A – series:

1. Medical first aid, bleeding control, ATLS, TRIAGE

2. Wound types. Principles of wound care. Soft tissue defects and reconstructive surgery.

3. Etiology, diagnosis and classification of fractures. Basic principles of AO (ASIF) fracture

classification.

4. Classification and management of open fractures.

5. Physiology of bone remodeling. Principles of fracture healing and treatment of bone union
disorders.

6. Joint dislocations. Diagnosis and therapy of joint-related soft tissue injuries.

7. Principles and types of non-operative (conservative) fracture treatment.

8. Operative fracture treatment. Different types of ostesosyntheses. AO (ASIF) principles of fracture

management.

9. Multiple trauma, polytrauma. Management of severely injured patients. Damage control. ATLS
guidelines.

10. Management of the septic condition of soft tissues, bones and joints.

11. Inactivity-induced atrophy, reflex dystrophy, compartment syndrome.

12. Replantation, revascularization, microsurgery.

13. Head and spine injuries.

14. Injuries of the chest.

15. Injuries of the abdomen.

BU SHEHAB HUSSAIN 2
 1. Medical first aid, bleeding control, ATLS, TRIAGE.

Medical first aid:

• First aid is all about providing initial lifesaving care before the arrival of professional help. In
first aid, your main aim is to preserve the life of the patient until he/she can be treated by
medical professional.
• The 3 main aims of first aid:
1. Preserve life
2. Prevent further harm
3. Promote recovery
• Always make sure that the environment is safe before approaching the patient. Make sure
to call 911/112 as soon as possible.
• The goal is to identify and treat immediate life threats and this is ensured by the ABC
assessment:
ABC: What to check: What to do:
Airway: -Ensure it is clear. - To maintain the patency of
- Inspection of the patient’s the patient’s airway, the
head and neck, checking head should be tilted, and
the patient’s voice and the chin should be lifted up.
auscultation if that is
possible.
- Make sure there no fluids
or foreign bodies
obstructing the airways.
Breathing: -Respiratory rate -Seating the patient
-Chest wall movement comfortably.
-Distension of neck veins -Inhalation medications to
-lateralization of the alleviate bronchoconstriction
trachea e.g. in asthma
-Oxygen saturation. -Bag-mask ventilation to
improve peripheral
oxygenation
-Decompression of a tension
pneumothorax if suspected
or confirmed
Circulation: -Bleeding -Stop ongoing bleeding
-Skin color: pale or not -Elevation of legs to improve
-Sweating is a sign of cerebral perfusion
compromised circulation -Fluid administration
-Level of consciousness
-Capillary refill time
-Pulse
-Blood pressure
• Other considerations are, consider cervical spine injuries and thus be careful to move the
patient. Start CPR immediately in case the patient is unconscious. If defibrillator is
available, then defibrillate the patient.

BU SHEHAB HUSSAIN 4
Bleeding control:

• The following signs can help in diagnosing an ongoing haemorrhage or shock:

▪ The level of consciousness, skin temperature and colour, nail bed capillary refill
time, and rate and quality of the pulses are all clinical markers for blood circulation
and tissue perfusion.
▪ Identify and control external bleeding with direct pressure, roll over the patient to
identify posterior bleeding.
▪ Cardiac and blood pressures should be checked.
▪ Draw blood for basic laboratory studies, including haematocrit and a pregnancy test
for females of childbearing age.
• Once haemorrhage is diagnosed the following should be done:
▪ Resuscitate with 2 large-bore (14-16 gauge) intravenous catheters, using warmed
fluids and packed RBCs if necessary.
▪ Control haemorrhage.
▪ Treat cardiac tamponade, cardiac arrest, and massive haemothorax, consider
immediate resuscitative thoracotomy.
▪ Use the left lateral recumbent position for pregnant patient at more than 20 weeks
of gestation. If this positioning is not possible, push the uterus laterally to relieve
pressure on the inferior vena cava, which may be responsible for decreased venous
return.
• Options for haemorrhage control:
Apply direct pressure:
-For visible external bleeding all you need to do first is to apply pressure on the bleeding source.
-Elevate the bleeding limb if that is possible.
-In case you cannot exactly identify the point of bleeding then apply pressure on one of the pressure points close to the
site of bleeding. Pressure points can be found where the pulses are.
Use Tourniquets:
-apply tourniquet in case of life-threatening bleeding from an arm or leg.
-The tourniquet should be placed above the bleeding site and it should be tightened until the bleeding stop. After
securing the tourniquet note the time of application (tourniquet not only stop bleeding but also cut the blood supply to
distal structures and thus it should not be kept for too long).
Wound packing and direct pressure:
-If tourniquet is not available or the bleeding is from the neck, shoulder, or groin then, pack (stuff) the wound with
bleeding control gauze (or clean clothes) and then apply pressure with both hands.
Topical haemostatic agents:
-These agents promote the clotting process. They can be applied as powder or gel, or pre-dosed in a dressing.
-These may be particularly useful in situations where the wound is not clotting, which can be due external factors, such
as size of wound, or medical factors such as haemophilia.
Surgical control of bleeding:
-Most of the internal bleedings needs surgical intervention.
-Intra-abdominal haemorrhage is a common life-threatening source of bleeding and it must be considered in any
hypotensive patient. eFAST and DPL (Diagnostic peritoneal Lavage) can be used to assess abdominal bleeding.
-Surgical control of bleeding include suture, glue, coagulation, packing, vascular occlusion, and vascular embolization.
Stabilizing fractures causing bleeding:
-Fractures can cause serious bleeding. Temporary stabilization by splinting can be lifesaving.
-Pelvic fractures can especially cause massive blood loss. In the primary survey (explained next), presumed bleeding
from pelvic fractures should be controlled with non-invasive techniques, such as pelvic binder, a sheet wrapped around
the pelvic region. Military antishock trousers or a pneumatic antishock garment may also be considered in efforts to
tamponade bleeding from pelvic fractures.

