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Orthopedic +Trauma Management PDF Print E-mail

Orthopedic +Trauma Management

 

Trauma refers to "a body wound or shock produced by sudden physical injury, as from violence or accident."[1] It can also be described as "a physical wound or injury, such as a fracture or blow."[2] Major trauma (defined by an Injury Severity Score of greater than 15)[3] can result in secondary complications such as circulatory shock, respiratory failure and death. Resuscitation of a trauma patient often involves multiple management procedures. Trauma is the sixth leading cause of death worldwide, accounting for 10% of all mortality, and is a serious public health problem with significant social and economic costs.


Classification

Trauma can be classified by the affected area of the body[4] (percentages of total incidence[5]):

Trauma may also be classified by the affected demographic group (for example, trauma in the pregnant, pediatric, or geriatric patient).[4] They may also be classified by the type of force applied to the body, such as blunt trauma versus penetrating trauma.

Causes and risk factors

Blunt trauma is the leading cause of traumatic death in the United States.[6] Most cases of blunt trauma are caused by motor vehicle accidents.[6] Falls, a subset of blunt trauma, are the second most common cause of traumatic death.[7] In most cases a fall of greater than three times the victim's height is defined as a severe fall.[7] Penetrating trauma is caused when a foreign object such as a bullet or a knife enters a tissue of the body, creating an open wound. In the United States most deaths caused by penetrating trauma occur in urban areas and 80% of these deaths are caused by firearms.[8] Blast injury is a complex cause of polytrauma. It commonly includes both blunt and penetrating trauma and may also be accompanied by a burn injury.

By identifying risk factors present within a community and creating solutions to decrease the incidence of injury, trauma referral systems can help to enhance the overall health of its population.[9] Ingestion of alcohol and illicit drugs are risk factors for trauma, particularly traffic collisions, violence and abuse.[5] Long-acting benzodiazepines increase the risk of trauma in elderly people.[5]

Diagnosis

Radiograph of a close-range shotgun blast injury to the knee. Birdshot pellets are visible within and around the shattered patella, distal femur and proximal tibia.
Radiograph of a close-range shotgun blast injury to the knee. Birdshot pellets are visible within and around the shattered patella, distal femur and proximal tibia.

Physical examination

The purpose of the primary survey is to identify life-threatening problems. Upon completion of the primary survey, the secondary survey is begun. This may occur during transport or upon arrival at the hospital. The secondary survey consists of a systematic assessment of the abdominal, pelvic and thoracic area, complete inspection of the body surface to find all injuries, and a neurological examination. The purpose of the secondary survey is to identify all injuries so that they may be treated. A missed injury is one which is not found during the initial assessment (for example, as a patient is brought into a hospital's emergency department), but rather manifests itself at a later point in time.[10]

Imaging

X-rays of the chest and pelvis are commonly performed in major trauma.[5] Focused assessment with sonography for trauma (FAST), can also be used. Computed tomography (CT) scans are the gold standard in imaging in major trauma.[11] They however may only be performed in people with a relatively stable blood pressure, heart rate, and sufficient oxygenation.[5] Full-body CT scans known as pan-scans improve survival in those who have suffered major trauma.[12] The scans are done using intravenous radiocontrast but not oral contrast.[13] There are concerns of radiation exposure and concerns regarding negative effects of contrast on the kidneys. However some centers routinely do CTs with contrast before verifying renal function even in the elderly and have not found negative side effects with respect to the kidneys.[11] With modern imaging technology a complete scan can be performed in less than 10 minutes.[5] In the emergency department in the United States CT or MRI imaging is done in 15% of people who present with injuries as of 2007 (up from 6% in 1998).[14] In those who poor blood pressure or a fast heart rate from a presumed abdominal bleeding delaying surgery for abdominal CT imaging may worsen outcomes.[15]

Surgical techniques

Surgical techniques, such as diagnostic peritoneal lavage, placement of a thoracostomy tube, or pericardiocentesis are often used in cases of severe blunt trauma to the chest or abdomen, especially in the setting of deteriorating hemodynamic stability. In those who are hypotensive due to presumed internal abdominal bleeding transfer to the operating room for a laporotomy is the preferred method of determining a definitive diagnosis.[5]

Management

Color photograph of a United States Navy hospital corpsman listening for correct placement of an endotracheal tube in a simulated trauma victim during a search and rescue exercise. His assistant is holding a bag of intravenous fluid.
A Navy corpsmen listens for the correct tube placement on an intubated trauma victim during a search and rescue (SAR) exercise

