Leading causes of injury death by manner of death in the USA 1995. Data from Fingerhut & Warner 1997.5

Initial management of the acutely injured patients.
Priorities. a) the patient may have more than one injury; b) the obvious injury is not necessarily the most important one.

Categories of injury: 1. Exigent. These are the most life-threatening conditions,



requiring instantaneous intervention (complete airway obstruction). 2. Emergency. Those conditions requiring immediate intervention over a period of few minutes. 3. U 3 Urgent. Th Those conditions requiring i di i i i intervention within the fi i i hi h first hour. 4. Deferrable. Those conditions that may or may not immediately apparent but will subsequently require treatment (urethral disruption).

Steps in initial resuscitation (ABC). Airway
- removal of debris and the "chin lift" or "jaw thrust" maneuvers (pull the tongue forward) to clean the airway of less (p g ) y severely injured patients.

Chin-lift maneuver. The tips of the fingers are placed beneath the patient's chin and the jaw is lifted anteriorly while the mouth is opened by drawing down on the lower lip with the thumb of the same hand.

Endotracheal intubation is required at patients with severe head injury, profound shock.

Jaw-thrust maneuver. Two hands are placed on the mandibular rami and pushed anteriorly, so opening the airway.


Endotracheal and nasotracheal intubation Consider spine injury Potential spinal injuries. In some situations a surgical airway may be required. Surgical cricothyroidotomy may be preceded by needle cricothyroidotomy with jet insufflation to improve oxygenation. Technique for tracheostomy. Before intubation the spine should be stabilized until an injury has been excluded. A rigid cervical collar and paracervical rolls are placed to protect the cervical spine. 2 .07. Surgical airway Cricothyroidotomy is a preferable emergency procedure.23.2010 Cervical spine injury is always a possibility (ovoid movement of the neck). Side view demonstrates that the cricothyroid membrane is more superficial than the trachea which makes performance of a cricothyroidotomy technically easier than a tracheostomy. The patient is completely immobilized on a long backboard. Technique for cricothyroidotomy.

Остановка кровотечения (компрессионная повязка. Fluid resuscitation begins with a 1000 ml bolus of LR.07. In some circumstances (tension pneumothorax) decompression of the chest by needle catheter placement is appropriate prior to the g p radiograph.clear consciousness.v. Response to therapy is monitored by skin perfusion.  13-14 points . malposition of endotracheal tube.incomprehensible sounds 3 points . lines should be placed percutaneously. or with venous cut-down. or CVP.no response p p 2 points . Total score = 3 .never 2 points .15. 2 points . an assisted ventilation is necessary. X-ray to exclude).  Most common reasons for ineffective ventilation after intubation   If there is a decreased respiratory drive or an unstable chest wall.v. 6 points .) Eye opening: 1 point .spontaneously Best verbal response 1 point .flexion withdrawal  9-12 points . auscultation.no response Less than 10 points a patient is serious injury.циркуляция  Neurologic assessment A brief examination is done to determine a) level of consciousness (GCS).obey  3 points . 1 point . UO. When possible control of the bleeding precedes placement of the i. 3 .death. or internal jugular (subclavian) vein cannulation. 4 points . and hemothorax (palpation.to pain 3 points . Circulation (perfusion)  С .disoriented and converses 5 points .sopor.oriented and converses  Best motor response: Newly placed central venous catheter via the subclavian access route.extension (decerebral rigidity) 3 points . pneumothorax. lines.flexion abnormal (decortical rigidity)  15 points . b) pupillary condition c) movement of extremities (paralysis).localized pain  4-8 points . (compressive dressing.coma.inappropriate words 4 points . tourniquet.2010 Breathing (ventilation) Assisted ventilation may be done using Ambu bag or with a help of mechanical ventilator. и др. Minimum two i.to verbal stimuli 4 points .stupor. жгут.23. or placement of pneumatic antishock garment (pelvic injuries) may be required. 5 points .

and perfusing adequately a priority plane should be established for subsequent treatment. catheters (NG. wrists. TYPES OF TRAUMATIC INJURIES  swellings located along tendon sheaths or joint capsules.07. and feet.  a priority plane should be established for subsequent treatment. obtaining and b i i d collecting data from laboratory and radiologic tests. usually nontender or painful The origin is unclear (overexertion. ventilating. The dorsum of the hand and wrist is a frequent site of involvement.23. Ganglion? Ganglia are cystic. Examination is done in a headtoe manner. It grows from a joint and filled with synovial fluid like a shell 4 . Ganglia may also develop elsewhere on the hands. round. This time is also for placement of additional lines. ankles. etc. Examination is done in a head toe head-toe manner When the patient is oxygenating. Flexion of the wrist makes ganglia more prominent. hereditary predisposition). Lateral radiograph demonstrating an L1 burst fracture (arrow). Foley.2010 Exposure to complete examination Reexamine the patient completely but expeditiously (diagnosing other injuries).) and monitoring devices. extension tends to obscure them.