BU SHEHAB HUSSAIN 5
Advanced Trauma Life Support (ATLS):

• ATLS is the standard of care for trauma patients, and it is built around a consistent approach
to patient evaluation. This protocol ensures that the most immediate life-threatening
conditions are quickly identified and addressed in the order of their risk potential.
• The algorithm of ATLS consist of the following:
1. Preparation & Triage
2. Primary survey
3. Resuscitation
4. Adjuncts to primary survey and resuscitation
5. Secondary survey
6. Adjuncts to secondary survey
7. Post-resuscitation monitoring and re-evaluation
8. Definitive care
1) Preparation & Triage:
▪ The objective of triage is to prioritize patients with a high likelihood of early
clinical deterioration. Useful especially in big emergency situations such as a
building fire.
▪ Triage of trauma patients considers vital signs and perihospital clinical course,
mechanism of injury, patient age, and known or suspected comorbid conditions.
▪ Findings that lead to an accelerated workup include multiple injuries, extremes of
age, evidence of severe neurologic injury, unstable vital signs, and pre-existing
cardiac of pulmonary disease.
▪ Many scoring systems have been developed to help us prioritize patients:
➢ Revised Trauma Score (RTS)
➢ Acute Physiology and Chronic Health Evaluation (APACHE II)
➢ Simplified Acute Physiology Score (SAPS II)
➢ Trauma – Injury Severity score (TRISS)
➢ Injury Severity Score (AIS / ISS)
➢ Glasgow Coma Scale (GCS)
▪ Triage system categorize the patients’ need for an intervention into the following
groups:

BU SHEHAB HUSSAIN 6
2) Primary survey: Primary survey can be repeated until the patient is stable.
▪ In the primary survey, airway, breathing, and circulation are assessed, and
immediate life-threatening problems must be diagnosed and treated.
▪ The primary survey consists of 5 steps (ABCDE) that are performed in order:
A: Airway and c-spine protection:
-Patients who answer questions appropriately have a patent airway.
-Signs of respiratory distress can indicate compromised airways.
-Mouth and larynx should be inspected for any sign of obstruction.
-Unconscious patient should be intubated.
-Assume cervical spine injury in blunt trauma patients until proven otherwise.
B: Breathing and ventilation:
-Assess oxygenation status with pulse oximetry.
-Inspect and auscultate chest wall for injuries.
-If hemodynamic instability is apparent then immediately suspect tension
pneumothorax or massive haemothorax.
C: Circulation with haemorrhage control:
-Check and stop bleedings.
-Restore the hemodynamic stability by any means.
D: Disability/ Neurologic status:
-Assess the patient’s Glasgow Coma Scale, score: GCS score less than 8 is an
indication for intubation.
-Assess the pupillary size (can indicate focal neurological injury).
E: Exposure/Environmental control:
-Patient is fully undressed and environment is controlled to protect from
hypothermia or hyperthermia.
3) Resuscitation:
▪ This step focuses on the management of life-threatening problems identified in the
primary survey.
▪ It includes e.g. oxygenation and ventilations, shock management, intravenous lines,
warmed Ringer’s lactate solution, etc.
4) Adjuncts to primary survey and resuscitation:
▪ Radiography of the cervical spine, anterioposterior chest and anterioposterior pelvis.
This can provide information about potentially dangerous conditions in minimum
amount of time. eFAST and DPL (diagnostic peritoneal lavage) can also be
performed.
▪ Laboratory studies: CBC, electrolytes level, renal functionals, hCG levels in females.
▪ Blood preparation: contacting the blood bank and making sure that blood is
available in case it is needed.
▪ Urinary and gastric catheterization.
▪ Temperature, ECG and oxygen saturation monitoring.
▪ At this point, the physician should have enough knowledge of the patient’s status to
consider transfer to a higher level of care if needed.
5) Secondary survey:
▪ The secondary survey is performed only after the primary survey has been finished
and all immediate threats to life has been addressed. The secondary survey is a head-
to-toe examination designed to identify any injuries that might have been missed.
▪ The so-called AMPLE history is obtained: A: Allergies, M: Medications, P: Past medical
history, L: Last meal, E: Events prior to accidents.

BU SHEHAB HUSSAIN 7
 ▪ The patient then should be physically examined from head to toe, including rectal
exam.
▪ During all steps the vitals of the patient should assessed frequently.

6) Adjuncts to secondary survey:

▪ Specialized diagnostic tests are performed to confirm potentially life-threatening
injuries. These tests are done after the patient hemodynamic and ventilation status is
normalized. These tests include CT scanning, MRI, X-ray of extremities, Endoscopy and
ultrasonography.
7) Post resuscitation monitoring and re-evaluation:
▪ Basically, re-checking everything e.g. the vital signs and urinary output.
8) Definitive care:
▪ This step is carried out after identifying the patient’s injuries and their definitive
treatment plan.

BU SHEHAB HUSSAIN 8
 2. Wound types. Principles of wound care. Soft tissue defects and reconstructive
surgery.

