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ORTHOPAEDICS AND TRAUMATOLOGY

FACULTY OF MEDICINE
HASANUDDIN UNIVERSITY

CASE REPORT
DECEMBER 2015

Case study:
Mild Head Injury GCS 15 (E4M6V5) + Closed fracture Right 2nd Metacarpal base
+ Open Fracture of the Left 1/3 Middle Tibia grade IIIA + Open Fracture of the
Left 1/3 Middle Fibula grade IIIA + Open Fracture of the left 1st Metatarsal Shaft
grade IIIA + Open Chipped Fracture of left Posterior Talus Process grade IIIA

BY:
Fathin Hanina BT Khairul Parman
C 111 10 853
RESIDENT:
dr. Fahroni C. Winata
dr. Nur Rahmansyah
SUPERVISOR:
dr. Notinas Horas, M.Kes, Sp.OT
Submitted in Fulfilment of The Requirement for Clinical Rotation at
Department of Orthopaedics and Traumatology
Faculty of Medicine
Hasanuddin University
2015

APPROVAL SHEET

This case report entitled Mild Head Injury GCS 15 (E4M6V5) + Closed fracture
Right 2nd Metacarpal base + Open Fracture of the Left 1/3 Middle Tibia grade IIIA
+ Open Fracture of the Left 1/3 Middle Fibula grade IIIA + Open Fracture of the
left 1st Metatarsal Shaft grade IIIA + Open Chipped Fracture of left Posterior Talus
Process grade IIIA prepared by
Name

: Fathin Hanina Bt Khairul Parman

Students ID : C 111 10 8583


University

: Hasanuddin University

Submitted in fulfilment of the requirement for clinical rotation at DEPARTMENT


OF ORTHOPAEDICS AND TRAUMATOLOGY Faculty of Medicine
Hasanuddin University.

Makassar, December 2015

Resident I,

Resident II,

dr. Fahroni C. Winata

dr. Nur Rahmansyah


Supervisor,

dr. Notinas Horas, M.Kes, Sp.OT

PART I
CASE REPORT

I.

Patients Identification

II.

Name
Age/ Date of Birth
Gender
Medical Record No
Date of Admission

:A
: 24 years old (21/09/1991)
: Male
: 73 47 50
: 28/11/2015

History Taking

Chief complaint: Wound on the left lower extremity.


History of Presenting Illness :
Suffered since 6 hours before admitting to RSWS due to motorcycle
accident. He was hit by a motorcycle on his left side while trying to turn
right at a junction without wearing a helmet and was thrown onto the
asphalt road. He then fainted and the exact mechanism how he fell is
unknown.
History loss of consciousness (+) Vomiting (+) Nausea (-)
History of previous illnesses (-)

III.

Physical Examination
Airway

: Clear, Airway obstruction (-) cervical spine control

Breathing

: 22x/minutes, right & left thorax in symmetric,


spontaneous

Circulation

: BP = 110/80mmHg, pulse = 80x/minutes, strong

Disabilaty

: Glasgow Coma Scale 15 (E4M6V5) pupil isochroous


2,5mm/2,5mm, light reflex +/+

Exposure

: T= 36.8 C (Axillary)

Right hand region


Inspection

: Wound (-) Deformity (-), swelling (+), hematoma(+)

Palpation

: Tenderness (+)

ROM : Active and passive motions of the wrist joint cant be


evaluated due to pain.
Active and passive motions of the MCP and IP joint of the
thumb cannot be evaluated due to pain.
Active and passive motions of the MCP, PIP and DIP joint
of the index, middle, ring, and little finger cannot be
evaluated due to pain
NVD : Sensibility (+), radial and ulnar artery pulses are palpable,
CRT < 2
Ventral View

Dorsal View

Left leg region

Inspection : Multiple lacerated wound at the anterolateral aspect of the


left leg sized 3x0.5 cm and 1x0.5 cm, Deformity (+),
swelling (+), hematoma (+)

Palpation : Tenderness (+)

ROM

: Active and passive motions of the knee joint cant be


evaluated due to pain.
Active and passive motions of the ankle joint of the thumb
cannot be evaluated due to pain.

