726 \200 Stab involvement: Liver (40%) Small bowel (30%) Diaphragm (20%) Colon (15%) a m u a r t d n a Blunt involvement: Spleen ( 50%) Liver ( 40%) Small bowel ( 10%) Retroperitoneal (15%) s c i d e a p o h t r O 2 Baseline observations: HR, BP, respirations, temperature, urine output. 3 Look for signs of GU injury (suggested by haematuria): \200 Blood at the urethral tip, signifying rupture d urethra. \200 Test the urine. Is there frank or microscopic haematuria? \200 Do a recta l exam to assess bowel integrity, presence of blood, or high- riding prostate (this suggest s bladder neck injury). \200 If any suspicious signs, seek urological help to plan urethra l repair. Rarely, GU trauma needs ureteroureterostomy, ureteroneocystostomy, or even kid- n ey autotransplantation. 4 Consider peritoneal lavage or FAST scanning (BOX 1). 5 Arrange a prompt exploratory lapar otomy if there is: \200 Shock (eg ruptured spleen) \200 Penetration to unknown extent \200 Peritonism (rupt ured viscus) \200 Pneumoperitoneum (OHCM p609, \201 g 1) A non-functioning kidney on IVU is a relative indication. Don \200\231t deny analge- sia on \201 nishing your assessment , simply for fear of masking signs. 6 Blood tests FBC (raised WCC may occur in ruptured spleen), U&E, amylase. 7 Radiology Prim ary survey adjuncts as for p725. Abdominal images are part of the secondary assessment: con sider these along with IVU, thoracolumbar spine, and other injured sites. See BOX OPPOSITE for the implications of radiol- ogy investigations. 1 \200\207Thinking of mechanisms in trauma is essential, as it will trigger thought of inj uries that may remain occult until too late (such as the above). 727 Emergency ultrasound Investigations are often required in abdominal trauma because physical examination alone may yield equivocal results. Focused Assessment with Sonography for Trau ma (FAST) has all but replaced diagnostic peritoneal lavage (DPL) as the bedside investigat ion of choice in abdominal trauma. as it is a rapid, repeatable and non-invasive test. It i s used to evaluate the evaluate the patient for free peritoneal or pericardic \202 uid \200\224which in the context of trauma is assumed to be blood. The FAST consists of four wi ndows \200\224the peri- hepatic, perisplenic, pelvic and pericardic It is considered positi ve when in- tra-abdominal or pericardial \202 uid is seen, and negative in the absence of this. FAST scanning can detect more than 100 \200\223250mL of \202 uid in the abdomen.21 8 However its sensitivity is user dependent and it is not sensitive at detecting liver and spleen tears219 or hollow viscus injuries. a m u a r t d n a s c i d e a p o h t r O Fig. 1. Shown are four transducer positions in the FAST: (1) pericardial area, (2) right up per quadrant, (3) left upper quadrant, and (4) pelvis. Reproduced from ACS Surgery: Princip les and Practice, American College of Surgeons. Decker Intellectual Properties, 2012 It has been found to decrease the time to recognition of intraabdominal trau- ma, the time to theater, and reduce the number of CT scans performed.220 \200\223222 However it has not been shown to reduce mortality.223 The role of FAST is therefore best con \201 ned to use with haemodynamically unstable patients \200\224 who can \200\231t be transferred to CT for more de \201 nitive imaging. In such patients FAST can be used to identify whether the ca use for haemodynamic instabil- ity is intraabdominal or intra-thoracic. Sonography at the b edside can also be used to evaluate the chest for a haemothorax or pneumothorax. It has gre ater sensitivity for small pneumothoraces than CXR, especially in the su- pine trauma patie nt. Radiographic implications in abdominal trauma \200 Lower rib fracture = ?liver/spleen tra uma \200 Pelvic fracture = ?rectal/urethral injury \200 Spine fracture = ?renal/pancrea tic/aortic/caval trauma \200 Free gas = bowel rupture \200 Bowel displaced = ?haemoperi toneum. \200 Head injury In the UK, manage according to NICE guidelines. This is a summary.224 De \201 nition Any trauma to the head other than super \201 cial injury to the face. Emergen cy care As always, treat ABCDE \200\224 Airway, Breathing, and Circulation, Disability, Exp osure (p725). \200 Give O2 and treat shock. \200 Protect the cervical spine. \200 Note p upil sizes and reactivity. \200 Do not neglect other injuries. Primary brain damage occurs with the initial trauma. The clinical imperative is to prevent or amelio- rate secondary b rain injury, ie further neu- ronal death: successful management of A, B & C is the \201 r st step. 728 \200 Cranial injuries: \200 Skull fracture Intracranial injuries: \200 Diff use axonal injur y \200 Extradural bleed* \200 Subdural bleed* \200 Subarachnoid bleed# \200 Intrace rebral bleed \200 Cerebral contusion OHCM images on: *p487; #p483. a m u a r t d n a Ask about: \200 Injury time