Introduction:

• Trauma (WHO): Trauma is an injury of the body caused by acute outer (mechanical,
thermal, electrical, chemical, radiation) impact, the injury is higher than what the normal
body can tolerate.
• Wound: Disruption of the normal structure and function of the skin and the
underlying soft tissue that is caused by trauma or chronic mechanical stress (e.g
ulcers) or in surgery.
• Wounds can be classified into acute and chronic and to open and closed. Wounds can also
be classified into simple wounds (affect skin, mucous membrane, subcutaneous tissue,
superficial muscle and partially the muscle) and compound wounds (involvement of other
tissues).
▪ Acute wound: Injury to the skin that occurs suddenly rather than over time. It heals at
predictable and expected rate according to the normal wound healing process
▪ Chronic wound: Develops when any acute wound fails to heal in the expected time
frame for that type of wound, which might be couple of weeks or even more. Examples
are ulcer, decubitus, and burn wounds.
▪ Open wound: have exposed body tissue in the base of the wound e.g. surgical
wounds.
▪ Closed wound: have damage that occurs without exposing the underlying body tissue
e.g. abrasions.
• Wound healing is divided into 4 phases: hemostasis, inflammation, proliferation/repair and
maturation and remodelling.
• Skin injuries: Wounds, burn, chemical injuries, contusion and necrosis

Types of wounds:

Mechanical wounds: Other types of wounds:

1. Abraded wound (vulnus abrasum) Chemical wounds:
2. Punctured wound (v. punctum) [Link]
3. Incised wound (v. scissum) [Link]
4. Cut wound (v. caesum) Wounds caused by irradiation
5. Crush wound (v. contusum) Wounds caused by thermal forces:
6. Torn wound (v. lacerum) [Link]
7. Bite wound (v. morsum) [Link]
8. Shot wound (v. sclopetarium) Special wounds

BU SHEHAB HUSSAIN 9
Abraded wound (vulnus abrasum): Punctured wound (vulnus punctum):
-Superficial damage to the epidermis. -Caused by a sharp pointed object e.g. knife
-Caused by blunt trauma (not penetrating trauma). (stabbing), nails.
-It is mild with good wound healing -Since the wound has small opening and may not
-Common on elbows, knees and shins bleed much, then you may think that it is a ‘’good’’
-Treatment: Cleaning the injury, bandage, wound but these wounds can be easily infected, big
ointments. vessels can be affected, organs and nerves can be
damaged and if it is in the thorax then
pneumothorax might develop.
-These types of wounds heal poorly.
-Primary treatment is to stop bleeding e.g. by
applying pressure.

Incised wound (vulnus scissum): Cut wounds (vulnus caesum):

-Caused by sharp objects e.g. scalpel. -Caused by sharp object with additional blunt force.
-Direction of the cut parallel with the skin surface. -The direction of the force is perpendicular with the
-The wound has even edges with narrow corner surface.
-It is the best regarding the healing process. -Result in more serious destruction.
-The surgical wounds belong here. -Healing process is bad.
Crush wounds (vulnus. contusum): Torn wound (vulnus lacerum):
-Caused by blunt force which put pressure -Also called laceration wound and it is produced by
(compress) on the body e.g. closing the door on your the tearing of body soft tissues.
fingers (yeah that hurts). -It is often irregular and jagged.
-Result in torn with uneven edges. -Often contaminated with bacteria from the object
-Tissues under the wound are destructed and there that caused it.
is blood accumulation. -Strongly bleeds.
-Healing process is bad. -Healing process is bad.
Shot wounds (vulnus. Scolperatium): Bite wounds (vulnus. Morsum):
-Physical trauma caused by a bullet from a firearm. -Damage is dependent on the teeth and the bite
-Damage is dependent on location and it ranges force.
from bleeding, broken bones, organ damage, and -Damage caused may be: ragged wound – crushed
wound infection. tissue – torn – puncture – bone fracture – severely
-Based on the bullet velocity, mass and entry point infected wound.
we can classify gunshot wounds into high and low -Most importantly here is to prevent rabies and
energy wounds. tetanus.
-High energy wounds more dangerous as they result -Bite wounds are left open except on the face.
in more and atypical damage. In high energy wounds
there is a high pressure which dissipate into the
surrounding tissues damaging them. Furthermore,
high energy bullets form cavitation and this creates
a suction effect which result in sucking everything
from outside to inside our body. These types of
wounds also result in atypical bone fractures.
-Healing is really dependent on location and extent
of damage.

BU SHEHAB HUSSAIN 10
Abraded wound (vulnus abrasum): Punctured wound (vulnus punctum):

Incised wound (vulnus scissum): Cut wounds (vulnus caesum):

Crush wounds (vulnus. contusum): Torn wound (vulnus lacerum):

Shot wounds (vulnus. Scolperatium): Bite wounds (vulnus. Morsum):

BU SHEHAB HUSSAIN 11
Wound management and care:

