. No motor response 

2. Extension to pain

3. Abnormal / decorticate flexion to pain

4. Normal flexion / Withdrawal to pain

5. Localizes to pain

6. Obeys commands

 

Head Injury < 9

 

Intubate

CT Head

Neurosurgery consult

Oxygenate

Avoid hypotension

Maintain low ICP

 

Low ICP

 

Maintain BP

- avoid glucose containing fluids

- Ringer's lactate or N/S

 

Hyperventilation

- low CO2 can cuase cerebral ischaemia

- keep CO2 at 35 mmHg

- can lower CO2 to 30 mmHg in acute deterioration

 

20% Mannitol

- indicated for acute neurological deterioration in patient without hypotension

- 1g / kg IV as bolus over 5 minutes

 

Seizures

 

Diazepam 0.2 mg / kg at rate 5 mg / minute

- so maximum dose 20 mg in 100 kg man

 

Phenytoin

- loading dose 1g IV at 50mg / minute

- maintenance dose then 100 mg / 8 hours

- titrate based on serum levels

 

E.  Exposure   

 

Suitably undress

Avoid hypothermia / keep warm

 

Do not proceed to Secondary Survey until stable

 

Early monitoring 

- PR / BP

- O2 sats

- arterial line

- NGT / IDC - if no CI

 

Trauma Series    

- lateral C spine / CXR / AP pelvis

 

Blood at meatus / high riding prostate / suspected urethral disruption

- urethrogram / 15 mls contrast via IDC in urethral meatus with balloon minimally inflated

- if urethra intact on xray / advance into bladder

- inflate with 1500mls contrast / saline and leave balloon inflated

- looking for bladder injury

- extraperitoneal - IDC left in situ draining

- intraperitoneal - requires surgery

- if urethra not intact requires urology intervention / surgery

 

Secondary survey

 

Meticulous examination from head to toe encompassing all systems looking for occult injury

 

History

 

Get ancillary history        

- ambulance officers / police / Family / Patient / Witnesses

 

Allergies

Medications

Past medical history

Last ate

Events related to accident         

- MOI / Restraint / Ejection

 

Head to toe

 

Scalp - lacerations / open fractures

Eyes  - pupils

Face - fractures

Mouth

C spine    

- tender

- step / gap / boggy swelling

- ROM if conscious and co-operative / no distracting injuries

 

Neck 

- subcutaneous emphysema

- lacerations

- tracheal deviation

- oesophageal injury

- vessel injury

 

Chest

- breath Sounds

- heart Sounds

- subcutaneous emphysema

- ribs / sternum / clavicle fracture

 

Abdomen 

- distension

- tenderness

 

Pelvis     

- spring test

- push / pull test

- tenderness / ecchymosis

- blood meatus / scrotal ecchymosis / open injuries (rectum / vagina) / high riding prostate

 

UL   

- shoulder girdle and clavicle / SC jts

- long bones

- dislocations

- neurovascular

- compartments

 

LL   

- long bones

- dislocations

- neurovascular

- compartments

 

Spine logroll

- step / gap / boggy swelling / tender / ecchymosis

- PR -  tone / power / sensation / BCR / anal wink reflex

 

 

Fat Embolism

Definition

 

Embolic marrow fat macroglobules damage small vessel perfusion

- leading to endothelia damage in pulmonary capillaries

- leads to respiratory failure and ARDS like picture

 

Epidemiology

 

Fat embolism

- 90% of traumas

 

Fat Embolism Syndrome

- 3 - 4 % 

- 10% mortality

 

Aetiology

 

Long bone or pelvic trauma

Femoral fracture + head injury

Nonoperative femoral treatment

Reamed femoral nails

Bilateral femoral fractures

 

Orthopaedic procedures including THA

 

Liposuction

IV lipids

 

Pathology

 

1.  Mechanical

- blockage

- likely minimal part 

 

2.  Biochemical

- damage to endothelium

- via fatty acids liberated by lipoprotein lipase

- leads to increased endothelial permeability

 

Diagnosis / Gurd's criteria 

 

One major and 4 minor criteria, plus fat microglobulinaemia must be present

 

Major

- respiratory symptoms / pulmonary oedema

- cerebral signs / altered mental status

- petechial rash (only 20 - 50%, over upper body especially axilla)

 

