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block 5a gabatino gauiran go gomez gonzales e gonzales l granada n.
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TRAUMA SGD

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  1. Block 5A Gabatino, Gauiran, Go, Gomez, Gonzales E, Gonzales L, Granada TRAUMA SGD

  2. General Data • OR • 54/M • RC • Sta Ana, Manila • Right handed • c/c injuries secondary to vehicular crash

  3. History of Present Illness • DOI: 12/14/09 (3 days post injury) • TOI: 6pm • POI: Carmona complex, Makati • MOI: VC jeep vs tricycle (side of the tricycle and front of jeep)

  4. History of Present Illness • Brought to Ospitalng Makati, wounds dressed, X ray done, ATS, TeANA given, THOC to PGH secondary to lack of funds

  5. Review of Systems • (-) loss of consciousness • (-) fever • (-) nausea • (-) vomiting • (-) dizziness • (-) cough and colds • (-) chest pain • (-) abdominal pain • (-) bowel changes • (+) polyuria, polydipsia, polyphagia • (+) numbness of bilateral peripheral extramities ( glove and stocking distribution)

  6. Past Medical History • (-) Diabetes • (-) Hypertension but had episodes of hypertension since 2 years ago, highest Bpof 160/80 usual BP of 150/80 • (+) hospitalization due to head injury (2008) • (-) PTB, BA • (-) food and drug allergies

  7. Family Medical History • No known medical illness in the family

  8. Personal Social History • Smoker >30 pack year • Heavy alcoholic beverage drinker 1-2 bottles of 500ml redhorse daily since 25 years old • Denies illicit drug use • Denies promiscuity • Works as a tricycle driver

  9. Physical Examination at the ER • Awake, coherent, NICRD, ambulatory • Vital Signs: BP 150/90, HR 82, RR 20, T afebrile • HEENT: AS, PC, pupils 3 mm EBRTL, (-) CLAD/TPC/NVE/ANM • Chest/Lungs: ECE, Clear Breath Sounds, (-) crackles/wheezes

  10. Physical Examination at the ER • Heart: AP, DHS, NRRR, (-) murmurs • Abdomen: soft, flabby abdomen, NABS, (-) tenderness, (-) masses/organomegaly • Extremities(both upper extremities and left lower extremity): Pink nail beds, Full and equal pulses, (-) cyanosis, (-) clubbing, (-) gross deformities

  11. Physical Examination: Left LE • Grossly deformed thigh (distal 1/3 of the thigh slightly angulated medially) • (+) swelling, tenderness, warmth, redness over distal thigh and knee • Intact sensation over (L) thigh, leg and foot • Able to wiggle toes and dorsi/plantar flex ankle • Intact and full popliteal, dorsalispedis and post tibial pulses, pink nailbeds, (-) cyanosis • 1.5x 1.5 cm wound over the anterior distal thigh with no bone protrusion and adequate tissue coverage, no gross contamination with debris

  12. RADIOGRAPHS

  13. Assessment at the ER Fx: Open complete comminuted distal third femur (L) secondary to VC

  14. Plan at the ER • Therapeutics: • Cefazolin 1g IV LD then 1g q8 • Gentamycin 240mg IV OD • Long leg posterior splint • Surgical Plan: • Debridement • Skeletal traction

  15. Course in the Wards/ER • Seen at the ER 12/17/2009 (3 days post injury) • 12/19/09 – debridement of anterior thigh wound, arthrotomy of the L knee joint and skeletal traction inserted on proximal tibia – 15kg • 12/26/09 – diagnosed with hypertension stage II fairly controlled with HHD , DM type II newly diagnosed with nephropathy, neuropathy, t/c retinopathy, T/c Alcoholic liver disease • 12/29/09 – scheduled for OR, deferred due to lack of funds for IM nail

  16. Present Physical Examination 18th hospital day, 21 days post injury • Awake, coherent, NICRD, ambulatory • Vital Signs: BP , HR , RR , T afebrile • HEENT: AS, PC, pupils 3 mm EBRTL, (-) CLAD/TPC/NVE/ANM • Chest/Lungs: ECE, Clear Breath Sounds, (-) crackles/wheezes

  17. Present Physical Examination • Heart: AP, DHS, NRRR, (-) murmurs • Abdomen: soft, flabby abdomen, NABS, (-) tenderness, (-) masses/organomegaly • Extremities (both upper extremities and left lower extremity): Pink nail beds, Full and equal pulses, (-) cyanosis, (-) clubbing, (-) gross deformities