• The main thing here is to promote wound healing and to eliminate anything that may disturb
wound healing process. In other words, here our main aim is to maintain a good blood
supply with good tissue oxygenation. All wounds should be as clean as possible and
debrided of non-viable tissues and foreign bodies. Depending on the nature of the
wound, sutures, suction drains, or pressure dressings may be applied. Prober suture
technique should incorporate three major principles including proper distribution of tension
to the deeper layers, atraumatic handling of the tissues, and eversion of wound margins.
• Wound closure happens in one of three ways:
Primary wound closure: Secondary wound closure: Delayed primary closure:
-It is the fastest type of closure, -Also known as healing by -Also known as healing by tertiary
also known as healing by primary secondary intention. intention.
intention. -Here the wound edges cannot be -The wound is first cleaned and
-Wounds that heal by primary approximated (there is a big observed for a few days (2-3 days)
closure have a small, clean defect defect) and thus healing requires a to ensure no infection is apparent
that minimizes the risk of granulation tissue matrix to be before it is surgically closed.
infection. Also, keratinocytes have built to fill the wound defect. -This is combination of healing by
only to migrate for a small -This type of closure requires primary and secondary intention.
distance. more time and energy than -The main reason for choosing this
-Surgical incisions, paper cuts, and primary wound closure and type of closure is the reduce the
small cutaneous wounds usually creates more scar tissue. risk of infection.
heal by primary closure. -Some wounds may require flaps -Examples are dog bites,
and grafts due to very large lacerations involving foreign
defect. bodies.
-Majority of wounds belongs here.
• Which type of closure is dependent on:
▪ Degree of wound drainage
▪ Existing amount of tissue for wound closure
▪ Infection status of the wound
• We talked about the different types of closure but how do we actually close a wound:
Open wound treatment: Closed wound treatment:
Clean surgical wound: Dirty wound: -Main aim to minimize
1-Cleaning and disinfection -Main aim to remove devitalized inflammation: RICE:
2-Local anaesthesia tissue (dead skin which promote -Rest
3-Excision of the wound edges and bacterial growth), contamination -Ice
wound irrigation (necrotomy) and residual suture material that -Compression
4-Suturing the wound (tension has may disrupt the body’s ability to -Elevation
to be minimized for a better blood heal.
circulation) -Dirty wounds are: infected -Complications: Compartment
5-Sterile dressing and wounds, wounds with foreign syndrome
immobilization. bodies, and bite wounds.
6-Tetanus protection 1-Cleaning via pressured irrigation
using warm, isotonic saline.
2-Debirdment: removal of dead
tissue under local anaesthesia.
3-Ensure drainage of exudate.
4-Moist dressing and
immobilization.
5-Delayed/secondary surgical
wound treatment after 3-8days.
6-Tetanus protection
7-Antibiotic treatment

BU SHEHAB HUSSAIN 12
 • A very important aspect in wound management is to prevent tetanus and rabies:
▪ Tetanus is caused by bacteria (clostridium tetani) which produces a neurotoxins
resulting in painful dangerous muscle spasms and rigidity. Tetanus can be prevented by
active immunisation (Our body produce antibodies due administration of inactive toxin)
and passive immunisation (we administer the antibodies directly). Infants get vaccinated
against tetanus multiple times (DTaP vaccine) but the effect of this vaccine does not last
and we need a booster vaccine each 10 years. So, when you have a wound then there is
possibility of tetanus to develop and the way the doctors will prevent tetanus is
dependent on:
➢ If the wound is clean and you haven’t had your booster shot in the last 10 years,
then you will receive a booster shot.
➢ If the wound is dirty (deep and contaminated with dirt and soil) then you will
receive a tetanus booster regardless of whether you had your booster shot in
the last 10 years or not.
➢ If you have never received a primary immunization as a child and you have an
open wound then you will receive the first vaccine dose (active immunisation)
as well as a single dose of a special immunoglobulin with high activity against
tetanus (passive immunisation).
▪ Rabies is a virus that is contracted from a bite of infected animal. Rabies manifest in complex
of symptoms most importantly the fatal progressive encephalitis. Postexposure prophylaxis
for those who have never been vaccinated consist of a dose of human rabies
immunoglobulin (HRIG) and rabies vaccine given multiple times. For those who have been
vaccinated or are receiving preexposure vaccination for rabies should only receive the
vaccine.

The process of wound healing:

Hemostasis – inflammation: Granulation -proliferation: Remodelling -scar:

-This phase starts immediately -Starts when the wound is -During this phase the new
and lasts for 2-4 days. cleaned out and the focus here tissue slowly gains strength
-The main aim is to stop is to fill and cover the wound. and flexibility.
bleeding, to kill bacterial and -Three main events occur: -Collagen fibres reorganize,
to remove debris preparing filling the wound, contraction tissue remodels and matures
the wound for the growth of of the wound margins and and there is overall increase in
new tissue. covering the wound tensile strength
-Mainly neutrophils, platelets (epithelization). -This phase varies greatly from
and macrophages are -This phase can last from 4 -24 wound to wound and it lasts
involved. days. from 21 days to 2 years.
-Different inflammatory -Fibroblasts are mainly
mediators are secreted which involved.
causes edema, erythema, heat
and pain.

• Wound healing is a complex process and many things can affect this process: Drugs,
Infections/ischemia, Diabetes, Nutritional deficiency, Oxygen(hypoxia), Toxins,
Hypothermia/hyperthermia, Excessive tension, Acidosis and local anesthetics.

BU SHEHAB HUSSAIN 13
Reconstructive surgery:

• Reconstructive surgery is all about repairing people and restoring function. It is performed to
repair and reshape bodily structures affected by birth defects, developmental abnormalities,
trauma/injuries, infections, tumours and disease. It is main a job for plastic surgeons.
• The main techniques used are: Skin graft, flap surgery and tissue expansion
▪ Skin grafts: Used to close wounds, prevent fluid and electrolyte loss and reduce bacterial
burden and infection. Skin grafts are contraindicated in the case of contaminated
wounds or insufficient blood supply.
▪ Flap surgery: Flap reconstruction involves the transfer of a living piece of tissue from
one part of the body to another, along with the blood vessel that keeps it alive. Unlike
a skin graft, flaps carry their own blood supply, so can be used to repair more complex
defects.
▪ Tissue expansion: it is a procedure that enables the body grow extra skin by stretching
surrounding tissue.