Trauma to underlying structures must be presumed requiring further investigation. but X-ray is always necessary X- Treatment is only indicated if ganglion causes severe pain or limits activity Treatment is only indicated if ganglion causes severe pain or limits activity  Massage (recurrence)  Aspiration (recurrence)  Surgical removal of all the cyst by orthopedist Bursitis. localized tenderness. The swelling is superficial to the olecranon process. Also bursitis may affect any other joints. Sprain.2010 Ganglion cyst Diagnosis is clinical. elevation. edema. Contusion of soft tissues is characterized by pain. Local swelling and bruising are common.23. Swelling and inflammation of the olecranon (or any other) bursa may result from trauma. elastic bandage. and bruising as a result of laceration of small vessels of the skin and subcutaneous tissue. Some fibres are torn but the whole ligament is mechanically intact.07. Bone percussion is painless. progressive active exercises after healing Bivalved cast. Pain is provoked by movements in the joint. NSAID. no weight bearing. Bony landmarks of the joint may be attenuated due to fluid. The two halves are rejoined 5 . after two days heat may be used. Treatment: first 24-48 hours – ice or chemical cold pack. removable splint or light cast.

When the muscle contracts the long head bunches near the elbow. Medical treatment is the same. The ligament is broken in two. The active movements are lost. Localized tenderness. Suture is done only at some types of rapture (arthroscopic suture of the cruciate ligament of the knee) Tendon and muscle rapture. 6 . Retraction of ends (muscle contraction). Medical therapy is the same. passive movements may be painful. Treatment: suturing followed by immobilization with external splintage for 3-6 weeks.23. Rapture of the insertion of the quadriceps muscle into the patella Local swelling and bruising. Tendon rapture. immobilization is necessary. Loss of active movements may not be obvious if other muscles take over the function of the tendon. Because of the gap the healing does not occur leading to impaired function.2010 Ligament rapture. The gap is visible or palpable. Clinical picture is the same but accompanied by joint's instability found during local examination. Rapture of the tendon of the long head of the left biceps muscle. Velpeau’s bandage can be used.07.

loss of normal joint shape. edema and bruising.07. Local anesthesia (if used) is done into joint’s cavity (20 ml 1% lidocaine).2010 Dislocation and sublaxation Clicking sound when the dislocation has occurred.23. hemarthrosis. The foot is twisted toward the side to which the tallus is dislocated. sedation. Assistant helps to stabilize the leg. dislocation of the ankle dislocation of the right shoulder Ankle dislocation. Pain and tenderness. Commonly reduction is done under i. The extremity may be shortened and loses its normal axis. Always assess neurovascular status. The joint area looks like hollow. 7 . The extremity may be shortened and loses its normal axis Subcoracoid dislocation of the left shoulder Treatment of dislocation Closed joint reduction.v.

MCP joint in 900 flexion. DIP and PIP joints in a full extension IP joints middle/distal phalanx: full extension at IP joints. The physician holds the patient’ injured hand in a hand-shake position.        Immobilization after reduction of dislocation Positioning used to immobilize a body part Ankle/foot: 90 0 angle between foot and leg.2010 Closed joint reduction. After reduction a shoulder immobilizer is necessary at position of internal rotation and adduction. Traction is applied in the line of the femur. Neutral eversion/inversion Knee: 15-200 flexion Shoulder: resting at the side of the body Elbow: 900 angle between forearm and arm. MCP joint. Closed reduction of a radial head. The arm hangs free off the table with appropriate weights (approximately 5kg) attached at the wrist (Stimson’s method). proximal phalanges: wrist position as above. X-ray confirms reduction. Usually it takes 20-30 minutes to achieve reduction. Traction and contratraction are applied over a period of several minutes. which should reduce the dislocation with a click.07. 300 flexion Metacarpals. Reduction is achieved with a clunk and is confirmed by radiology. 20-300 wrist extension Thumb: wrist position as above. Matson’s method is shown using two wrapped sheets.  8 . Motais (left) and Kocher’s methods of shoulder reduction Kocher’s method of reduction of dislocated hip.23. Neutral pronation/suppination Wrist: Neutral pronation/suppination. An assistant stands on the side and steadies the pelvis. Shoulder joint dislocation. Thumb in 450 abduction above abduction. Dzhanelidze’s method uses force produced by doctor’s weight.