People who have suffered trauma may require specialized care, including surgery and blood transfusion. Outcomes are better if this occurs as quickly as possible thus the so called golden hour of trauma. This is not a strict deadline, but recognizes that many deaths which can be prevented by appropriate care occurring in a relatively short time after injury.[16]

Community-based trauma referral systems seek to decrease overall injury-related morbidity and mortality and years of life lost within a population by ensuring the provision of optimal care during both the acute and late phases of injury.[9] Such systems have been established in many places to provide rapid care for injured people. Research has shown that deaths from physical trauma decline where there are organized trauma systems.[citation needed] The care of acutely injured people is a public health issue that involves bystanders and community members, health care professionals, and health care systems. It encompasses prehospital assessment and care by emergency medical services personnel, emergency department assessment, treatment, and stabilization, and in-hospital care among all age groups.[17] An established trauma system network is also an important component of community disaster preparedness, facilitating the care of victims of natural disasters or terrorist attacks.[9] In those with cardiac arrest due to trauma cardiopulmonary resuscitation (CPR) is considered futile but still recommended.[18]

Stabilization and transportation: Trauma center

Color photograph of a room designed to handle victims of major trauma. Visible are an anesthesia machine, a Doppler ultrasound device, a defibrillator, a suction device, a gurney, and several carts for storing surgical instruments and disposable supplies.
The trauma room in the emergency department of the University Hospital in Mannheim, Germany

In the prehospital setting the use of stabilization techniques improve the chances of a person surviving the transport to the nearest trauma-equipped hospital. After ensuring their own safety and taking isolation precautions, a primary survey is performed, consisting of checking and treating airway, breathing, and circulation (called the ABC's) then an assessment of the level of consciousness.[10] To prevent further injury, unnecessary movement of the spine is minimized by securing the neck with a cervical collar, and the back with a long spine board with head supports, or other medical transport device such as a Kendrick extrication device, before moving the person.[19] Unless the person is in imminent danger of death, first responders will typically "load and go," transporting immediately to the nearest appropriate facility.[10] Helicopter EMS transport reduces mortality compared to ground based transport in adult trauma patients.[20]

Rapid transportation of those who are severely injured is associated with improved outcomes.[5] In the prehospital environment, the availability of advanced life support does not improve outcomes for major trauma, when compared with basic life support.[21][22] The evidence is also inconclusive with respect to support for prehospital intravenous fluid resuscitation and some evidence has found it may be harmful.[23]

People who have severe trauma frequently require specialized physicians and equipment. Designated trauma centers have improved outcomes compared to non designated centers.[5] The transfer directly to a trauma center is associated with improved outcomes compared to transfer to a non trauma center.[24]

Intravenous fluids

Traditionally high volume intravenous fluids were given in people with hemodynamic instability due to trauma. This is still appropriate for those with isolated extremity, thermal or head injuries.[25] The current evidence however supports limiting the use of fluids for penetrating thorax and abdominal injuries allowing mild hypotension to persist.[4][25] If blood products are needed a greater relative use of fresh frozen plasma and platelets to packed red blood cells has been found to result in improved survival and less overall blood product usage.[26]

Blood substitutes such as hemoglobin-based oxygen carriers and perfluorocarbon emulsions are in development. As of June 2008 however there are none available for commercial use in North America or Europe.[27][28] The only countries where these products are available for general use is South Africa and Russia.[27]

Medications

In people who are bleeding due to trauma tranexamic acid decreases mortality.[29] Factor VII may also be appropriate in certain cases associated with severe bleeding[25] such as those who have bleeding disorders.[5] While it decreases blood use it does not appear to decrease mortality.[30]

Surgery: Trauma surgery

Damage control surgery is employed in the management of trauma.[5] This involves performing the least number of procedures to save life and limb.[5] Less critical procedures are left until the person is more stable.[5]

Prognosis

Death from trauma have been classically described as occurring during three peaks: immediately, early, and late. The immediate deaths are usually due to apnea, severe brain or high spinal cord injury, and rupture of the heart or large blood vessels. The early deaths occur within minutes to hours and are often due to a subdural hematoma, epidural hematoma, hemothorax, pneumothorax, ruptured spleen, liver laceration, or pelvic fractures. This is known as the golden hour. The late deaths occur days or weeks after the injury.[10] This classical distribution however may no longer be occurring in the United States due to improvements in care.[5]