Soft tissue defects:

Treatment of Subcutaneous Injuries:

Hematoma: Contusion: Decollement: Necrosis:
Fresh: suction Rest, Ice, compression Surgical evacuation Surgical necrotomy
If not:open evacuation Drainage 4-5 days Skin grafting

BU SHEHAB HUSSAIN 14
 3. Etiology, diagnosis and classification of fractures. Basic principles of AO
(ASIF) fracture classification

Introduction:

• A bone fracture is a medical condition in which there is a damage in the continuity of the
bone. The fracture develops when a bone is impacted with greater pressure or force than
it can support. This force usually occurs suddenly or is very intense.
• The most common causes are trauma and any other condition that result in weakened bone
structure e.g. osteoporosis, bone tumours, metastasis and Paget disease of the bones.
• Risk factors: Older ages, osteoporosis, endocrine disorder, corticosteroids, physical
inactivity, alcohol, and smoking.
• Fractures can be closed or open:
▪ A closed fracture is also called a simple fracture. In a closed fracture, the broken bone
doesn’t break your skin.
▪ An open fracture is also called a compound fracture. In an open fracture, the ends of the
broken bone tear your skin. When your bone and other internal tissues are exposed, it
puts you at higher risk of infection.
• Fracture management can be conservative (e.g. cast) or surgical and generally involves
anatomic reduction, fixation, and/or immobilization.

Signs and symptoms of bone fracture:

• The immediate appearance of deformity in a limb bone is diagnostic of a fracture.

• Swelling, redness, and bruising in the injured area.
• Crepitation.
• Bone fragments penetrating the skin.
• Pain.
• Abnormal motion and loss of function.

Classifications of bone fractures:

1. Simple (closed) or Compound (open):

▪ A simple fracture, or closed fracture, cracks the bone but does not break the skin
▪ A Compound fracture, or open fracture, breaks the bone, and then the broken pieces of
bone pierce the skin. Obviously, compound fractures are more serious than simple
fractures. They can be more painful, require additional treatments, and take longer time
to heal. Most compound fractures require surgical intervention during the treatment. A
simple fracture on the other hand, may only need a splint or cast to heal. Open fractures
can be classified according the pattern of soft-tissue injury:
➢ Type 1: fractures are characterized by a wound that is less than 1 cm.
➢ Type 2: Fractures are characterized by a wound that is longer than 1 cm, slight
contamination but no major soft-tissue damage.
➢ Type 3: fractures are characterized by larger wounds with severe soft-tissue
disruption and defects. If the defect it too big then we might need a local or distant
flap for adequate coverage.

BU SHEHAB HUSSAIN 15
2. Complete and incomplete fractures:
Complete Incomplete
Fracture extends through the entire cortex Fracture extends through part of the cortex
-Transverse: It occur as the result of a -Buckle fracture are compression fractures
strong force applied perpendicular to the and are very common in children. They
long axis of a bone. The fracture line is happen when one side of the bone buckles,
perpendicular to the shaft of the bone. This or bends, but doesn’t break all the way
is stable fracture and it is treated through (incomplete). It is a stable fracture,
conservatively. meaning that the broken pieces of bone
have not separated from each other.
-Oblique: Occur at a plane oblique to the Children are more at risk of buckle
long axis of the bone. Oblique fractures are fractures than adult because children’s
created by a violent twisting movement bones are quite flexible, they tend to bend
about the long axis of the bone. Oblique rather than break when they are put under
fractures are rare and are almost always a pressure. Taking part in sports, rough play,
radiological artefact. and other typical childhood activities are all
-Spiral: Occurs when a long bone is broken risk factors for buckle fractures. In most
by a twisting force. Most spiral fractures cases, a buckle fracture is treated with a
involve the long bones of the arms, splint and cast. A splint is usually put on
including humerus, ulna, and radius. The first, which keeps the limb in place for the
bones here are broken on an angle and first few days until the swelling goes down.
thus they often separate into two parts that However, if there is no or minimal swelling,
do not align and have rough, uneven edges. a cast may be applied immediately.
When this fracture is seen in child then it -Greenstick fracture: occurs when a bone
can be an evidence of child abuse. bends and cracks, instead of breaking
-Comminuted: It is a break or splinter of completely into separate pieces. The
the bone into more than two fragments. fracture looks similar to what happens
This type of fracture requires a high degree when you try to break a small, ‘’green’’
of injury to occur and thus it mostly occurs branch on a tree. Again since the children’s
after high-impact trauma such as car bones are softer and more flexible then this
accidents. Repairing a comminuted fracture type of fracture is mostly seen in children.
often requires open surgery to restructure Even mild greenstick fractures are usually
the bone to normal position. immobilized in a cast. This holds the
-Segmental: It is a fracture composed of at cracked pieces of bone together and
least two fracture lines that together isolate prevent the bone from breaking all the way
a segment of bone, usually a portion of the through if the child falls on it again. This
diaphysis of a long bone. These fractures type of fracture is often misdiagnosed as
are associated with increased morbidity sprains or bruises. The type of injury here is
and long-term complications such as tension (pulling away) injury and not
delayed union, non-union and/or infection compression injury as in buckle fractures.
as they compromise the blood circulation.

