Extremity trauma part 1

emergency treatment of extremity trauma

1. Treatment of extremity trauma and compartment syndrome in er Dr. pratik agarwal

2. CASE SCENARIO 2 5YRS/MALE A/H/O RTA DUE TO DASH BY 4 WHEELER WHEN HE WAS DRIVING 2 WHEELER 2 HRS BACK. C/O PAIN IN left LEG, riight SHOULDER and bleeding from right foot SICNE THEN. NO H/O ANY OTHER INJURY NO H/O LOC, VOMITING, CONVUSION, ENT BLEED, EVENT OF AMNESIA. NO H/O ANY MEDICAL COMORBIDITIES

3. Types of injuries to extremeties encountered in emergency room- Fractures Dislocations Open wounds Amputations Sprains and strains Impaled objects Crush injury and crush syndrome Compartment syndrome

4. ASSESSMENT AND MANAGEMENT HISTORY- MECHANISM OF INJURY- VERY IMPORTANT, can GIVE IDEA ABOUT TYPE OF INJURY AND SEVERITY OF INJURY. FALL ON OUT STRETCHED HAND CAN LEAD TO CLAVICULAR FRACTURE SUPRACONDYLAR FRACTURE RADIUS AND ULNA SHAFT FRACTURE DISTAL END RADIUS AND ULNA FRACTURE SCAPHOID FRACTURE WRIST SPRAIN POSTERIOR SHOULDER DISLOCATION

5. FALL FROM HEIGHT CALCANEUM FRACTURE ANKLE SPRAIN FEMUR FRACTURE, PELVIS FRACTURE VERTEBRAE FRACTURE ABDOMINAL OR THORACIC ORGAN INJURY, RIB FRACTURE

6. OTHER MODE OF INJURY DASH BOARD INJURY POSTERIOR DISLOCATION OF HIP NECK OF FEMUR FRACTURE IT FEMUR FRACTURE

7. CAN LEAD TO OPEN WOUNDS, FRACTURES, AMPUTATIONS INJURY BY SHARP OBJECT INJURY BY BLUNT OBJECT

8. ASSESSMENT- IDENTIFY IMMEDIATE LIFE THREAT (AIRWAY, BREATHING & CIRCULATION) LOOK FOR ANY OBVIOUS FRACTURE ( CREPITATION IS DEFINITIVE SIGN OF FRACTURE ) ANY EXTERNAL BLEEDING ANY EXTERNAL WOUND- ABRASION, BRUISE, PENETRATION, LACERATION, AVULSION ANY OBVIOUS SWELLING TENDERNESS DEFORMITY RANGE OF MOVEMENT OF ALL JOINTS MOTOR AND SENSORY FUNCTION DISTAL PULSES

9. MANAGEMENT- 1 st thing we will manage is airway, breathing and circulation ( abc ). If we suspect any hemorrhage and if patient is hemodynamically unstable we will manage first circulation, then airway and finally breathing ( cab ). Then our aim will be to immobilize injured part by using splint, padding, etc. this will decrease pain, disability and serious complication. Pain control with analgesic. Finally we manage the underlying injury

10. Types of injuries to extremeties encountered in emergency room- Fractures Dislocations Open wounds Amputations Sprains and strains Impaled objects Crush injury and crush syndrome Compartment syndrome

11. fractures

12. Types of fracture Open fracture- fracture in which piece of broken bone protruding through overlying skin. Closed fracture- fracture in which there is no break in continuity of overlying skin.

13. Assessment- Swelling Tenderness SURROUNDING NEUROVASCULAR INJURIES may be present- so ckeck for distal pulses, motor and sensory function. Range of movement Bony deformity Bony crepts Note- LIFE THREATENING HEMORRHAGE- SEEN IN FEMUR FRACTURE AND PELVIS FRACTURE FRACTURE MAY OR MAY NOT BE ASSOCIATED WITH JOINT DISLOCATION CONTAMINATION- IMP COMPLICATION NOT TO IGNORED IN CASE OF OPEN FRACTURE

14. MANAGEMENT- IN CASE OF CLOSED FRACTURE- ABC/CAB IMMOBILIZE ANALGESIC XRAY- WE MUST DO SPECIFIC VIEW FOR DIFFERENT PART. XRAY MUST COVER ONE JOINT ABOVE AND ONE JOINT BELOW THE FRACTURE SEGMENT TEMPORARY STABALISATION BY GIVING SPLINT, SLAB OR BINDERS. THEN SHIFT THE PATIENT TO WARD FOR DEFINITIVE MANAGEMENT.