Long term prognosis is also frequently complicated by pain with over half of people having moderately severe pain one year later.[31] Many also experience a reduced quality of life years later.[32] 20% of people who sustain a traumatic injury will sustain some form of disability.[33] Physical trauma can lead to development of post-traumatic stress disorder (PTSD).[34] However, a study found no correlation between the severity of trauma and the development of PTSD.[35]

Epidemiology

Deaths from injuries per 100,000 inhabitants in 2004[36]
no data
< 25
25-50
50-75
75-100
100-125
125-150
150-175
175-200
200-225
225-250
250-275
> 275
Incidence of accidents by activity

Trauma is the sixth leading cause of death (accounting for 10% of all mortality) worldwide, and the fifth leading cause of significant disability.[3] In people between the ages of 1–45 years, trauma is the leading cause of death.[3][4][16][33][37] The primary causes of death are central nervous system injury, followed by exsanguination.[3]

Research

Patients who were admitted into an ICU and received a trauma diagnosis causes a negative change in their health related quality of life with a potential to create anxiety and symptoms of depression.[38]

In children: Pediatric trauma

Accidents are the leading cause of death in children 1–14 years of age.[33] In the US approximatively 16,000,000 children go to an emergency department due to some form of injury every year.[33] Male children are more frequently injured then female children by a ratio of two to one.[33] The top five worldwide unintentional injuries in children are as follows:[39]

Cause Number of deaths resulting
Traffic collision

260,000 per year

Drowning

175,000 per year

Burns

96,000 per year

Falls

47,000 per year

Toxins

45,000 per year

An important part of managing trauma in children is weight estimation. A number of methods to estimate weight exist including the: Broselow tape, Leffler formula, and Theron formula.[40]

In pregnancy

Trauma occurs in 6-7% of all pregnancies and is the leading cause of maternal death. Trauma during pregnancy is a serious issue as the mothers will have an increased heart rate and increased blood pressure to accommodate the child, these hemodynamic changes will alter the presentation of shock.[4][41]

There are also diagnostic issues with trauma during pregnancy as ionizing radiation as it can cause birth defects.[4]

See also--Advanced Trauma Life Support---Psychological trauma---Traumatology--Wound


In psychology and medicine

  • Trauma (medicine), an often serious and body-altering physical injury, such as the removal of a limb
    • Blast injury, a type of physical trauma caused by an explosion
    • Blunt trauma, a type of physical trauma caused by impact or other force applied from or with a blunt object
    • Penetrating trauma, a type of physical trauma in which the skin or tissues are pierced by an object
  • Psychological trauma, an emotional or psychological injury, usually resulting from an extremely stressful or life-threatening situation
    • Post-cult trauma, the intense emotional problems that some members of cults and new religious movements experience upon disaffection and disaffiliation
    • Vicarious traumatization, transformation in the self of a trauma worker or helper that results from empathic engagement with traumatized clients and their reports of traumatic experiences.
  • Geriatric trauma, trauma in the elderly
  • Pediatric trauma, trauma in children
  • Trauma center, a hospital equipped to provide comprehensive emergency medical services to patients suffering traumatic injuries
  • Trauma surgery, a surgical specialty
  • Trauma team, a group of healthcare workers who attend to seriously ill or injured casualties who arrive at a hospital emergency department

In media, popular culture, and entertainment

In comics

  • Trauma (comics), a character associated with Avengers: The Initiative in the Marvel Universe

In film and television

In games

In music

In people

In sports teams

 

 

Orthopedic surgery or orthopedics (also spelled orthopaedic surgery and orthopaedics in Commonwealth countries and Ireland) is the branch of surgery concerned with conditions involving the musculoskeletal system. Orthopedic surgeons use both surgical and nonsurgical means to treat musculoskeletal trauma, sports injuries, degenerative diseases, infections, tumors, and congenital disorders.

Nicholas Andry coined the word "orthopaedics", derived from Greek words for orthos ("correct", "straight") and paideion ("child"), when he published Orthopaedia: or the Art of Correcting and Preventing Deformities in Children in 1741. Correction of spinal and bony deformities became the cornerstone of orthopaedic practice. Today, over 6 months of training is dedicated to the treatment of the pediatric population.

In the United States orthopedics is standard, although the majority of college, university and residency programs, and even the American Academy of Orthopaedic Surgeons, still use Andry's spelling. Elsewhere, usage is not uniform; in Canada, both spellings are acceptable; orthopaedics usually prevails in the rest of the Commonwealth, especially in Britain.

 

Training

In the United States, orthopedic surgeons have typically completed four years of undergraduate education and four years of medical school. Subsequently, these medical school graduates undergo residency training in orthopedic surgery. The five-year residency consists of one year of general surgery training followed by four years of training in orthopedic surgery.