3. Classification based on location: Useful in describing a fracture on x-rays.

▪ Diaphyseal fractures: proximal 1/3, middle 1/3, or distal 1/3.
▪ Metaphyseal fractures: between epiphysis and diaphysis.
▪ Epiphyseal fracture: Associated with severe deformity later in life.

BU SHEHAB HUSSAIN 16
4. Other classifications:
▪ Direct injury fractures: Bones are broken by a direct blow e.g. a direct blow to the
knee would shatter the patella into many small fragments
▪ Indirect injury fractures: More fractures are caused by indirect injury. Example is
twisting injury.
▪ Pathological fractures: Occur through abnormally weak bone. So, these structures
would not have happened if the bone was healthy. Tumors, cysts and osteoporotic
bone are common sites of pathological fractures.
▪ Fatigue fractures: Repeated small bending stresses will break any material including
the bone. The commonest example is a fracture of the second metatarsal in young
adults who walk excessive distances.
▪ Undisplaced fractures: Fragments are in almost anatomical position and
manipulative reduction is not required.

Transverse fracture Oblique fracture

Spiral fracture Segmented fracture

Comminuted fracture Greenstick fracture

BU SHEHAB HUSSAIN 17
 Buckle fracture Pathological fracture

Basic principles of AO (ASIF) fracture classification:

• This is a system that is used worldwide in trauma clinics to classify bone fractures.
• Numbers and letters are used in this system to describe the fracture location and severity.
• The higher up we go in numbers and letters the more severe the fracture is and difficult to treat.
• This system not only enable us to describe fractures but also guide us to choose the proper
treatment for different fractures.
Bone affected is marked by Severity is marked by letter and it is different for different
numbers: parts of the bone:
1 = Humerus Diaphysis: Metaphysis:
2 = Forearm A = Simple fracture A = Extra-articular (fracture
3 = Femur B = Multifragmental fracture does not involve the joint
4 = Tibia C = Complex fracture space)
B = Simple intra-articular
(The fracture involves one
part of the articular surface
but the remainder is still
attached to the metaphysis)
C = Complex intra-articular
(Complete separation and
disruption of the joint
surface)

• This is a simplified version of the classification and more numbers and letters can be added
for more detailed description however I wrote what was mentioned in the lecture.

BU SHEHAB HUSSAIN 18
 4. Classification and management of open fractures.

Introduction:

• Open fractures imply a communication between the external environment and the fracture.
Four components characterize the injury:
1. Fracture
2. Soft -tissue injury
3. Neurovascular compromise
4. Contamination
• The risk of a fracture being open is related to the amount of soft-tissue coverage in that
region of the body and to the amount of energy imparted to that region.
• The immediate effect of a high-velocity injury producing an open fracture is contamination
of the soft and hard tissues. In addition, there may be hypovolemic shock. This produces a
perfect medium for bacterial infections. (The greatest problem with open fractures is the
risk of infection).
• Open fractures are classified by the Gustilo and Anderson classification system. In this
system open fractures are divided into three types in ascending order of severity, based on
skin and soft-tissue damage. Type III injuries are further subdivided into 3 types based on
the degree of contamination, the extent of periosteal stripping, and the presence of arterial
injury.

Gustilo and Anderson classification:

Comparison point: Type I: Type II: Type III:

Wound size: Less than 1 cm long More than 1 cm long Extensive (Laceration)
Contamination: Clean puncture Moderate High degree of
contamination contamination
Soft tissue damage: Little damage Moderate Extensive damage
Fracture type: Usually simple Moderate Great deal of
transverse or short comminution comminution and
oblique instability.
Cause: Indirect force Direct force Direct force
Energy: Small energy injury High or moderate High energy
Risk of septic 5% 10% 30%
complications:
• Subtypes of type III:
III/A: Adequate soft-tissue cover of bone despite extensive soft-tissue damage. Periosteum is
intact.
III/B: Extensive soft-tissue injury with periosteal stripping and bone exposure.
III/C: Open fracture with arterial injury requiring repair.

Work up of open fractures:

• Advanced Trauma Life support (ATLS) should be carried on since open fractures usually
result from extensive injuries.
• Basic orthogonal radiographs of the injured part should be obtained.

BU SHEHAB HUSSAIN 19
 • CT and MRI provide further detail of bone and soft-tissue injury, but they are only required if
the patient is stable.
• Ultrasound to assess tissue perfusion and myofascial compartment pressure monitoring.

Basic principles of treatment:

• The treatment of high-energy injuries aims at preserving life, limb, and function, in that
order of priority. The intermediate objectives are:
▪ Prevention of infection.
▪ Fracture stabilization.
▪ Soft-tissue coverage.
• Treatment of open fractures essentially consist of four steps:
1. Initial emergency treatment: Temporary splinting of the fracture, wound dressing,
antibiotic therapy, and tetanus immunization.
2. Primary surgical treatment: debridement, irrigation, and fracture stabilization.
3. Delayed surgical treatment: wound closure/cover within an appropriate time scale.
4. Rehabilitation and flow-up.
• Management of different Gustilo and Anderson types of fractures:
i. Type I: After proper soft tissue management, then the fracture can be treated as a
closed fracture.
ii. Type II: First soft tissue management, then the fracture is fixated with nailing or
plate. Primary closure (topic 2) is possible here.
iii. Type III: Soft tissue management, then the fracture is fixated with nailing or plate. As
the wound is extensive here then plastic surgery should be done to cover the wound
e.g. using flaps. Microsurgery might also be needed to reconstruct vessels and
nerves.