and mechanism \200\224impact or acceleration/decelera- tion. \200 Trend in consciousness level. Check ears and nose for bleeding or CSF leaks (oto \200\223 & rhinorrhoea respec- tively \200\224p560). The presence of these or blood behind the tympanic membrane may indicate a fractured base of skull. Bruising over the mastoid (Ba ttle \200\231s sign) and periorbital bruising ( \200\230raccoon eyes \200\231) are late and unreliable signs of fractured base of skull. Neurological assessment \200 Write full not es; record times. \200 Assess the Glasgow Coma Score (GCS, p720) accurately and repeatedl y. Re- cord all 3 parameters (motor, eyes, and verbal). If there is a diff erence be- tween the sides, record the better result. If there is the possibility of a spinal injury, check for a response such as grimacing to a painful stimulus applied above the clavicles. Assess and record any contribution to mental status from alcohol or other drugs. s c i d e a p o h t r O Pupils \200\224check size and reactivity every few minutes until stable. Unequal pu- pils are less important if conscious, but a grave sign in coma. Spinal cord \200\224look for localizing neurological long tract signs ie: assess pow- er, t one, re \202 exes, and all sensory modalities, comparing right side vs left, upper body vs lower. Check for priapism and anal tone. Low BP together with an inappropriately low pulse rate indicates sympathet- ic disruption in cervical spinal cord injury. Medical management of head injury There are a number of specialist inten- sive care measure s that can prevent secondary injury and optimize recovery: \200 Avoidance of hypotension: Keep systolic BP >90. Even a single episode of low BP is associated with worse outcomes in severe traumatic brain injury.225 \200 Avoidance of hypoxia: Keep PaO2 >60mmHg or sats > 90%. \200 Careful IV \202 uid therapy: \200\207Treat hypovolaemia ( \200\230 cerebral hypoperfusion); \200\207do not overload (preventing cerebral oedema); do not use glucose p repa- rations (which damage brain tissue). Hyperventilation: Avoid in the \201 rst 24h post injury. After this use only as a tempori zing measure for reduction of acute elevations of ICP. Hyperventi- lation reduces PaCO2, wh ich causes cerebral vasoconstriction, thus reducing the eff ects of \200\200ICP.1 However, vasoconstriction may lead to increased ischae- mia thereby worsening neurological injury.2 26 \200 Mannitol: 0.25 \200\2231g/kg of 20% mannitol solution causes osmotic diuresis, ai m- ing to reduce ICP; useful in acute deterioration. Avoid systemic hypotension. If \201 ts occur (in any situation), see p724. 1 Cerebral perfusion pressure (CPP) = mean arterial blood pressure (MABP) \200\223 intracr anial pressure (ICP). 729 Investigating and managing head injury patients Imaging Urgent CT head if: Cervical spine (x-ray/CT) if: Patients with neck pain or tender- ness + one of: \200 Age >65 \200 Dangerous mechanism \200 Unsafe to assess range of move- GCS <13 at initial assessment \200 GCS <15 at 2h post injury \200 Open or depressed sku ll or basal a m u a r t d n a s c i d e a p o h t r O skull fracture Post-traumatic \201 t \200 Focal CNS de \201 cit \200 >1 episode of vomiting \200 Retrograde amnesia > h ment Inability to rotate neck 45 de- grees to the left and right \200 Extremity paraesthesiae \200 Focal CNS de \201 cit CT cervical spine if: \200 GCS <13 at initial assessment \200 Intubated \200 Patient is has multi-region trau- CT head if any LOC/amnesia & \200 Age >65 years \200 Dangerous mechanism of injury \200 Coagulopathy ma requiring CT scanning Abnormal plain \201 lms \200 Ongoing clinical suspicion \200 If CT abnormal, GCS <15, or signi \201 cant symptoms or signs, you must ad- mit \200\230under a consultant with specialist training in managing head injured patients \200 \231. Those not ful \201 lling the admission criteria may be discharged with a head injury information sheet. Tertiary referral to a neurosurgical service should be ac- cording to a greed local guidelines/policy. See also \200\230The neck \200\231, p658 and \200\230Does he need a radiograph? \200\231, p778. Imaging diff use axonal injury (DAI) This important and historically underestimated type of brain injury is usually the result of ro- tational acceleration/deceleration forces to the unrestrained head, causing microscopic shear- ing of axons, though not necessarily at the pre- cise moment of injury. Delay can be in the order of hours to days (ie as part of secon dary injury). Imaging with CT may show the typical patterns of intraventricular haem- orrha ge, hemispheric intra-parenchymal hemorrhage, hemorrhage in the brainstem and corpus callos um, though often no abnormality is visualized (in 50 \200\22380%).228 MRI is the superior m odality, as it is more sensitive at revealing the presence of injury.229 Outcome of injury is often a persistent