  18. Present Physical Examination • Left lower extremity on skeletal traction inserted in the proximal tibia • (-) erythema, warmth, discharge, swelling, pain around pintracts. • (+) surgical incision over the anterior knee and thigh, good healing, no discharge, no redness, no necrotic tissue at incision site • (+) warmth over the periphery of the (L) knee, (+) mild swelling, (+) mild erythema • Intact popliteal, dorsalispedis and post tibial pulses • Intact sensation on thigh, leg, toes and feet

  19. OPEN FRACTURES

  20. OPEN FRACTURES • Osseous disruption in which a break in the skin and underlying soft tissue communicates directly with the fracture and its hematoma • Any wound occurring on the same limb segment as a fracture must be suspected to be a consequence of an open fracture until proven otherwise

  21. CONSEQUENCES of OPEN FRACTURES • Contamination of the wound and fracture by exposure to the external environment • Crushing, stripping, and devascularizationthat results in soft tissue compromise and increased susceptibility to infection • Destruction or loss of the soft tissue envelope may affect the method of fracture immobilization, compromise the contribution of the overlying soft tissues to fracture healing and result in loss of function from muscle, tendon, nerve, vascular, ligament, or skin damage.

  22. MECHANISM of INJURY • Results from application of violent force which is dissipated by soft tissues and osseous structures • The applied force is directly proportional to resulting osseous displacement, comminution and degree of soft tissue injury

  23. CLINICAL EVALUATION of PATIENTS with OPEN FRACTURES • ABCDE • Resuscitation and attention to life-threatening injuries • Evaluate injuries to head, chest, abdomen, pelvis, spine and all extremities • Assess neurovascular status of affected limbs • Assess skin and soft tissue involvement • Removal of obvious foreign bodies • Irrigation with pNSS • Radiographic evaluation

  24. GUSTILO and ANDERSON Classification of OPEN FRACTURES

  25. FACTORS which MODIFY CLASSIFICATION • Contamination • Exposure to soil, water, fecal matter, oral flora • Gross contamination on PE • Delay in treatment > 12 hrs • Signs of high-energy mechanism • Segmental fracture • Bone loss • Compartment syndrome • Crush mechanism • Extensive degloving of SQ fat and skin • Requires flap coverage

  26. GENERAL MANAGEMENT PRINCIPLES • Perform a careful clinical and radiographic evaluation • Wound hemorrhage should be addressed with direct pressure rather than limb tourniquets or blind clamping • Initiate parenteral antibiosis • Assess skin and soft tissue damage; place a saline-soaked sterile dressing on the wound

  27. GENERAL MANAGEMENT PRINCIPLES • Perform provisional reduction of fracture and place a splint • Operative intervention: open fractures constitute orthopaedic emergencies, because intervention less than 8 hours after injury has been reported to result in a lower incidence of wound infection and osteomyelitis • Do not irrigate, debride, or probe the wound in the emergency room if immediate operative intervention is planned • Bone fragments should not be removed in the emergency room, no matter how seemingly nonviable they may be

  28. EMPIRIC ANTIBIOTICS • Gustilo I: Cefazolin 1 g IV q8h • Gustilo II: Cefazolin 1 g IV q8h • Gustilo III: Cefazolin 1 g IV q8h + Aminoglycoside 3-5 mg/kg/day • Organic contamination: Penicillin 2,000,000 units q4h or Metronidazole 500 mg q6h

  29. TETANUS PROPHYLAXIS • Incomplete (<3 doses) or unknown: (+) dT, (+/-) TIG • Complete and > 10 years since last dose: (+) dT, (-) TIG • Complete and < 10 years since last dose: (-) dT, (-) TIG

  30. OPERATIVE TREATMENT • Irrigation and debridement • Removal of foreign bodies • Fracture stabilization • Soft tissue coverage and bone grafting • Limb salvage

  31. FRACTURE STABILIZATION EXTERNAL FIXATION INTERNAL FIXATION Periarticular fractures Distal/proximal tibia Distal/proximal femur Distal/proximal humerus Proximal ulnar radius Selected distal radius/ulna Acetabulum/pelvis Diaphyseal fractures Femur Tibia Humerus Radius/ulna • Severe contamination: any site • Periarticular fractures • Definitive • Distal radius • Elbow dislocation • Selected other sites • Temporizing • Knee • Ankle • Elbow • Wrist • Pelvis • Distraction osteogenesis • In combination with screw fixation for severe soft tissue injury