BU SHEHAB HUSSAIN 20
 5. Physiology of bone remodelling. Principles of fracture healing and treatment of
bone union disorders.

Physiology of bone remodelling:

• Bones are mainly composed of organic 35% (type I collagen, cells, ground substance) and
inorganic (Ca2+, PO43-) Substances. So, to form bone tissue or repair bone tissue we need
those substances.
• To build up bones we need the following cells:
▪ Osteoblasts: They synthesize and secrete collagen fibres and other organic
components. They are important to initiate the process of calcification. With time,
enough extracellular matrix accumulates around the osteoblasts until they are
embedded in it and develop into osteocytes.
▪ Osteocytes: They are the main cells of bony tissue. They carry out their daily
metabolism by exchanging nutrients with the blood.
▪ Osteoclasts: Their task is to degrade the extracellular matrix. This process goes hand
in hand with the coordination of osteoblasts (bone remodelling). This is part of the
normal development, maintenance, and repair process of bones.
• Bone remodelling is a constant process in which mature bone tissue is removed and new
bone tissue is formed. Bone remodelling serves to adjust bone architecture to meet
changing mechanical needs and it helps to repair microdamages in bone matrix preventing
the accumulation of old bone. Bone remodelling is mainly triggered by microdamage,
stress and hormones.

• Histologically, the bone consists of multiple columns, each called an osteon. Each column is
multiple layers of osteoblasts and osteocytes around a central canal called haversian canal.
Different osteons are connected to each other by Volkmann’s canals.
• Macroscopically, the bones are classified into cortical (80% of the skeleton) and
spongy/trabecular bones (20% of the skeleton). Microscopically, the bones are classified
into lamellar and woven bones:
Lamellar bones: Woven bones:
-Collagen fibres arrange in parallel layers -Collagen fibres are randomly arranged
-The normal adult bones belong here -In adults, seen at sites of fracture healing, tendon or
ligament attachment and in pathological conditions

BU SHEHAB HUSSAIN 21
Principles of fracture healing:

• Bone fracture is a medical condition in which there is a damage in the continuity of the
bone resulting in loss of function of the affected bone. A bone fracture may be the result
of high force impact or stress, or a minimal trauma injury as a result of certain medical
conditions that weaken the bones such as osteoporosis, bone cancers.
• A fracture begins to heal as soon as the bone is broken and, provided the conditions are
favourable, healing proceeds through several stages until the bone is consolidated.
• Two systems of blood circulation supply the bones with blood: the periosteal system
supplying 2/3 of the bone and the intramedullary bone circulation (1/3). At least of the 2
systems, one must be intact for the bone to heal. This is very important information to
acknowledge especially by surgeons operating fractures because there is no way that a
fracture will heal if both circulation systems are injured.
• Another very important requirement for bone healing is an intact growing metaphyseal
plate. This plate contains pluripotent cells which are essential to repair and form new
bone tissue. If this plate is damaged e.g. during surgery then a serious deformities will
arise. To sum up, 2 basic requirements are needed for bone healing: [Link] pluripotent
cells [Link] supply.
• When a bone fractures, two major things occur: Blood supply is damaged (mostly the
periosteal) and function of that bone is lost. So, our main job is ensure a prober blood
supply to the affected bone and to put back the fractured bone into the correct anatomical
position.
• Healing starts with the inflammatory phase then moves into the reparative phase and
finishes with remodelling. It is crucial to stabilize the fractured bone segment in the first two
phases to allow the formation of new blood vessels. During these 3 phases there will be a
cascade of tissue differentiation starting immediately after the fracture. The cascade starts
with hematoma (blood help attract cells into the fracture site), granulation phase (precursor
for callus formation), Connective tissue (soft callus forms here), fibrocartilage formation
(appears after 3 weeks), and mineralization of the cartilage (bone/ hard callus forms).

Main phases of bone healing:

Inflammatory: Reparation: Remodelling:
-Starts immediately after the -starts from the 5th day and -This phase last for a long
fracture and lasts for 3-5 lasts for 10 days. time and the main aim to
days. -Here fibroblasts and increase the strength and the
-Good blood supply is chondroblasts starts lay stability of the bones
essential in this phase down collagen forming the -Osteoclasts and blasts are
-Hematoma and granulation soft callus around the involved in this phase
tissue are present in this fracture.
phase. -New blood vessels grow in
-Granulation tissue serves as this phase too
precursor for callus -Soft callus stabilize the
formation in later stages. fracture more and thus
-The tissue formed here is fractured bone is slightly
soft and fractured bone is movable.
movable, thus movement -Soft callus get mineralized
should be limited in this and hard callus forms and
stage. this basically new bone
tissue.