07. Radial gutter splint is used for 2nd -3rd metacarpal or fingers injuries (below). Hold the bandage in desired position until splint hardens (5-10min with fiberglass. Ulnar gutter splint is used for 4th -5th metacarpal or phalanx injuries (above). The splint is applied to the soft roll (after water deepening). Note: the splint reaches the level of MCP joints Commercial sling. With the arm resting across the chest the wrist is elevated higher when the elbow with the thumb pointing upward. 10-15 min with plaster) l ) Posterior elbow splint (above) and sugar tong forearm splint (below) are used for forearm and wrist injuries. The elbow is fixed at 900 angle. circular fashion.2010 Immobilization after reduction of dislocation Splint padding is done to entire area to be splinted. Thumb spica splint Long leg splint is used for knee and tibia injuries (it consists of two splints for additional stability) 9 . Fiberglass (prefabricated splints can be measured and cut)/plaster (10-15 layers): generally immobilize one joint above and one joint below injury. Evenly.23. at least two layers with extra over bony prominences.

2010 Ankle splint is used at isolated ankle injuries (it consists of two splints). Clinical signs Relative signs: local tenderness. infectious. cast sores. joint contracture Complications of dislocation: ischemia (vascular compression). and radiologic signs of th fr t r i n f the fracture. B) after 1 week osteoblasts start to form as the clot retracts. 10 . C) after 3 weeks a procallus begins to form and stabilize the fracture. recurrent dislocation. swelling and bruising. instability. deviation Fracture of extremity. pathologic mobility. disturbance of function of extremity. E) in 3 to 4 months osteoclasts begin to remodel the fracture site. Range-of-motion exercises for the affected joint after period of healing and immobilization Compression of the popliteal artery Fracture healing (union) A) Formation of hematoma. bone crepitation. Complications of casts: burns.   of extremity's axis.direct force and indirect force Mechanism of cancellous bone fracture: .23. Peripheral blood circulation and nervous function must be examined (physical examination or using additional tools). Absolute signs (pathognomonic) to fractures: exposure of the bone fragments or obvious protrusion of bone fragments under the intact skin.07. D) from 6 to 12 weeks a callus forms with bone cells.compression and traction injuries (avulsion). Fracture is a structural break in the normal continuity of the bone. neurologic. F) with normal apposition the bone will be completely remodeled in 12 months. Mechanism of tubular bone fracture: . joint stiffness.

2010 Obvious deformity of the limb Obvious deformity of the limb Radiologic confirmation of fracture is absolutely necessary.23. 11 . Unstable burst fracture of L1 (arrow) (result of a motor vehicle accident). Pelvic disruption (arrow). It is done at two planes (AP and lateral view).07.

2010 Description according to fracture line Description according to displacement of bone fragments Treatment of fractures General management      ABC approach Correction of blood loss and shock (pelvic fracture may lead to approximately 2 L blood loss) Pain: splintage and analgesics Coexisting injuries are treated according to priority plane Tetanus toxoid and AB (for open fractures) Splintage is done at the scene of injury (to reduce pain and additional trauma due to displacement of bone fragments) Buck’s traction may be used for hip fractures until surgery is performed. 12 .23.07.

Surgery is finished by closure of the wound. “hanging cast” Closed manipulations Traction (fixed or sliding) Operation 13 . Scheme for fracture management          Define fracture D fi f Detect complications Does the fracture need reduction? Is the fracture stable or unstable? How can the fracture be stabilized? Does the fracture need immobilization and for how long? How can the patient best be rehabilitated?   Distal superficial femoral artery traumatized at the site of a fracture of the distal third of the femur.2010 Local management  Possible methods of fracture treatment protection alone immobilize with external splint without reduction closed reduction (manipulation or traction) followed by immobilization with external splint or traction. Blood supply is restored parallel to open reduction of fracture Fracture reduction using: Restoration of bone integrity (methods of fracture reduction) Gravity reduction U-slab with collar and cuff sling. An open fracture of the tibia at initial operation.23. Closed manipulations     Gravity methods: collar and cuff. excision of fractured fragment and prosthetic replacement Treatment of open fracture The aim of surgery is to convert open fracture to closed one. Tetanus toxoid and AB are considered.07. Dissection and excision of tissue as well as lavage with copious quantities of fluid (by a jet lavage system). open reduction and external fixation. Wound irrigation.

