Mechanisms of Trauma - Orthopedics

Snapshot
- A 35-year-old male presents to the ED C-collared on a backboard after being hit in a motor vehicle accident. He breathes spontaneously without any frank bleeding, but bruises are noted throughout his hip and abdomen. His blood pressure is 90/60 mmHg, pulse is 110/min, respirations are 20/min, and SaO₂ is 95% on room air. After 1 L Lactated Ringer's and some pain medications are administered, the radiology technician takes images of his C-spine, chest, and pelvis. The pelvic radiograph is shown.

introduction
- Trauma is the leading cause of death in patients < 45 years old (accident, homicide, suicide)
  - causes more deaths in children/adolescents than all diseases combined
- Timeline of trauma mortality is important for prognosis
  - minutes: death usually at scene
  - early: death within 4-6 hours without intervention
  - days-weeks: death from multiple organ dysfunction, sepsis, etc.
- Broadly, trauma is either blunt or penetrating
  - blunt is more common
- Knowing mechanism is important to anticipate injuries for appropriate triage
- Beyond managing trauma, underlying cause must always be sought (6 S's)

Presentation of Mechanisms
- Motor vehicle collision
  - head-on: head/facial, thoracic (aortic), lower extremitiy (LE) injury
    
    aortic tear (aortic transection) presents with rapidly worsening blood pressure and a widened mediastinum
  - lateral/T-bone: head, cervical, thoracic, abdominal, pelvic, LE injury
  - rear-end: hyper-extension of cervical spine (whiplash injury)
  - rollover accidents: most fatal
- Pedestrian-automobile impact
  - children: high risk of run-over injury (multisystem)
    
    Waddell's triad: tibia-fibula or femur fracture, intrathoracic/abdominal injury, contralateral head injury
    
    fibular fracture associated with fibular nerve injury
  - adult: generally lower extremity injury, but also truncal and head injury from impact
- Falls
  - landing position important
    
    vertical: LE, pelvic, spine, head injury (impact ascends through skeleton)
    
    horizontal: facial, UE, rib fractures; intrathoracic and abdominal injuries
- Gunshot wounds (GSW)
  - injury depends on weapon used, location of GSW(s), and underlying structures
    
    handgun: low/medium velocity, extent of damage may be limited to small area
    
    hunting rifle: high velocity, widespread injury
    
    shotgun: widespread tissue damage at close range, wadding deposition in wound
- Stab wounds (SW)
  - injury depends on weapon used (length in particular), location of SW(s), underlying structures
  - type of penetration can vary (stab, slash, impalement)
- Amputation
  - transport amputated appendage wrapped in moist gauze, put in a plastic bag, placed on ice
- Dental trauma
  - avulsed tooth should be immediately gently cleaned (rinse, do not scrub) and replaced in the socket as soon as possible
  - transport medium for avulsed tooth
    
    milk or special tooth solution
- Cervical spine fractures
  - presents with midline spinal tenderness +/- neurologic deficits if cord compression
  - stable fractures without cord compression are often managed non-operatively with a hard collar
  - types
    
    Jefferson burst fracture

evaluation and management
- Primary and secondary surveys with resuscitation as needed
  - intubation - secure the airway first
    
    indications
    
    failure to oxygenate
    
    failure to ventilate
    
    inability to protect airway (GCS < 8)
    
    impending airway loss
    
    complications
    
    esophageal intubation
    
    intubation of the right mainstem bronchus
    
    inability to intubate
    
    perform an emergency cricothyrotomy
    
    inability to extubate
    
    tracheal stenosis
    
    from chronic intubation resulting in a narrowed airway and inspiratory stridor
  - type and cross for potential transfusions as soon as possible
    
    establish IV access or IO access if not possible
  - for penetrating injuries, do NOT remove object if present in body
    
    may be tamponading vessel
    
    remove in operating room
- Amputated body part
  - wrap amputated body part in saline-moistened sterile gauze and sealed in sterile plastic bag

Imaging
- Doppler ultrasound
  - perform to assess vascular injury or compromise
  - the presence of distal pulses does not rule out vascular injury
- radiography (XR/CT)
  - based on mechanism of injury
  - never send unstable patient to CT scanner - obtain focused assessment with sonography in trauma (FAST) exam or diagnostic peritoneal lavage if FAST equivocal
- MRI
  - indicated for all traumatic spinal cord injuries with neurologic deficits

SUMMARY
- Trauma does not cause isolated injuries
  - as suggested in Waddell's triad above, think about other possible injuries to anticipate necessary interventions (and possible test question answer choices!)
  - Principles
    
    chief concern: vascular compromise
    
    consider nearby vasculature
    
    if no nearby vasculature next best step: cleaning + tetanus ppx
    
    if nearby vasculature and stable vitals next best step: doppler studies or CT angiogram
    
    if clear vascular injury (absent pulses, worsening hematoma) next best step: surgical exploration
  - injury to bone, artery and nerve
    
    next best step: repair the bone first - this is rough work
    
    second step: vascular repairthird step: nerve repair
    
    ppx: fasciotomy to protect from compartment syndrome
  - shotgun, military contraband injuries
    
    tend to be high velocity and cause a large area ("cone") of tissue destruction
    
    next best step: surgical debridement, amputation if severe, antibiotics, tetanuscrushing injuries
    
    worry about hyperkalemia, myoglobinemia/uria, renal failure and compartment syndrome
    
    next best step: IV fluids, mannitol, alkalinization of the urine and management of severe electrolyte abnormalities as presented
  - The next best step is never management of the pathology if the patient's vitals are unstable or could lose an airway - never forget ABCs of resuscitation!

Action	Numeric Key	Letter Key	Function Key
Show Bullets		S	Enter (frontside only)
20%	1	N
40%	2	H
60%	3	F	Enter (backside only)
80%	4	E
100%	5	M
Toss	0	T