Selection for residency training in orthopedic surgery is very competitive. Approximately 700 physicians complete orthopedic residency training per year the United States. About 10 percent of current orthopedic surgery residents are women; about 20 percent are members of minority groups. There are approximately 20,400 actively practicing orthopedic surgeons and residents in the United States.[1] According to the latest Occupational Outlook Handbook (2009–2010) published by the United States Department of Labor, between 3–4% of all practicing physicians are orthopedic surgeons.

Many orthopedic surgeons elect to do further training, or fellowships, after completing their residency training. Fellowship training in an orthopedic subspeciality is typically one year in duration (sometimes two) and sometimes has a research component involved with the clinical and operative training. Examples of orthopedic subspecialty training in the United States are:

  • Hand surgery
  • Shoulder and elbow surgery
  • Total joint reconstruction (arthroplasty)
  • Pediatric orthopedics
  • Foot and ankle surgery
  • Spine surgery
  • Musculoskeletal oncology
  • Surgical sports medicine
  • Orthopedic trauma

These specialty areas of medicine are not exclusive to orthopedic surgery. For example, hand surgery is practiced by some plastic surgeons and spine surgery is practiced by most neurosurgeons. Additionally, foot and ankle surgery is practiced by board-certified Doctors of Podiatric Medicine (D.P.M.) in the United States. Some family practice physicians practice sports medicine; however, their scope of practice is non-operative.

After completion of specialty residency/registrar training, an orthopedic surgeon is then eligible for board certification. Certification by the American Board of Orthopaedic Surgery means that the orthopedic surgeon has met the specified educational, evaluation, and examination requirements of the Board.[2] The process requires successful completion of a standardized written exam followed by an oral exam focused on the surgeon's clinical and surgical performance over a 6-month period. In Canada, the certifying organization is the Royal College of Physicians and Surgeons of Canada; in Australia and New Zealand it is the Royal Australasian College of Surgeons.

In the United States, specialists in hand surgery and sports medicine may obtain a Certificate of Added Qualifications (CAQ) in addition to their board certification by successfully completing a separate standardized examination. There is no additional certification process for the other subspecialties.

Practice

According to applications for board certification from 1999 to 2003, the top 25 most common procedures (in order) performed by orthopedic surgeons are as follows[3]:

  1. Knee arthroscopy and meniscectomy
  2. Shoulder arthroscopy and decompression
  3. Carpal tunnel release
  4. Knee arthroscopy and chondroplasty
  5. Removal of support implant
  6. Knee arthroscopy and anterior cruciate ligament reconstruction
  7. Knee replacement
  8. Repair of femoral neck fracture
  9. Repair of trochanteric fracture
  10. Debridement of skin/muscle/bone/fracture
  11. Knee arthroscopy repair of both menisci
  12. Hip replacement
  13. Shoulder arthroscopy/distal clavicle excision
  14. Repair of rotator cuff tendon
  15. Repair fracture of radius (bone)/ulna
  16. Laminectomy
  17. Repair of ankle fracture (bimalleolar type)
  18. Shoulder arthroscopy and debridement
  19. Lumbar spinal fusion
  20. Repair fracture of the distal part of radius
  21. Low back intervertebral disc surgery
  22. Incise finger tendon sheath
  23. Repair of ankle fracture (fibula)
  24. Repair of femoral shaft fracture
  25. Repair of trochanteric fracture

A typical schedule for a practicing orthopedic surgeon involves 50–55 hours of work per week divided among clinic, surgery, various administrative duties and possibly teaching and/or research if in an academic setting. In 2009, the median salary for an orthopedic surgeon in the United States was $406,847.[4]

History

Orthopedic implants to repair fractures to the radius and ulna. Note the visible break in the ulna. (right forearm)

Jean-Andre Venel established the first orthopedic institute in 1780, which was the first hospital dedicated to the treatment of children's skeletal deformities. He is considered by some to be the father of orthopedics or the first true orthopedist in consideration of the establishment of his hospital and for his published methods.[citation needed]