NVD

: Sensibility (+), dorsalis pedis and tibialis posterior artery


pulses are palpable, CRT < 2
Anterior view

Lateral view

Medial view

Left foot region

Inspection : Multiple lacerated wound sized 5x3 cm and 4x0.5 cm at


the dorsal and medial aspect, Lacerated wound over the
medial malleolus sized 5x0.5 cm, Deformity (+), swelling
(+), hematoma (+)

Palpation : Tenderness (+)

ROM

: Active and passive motions of the ankle cant be evaluated


due to pain.
Active and passive motions of the MTP, IP joint of the big
toe is limited due to pain.
Active and passive motions of the MTP, PIP and DIP joint
of the 2nd toe is limited due to pain.
Active and passive motions of the MTP, PIP and DIP joint
of the 3rd, 4th, and 5th toe is normal

NVD

: Sensibility (+), dorsalis pedis and tibialis posterior artery


pulses are palpable, CRT < 2

Dorsal view

Medial view

Lateral view

Plantar view

V.

Laboratory Findings
RESULT

NORMAL VALUE

WBC
RBC
HGB
HCT
PLT
Clotting time
Bleeding time
Ureum
Creatinin
SGOT
SGPT
Natrium
Potassium
Chloride

25.10
4.35
12.6
37.8
314
800
300
33
0.93
37
41
141
3.3
111

4,00-10,00 103/mm3
4,00-6,00 106/mm3
14,0-18,0g/dl
43,0-56,0%
150-400 103/mm3
4-10menit
1-7menit
10-50mg/dl
<1,3mg/dl
<38 U/L
<41 U/L
136-145mmol/l
3,5-5,1mmol/l
97-145mmol/l

HBsAg

Non-reactive

Non-reactive

VI. Radiological Findings


Head CT-Scan

Brain swelling & soft tissue swelling left maxillofacial

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Lateral cervical

AP Thorax

11

AP Pelvic

12

AP/Oblique Right Hand

Fracture at the base of 2nd right metacarpal bone.

AP/Lateral Left leg

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Transversal fracture of 1/3 middle left tibia and fibula bone


AP/Lateral Ankle Left Foot

Chipped fracture of posterior tarsal process of the left foot


AP/Oblique left foot

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Fracture of 1st left foot metatarsal shaft


VII.

Resume

Male, 24 years old with wound on left lower leg after a motorcycle accident.
History loss of consciousness (+) vomit (+) diagnosed with mild head injury
GCS 15 + closed fracture right 1 st metacarpal base + open fracture 1/3 middle
of left tibia + open fracture 1/3 middle of left fibula + open chipped fracture
of the posterior left talus process + open fracture of the 1st left metatarsal
shaft with LLD 1cm. NVD are normal.
VIII. Diagnosis
1. Mild Head Injury GCS 15 (E4M6V5)
2. Closed fracture Right 2nd Metacarpal Base
3. Open Fracture of the Left 1/3 Middle Tibia grade IIIA
4. Open Fracture of the Left 1/3 Middle Fibula grade IIIA
5. Open Chipped Fracture of the Posterior Process of Left Talus grade IIIA
6. Open Fracture of the left 1st Metatarsal Shaft grade IIIA

IX. Management

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Intravenous crystalloid fluid drips


Analgesics
Antibiotics
Anti-tetanus toxoid injection
Immobilize fracture with volar slab at right upper limb & apply long leg
back slab at left lower limb
Debridement
Plan for ORIF:
- The left tibia & fibula
- 2nd right Metacarpal Base
- 1st left Metatarsal shaft

PART II
LITERATURE REVIEW
I.

Background

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High-velocity trauma is the number 1 cause of death in the 18- to 44-year


age group worldwide. Blunt trauma accounts for 80% of mortality in the
<34-year age group. In the 1990s in the United States alone, income loss
resulting from death and disability secondary to high-velocity trauma
totaled 75 billion dollars annually; despite this, trauma research received
less than 2% of the total national research budget. The polytrauma patient
is defined as follows: (1)

II.