vegetative state (p776): likelihood cor- relates with the site and nu mber of lesions present on imaging. Brain areas at risk \200 Hemispheric white matter Corpus callosum \200 Brainstem.227 NB: see p758 for Injuries to the face and neck. Wound management Principles of management Where possible, convert dirty ragged wounds into clean wounds that can be reconstructed simply eg by waiting for heal- ing by secondary inte ntion (may be suitable for small wounds in inconspicu- ous places or concave areas) or perf orm primary closure by suturing or other means. Other more complex options in the reconstru ctive ladder include skin grafts, \202 aps, tissue expansion and tissue engineering, and require specialist care. Important points in the management of wounds 1 Irrigation, irrigat ion, and more irrigation with 0.9% saline or clean tap wa- ter. It is vital to clean the wo und well as soon as possible particularly if the patient is referred to specialist care tha t could incur further delay. 730 a m u a r t d n a 2 In \201 ltrate with lidocaine (blocks voltage-gated Na+ channels to prevent de- polariza tion) 4mg/kg plain or 7mg/kg with adrenaline. See opposite. Lido- caine is a vasodilator ( \200\230 increases its own systemic clearance). Adrenaline is used where vasoconstriction t o reduce bleeding is useful and if the predict- ed dose of lidocaine needed would exceed 4m g/kg. 1 in 200,000 adrenaline is most suitable for daily use (1 : 1000 is 1mg/mL). Use the minimum strength for job. Local anesthesia (LA) will still work at dilute concentrations bu t you will need to wait for longer; for suturing 0.5% provides a good eff ect with less tox icity. In \201 ltrate through devitalized tissue of the wound using a small volume to avoi d distorting the tissues. Local blocks are also an op- tion. Use a \201 ne needle (eg ins ulin syringe or dental syringe), warm the local anesthetic and inject slowly to reduce pain . Topical anesthetic \200\224eg LET (lidocaine 4%, epinephrine 0.1% & tetracaine 0.5%) may help. Wait for anaes- thetic (3min) and vasoconstrictor eff ect (7min). s c i d e a p o h t r O 3 Remove debris, foreign bodies and necrotic tissue; ragged or shelved skin edges may need trimming. Avoid excessive tissue resection on the face where reconstruction may be diffi cu lt. Abrasions need to be scrubbed thor- oughly otherwise permanent tattooing will occur aft er re-epithelialization. 4 Use absorbable subcutaneous sutures (Vicryl /PDS ) to bring sk in edges together and avoid skin tension. Use interrupted mono \201 lament (nylon/ Prolene ) on the skin in most cases for optimal apposition 6 \200\2310 for the face, 5 \200\2310 or thicker for other areas. Very thick sutures are not needed as the strength of repair lie s in the deeper layer. Avoid skin tension and wound inversion. Vicryl Rapide or other abs orbables may be considered as skin sutures in non-cosmetic areas: brush suture knots away a fter a week. (Su- tures: OHCM p572.) 5 Remove sutures at the correct time to minimize risk of unsightly permanent stitch marks: face 5 days, upper limb/body 7 \200\22310 days, lower limb 14 days. Suture alternatives avo id sharps and the need for removal. Steristrips : Good for non-hairy skin that is unlikely to get wet. Avoid too much traction (may cause fragile skin to blister). They may be combi ned with buried dermal absorbable sutures. Glues: (eg Dermabond ) After haemostasis, place directly on top of accurately apposed and dried skin edges. Avoid thick layers as the exot hermic reaction may hurt. Allow to dry for 30sec,then apply another thin layer. Avoid getti ng the glue inside the wound as it is cytotoxic. Post-op: \200\230you can shower, but don \200\231t soak or scrub \200\231.NEJM 2008 video Antibiotics Often not needed,230 unless hu man/animal bite, hand wound.231 Tetanus Prophylaxis is vital. A full course (p151) provides good immunity. Vac- cinate those who have not completed their schedule and where there is uncer- tainty.1 Human immunoglobulin is for wounds that are prone to cause tetanus eg invol ving manure, extensive necrosis (give vaccine and Ig in diff erent arms). tinyurl.com/57k3vf 1 A full adult course if unimmunized would be 0.5mL of \200\230combined tetanus & low-dose diphtheria and inactivated polio vaccine \200\231 IM repeated \211\210 2 at monthly inter vals with boosters at 10 & 20yrs. We thank Prof Tor Chiu for this page. 731 Calculating lidocaine (= lignocaine) doses232 For more information on local anesthetic dose s, toxicity, and onset and dura- tion times. For lidocaine doses (without adrenaline): Perc entage Concentration (mg/mL) Approx. allowable volume (mL/kg) 0.25% 0.5% 1% 2% a m u a r t d n a s c i d e a p o h t r O 2.5 5 10 20 1.12 0.56 0.28 0.14 Fig 1. Maximum safe volume of plain lidocaine by body weight. Max. safe dose of lidocaine with- out adrenaline: 3mg/kg; with adrenaline: 