g . may be used for fractures of the hip and femur. A split plaster of Paris cast.2010 Fracture reduction using skeletal and skin traction (fixed or sliding) Stabilisation of fractures using Plaster cast Methods of stabilisation of fractures (immobilization of the fracture)    External splint: a) plaster of Paris or plastic cast. a form of skin traction. ) Continuous traction a) “hanging cast”. g Lumbar fracture-dislocation treated by posterior spinal instrumentation and fusion from L2 to L5. The nail stabilizes a femoral fracture and both proximal and distal locking help maintain length. Stabilisation of fractures using external fixation External fixator applied to a severe lower limb injury. The fixator provided early stability and allowed for care of the soft tissues. plate. nail) . Stabilisation of fractures using internal splints Intramedullary nail.07. p . rotation and alignment. which was associated with extensive soft tissue damage with blistering and skin loss. Volkmann’s contracture following fracture of the humerus. Internal splint ( p (screws. Extracapsular fracture of neck of femur fixed by internal fixation with a sliding compression screw and six-hole plate 14 . b) fixed or sliding traction (skin or skeletal) The principal elements of sliding traction: traction and countertraction Russel traction.23. At elderly patients a surgery should be considered over closed stabilization especially sustained to fracture of the femoral neck. b) external fixation.

Late: joint stiffness.23. pain is followed by angiospasm. embolism. arterial injury followed by acute arterial ischemia. deformed union. Early: skin necrosis. cytotoxic drugs)     Surgical treatment with open reduction of bone fragments is indicated at the following situations:      Compound fractures Reduction of fracture (failure of other types of reduction) Stabilisation of fracture (failure of other types of reduction) Management of complications (vascular or head injury) Soft tissue management Complications of fractures Local (nerve. DVT.2010 Stabilization of fracture using continuous traction Causes of delayed and nonunion of fractures               General rules of bone healing (duration of immobilization) Fracture of low limb heals twice longer Fracture in adults heals twice longer Transverse heals longer then spiral and oblique Compound and comminuted are particularly slow to unite C d d i d i l l l i No fracture unites in less then 3 weeks Compound fractures Severe initial injury Foreign body Soft tissue interposition Distraction Infection Poor blood supply Inadequate immobilization Pathological fracture g Osteoporosis Nutritional disorders (malnutrition. infection. hypovolemia) release of compression → reperfusion injury (edema of muscle compartments.MODS (ARF and AHF) and purulent septic complications 15 . D deficit) Metabolic disorders (uremia. vit. compartment syndrome. Crash-syndrome is a condition caused by prolonged compression and crashing of soft tissues (mainly muscles) resulting in characteristic local and general pathologic changes in the body developing during and after release of compression Pathology of the crash-syndrome compression → acute arterial ischemia (compression of arteries. osteomyelitis.07. acute compartment syndrome (edema of muscle compartments). pseudoarthrosis. and ischemic muscle necrosis) → resorption of toxins from necrotic tissues → endotoxicosis → multiple organ failure Most common complication of the syndrome are: . gas gangrene. hyperparathyroidism) Drugs (steroids.

joint contractures At the early period it is very difficult to determine how much tissues are devitelized.2010 Clinical picture General: early period – signs of traumatic shock with characteristic hemodinamic changes.elastic bandaging (to decrease postischemic edema) . Formely used subcutaneous fasciotomy is currently less popular Open fasciotomy with or without necrectomy is a method of choice 16 . muscle and j p . hypoproteinemia. external fixation is useful if a patient has coexisting fracture. and signs of compartment syndrome develop (acute arterial ischemia) Second period is characterized by signs of ARF and poliorganic failure with characteristic clinical and laboratory picture with progress of fluid-electrolyte disorders and intoxication. ARF anemia h poproteinemia etc Early surgery is indicated at case of steadily progressing edema and development of life-threatening ARF  Without aforementioned indications a surgical procedure is done only after demarcation of necrotized tissues. Early surgery – fasciotomy. etc. anemia. p purulent complications. etc. Further an edema increases.cooling and splinting of the extremity .treatment of ARF. Local: Initially the skin is warm. Late period is accompanied by necrosis and sequestration of dead muscles. Treatment .23.aggressive antishock and detoxication therapy . PS on arteries is present. skin necroses appear. is done to decompress compartment pressure  A postoperative wound is managed according to common rules of untidy wound care preventing cumulation of necrotic tissues. So an extend of surgery is difficult to measure.07. Local changes are less important and characterized by edema and local septic complications.

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