Injury Severity Score >18

Hemodynamic instability

Coagulopath

Closed head injury

Pulmonary injury

Abdominal injury

Epidemiology
Road traffic accidents are the first cause of death for <45-year old people
whereas victims are usually young and in their most productive age. In
USA, trauma accounts for 145.000 deaths per year (disabilities of threefolds this number), and in developing countries, trauma is the first cause of
death for all ages. In Egypt, there is about 7000 death toll per year caused by
trauma which is more than the casualties caused by wars. Car accidents
usually cause multiple injuries with vast inflammation and severe bleeding
that affect several organs, limbs or visceral tissues. This requires physicians
and surgeons from different specialties to cooperate in managing such cases.
Polytrauma is known as multiple injuries at the same onset that usually
affect multiple organs. This type of injury is usually severe and associate

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with systemic inflammation and a state of immunity.(2) Rapid transport of


the severely injured patient to a trauma center is essential for appropriate
assessment and treatment. The patients chance of survival diminishes
rapidly after 1 hour, with a threefold increase in mortality for every 30
minutes of elapsed time without care in the severely, multiply injured
patient.
III. Advanded Trauma Life Deaths (ATLS)
The management of the multiply-injured patient has been revolutionised
during the past century. Advances in prehospital care, resuscitation, implants
and intensive-care medicine have all contributed to better treatment of the
patient in physiological crisis after trauma, who is at risk for the multipleorgan dysfunction syndrome and is battling for survival.
The introduction of standardised surgical treatment for fractures in the
early 1950s by the AO group and the implementation of advanced trauma
life-support training were probably the greatest stimuli affecting the
philosophy in the treatmen of patients with polytrauma. However, more
recent developments in molecular medicine and genetics have inuenced
our perception of management leading to the concept of damage control
orthopaedics. While the basic concept of save life - limit disability has not
changed, the type and timing of our interventions have been gradually
modied. This review highlights the current concepts in the management of
patients with multiple injuries with particular emphasis on the surgical
priorities in damage control orthopaedics.(3) Trauma deaths tend to occur in
three phases:

Immediate: This is usually the result of severe brain injury or disruption


of the heart, aorta, or large vessels. It is amenable to public health
measures and education, such as the use of safety helmets and passenger
restraints.

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Early: This occurs minutes to a few hours after injury, usually as a result
of intracranial bleeding, hemopneumothorax, splenic rupture, liver
laceration, or multiple injuries with significant blood loss. These
represent correctable injuries for which immediate, coordinated,
definitive care at a level I trauma center can be most beneficial.

Late: This occurs days to weeks after injury and is related to sepsis or
multiple organ failure.(1)

Table 1. ATLS primary survey(4)


IV. Scoring system
A. Revised Trauma Score (RTS)
A revised trauma score results from the sum of respiratory rate, systolic
blood pressure, and Glasgow coma scale and can be used to decide which
patients should be sent to a trauma center (Table 2).

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Table 2. Revised Trauma Score.

B. Injury Severity Score (ISS)


This anatomic scoring system provides an overall score for patients
with multiple injuries. It is based on the Abbreviated Injury Scale (AIS),
a standardized system of classification for the severity individual injuries
from 1 (mild) to 6 (fatal). Each injury is assigned an AIS score and is
allocated to one of six body regions (head, face, chest, abdomen,
extremities including pelvis, and external structures).
The total ISS score is calculated from the sum of the squares of the
three worst regional values. It is important to emphasize that only the
worst injury in each body region is used. The ISS ranges from 1 to 75,
with any region scoring 6 automatically giving a score of 75. The ISS
limits the total number of contributing injuries to three only, one each
from the three most injured regions, which may result in underscoring the
degree of trauma sustained if a patient has more than one significant
injury in more than three regions or multiple severe injuries in one
region.

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To address some of these limitations, Osler et al. proposed a


modification to the system which they termed the New Injury Severity
Score (NISS). This is defined as the sum of squares of the AIS scores of
each of a patients three most severe injuries regardless of the body
region in which they occur. Both systems have been shown to be good
predictors of outcome in multiple trauma patients.

Picture 1. Injury Severity Score (ISS)


V.