Minor

- PR > 110

- fever > 38.5

- retinal petechiae / fat globules

- jaundice

- elevated ESR

- renal dysfunction

- acute drop in Hb / platelets

- fat globules in urine or sputum

 

Management

 

Supportive

- maintain BP, UO

- mechanical ventilation

 

Prevention

- stabilisation of long bone fractures

- both reamed and unreamed nails cause increase fat embolism

 

 

 

Gunshot Wounds

Concept

 

Treat the wound, not the gun velocity

 

Management based on gun velocity old fashioned because

1.  Only 1/3 guns are known 

2.  High velocity guns can produce low energy transfer wounds

 

Wound Ballistics

 

Kinetic Energy = 1/2mv2

- important factor is tissue interaction

- energy transfer

 

Two mechanisms of tissue injury

 

1. Permanent cavity

- tissue actually hit by the bullet

- increases with distance travelled through tissue

 

2. Temporary cavity

- tissue stretched by the bullet passage

- as vacuum created, microbes can be sucked in at exit or entry

- increased with distance travelled through tissue

 

Microbes

 

Bullets are not sterile

- suck microbes in as well

- clothing fabric gets pulled in too

- wadding also gets into wound

 

Pathology

 

Amount of tissue damage depends on

 

1. Bullet type 

- partially jacketed fall apart

- Dum Dum - soft nosed bullets deform and start to spin earlier

 

2. Target tissue

- inelastic brain worse than elastic muscle

- bone fragments can produce their own injury

 

3. Tissue width 

- bullets really cause damage after they spin 180°

- occurs when hit tissue

- has to be > 12cm tissue thickness for this to start

- hence calf may have low energy transfer wound

- thigh / abdomen have high energy transfer

- energy transfer can increase as travel along wound

 

4. High velocity bullets

- have more kinetic energy to transfer

- much worse if start to spin / > 12 cm tissue

- better outcome if already exited prior to spin or fragmentation

 

Management

 

Initial

 

ATLS

- secondary survey

- entry wound / exit wound

- NV injury

- history gun type & range

- cover wound

- ADT & antibiotics

- splint 

 

Abdomen

- all GSW that pass through the abdomen become infected without 2/52 antibiotic treatment

 

Lumbar spine

- all bullets retained in the lumbar spine should be removed acutely

- the cauda equina involves multiple levels & LMN have a better chance of recovery

- better if < 48/24 or > 2/52 to avoid oedema

 

Operative Management

 

Gunshot Wound Compound Pelvic Fracture

 

First OT

- scrub

- large incisions to explore wound

- excise all devitalised tissue 

- washout +++

- skeletal stabilisation

- always leave wound open

 

Remove bullet if

- easy to do so

- danger of later migration causing injury

- likely to cause later pain (i.e. hand / foot)

 

Second OT

- 48 hours

- DPC if wound clean

- SSG / muscle flaps as needed

 

Non-Operative Management

 

In USA good success with non-op management of low energy transfer wounds 

 

Gunshot wound elbowGunshot wound elbow 2

 

Principles of External Fixation

Indications

 

Acute / damage control

- compound injures

- periarticular injuries

- high energy injuries / let soft tissues settle

- multi-trauma (avoid second hit)

 

Chronic / definitive management

- mal /non union

- infection

- deformity

- LLD

 

Problems

 

Pin site infections

Malunion

Non union

 

Construction

 

Pins

 

Diameter

- < 1/3 diameter of bone

- 3, 4, 5 mm

 

Materials

- stainless steels

- titanium

- HA coated

 

Bars

 

Increased diameter

- increased strength and rigidity

 

Clamps

 

Modular, multidirectional

- pin to bar

- bar to bar

 

Frame types

- uniplanar

- biplanar

- circular

- hybrid (combination of planar + circular)

- joint spanning (non or articulated)

 

Increasing strength / stiffness

 

Increase pin diameter

Increase number of pins

Increase pin spread on same side of fracture

- near / far / near / far

 

Decrease distance of bar to bone

Increase number of bars

 

Note:  Increasing stiffness can lead to non union

- to increase union rates

- reduce stiffness

- i.e. reduce above factors

 

MRI issues

 

Non compatible

- local heating

- production of current

- costly disruption of MRI machine

- interference with pictures

 

Healing

 

1.  Rigid inter-fragmentary fixation

- intramembranous ossification

 