Antonius Mathysen, a Dutch military surgeon, invented the plaster of Paris cast in 1851. Many developments in orthopedic surgery resulted from experiences during wartime. On the battlefields of the Middle Ages the injured were treated with bandages soaked in horses' blood which dried to form a stiff, but unsanitary, splint. Traction and splinting developed during World War I. The use of intramedullary rods to treat fractures of the femur and tibia was pioneered by Gerhard KĂĽntscher of Germany. This made a noticeable difference to the speed of recovery of injured German soldiers during World War II and led to more widespread adoption of intramedullary fixation of fractures in the rest of the world. However, traction was the standard method of treating thigh bone fractures until the late 1970s when the Harborview Medical Center in Seattle group popularized intramedullary fixation without opening up the fracture. External fixation of fractures was refined by American surgeons during the Vietnam War but a major contribution was made by Gavril Abramovich Ilizarov in the USSR. He was sent, without much orthopedic training, to look after injured Russian soldiers in Siberia in the 1950s. With no equipment he was confronted with crippling conditions of unhealed, infected, and malaligned fractures. With the help of the local bicycle shop he devised ring external fixators tensioned like the spokes of a bicycle. With this equipment he achieved healing, realignment and lengthening to a degree unheard of elsewhere. His Ilizarov apparatus is still used today as one of the distraction osteogenesis methods.

Ruth Jackson became the first female Board-certified Orthopaedic Surgeon in the U.S in 1937. Orthopaedics continues to be a male-dominated field. In 2006, 12.4% of orthopaedics residents were women.[5]

David L. MacIntosh pioneered the first successful surgery for the management of the torn anterior cruciate ligament (ACL) of the knee. This common and serious injury in skiers, field athletes, and dancers invariably brought an end to their athletics due to permanent joint instability. Working with injured football players, Dr MacIntosh devised a way to re-route viable ligament from adjacent structures to preserve the strong and complex mechanics of the knee joint and restore stability. The subsequent development of ACL reconstruction surgery has allowed numerous athletes to return to the demands of sports at all levels.

Modern orthopedic surgery and musculoskeletal research has sought to make surgery less invasive and to make implanted components better and more durable.

Arthroscopy

The use of arthroscopic techniques has been particularly important for injured patients. Arthroscopy was pioneered in the early 1950s by Dr. Masaki Watanabe of Japan to perform minimally invasive cartilage surgery and reconstructions of torn ligaments. Arthroscopy helped patients recover from the surgery in a matter of days, rather than the weeks to months required by conventional, 'open' surgery. Knee arthroscopy is one of the most common operations performed by orthopedic surgeons today and is often combined with meniscectomy or chondroplasty. The majority of orthopedic procedures are now performed arthroscopically.[citation needed]

Arthroplasty

The modern total hip replacement was pioneered by Sir John Charnley in England in the 1960s.[6] He found that joint surfaces could be replaced by metal or high density polyethylene implants cemented to the bone with methyl methacrylate bone cement. Since Charnley, there have been continuous improvements in the design and technique of joint replacement (arthroplasty) with many contributors, including W. H. Harris, the son of R. I. Harris, whose team at Harvard pioneered uncemented arthroplasty techniques with the bone bonding directly to the implant.

Knee replacements using similar technology were started by McIntosh in rheumatoid arthritis patients and later by Gunston and Marmor for osteoarthritis in the 1970s developed by Dr John Insall in New York utilizing a fixed bearing system, and by Dr Frederick Buechel and Dr Michael Pappas utilizing a mobile bearing system.[7]

Uni-compartmental knee replacement, in which only one weight-bearing surface of an arthritic knee is replaced, is an alternative to a total knee replacement in a select patient population.

Joint replacements are available for other joints on a limited basis, most notably shoulder, elbow, wrist, ankle, spine, and fingers.

In recent years, surface replacement of joints, in particular the hip joint, have become more popular amongst younger and more active patients. This type of operation delays the need for the more traditional and less bone-conserving total hip replacement, but carries significant risks of early failure from fracture and bone death.

One of the main problems with joint replacements is wear of the bearing surfaces of components. This can lead to damage to surrounding bone and contribute to eventual failure of the implant. Use of alternative bearing surfaces has increased in recent years, particularly in younger patients, in an attempt to improve the wear characteristics of joint replacement components. These include ceramics and all-metal implants (as opposed to the original metal-on-plastic). The plastic (actually ultra high-molecular-weight polyethylene) can also be altered in ways that may improve wear characteristics.

See also---Bone fracture--Bone grafting--Broström procedure--Computer Assisted Orthopedic Surgery--Arbeitsgemeinschaft für --steosynthesefragen--Gait analysis--Halo Brace--Hand surgery--Podiatric surgery--Orthopedic nursing--Traction--Partial knee replacement--Epiphysiodesis--Reconstructive surgery--Buddy wrapping--Anterior cruciate ligament reconstruction--Tommy John surgery