7mg/kg. Use diff erent strengths for different jobs: 0.25 \200\223 0.5% for in \201 ltration & IV regional anesthesia; 1% for nerve blocks, epidural anesthesia, and IV re- gional anesthesia; 2% for nerve blocks. NB: 1%=10mg/mL. Wound healing and associated problems Wound healing is a fascinating but complex web of phy siology: to attempt to explain it in detail would be un \202 attering to such a remarkable process.233 Fig 2. The above diagram outlines the important and overlapping stages during the wound hea ling process \200\224NB: milestones are variable. Courtesy of Dr Tom Turmezei. Wound healin g problems Wound healing capability \200\201 with \200\200age, malnutrition, DM, steroid therapy, smoking (p737), peripheral vascular disease and irradiation. Wound infection worse ns scarring and so topical chloramphenicol can be used to reduce the risk of cosmetic insul t (eg on face). Keloid scarring is exaggerated scarring (from excess collagen production, e specially type III) to beyond the con \201 nes of the initial wound and can appear progres sively and after a delay. Hypertrophic scarring is exaggerated scarring within the con \201 nes of the initial wound, is often associated with a wound across a joint surface, and tends to regress. Both are more common in dark-skinned individuals. \200 Major burns: emergency treatment 732 \200 The majority of burns are minor; non-specialist staff will see very few major burns. Their task should be to ensure the rapid and safe transfer to Burns units (with ITU resources and access to burn surgery) experienced in their care. Staff should be familiar w ith ATLS and EMSB protocols (Early Management Airway and breathing Inhalational injury can occur by many mechanisms: thermal, chemical/acids, irritant or systemic eff ects. Direct da mage to lung parenchyma is rare. Risk of inhalational injury is best judged by clinical as- sessment \200\224have a high index of suspicion (there is no single diagnostic sign). Ther mal damage to the upper airway may cause airway obstruction through oedema which may be exa cerbated by concomitant cutaneous injury. \200 History Fire in enclosed space eg house \201 re. \200 Signs Burns of oropharynx, burnt nasal hairs, change in voice, soot in uppe r ).234 of Severe Burns a m u a r t d n a airway or sputum or bronchoscopic evidence. \200 Management \200 Give high- \202 ow O2. Formal airway assessment by an ICU anesthetist is advisable. \200\207Early expectant intu bation is preferable. Diffi - culty with ventilation may be related to thoracic burns if th ey are deep and circumferential and so restrict breathing movements \200\224an escharotomy (see Decompression, opposite) may be needed. Chest injuries such as tension pneumothorax or \202 ail chest may be caused by the event eg force of explo- sion, running/jumping to sa fety. s c i d e a p o h t r O Carboxyhaemoglobin (COHb) Check COHb particularly within the \201 rst hour, as levels can drop quickly; blood gas result of >10% COHb con \201 rms exposure (oximetry is unreliable ). 100% O2 will reduce the half life of COHb from 250 to 40min (there are very few indicati ons for using hyperbaric oxygen except for deteriorating neurological signs \200\224COHb bl ood levels are not a good indicator). \200 Cyanide (CN) Comes from burning foam and disru pts cellular metabolism. It is not readily measured in the clinical situation \200\224suspe ct where there is persistent evidence of tissue poisoning (mechanism of toxicity is cytochr ome inhibition). The safest treatment is single-dose sodium thiosulfate followed by hydroxo cobalamin given as early as possible. The eff ects of CO and CN are often overestimated. (A lso see OHCM, p854.) Circulation Insert 2 large-bore IV cannulae even if you have to go through burnt skin. The estimation of burn surface areas (BSA \200\224see MINIBOX) is impor- tant as the size of th e burn injury re \202 ects magnitude of in \202 ammatory reac- tion; subsequent \202 ui d shifts may lead to shock if uncorrected (occurs over hours rather than minutes as in actu al hemorrhage). The aim of \202 uid \200\230resusci- tation \200\231 in burns is to anti cipate and prevent shock. First Aid \200 Remove burnt clothing \200 Cool burns and warm patient: irrigate with cool water for 10 \200\22320 minutes \200 Can use cling \201 lm in thermal burns (do not wrap circumferentially) \200 Cooling gels/masks simple to use es pecially for the face, but have the most eff ect when left exposed to the air \200 Chemic al burns need continued irrigation. Burn surface area (BSA) Use rule of 9s (MINIBOX) or a b urn chart \200\224eg Lund and Browder (OHCM, p859). Fluids There are several commonly used formulas for \202 uid administration \200\224the Parklands formula (below) is often prefe rred to formulas using colloids (Muir & Barclay) but the actual dangers of the latter are p robably