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Orthopedic Trauma

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					 Combat extremity Wounds
Combat Extremity Wounds
 Improvements in body armor have reduced axial
    trauma, but the overall percentage of skeletal
  trauma on the modern battlefield has increased.
   The severity of the wounds and the amount of
     energy absorbed by the limbs with modern
   battlefield injuries cannot be overemphasized.”
“.




          Journal of Orthopedic Trauma
                     TLO
   Action : The soldier will identify combat
    extremity wounds and determine the correct
    interventions for these patients

   Conditions: Classroom environment with
    PowerPoint presentation

   Standard: Soldiers will complete a 10
    question written exam in less than 5 mins
                     ELOs
   ELO #1: Factors effecting extremity wounds



   ELO #2: Early management of extremity wounds



   ElO #3: Interventions for extremity wounds
       Safety Requirements

 Be   aware of your environment

 Maintain  professional behavior
  at all times
( No running with scissors)
Risk factors


LOW
Environmental considerations

 Indoor   Classroom

 No   opposing force
             Evaluation

    The Solider will be evaluated
    using a 10 question exam. The
    solider will complete the exam in
    less than 5 minutes with a
    minimal score of 80%
     Instructional lead in
This block of instruction will take
 place in a classroom setting, using a
 PowerPoint presentation and
 reference materials.
   In actual combat the solider would
 encounter enemy fire ,hostile terrain
 and host of environmental factors
 while weighed down weapons and
 equipment
                   Target
     This presentation is designed for
 Line medics/ corpsman


   W56, Nurses and physicians attached to
    BAS, Forward surgical teams or Shock
    platoons.
                        SAFTY

   In the combat zone the provider will need to
    conscious of hostile fire, and environmental factors.

   Scene safety and BSI should be observed at all times
       ELO #1: Factors effecting
          extremity wounds

   Action: Determine factors effecting
    extremity wounds.

   Condition: same as TLO

   Standards: Same as TLO
               ELO#1
Factors affecting Extremity wounds
              ELO#1
    Factors affecting Extremity
             wounds
 Energy level (height of a fall / speed of car /
  caliber of bullet)
 Degree of contamination (soil, broken glass,
  shrapnel)
 Degree soft tissue injury (crushed / avulsed)
 Complexity of fracture pattern (number of bony
  pieces)
 Vascular injury
             High Energy
    High-energy sources produce
    wounds characterized by violent
    tissue destruction. Violent tissue
    destruction and contamination
    requires radical débridement
            Compound Fracture
   A compound fracture, also called a open fracture, is
    an injury that occurs when there is a break in the
    skin around a broken bone. Compound fractures are
    generally treated with surgery to clean the site of
    injury and stabilize the fracture
Fracture types
Complexity of fracture pattern
         Fracture
Compound Fracture
Compound
Compound Fractures
     Traumatic Amputations

 Though amputations are visually
  dramatic, attention must be focused on
  the frequently associated life-
  threatening injuries.
 Most commonly due to explosive
  munitions, with penetration and blast
  effects or Parachute Injuries.
     Compartment syndrome

   Caused especially by crush injuries,
    electrical burns, circumferential scars, tight
    casts, hematoma in compartment, snake
    bites, and anything else that can increase
    pressure in a compartment.
        Compartment Syndrome
         Signs and symptoms

   Severe, constant pain in affected limb, pain
    on muscle palpation, passive stretch, and
    active contraction, paresthesia loss of distal
    pulses are late signs and indicate poor
    outcome
Compartment syndrome
                Check on learning
   High-energy sources produce wounds characterized by violent tissue
    destruction

   Though amputations are visually dramatic, attention must be
    focused on the frequently associated life-threatening injuries

   Severe, constant pain in affected limb, pain on muscle palpation,
    passive stretch, and active contraction, paresthesia loss of distal pulses
    are late signs and indicate poor outcome
 A compound fracture, also called a open fracture, is an injury that
  occurs when there is a break in the skin around a broken bone.
               ELO #2
    Early Management of Extremity
              wounds

