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II.

Evaluating The Trauma Patient from The Orthopaedic Perspective

As alluded to already, the patient who presents from an accident scene should receive a much different type of workup than would be called for by a scheduled history and P.3

physical examination, though certainly history and physical examination are part and parcel of the process. The difference in this setting is that the sequence and algorithms in workup, diagnosis, and treatment are very different than that for a patient presenting in a nonemergent setting. It is important to acknowledge that there is a “captain of the ship,― typically an ATLStrained general surgeon, who will have the clearest overview of the patient and who will be delegating many simultaneous responsibilities. The person taking primary responsibility for the orthopaedic injuries must heed the captain's call and clearly communicate diagnostic or treatment priorities for the orthopaedic conditions and ultimately fit into the context of overall priorities. Trauma care is organized in three stages: primary survey, secondary survey, and definitive management. The primary survey occurs even before, or at least at the same time as, the history, so it will be discussed here first. Meanwhile other members of the team are simultaneously obtaining the trauma series of x-rays to be readily available for interpretation, drawing blood, or inserting a urinary catheter.

Primary survey. The primary survey is concerned with the preservation of life. The first steps in managing the trauma patient follow the ABCs. It is important to correct each of these problems in sequence. Another way to think of it is that a competent

but the surgeon in charge should follow the established ABC sequence. vomitus.. The major lifethreatening problems are tension pneumothorax. Control of external bleeding is accomplished by direct pressure and bandage. Any obstruction (e. blood. then blood . Again. Prompt determination of vital signs is essential. The classic Trendelenburg (head down) position is not used for more than a few minutes because it can interfere with respiratory exchange. tongue. Simple elevation of the lower extremities helps prevent venous bleeding from the limbs and increases cardiac venous return and preload. o Breathing.g. massive hemothorax. The most common cause of preventable death in accidents is airway obstruction. After airway obstruction has been ruled out or controlled (i. If blood loss is minimal. this aspect of the physical exam requires the examiner to inspect. After breathing has been addressed. rapidly infuse 1 to 2 L of isotonic Ringer lactate or normal saline solution. In the critically injured or hemodynamically labile patient.e. touch. venous blood samples should be taken for type and cross matching.. the patient's ventilation should be assessed. and flail chest. intubation). and auscultate the patient as this is typically done before roentgenographic diagnosis is available. cardiovascular status must be immediately evaluated and supported. o Airway. o Circulation.airway must be established if life is to continue through the rest of the evaluation. Until cross-matched blood is available. so the trauma leader must immediately check that the patient's airway is adequate and patent. dentures) must be removed and the airway secured by a jaw thrust maneuver or tracheal intubation. These initial steps generally have been performed by the paramedic team.

hypotension in a trauma patient should not be assumed to come from a long bone fracture.0–2. the examiner is ruling in or out the next most critical clues to saving life and limb. Recall that the trauma x-ray series was being taken in the trauma room while the primary survey was being conducted. tibia 1. Any patient who is involved in high-energy trauma.5–1.4 reviewed.5 1. forearm.0  Trauma x-ray series. knee. and an anteroposterior pelvic view. . The trauma series consists of three x-rays: lateral cervical spine.5–4. even before a thorough history and physical exam. this x-ray trauma series should be P. In general. femur Humerus. The following gross estimates of localized blood loss (units) from adult closed fractures can be useful in establishing baseline blood replacement requirements: 1. has head injuries.5 Pelvis Hip.0–1.5 Elbow. Now that the primary survey has been performed and the most critical steps have been taken. ankle0. or is under chemical substance influence should have these views. an anteroposterior chest.pressure should return to normal and remain that way with only a maintenance intravenous amount of balanced saline solution. and another source must be sought.