overestimated, particularly in uncomplicat- ed patients. The administration of coll oid is generally regarded as being safe after the 1st day (when capillary permeability reco vers) but is not always given; similarly blood is advocated by some but rarely given. Wallace rule of nines \200 Arm (all over) 9% \200 Leg (all over) 18% \200 Front 18% \200 Back 18% \200 Head (all over) 9% \200 Genitals/perineum 1% We thank Prof Tor Chiu for help with this page. Parklands formula Time of injury is taken as the start time and with any delay, the de \201 cit needs to be calculated and given: 733 Volume of Hartmann \200\231s (mL)1 = 4 \211\210 body weight (kg) \211\210 BSA (%). \200 is given in the 1st 8h \200 The other in the next 16h. \200\207NB: do not confuse the formulas: Muir & Barclay use half the volume but in the for m of colloid. Use the appropriate \202 uid with the formula. All formulas represent start ing points: tailor continuing \202 uids to the response. The patient should be catheteriz ed as the best single measure is the urine output \200\224aim for more than 0.5mL/kg/h.235 The temperature gradient (core and periphery) is used in some units to measure peripheral p erfusion. Burn depth This has implications for healing/scarring but assessment can be hard, particularly for intermediate-thickness burns. Many burns, especially scalds in children, are mixed depth. Also, burns can evolve for up to 48h. In A&E, the most important aspect of assessing burn depth is erythema; to avoid over- estimating burns, don \200\231t count mil d redness, blisters or oedema. Laser Doppler imaging (LDI) can provide reliable objective m easures of burn depth but ma- chines are costly. \200 Full-thickness burns are white/gray /black, thick and insensate and can cause a m u a r t d n a s c i d e a p o h t r O constriction if circumferential Super \201 cial burns are painful, red and have blisters. Decompression Full thickness bur ns are tough and in \202 exible; if circumferen- tial, they can have a tourniquet-like eff ect and hinder breathing or limb circu- lation. Also, big volumes of crystalloid may lead to marked soft tissue swelling. In such cases decompression may be needed, which may involv e escharotomy (incising in \202 exible burn eschar along prescribed lines) and fasciotomy. It is rarely needed at once and, contrary to some advice, it is best performed under contr olled conditions ie in the operating theater and under GA. Transfer and dressings There is no need for anything fancy. Simple cleaning of the wound with sterile 0.9% saline is adequa te. Blisters should be left alone unless tense and causing pain. \200 Apply cool wet dres sings for pain relief. \200 Using Cling \201 lm covered with blankets to keep warm is adequate. \200 Hands (and feet) can be put into clean plastic bags, and should be elevate d. \200 Analgesia should be adequate; use IV opiates if necessary, titrated to com- fort. Tetanus prophylaxis is given as necessary (p730). Pediatric burns Standard estimation of area cannot be applied: Wal- lace \200\231s rule of 9s must be modi \201 ed but is then rather unwieldy, and speci \201 c burn charts are mor e reliable. For small burns you can use the patient \200\231s palm and \201 ngers \200 \224equivalent to 1% BSA \200\224to estimate burn size. There is a lower threshold to begi n resuscitation (10% BSA). \200 Maintenance \202 uids in the form of dextrose-saline ar e given, and a higher urine output is needed: >1mL/kg/h. Keep warm as there is a greater tendency to hypothermia. \200 Be alert to possibility of non-accidental injury. Because of advances in wound management in specialized burns centers (eg autologous split-thickness skin grafts cultured fetal skin \201 broblasts) even 9 5% burns are survivable by 50% of children.236 Mortality risk prediction The percentage of burnt surface area + age gives a very rough prediction of mortality (though it \200\231s us efulness has been reduced by improvements in burns care.) For example: \200 10% burn in a 20-yr-old \211\210 30% risk of mortality \200 10% burn in a 90-yr-old \211\210 100% ri sk of mortality. In general, burns mortality is related to surface area involved, inhalatio nal in- jury, age and comorbid illnesses. 