   Action: Determine the management
    techniques for extremity wounds

   Conditions: Same as TLO

   Standards: Same as TLO
       "There is no good reason why
    wounded soldiers are continuing to
    die on the battlefield from extremity
                  bleeding.“
Capt. Michael J. Tarpey, Battalion
surgeon ,3rd Infantry Division's 1-15 Infantry
            Early Management of
             Extremity wounds
   Control of hemorrhage

   Temporary splinting

   IV antibiotics

   Tetanus prophylaxis
           The Tourniquet

   Designed for one-handed
    application, the tourniquet allows a
    soldier to apply the tourniquet to
    himself if needed and replaces the
    Army's field-expedient method,
    where a soldier would use a
    bandage and a stick to stop blood
    flow from a wound
“There is no pre-hospital
device deployed in this war
that has saved more lives
than tourniquets.”
Col. Holcom , 10th CSH
The Special Operations Forces Tactical
Tourniquet
                IMMBOLISATION

   It is essential for the provider to immobilize any
    fractures prior to CASVAC

   Failure to immobilize all fractured extremities could
    lead to vascular injuries or compartment syndrome
Transportation cast
                 ElO #3:
    Interventions for extremity wounds


   Action: Determine interventions for
    extremity wounds

   Conditions: Same

   Standards: Same
               Treatment of fractures
   Débridement

   Reduction

   Fixation

   Evacuation
Wound Management
     Compound Fractures
          Wound Management
Treat by irrigation and Debridement as
 soon as feasible to prevent infection.

Neurovascular status of the extremity
 should be documented and checked
 repeatedly.

Biplanar radiographs should be obtained.
PULSE LAVAGE
      PULSE LAVAGE
            PULSE LAVAGE
            High Pressure Irrigation

   Irrigation can remove enough wound
    bacteria to render the wound non-
    contaminated but only if the irrigant is
    delivered with sufficiently high pressure (
    <7 PSI) to mechanically remove bacteria
    from the wound surface
Antibiotic beads and spacers
    Antibiotic beads and spacers

   After fracture stabilization has been
    completed, bone defects may be filled with
    antibiotic-impregnated methacrylate beads.
    these beads provide local depot
    administration of antibiotic and maintain
    space for subsequent bone graft
              Internal fixation

   Internal fixation is the definitive treatment
    for compound fracture.

   This procedure is not performed in theater
INTERNAL FIXATION (ORIF)
EXTERNAL FIXATION
     Advantages of external
            fixation


Technically easy to perform


No soft tissue stripping;


Ease of removing hardware
    Disadvantages of external
            fixation


   Pin tract infections,

   Delayed union

   Non union , and Mal-union
      Technique of Amputation

  Tourniquet control is mandatory.

Surgical preparation of the entire limb, because
planes of injury may be much higher than initially
evident.

If a tourniquet was placed in the prehospital
setting for hemorrhage control, it is prepped
entirely within the surgical field.
Fasciotomy
Indications for performing a
         Fasciotomy
         fasciotomy




     Treatment is by fasciotomy and
 requires immediate surgical consultation
Technique of Amputation
    Indications for performing a
             fasciotomy

   Greater than a 6-hour delay between injury
    and treatment.

   Prolonged hypotension and shock.

   Massive swelling, either preoperatively,
    postoperatively, or during evacuation.

   Massive associated soft tissue injury
Postoperative Management


Prevention of hemorrhage

Pain control

Prevention of contracture
                                    EXAM
•   Neurovascular status of the extremity should be documented and checked
1   repeatedly. True or false

•   2 Name one Advantages of external fixation
•
•   3 Irrigation can remove enough wound bacteria to render the wound non-
    contaminated. True or False

•   4 If a tourniquet was placed in the prehospital setting for hemorrhage control, it
    is prepped entirely within the surgical field.    True or false

•   4 Fasciotomy is the definitive treatment for what extremity injuries.

•   5 This injuries is Most commonly due to explosive munitions, with
    penetration and blast effects or Parachute Injuries.
                              Exam
6    It is essential for the provider to immobilize any fractures prior to
     CASVAC. True or false

7    These provide local depot administration of antibiotic and maintain
     space for subsequent bone graft

8    Name the best option for controlling hemorrhage in extremity
     injuries
9    Name a disadvantage of external fixation

10   A fracture that breaks the skin causing a open wound

				
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posted:2/10/2012
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