Damage Control Orthopaedics


Polytrauma is known as multiple injuries at the same onset that usually
affect multiple organs. This type of injury is usually severe and associate
with systemic inflammation and a state of immunity suppression extending
for certain period during which extensive surgical intervention should be
avoided. It needs special management and prolonged immobilization to
prevent subsequent complications such as suffocation, prolonged healing
and high rate of infection. Damage-control orthopaedics is warranted for
patients with multiple fractures as it helps in stabilizing patient's condition
and provides better control on the postoperative outcome.

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Early total-care (ETC) principle was more commonly used in


management of polytraumatic patients, aiming to fix many fractures as
possible in a single session and to allow patients to undergo tests and
therapies within shorter period.
Damage-control theory aims to correcting body fluids, electrolytes,
acid-base and nutritional imbalances, fixing multiple fractures in divided
sessions, stabilizing the patients again during the breaks between sessions
and not fixing more than two bones in each session.
Damage control orthopaedics is an approach that contains and stabilizes
orthopaedic injuries so that the patients overall physiology can improve. Its
purpose is to avoid worsening of the patients condition by the second hit
of a major orthopaedic procedure and to delay definitive fracture repair until
a time when the overall condition of the patient is optimized. Minimally
invasive surgical techniques such as external fixation are used initially.
Damage control focuses on control of hemorrhage, management of softtissue injury, and achievement of provisional fracture stability, while
avoiding additional insults to the patient.(2)

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Physiology of Damage Control Orthopaedics


The physiologic basis of damage control Orthopaedics is beginning to
be understood. Traumatic injury leads to systemic inflammation (systemic
inflammatory response syndrome) followed by a period of recovery
mediated by a counter-regulatory antiinflammatory response. Severe
inflammation may lead to acute organ failure and early death after an injury.
A lesser inflammatory response followed by an excessive compensatory
anti-inflammatory

response

syndrome

may

induce

prolonged

immunosuppressed state that can be deleterious to the host. This conceptual


framework may explain why multiple organ dysfunction syndrome develops
early after trauma in some patients and much later in others. Within this
inflammatory process, there is a fine balance between the beneficial effects
of inflammation and the potential for the process to cause and aggravate
tissue injury leading to adult respiratory distress syndrome and multiple
organ dysfunction syndrome. The key players in the host response appear to
be the cytokines, the leukocytes, the endothelium, and subsequent
leukocyte-endothelial

cell

interactions.

Reactive

oxygen

species,

eicosanoids, and microcirculatory disturbances also play pivotal roles. The


development of this inflammatory re-sponse and its subsequent, often fatal
consequences are part of the normal response to injury. When the initial
massive injury and shock give rise to an intense systemic inflammatory
syndrome with the potential to cause remote organ injury, this one hit can
cause an excessive inflammatory response that activates the innate immune
system, including macrophages, leukocytes, natural killer cells, and
inflammatory cell migration enhanced by interleukin-8 (IL-8) production
and complement components (C5a and C3a). When the stimulus is less
intense and would normally resolve without consequence, the patient is
vulnerable to secondary inflammatory insults that can reactivate the
systemic inflammatory response syndrome and precipitate late multiple
organ dysfunction syndrome.

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The second insult may take many forms as a result of a variety of


circumstances, such as sepsis and surgical procedures, and is the basis for
the decision-making process regarding when and how much to do for a
borderline multiply injured patient (as

will be defined later).

Hyperstimulation of the inflammatory system, by either single or multiple


hits, is considered by many to be the key element in the pathogenesis of
adult respiratory distress syndrome and multiple organ

dysfunction

syndrome.
The First and Second Hit Phenomena
Numerous studies have demonstrated that stimulation of a variety of
inflammatory mediators takes place in the immediate aftermath of trauma.
This response initially corresponds to the first-hit phenomenon. Hoch et al.
reported elevation in plasma concentrations of IL-6 and IL-8 in patients with
an injury severity score of 25 points. An immediate increase in expression
of neutrophil L-selectin was reported in patients with an injury severity
score of 16 points. Similarly, a significant (p < 0.05) increase in the
expression of the integrin CD11b was noted in more severely injured
patients. The development of multiple organ dysfunction syndrome has also
been associate with a persistent elevation of CD11b expression on both
neutrophils and lymphocytes for 120 hours, a finding that is suggestive of
neutrophil activation in the early development of leukocytemediated endorgan injury.