1 In electric shock injuries, higher volumes of \202 uid may be needed; see p789. Fractures Description \200 Site: Bone(s) fractured; part of bone (proximal, shaft, distal etc) \200 Obliquity: Transverse; short oblique; spiral; multi-fragmentary \200 Displac ement: Angulation; translation; rotation; impaction, foreshortening \200 Soft tissues: Op en/closed; neurovascular status; compartment syndrome. NB: when giving a displacement descr iption, this refers to the distal fragment. For angulated frac- tures, eg in the hand, the terms \200\230apex dorsal \200\231 and \200\230apex palmar \200\231 can also be used. Cli nical features Pain; loss of function; tenderness; deformity; swelling; crepitus; abnormal movement or positioning of a limb; soft tissues. Fracture healing (see also p738) A rule-of -thumb for fracture healing is given by the \200\230rule-of-3s \200\231. A closed, pediatr ic, metaphyseal, upper limb frac- ture is the simplest and will heal in 3 weeks. Any \200 \230complicating factor \200\231 doubles the healing time, ie adult; diaphyseal; lower limb ; open injury. For example an adult (6), diaphyseal (12) forearm fracture may take 12 weeks to heal. Likewise an open (6), adult (12), diaphyseal (24), tibia (48) may be expected to take 48 weeks (almost a year!) to heal. Metaphysis and epiphysis are de \201 ned on p683. Methods of managing fractures Immobilize and reduce the part (if needed, p736), eg using a plaster of Paris cast. The problem with this method is that \200\230fracture disease \200 \231 follows immobilization \200\224muscle atrophy, stiff joints, and osteoporosis \200\224 so anything speeding return of function may be bene \201 cial.1 If possible, fractures inv olving joint articulations should be treated by open re- duction, accurate reconstruction o f the joint surfaces, and \201 xation, such that immediate movement can occur \200\224see MINIBOX for the other indications for open reduction internal \201 xation (ORIF). Otherw ise, secondary osteoarthritis is inevitable. Prompt internal \201 xation, eg with plates and screws, nails or wires (Kirschner), of all fractures in those with polytrauma leads to large reductions in serious complications (fat embolism, acute respiratory distress syndrom e), as well as lessening the time during which mechanical ventilation is needed.237 Externa l \201 xation uses wires into bone, a bar, and a means (clamps) of at- taching the bar to the screws to align and engage the fractured cortices. The wires may be driven through the bone and out of the far side of the limb, so that a second bar can add stability. Further ri- gidity is aff orded by another set of screws at 90 to the \201 rst set. Because the intervention is away from the \201 eld of injury, this method is very useful when there are burns, loss of skin and bone, or an open fracture. Pathological fractures See p709. 734 \200 Seven key questions \200 How many fractures? \200 Can I see all the bone? \200 What i s broken? \200 Are the bones normal? \200 Any trapped air? \200 Any foreign body? \200 More plain \201 lms needed (IVU, CT, arteriogram)? a m u a r t d n a s c i d e a p o h t r O Indications for ORIF \200 Failed conservative \200\224 \200 2 #s in 1 limb \200 Bila teral identical #s \200 Intra-articular #s \200 Open #. 1 Healing may be speeded by 64 days with pulsed ultrasound (it \200\231s non-standard).217 735 Fixation Screw insertion to unite the fragments typi- cally begins with temporary wire or b one clamp \201 xation. A pilot hole is then drilled into bone, which must be substantial enough to support the screw head. Both near and far cortices are drilled with the pilot dri ll. Countersinking decreases incidence of stress risers and micro- fractures of the bone as the head of the screw compresses into the near cortex. The pilot hole is measured to aid s election of the best length of screw. Distal threads have a smaller diameter than proximal threads to give thread cutting action for self-tapping screws. Have eg 2 threads of the scr ew exiting the far cortex to assure that the largest threads of the screw purchase the far cortex. (Add eg 2mm to the pilot measurement.) Lag screw technique An oversized countersunk hole is drilled through the near cortex. The distal portion of the hole is drilled with a diameter corre- sponding to the core diameter of the screw. As the screw tightens, its dist al end engages the threaded hole of the distal fragment. The undersurface of the screw head contacts the countersink hole and pulls the distal fragment against the proximal fragment causing compression. A lag eff ect can only oc- cur if the screw can pass freely through th e gliding hole. Lag screws are most appropriate for oblique fractures.239 Fixation options \200 Kirschner wires (K-wires) \200 Cannulated screws \200 Staples \200 Self-tapping screws \200 Osteosynthesis lag screws \200 Herbert headless screws23 8 \200 Absorbable pins a m u a r t d n a s c i d e a p o h t r O Gustilo classi \201 cation of open fractures240 Type I Low-energy wounds <1cm long, eg cau sed by bone piercing skin Type II Low-energy wounds >1cm, causing moderate soft tissue dama ge Type III All high-energy injuries irrespective of wound size: IIIA fractures have adequate local soft tissue coverage \200 IIIB fractures have inadequa te local soft tissue coverage \200 IIIC implies arterial injury needing repair \200 Emergency management of open fractures: the 7 \200\230As \200\231 1 ATLS: As with al l emergencies manage in an ABC fashion. In the multi- trauma patient be careful not to be d istracted by the open fracture, but complete a primary survey assessing Airway, Breathing, Circulation and Disability - treating life threatening injuries as they are discovered. Cor - rect shock (p725); give blood if >1.5L lost or continued bleeding. Control of bleeding ma y require open surgery. 