15. MANAGEMENT CONT.. - IN CASE OF OPEN FRACTURE- THROUGH IRRIGATION TO BE DONE USING ANTI SEPTIC SOLUTION ANd NORMAL SALINE. IMMOBILIZE INJURED PART AND DRESSING OF OPEN WOUND. XRAY TEMPORARY STABALIZATION USING SPLINT, SLAB OR BINDER. THEN SHIFT THE PATIENT TO WARD FOR DEFINITIVE MANAGEMENT.

16. CLAVICLE FRACTURE MECH OF INJURY- FALL ON OUTSTRETCHED HAND XRAY - XRAY OF SHOULDER AP MIDSHAFT CLAVICLE FRACTURE- FIGURE OF 8 BANDAGE/CLAVICULAR BRACE WITH arm pouch sling. LATERAL SHAFT CLAVICLE FRACTURE- SHOULDER IMMOBILISER.

17. HUMERUS FRACTURE- XRAY OF SHOULDER AP/ AXIAL/ SCAPULAR Y VIEW XRAY OF HUMERUS AP/LAT

18. EARLY IMMOBILISATION- SHOULDER IMMOBILISER, ARM SLING POUCH, U SLAB.

19. Fracture around elbow- XRAY OR ELBOW AP/LAT

20. IMMOBILIZATION - ABOVE ELBOW SLAB, ARM POUCH SLING ABOVE ELBOW SLAB- EXTEND FROM MIDDLE OF UPPER ARM TO DISTAL PALMAR CREASE ELBOW AT 90* FOREARM IN MID PRONE WRIST USUALY IN NEUTRAL POSITION

21. RADIUS AND ULNA FRACTURE- XRAY OF FOREARM AP/LAT

22. IMMOBILIZATION - ABOVE ELBOW SLAB, ARM POUCH SLING ABOVE ELBOW SLAB- EXTEND FROM MIDDLE OF UPPER ARM TO DISTAL PALMAR CREASE ELBOW AT 90* FOREARM IN MID PRONE WRIST USUALY IN NEUTRAL POSITION

23. FRACTURE AROUND WRIST- XRAY OF WRIST AP/LAT

24. FRACTURE IN HAND- XRAY OF HAND AP/OBLIQUE

25. FRACTURE AROUND HIP JOINT- XRAY OF PBH AP NOTE- HEMODYNAMIC STATUS OF THE PATEINT MUST BE CHECKED CAREFULLY HEMORRHARGE IS VERY SERIOUS COMPLICATION SEEN IN PELVIC FRACTURE. TO STOP BLEEDING PELVIC BINDER IS USED.

26. XRAY PBH AP XRAY FEMUR AP/LAT

27. Thomas splint

28. Femur shaft fracture- NOTE- MID SHAFT FEMUR FRACTURE CAN LEAD TO FAT EMBOLISM. TO PREVENT FAT EMBOLISM IV FLUID TO BE GIVEN ALONG WITH OXYGEN. XRAY OF FEMUR AP/LAT . IMMOBILIZATION- THOMAS SPLINT

29. FRACTURE AROUND KNEE JOINT- XRAY OF KNEE AP/ LAT

30. XRAY OF KNEE AP / LAT/ SKYLINE VIEW

31. ABOVE KNEE SLAB EXTEND FROM MIDDLE OF THE THIGH TO BASE OF TOES KNEE IN 5-20* FLEXION ANKLE IN NEUTRAL POSITION

32. SHAFT TIBIA AND FIBULA FRACTURE XRAY OF LEG AP/ LAT IMMOBILIZATION- above KNEE SLAB

33. FRACTURE AROUND ANKLE OR FOOT- XRAY OF ANKLE AP/ LAT/ MORTISE VIEW

34. XRAY OF FOOT BP/OBLIQUE XRAY OF CALCANEUM- CALCANEUM VIEW

35. Below knee slab Extend from tibial tuberosity to the base of the toe Ankle in neutral position

36. HOW TO PREPARE SLAB

37. Things to remember while applying slab For upper limb 12-14 layers of pop is enough. For lower limb 16-20 layers of pop is enough. After applying pop always check for distal movement to prevent most common complication, compartment syndrome. Always give sling for upper limb and pillow for lower limb to prevent increase of swelling of distal part which will again lead to compartment syndrome .

38. How to apply thomas splint

39. Important things to recollect Extremity trauma have more dramatic appearance and may be disabling, but do not be distracted by those injuries, abc should be managed first if any threat present then extremity trauma. Everywhere we do x-ray ap & lat view except- Hand- ap / oblique Foot- ap / oblique Shoulder- ap / axial/ scapular y view Patella- ap / lat / skyline view X-ray must be done for one joint above and below the fracture segment. Immobilization must be done for one joint above and below the fracture fragment. Always check for distal pulse, motor function and sensory sensation before after applying splint. Any open fracture must not be sutured in emergency room.

40. Thank you