If a frame is too rigid

- osteopenic nonunion

- need to reduce rigidity

- may need bone graft

 

2.  Micro-motion / strain

- collagen formation and endochondral ossification

 

If a frame is too loose

- excessive callous

- hypertrophic non union

 

Types

 

Ankle External Fixation

 

Fracture blisters 1Fracture blisters 2

 

Ankle Ext Fix 1Ankle Ext Fix 2Ankle Ext Fix 3

 

 

 

 

Principles of Internal Fixation

Indications

 

Irreducible fractures

- fractures that cannot be reduced except by operation

 

Unstable fractures

- fractures that are inherently unstable and prone to re-displacement after reduction

 

Fractures that unite poorly

- i.e. fractures of the femoral neck

 

Pathological fractures

- fractures in which bone disease may prevent healing

 

Multiple fractures

- where fixation of one fracture facilitates treatment of the others

 

Fractures in patients who present nursing difficulties 

- i.e. paraplegics, multiply injured patients, elderly

 

Principles of Internal Fixation

 

Aim 

- produce stable fracture fixation

- minimum of devascularisation

- early motion and partial loading

 

Stable fixation 

- fixation that prevents motion of the fragments

- stable fixation is best represented by a simple fracture with a rigid plate applied across the fracture in compression

- the introduction of compression introduced stability

- stable fixation restores the load bearing capacity

 

Compression

- produces preloading, maintaining close contact of the fragment surfaces

- produces friction which resists transverse displacement and torque about the long axis

- allows the transfer of force from fragment to fragment rather than via the implant

 

Strain 

- relative deformation of a tissue

- displacement of fragments divided by the width of the fracture gap

- represents the degree of instability

- at very low levels of strain the bone heals by primary healing

- at intermediate levels healing is by callus 

- at high levels non-union occurs

 

Instability is best tolerated by multi-fragmentary fractures 

- the displacement is distributed over several interfaces 

- the individual strain is low

 

Strain is very high for bone fragments separated by a single narrow gap

- these fractures are very intolerant of even minute displacement

 

Types of Internal Fixation

 

1. Lag screws

2. Plates

3. Intramedullary Nails

4. Tension Band Wiring

 

Lag Screws

 

Stability is achieved by compression and bone contact

- load transfer occurs directly from fragment to fragment and not via the implant

- should be placed perpendicular to the fracture line

- can apply 2000-4000N

- 1 screw is never strong enough to achieve stable fixation and 2 or 3 screws are required

- provide excellent stability but their strength is usually inadequate to resist displacement under functional loads

- are therefore usually combined with a neutralisation plate

 

Lag ScrewLag Screw 2

 

Plates

 

1. Neutralisation plate

2. Buttress plate

3. Tension Band plate

4. Bridging Plate

 

Neutralisation plate

- used to protect lag screws

- conduct part or all of the force from one fragment to another

- protect the fracture fixation from bending, shear, and rotation

- e.g. lateral malleolus fractures - lag then apply a derotation plate

 

Derotation PlateNeutralisation Plate

 

Buttress plate / Antiglide Plate

- physically protect underlying thin cortex

- often used with metaphyseal fixation

- buttress is intra-articular (tibial plateau)

- antiglide is metaphyseal - diaphyseal

 

Antiglide PlageButtress PlateTibial Plateau ORIF

 

Compression plate (DCP - dynamic compression Plate)

- compression generated either by a tension device or by the dynamics of the plate itself (DCP)

- plate should be applied to the tension side of eccentrically loaded long bones

- produces fracture compression and resists tension forces

- DCP plate can produce about 600N (lag screw 2000-4000N)

- underlying bone loss due to interruption of blood supply / periosteum injury

- limited by decreasing the surface contact of the plate i.e. LCDCP (limited contact DCP)

- plate should be over bent to produce compression of the far as well as near cortex

- inner screws should be applied first

 

Forearm Fracture PlateCompression Plates

 

Bridging Plate

- used in the treatment of some multifragmentary fractures i.e. femur

- instead of individually fixing each fragment

- minimal disruption to blood supply

- reduction is performed indirectly

- compression is only sometimes possible

 

Concept

- 6 holes over each fragment if possible

- only fill 50% in intermediate fragments

- i.e. 3 bicortical screws sufficient

- near far near far concept

 

Intramedullary Nails

 