2 Assessment: Neurovascular status, soft tissues and photograph wound (reduces number of wound inspections). 3 Antisepsis: Take a swab from the wound, use copious irrigation with ster- ile 0.9% saline (eg 3L), then cover with a large antiseptic-soaked dressing. 4 Alignment: Align fracture and splint (also provides pain relief). 5 Anti-tetanus: Check s tatus and immunize appropriately (p730). 6 Antibiotics: 3rd generation cephalosporin, eg ce ftriaxone 1g/24h IV241 metronidazole if grossly contaminated; antibiotics prevent early infec- tion.242 7 Analgesia: Intravenous opiate analgesia titrated to eff ect. Fracture reduction and traction A displaced fracture needs realignment (reduction) unless f unction and ap- pearance of the limb are satisfactory. For example, a small displacement ac - ceptable in a fracture of the femoral shaft might not be acceptable in the radius, where it could interrupt supination. Reduction also allows freeing of any structures trapped betw een bone ends. Accurate reduction aids revas- cularization (vital in subcapital fractures o f the femur) and prevents later degeneration if fractures involve joints. In- ternal and ex ternal \201 xation has removed the need for much traction in adults, but it is still used for children. Methods of reduction \200 Manipulation under anesthesia (for analgesia and muscle relaxation) and radiographic screening. NB: if under GA, consent for ORIF (open reduction + internal \201 xation, p134) in case closed reduction is unsuccessful. \200 O ccasionally reduction will be required immediately, ie in A&E before an X-ray is even taken (eg for fracture- dislocation of the ankle or knee). 736 \200 a m u a r t d n a s c i d e a p o h t r O Traction (see below & \201 g 2) may be used for eg femoral shaft fractures or spinal injury. Open reduction aids accuracy, eg before internal \201 xation. Methods of traction The nex t problem is to hold the re- duction in place by using traction or \201 xation during hea l- ing, which takes from 2 weeks (babies) to >12 weeks (p734). \200 Skin traction uses ad hesive strapping to attach the load to the limb. The problems are that the load cannot be v ery great, and that sensitivity to the adhesive may develop. \200 Fixed traction The Thom as \200\231 splint ( \201 g 1). Weight can be added over a pulley (at the foot end) to rel ieve pressure on ischial tuberosity. Skeletal traction Using a pin through bone, bigger forces can be employed (eg Steinmann or Denham pin in the distal femur/proximal tibia for femoral shaft fractures, Gardner \200\223 Wells tongs or Crutch \201 eld skull calipers for cerv ical spine traction). Balanced traction ( \201 g 2) The weight of the limb balanced against the load. This can e nable to patient to easily lift the leg off the bed, eg for a bed pan. Fig 1. Thomas \200\231 splint. Gallows traction ( \201 g 2) is suitable for children up to 2yrs of age. The buttocks rise just above the bed. The ward nurses will be experts at setting up and adjusting traction devices, so ask if you can watch and help. See BOX, p735 for methods of \201 xation. Fig 2. Traction: balanced traction, and gallows traction. 737 Smoking and tissue healing \200\224the consequences of a cigarette break Trauma patients ne ed to knit back together well, and they face a number of complications without adding tobac co into the physiological equation. Not only do smokers increase risk of perioperative comp lication \200\224such as venous thromboembolism, respiratory tract infection & cardiac isch aemia \200\224they also reduce their chances of healing well, potentially undoing all the h ard graft of the surgical team in theater (eg plastics, orthopedics, general surgery). What damage are smokers doing? Nicotine increases the time it takes for a fracture to unite and reduces quality of bone healing. Tobacco smoking also reduces tissue oxygenation and wound healing. This is particularly pertinent for operations on the lower extremities \200\224eg Achilles tendon repair (p712) or calcaneal fracture ORIF (p756) \200\224because of the pre carious local blood supply combined with a propensity for compartment syndrome, \200\207p7 38. Is it justi \201 able to withhold surgery from smokers?1 Perhaps \200\230yes \200\231 , if a given problem has a non-operative alternative with similar outcome yet potentially d isastrous complications exacerbated by smoking: eg a calcaneal ORIF spiral- ling out of con trol into an amputation. Also perhaps \200\230yes \200\231, if resources must be distribut ed