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The concept that a secondary surgical procedure creates an additional


inflammatory insult (a second hit) was specifically addressed in a
prospective study of 106 patients with an average injury severity score of
40.6 points. Forty patients in whom respiratory, renal, or hepatic failure
developed, alone or in combination, following a secondary surgical
procedure were compared with patients in whom no such complications
developed. There was a significant (p < 0.05) elevation of the neutrophil
elastase and C-reactive protein levels and a reduction in the platelet count in
the forty patients with systemic complications. Abnormality of those three
parameters predicted postoperative organ failure with an accuracy of 79%.
The first and second-hit phenomena in trauma patients were
demonstrated in a study in which femoral nailing was considered to be the
second hit. That study demonstrated similar responses to reamed and
unreamed nailing in terms of neutrophil activation, elastase release, and
expression of adhesion molecules. These concepts of biological responses to
different stimuli (first and second hits) have nobecome the basis of our
treatment plans and illustrate the impact of the operative procedure on
trauma patients at risk for exhaustion of their biological reserve.(5)

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Patient Selection for Damage Control Orthopaedics


Because biomechanical and genetic testing is currently not practical, it
remains a clinical decision when to shift from early total care to damage
control orthopaedics. Which patient should be treated with damage control
orthopaedics instead of early
Total care after orthopaedic trauma should be decided on the basis of the
patients overall physiologic status and injury complexes. Many trauma
scoring systems (e.g., the abbreviated injury scale, injury severity score,
revised trauma score, anatomic profile, and Glasgow coma scale) have been
developed in an attempt to describe the overall condition of the trauma
patient. However, Bosse et al. noted that there is no score that assists in
decision-making during the acute resuscitation phase. Therefore, it may be
that one cannot rely exclusively on a scoring system. Additional data must
be synthesized, and the overall status of the patient should be stratified into
one of four categories. Patients who have sustained orthopaedic trauma have
been divided into four groups: stable, borderline, unstable patients, and
patients in extremis are fairly easy to define. Stable patients should be
treated with the local preferred method for managing their orthopaedic
injuries.
Unstable patients and patients in extremis should be treated with damage
control orthopaedics for their orthopaedic injuries. Borderline patients are
more difficult to define. One of us (H.-C.P.) and colleagues defined them as
patients with polytrauma and an injury severity score of >40 points in the
absence of borderline, unstable, and in extremis thoracic injury, or an injury
severity score of >20 points with thoracic injury (an abbreviated injury score
of >2 points); polytrauma with abdominal trauma (a Moore score of >3
points); Borderline orthopaedic trauma patients are probably best treated
with damage control orthopaedics. The term borderline patient describes a
predisposition for deterioration. Among other factors, thoracic trauma
appears to play a crucial role in this predisposition. However, whether
femoral fractures in patients with chest trauma should be treated with

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definitive stabilization or should be stabilized with a temporary external


fixator remains a subject of debate. The clinical situation, including the
presence or absence of a criterion indicating borderline status (Table II)

DAFTAR PUSAKA
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1.
Kenneth J. K JDZ. Handbookof fractures: Lippincott Williams &
Wilkins; 2010.
2.
Hafez MA MA, Hamza H Staged Surgical Management of Multiple
Fractures in Polytrauma Patient. Int J Osteol Orthop. 2015;2(1):8-10.
3.
Giannoudis PV. Surgical Priorities in Damage Control
in
Polytrauma. J Bone Joint Surg 2003(85-B):478-83.
4.
Willmott. H. Trauma and orthopaedics at a glance: John Wiley &
Sons, Ltd.; 2016.
5.
Craig S. Roberts H-CP, Alan L. J, Arthur L. M, Jorge L. R and Peter
V. G. Damage Control Orthopaedics. The Journal of Bone and Joint
Surgery. 2005;87-A(2).

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