Indication

- for fixation of the diaphysis of long bones

- reamed vs unreamed

- initial nails relied on interference fit on either side of the fracture and hence could only be successfully applied to midshaft fractures

- interlocked nails have expanded indications to distal and proximal 1/3 shaft fractures

 

Humeral Nail APFemoral NailTibial IMN

 

Tension Band Wiring

 

Concept

- relies upon compression by the dynamic component of the functional load

- allows some load induced movement

- really only suitable for metaphyseal regions

- eg. patella and olecranon

 

Patella TBW

 

Screws

 

Cortical screws

- greatest SA of thread for any given length

 

Cancellous screw

- smaller core diameter

- larger thread diameter

- threads further apart (increased pitch)

 

Splints

 

Plaster 

 

Roll of Muslin stiffened by dextrose or starch

- impregnated with hemihydrate of calcium sulfate i.e. dehydrated gypsum

- when H20 is added, the calcium sulfate takes up its water of crystallization

- exothermic

 

Fiberglass

- knitted fiberglass

- 45% polyurethane resin

- 55% fiberglass

- prepolymer is methylene bisphenyl di-isocyanate (MDI), which converts to a nontoxic polymeric urea substance

- MDI molecules have isocyanate end-groups that react with any molecule containing an active hydrogen

- exothermic reaction 

 

 

 

 

 

Rib Fractures and Flail Chest

Incidence

Rib fractures Flail Chest

 

10% of all multitraumas

 

Issues

 

Alters mechanics of ventilation / causes respiratory compromise

- significant morbidity 33%

- significant mortality 12%

 

Surgical Fixation

 

Rib Fracture Plates

 

Swart et al J Orthop Trauma 2017

- meta-analysis of surgical fixation

- decreased mortality

- decrease mechanical ventilation times

- decreased ICU and hospital sty

- decreased rates of pneumonia and tracheostomy

 

Traction

Indications

 

Relieve pain

Reduce deformity

Hold fracture reduced

Allow movement while relieving pain

 

Types

 

Skin

Skeletal

Fixed

 

Reduction Principles

 

1. Apply traction in the long axis of the limb

2. Reverse the mechanism that produced the fracture

3. Align the fragment that can be controlled with the one that cannot

 

Skin Traction

 

Applied over large area of skin - spreads load

 

Never more than 10lb (4.5 kg)

 

Contraindications

- circulatory impairment

- lacerations or abrasions on skin 

- marked bony shortening - requiring greater reduction force

 

Skeletal traction

 

Indications

- lower limb fractures 

- cervical spine

   

Sites

 

Distal femur

- entry medial to prevent injury femoral artery on exit

- just proximal to adductor tubercle

- above intercondylar notch

- below Hunter's canal

- perpendicular to distal femur

- flex knee, insert knife, turn 90o so there is a transverse nick in ITB so knee can flex if needed

 

Proximal tibia

- 2 cm posterior to crest and 2 cm inferior to tibial tuberosity

- insert laterally to avoid injury to CPN on exit

 

Distal tibia

- 5cm proximal to ankle joint in middle of tibia on lateral

 

Calcaneus

- 2 cm below and behind tip of lateral malleolus

 

Skull tongs

- 1.5 to 2 cm above superior tip of pinna

 

HTB

- roll patient and put on back piece

- apply front piece and attach

- apply halo pins x 4

- outer edge of eyebrows

- close eyes tightly to prevent inability to closure

- above and posterior to ears

- 8 pound / sq inch

- ensure below equator of head

- attach to thoracic brace

 

Fixed traction

 

Definition

 

Force applied against fixed point of body

- i.e. ischial tuberosity

 

Thomas splint (1876)

- counter traction

- up against ischial tuberosity

- need 2 cm clearance about thigh

- needs to be 15 cm longer than leg

- need slings to support leg and bandage over top

 

Balanced traction

- attach Thomas splint

- leg sits on padded slings on splint

- skin traction on calf

- tie to distal aspect of Thomas splint

- this is tensioned by winding about paddle pop stick

- weight hung off end of Thomas splint over pulley on edge of bed to pull away from ischium

- rope tied to Thomas splint and hung from top pulley with weight attached, this pulls the Thomas splint off the bed

- need safety rope attached to weight

- needs daily pressure care and regular oiling

 

Hamilton Russell traction

- also known as Australian traction

- first described by Dr Hamilton Russell of Melbourne in the 1920's