across a population in whom smokers are shown to fare much worse with a given operative management. The ethical counterpoise would be from a discriminatory angle, both in terms of costs and the concept of self- in \202 icted harm \200\224eg in comparison to dangerous s porting activity. How to approach the issue? Careful informed consent will be vital, though whether scare tactics are allowed is another matter altogether. Abstaining for 6 to 8 week s prior to elective surgery will reduce many of the side-eff ects of smoking, but this is n ot a luxury aff orded to trauma patients, and for some the stresses of what has happened ma y be too much to place on top of stopping smoking.2 Do smokers mobilize more keenly in the post-op period in response to their craving to get off the ward for a cigarette? There appe ar to be no studies to answer this yet! For giving advice on stopping smoking, see p512. a m u a r t d n a s c i d e a p o h t r O Salter and Harris classi \201 cation of epiphyseal injury I II The commonest injury, with the fracture line above the growth plate III There is a dis placed fragment, with the fracture line through the growth plate IV Union across the growth plate may interfere with bone growth V Compression of the epiphysis causes deformity and s tunting Seen in babies or pathological conditions (eg scurvy) Fig 3. Salter and Harris classi \201 cation of epiphyseal injury. Injuries to and around t he growth plate can be very diffi cult to distinguish from normal appearances, especially w hen they are viewed obliquely. Most physes are in plane that makes it relatively easy to di agnose the injury (eg distal radius, and to a lesser extent proximal femur), whereas some c ross the plane of the x-ray at multiple angles (eg proximal humerus). With these trickier p hyses, it is wise to liaise with someone with experience. Also consider comparison with the contralat- eral side. 1 With pressure to provide a cost-eff ective and fair service in the NHS, there are strong arguments from both parties. The debate certainly does not allow for smoke without \201 r e \200 244 2 Though even stopping one day before surgery has been shown to improve outcome. Complications from fractures Complications Synopsis: see MINIBOX. Fat embo- lism: Typically arises on day 3 \200\22310. Signs: confusion, dyspnoea, pulse \200\200, PaO2 \200\201, \201 ts, coma, T \200\200, petechial rash. CXR/CT: small subpleural nodular opacities.245 \200 Take to ITU \200 Get expert help \200 Correct shock \200 Monitor CVP & urine outp ut \200 Treat respira- tory failure (OHCM p180). Aim for early mobilization. Early \201 xation of fractures is preventive. Mortality: 10 \200\22320%. Crush and compartment syndrom es are a cause of ischaemia. Fluid loss, DIC, and myoglobin re- lease cause renal tubular n ecrosis: dialysis may be needed. Correct hypovolaemia vigorously. Watch urine output & plas ma K+. A limb \200\231s dead weight when immobile or in coma may cause crush in- jury/compa rtment syndrome in a vicious cycle of pressure \200\203vascular occlusion \200\203hypoxia \200\203necrosis \200\203pressure \200\200. Look for tell-tale signs of red- ness, mottlin g, blisters, swelling, and pain on passive muscle stretching. \200 Compartment syndrome is limb- and life-threatening. problems caused by delay requires vigilance and perhaps intrac ompartmental pressure measurement (NB: diagnosis is clinical; normal values for interventio n are contro- versial). \200\207Prompt fasciotomy is life-/limb- saving.246 Late complicat ions \200 Wound sepsis: Early wound cleaning is vital. Infection arises in 8% of closed fractures if internal \201 xation is used. Cef- triaxone 2g IV1 at induction halves risk. 247 \200 Failure of \201 xation: eg plates or nails 738 \200 Complications Immediate: \200 Internal bleeding \200 External bleeding \200 Organ inj ury, eg brain \200 Nerve or skin injury \200 Vessel injury (limb ischaemia: OHCM p658) Later \200\224local: \200 Skin necrosis/gangrene \200 Pressure sores \200 Infection \200 Non- or delayed union Later \200\224general: \200 Venous or fat embolism \200 Pul monary embolism \200 Pneumonia \200 Renal stones a m u a r t d n a s c i d e a p o h t r O Haematoma Avoiding Vascular granulation tissue Subperiosteal osteoblast stimulation Bone matrix Endochondral ossi \201cation Deformable woven bone (callus) break, or dislodge. Joint stiffness, contractures, malalign- ment (=malunion). Lamellar bone (p701) CRPS: Joint stiff ness and patchy osteope- nia \200\224see OPPOSITE. Fracture union Psychological problems in mobilizing: eg \200\230compensation neurosis \200\231. Fig 1. Bone healing. Non-union (atrophic or hypertophic) This is said to have occurred when there is no evidence of progression towards healing, clinically or radiologically. Delayed union is when the fracture has not healed within the time reason-