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Principle Management of Wound and

Fracture in Emergency Department


Presented in Clinical Update Seminar January 15th 2011

dr. Tedjo Rukmoyo, SpOT (K) Spine

Initial Management

ATLS Procedure

A : airway
B : breathing
C : circulation
D : disabilities
E
: exposure

Compressive dressings
for hemorrhage
Check
Cervical
Chest
Abdoment

X ray

Head
Pelvis
Neurovascular

Wound Inspection & Palpation


Concentrate

on

y Hemorrhage
y Location
y Size

y Border
y Wound type
y Exudate
y Infection
y Dressed or undressed

Wound management

Evaluate the wound


NeuroVasc status
Joint Movement
X-RAY !
Sterile saline dressing
Irrigate with NS
1 or 2 litres

Tetanus status immunity


IV antibiotics
Prepare minor set
Needle
Suture material
instruments

Wound irrigation
Irrigate with NaCl 0,9 %

1 2 litre
Brush, evacuate foreign
body
Use :
Povidon iodine
Savlon
Perhidrol
(hidrogen peroxide)
Irrigate with NaCl to
cleanse

Debridement

Excision:
y
y
y
y

Wound Edge
Skin Abrasion
Dead Tissue
Dirty Bone

Evacuate:
y Foreign body

Re-Irrigation / Spoel Irrigation Temporary

Primary Closure

Secondary closure & Packing

Dressing Types and Assistive Devices

Dry Dressings

dry wound

Wet-to-Dry Dressings

wet wound

Packing

deep wound

Vacuum Assisted Closure

Compression Elastic Bandage

Principle Wound and Skin


coverage

Without skin loss


y Primary clossure
y Contraindication :
1.

Contamination

2.

NV injury

3.

Tension

Principle Wound and Skin


coverage
With

skin loss :

y Secondary intention
y Release / counter incision
y STSG, FTSG
y Flap fasciocutaneus,

rotational

Fracture Classification
Close (simple)
Open

y Gustillo Anderson
Grade I
Grade II
Grade III a
Grade IIIb
Grade IIIc

Gustillo Anderson

> Grade III B


Vascular disruption
Arteriography
If can be repaired?
Possible Limb salvage
Failed?
amputation?

Debridement and Irrigation

As soon as possible
Scrub and brush
wound dirt
Superficial
debridement:
Identify and explore

-> extend wound


Excised non viable tissue

Debridement and Irrigation

Deep debridement :
When in doubt take it out
Check muscle : 4 c
Color
Capacity to bleed
Contractility
Consistency
Cover by tissue or moist dressing
Remove Foreign body

Debridement Procedure

Irrigation
Use NS, high volume
low pressure lavage
For grade II-III :

y 6 10 l

Use antiseptics,
perhidrol, antibiotic, etc

Upper extremity Immobilization


On Accidental Site

At the primary health care


(puskesmas or clinics)

Lower extremity Immobilization


On Accidental Site

At the primary health care


(puskesmas or clinics)

Skeletal Stabilisation

Evaluate vascular
status, limb salvage,
debridement and
irrigation
Stabilize the bone :
Restore length
Angular alignment
Rotation

Will promote healing


Decrease pain and
further damage

Method Skeletal stabilisation

Cast :
y splint, circular cast

Traction :
y skin, skeletal

External fixation :
y steinman or K wire

Internal Fixation

Plate and screw


y Accurate anatomical
y Mantain /w plate
y Various types

IM nails
y Restore alignment
y Callus healing
y Minimize soft tissue damage

Compartment syndrome

Rehabilitation
Early Range of Motion
Isometric, isotonic, isokinetic excercise
Motor Power excercise
Non weight bearing
Partial weight bearing
Full weight bearing
Return to normal activity