and a statement of the degree of violence involved.  History and physical examination. and alcoholism should be considered as contributing factors. Both odontoid and C7–C8 pathology are frequently missed injuries even after the secondary survey. The documented incidence of multiple level spine fractures is 7% to 12%. over.The cervical spine roentgenogram must show the inferior endplate of cervical vertebrae 7 (C7).and underpenetrated films. or a critical sacral fracture masked by the opacity of a backboard. If a spine fracture is detected. a pneumothorax in the upper lobe that was cut out of view due to positioning. lateral and odontoid cervical views. or it should be deemed inadequate and repeated. Care must be taken not to be misled by overlying backboards. and buckles which are frequently left on the x-ray field. The history should include a careful account of the accident. clips. Concomitant medical disease. a description of the mechanism of injury. then a complete spinal series including anteroposterior. A full spine series should be obtained in the unconscious trauma victim. Examples abound of subtle femoral neck fractures that were obscured on the x-ray by a belt buckle. Computed tomography (CT) may be required to rule out upper cervical fractures. drug abuse. All the x-rays should be taken with excellent technique so as not to obscure the many potential clues to danger which exist on the radiograph. and equipment. The transporting paramedic team or member of the accompanying family should be interviewed for these details if the patient cannot reliably give an appropriate history. A useful mnemonic to guide the initial history is the word AMPLE: o A: Allergies . and thoracic plus lumbar spine view is mandatory.

.The physician working up an orthopaedic patient should be particularly aware that open fractures should be treated with certain antibiotics to cover the spectrum of bacteria that are at risk for certain types of wounds (see open fractures below). and heart disease can increase surgical risk. This concern should not. A penicillin allergy is the most common. Patients on anticoagulants should have bleeding and clotting parameters checked as it may be prudent to stop such meds or reverse a coagulopathy prior to surgery. Steroids and nicotine (the use of tobacco products) increases orthopaedic surgical complications as well as outcomes as measured by healing time and healing rates. o L: Last meal This is important when considering whether or not the patient needs to go to the operating room urgently. Furthermore. every patient having an orthopaedic operation should receive perioperative antibiotics. o M: Medications Medications can influence surgical decision making. o P: Past illness Diabetes can influence outcomes of orthopaedic surgery. They will also tip off the practitioner to important comorbidities and perhaps imply the need for a general medicine consultation prior to surgery. Most anesthesiologists opt to hold on administration of anesthesia within 6 to 8 hours of food intake. making the question of allergies quite germane. as the risk of aspiration of food or vomitus is higher postprandial.

o Neurologic mental status. extrication time from vehicle. outside temperature.however. The patient should be completely undressed for the secondary survey for a most thorough exam. and necessary resuscitation is underway. The extremity neurologic exam can also be documented with the specific physical exam of each extremity. A brief “disability exam― in an awake patient is a rapid. o E: Events of accident Accident circumstances such as direction of impact.or limb-threatening conditions which will be discussed below. organized neurologic examination which documents mental orientation. the potentially life-threatening pathology of the ABCs has been addressed. override the emergent nature of certain life. The level of consciousness of the patient should first be noted. verbal response to questioning. which clue in certain medical or orthopaedic conditions and injury patterns. and many other possibilities are warning flags to the experienced practitioner. hours in the field.   P. and response to stimuli. smoke inhalation. but it is imperative that all four . accurate documentation is crucial since neurologic examinations can reveal progressive deficits. By this juncture. Furthermore. each extremity should be examined for motor and sensory function as well. being trapped under heavy objects. The Secondary Survey is a complete physical examination from head to toe.5  Secondary survey.

It is frustrating to the orthopaedic or neurosurgeon to be asked to evaluate a patient who has been sedated and chemically paralyzed in the trauma room. In general. o Head and neck. and withdrawal to painful stimuli (Table 1-1). The medics generally also note the position of the patient at the scene of the accident.extremities be included. Cranial trauma should raise an immediate suspicion for cervical spine injury given the sudden and violent force it . a Glasgow coma score is rapidly conducted based on pupil response to light. the use of maximal monitoring and minimal medication is a useful trauma room principle which avoids such frustration by the examiner who relies on accurate neurologic exams. particularly when the initial neurologic exam was not properly documented. Carefully palpate skull and facial bones and look for lacerations hidden in the hair. motor activity. This information is initially obtained by the medics who perform the initial in-the-field evaluation. In the unconscious patient. It is good to develop a pattern of examination and stick with that pattern each time for consistency. especially the head. and whether all limbs were actively moving. The Glasgow score therefore is used as the measure of neurologic progress or deterioration.