BU SHEHAB HUSSAIN 22
 • Long bones take about 3 months to heal and other bones need 6 weeks. Some bones take
too long to heal e.g. scaphoid and talus.
• Fractured bones can heal in two ways: Primary healing and secondary healing:
Primary bone healing: Secondary bone healing:
-Just like the skin, primary healing only -This is the natural way of healing
works when the edges are touching exactly, -The basic idea is to deposit a lot of bony
and this is achieved by surgical fixation. layers around the fracture. It is like
-ABSOLUTE STABILITY IS NEEDED, so this patching up the bones with a tape.
type of healing only occurs if there is no -Only relative stability is needed here
movement between the fracture ends. -Stages: Inflammation – soft callus – hard
-Mechanism: primary bone healing is led by callus – remodelling (details are mentioned
the formation of a so-called cutting cone. above).
When the two bony ends are fixed -Healing process is mainly carried out
together, osteoclasts start to tunnel outside the bone and thus we have callus
through the 2 ends and osteoblasts behind formation.
them lay down new bone and this is why
we need absolute stability otherwise even
slight movement can destroy these tunnels.
-Here the healing process in mainly carried
out inside the bones and thus we don’t
have callus formation here.

Treatment of bone union disorders:

• Normal bone union occur when a fracture bone unite in the right anatomical position in
a normal time interval. If the bone heals but in the wrong position we call that
malunion. When the bone does not want to heal we call that delayed bone union and
non-union.
• A fracture with delayed bone union takes longer to unite than normal but eventually
does so. Here there is capacity of healing but for some reason (e.g. poor blood supply) it
takes longer time to heal.
• In non-union there is no capacity to heal and we may need operative intervention in
order to allow the bone ends to unite. We have four types of non-union:
Hypertrophic: Atrophic: Septic and defect:
-Caused by mechanical -Here we have a big gap -Here bacteria invade the
problems. There is a good between the 2 bones, and callus and affect the
blood supply and callus we don’t see any callus pluripotent stem cells
formation on both ends formation. which are essential in the
but because there is not -The main problem here is healing process.
enough fixation the bone poor blood circulation. -This form is the most
does not heal. -Treated by enhancing the complicated regarding
-There excess callus blood supply by treatment. First the dead
formation (hypertrophic) transferring a well- tissue must be removed.
and this causes the nourished bony graft. This will create a big bony
elephants foot appearance defect which will be filled
on radiological images. with a bony graft.
-This type of non-union is -Defect non-union results
the easiest to treat, all we from gunshot and
need to do is to increase managed as the septic
stability. one.
BU SHEHAB HUSSAIN 23
 6. Joint dislocations. Diagnosis and therapy of joint-related soft tissue injuries.

Introduction:

• In order of decreasing severity, joint injuries may be classed as dislocation, subluxation,

sprain or contusion.
▪ A joint is dislocated or luxated when its articular surfaces are wholly displaced one
from the other so that all apposition between them is lost.
▪ A joint is subluxated when its articular surfaces are partly displaced but retain some
contact one with the other.
• Dislocation or subluxation of a joint may be congenital, spontaneous, traumatic or recurrent.
• Injury is by far the most common cause of dislocation and subluxation.
• Any joint may be affected, but those most commonly dislocated are the shoulder, elbow,
hip, ankle and interphalangeal joints of the fingers.
• Dislocation cannot occur without some damage to the protective ligaments and joint
capsule. Usually the capsule and one or more of the reinforcing ligaments are torn,
permitting the articular end of one of the bones to escape the joint cavity. It is not always
that one of the bone ends protrudes outside the joint capsule; sometimes the joint surfaces
may be completely dislocated and yet both remain within the capsule.
• In joints that depends for their stability mainly upon the surrounding muscles, dislocation
will occur most easily when the muscles are off their guard and this explains the high
incidence of shoulder dislocations in patients suffering epileptic fits.
• Clinical features of joint dislocation:
▪ Pain
▪ Bruising
▪ Swelling
▪ Instability of the joint
▪ Loss of ability to move the joint
▪ Visibly deformed joint (bone looks out of place)
• Diagnosis of joint dislocation:
▪ In most cases of dislocation, the clinical features are sufficient to make a diagnosis.
However, sometimes the dislocation might be overlooked due to severe swelling or
obesity.
▪ In doubtful cases, the diagnosis must depend finally on adequate radiographic
examination. It is important to note that radiographs should be obtained in two
planes because a dislocation might not be apparent in a single projection.
Ultrasound, CT and MRI can also be used.
▪ In subluxation, clinical features alone are not enough and there has to be a
radiographic evidence to make the diagnosis.
▪ Other specific clinical test should be done to establish the integrity of the arteries
and nerves close to the affected joint.
• Treatment of joint dislocation:
▪ Reduction: The first principle of treatment of a dislocation or subluxation is to
reduce the displacement; this is achieved by manipulating or repositioning the joint

BU SHEHAB HUSSAIN 24
 back into place. The patient should be given a sedative or anaesthetic to remain
comfortable and to allow the muscles near the joint to relax.
▪ Surgery: Mainly done if reduction was not successful or is not possible. Surgery is
also indicated if there is nerve or vessel damage. Open dislocations (dislocation with
open wound) are also treated surgically.
▪ Immobilization: after putting the joint back to its proper place, the joint should be
immobilized with e.g. sling, splint, or cast to allow the area to fully heal. This
especially important If the there is extensive injury to the main ligaments.
• Complications of joint dislocation:
▪ Infection
▪ Injury to important soft-tissue structures (artery, nerve)
▪ Avascular necrosis of one of the articulating bones ends from damage to the vessels
supplying it.
▪ Persistent instability leading to recurrent dislocation or subluxation.
• Joint contusion is caused when direct force hit the joint and affect soft tissues without
causing any deformity.
▪ Diagnosis: physical examination (pain, swelling, hematoma, loss of function), US, X-
ray, CT, MRI
▪ Therapy: Conservative
• Joint sprain is caused when indirect force hit the joint and shift the bones for a moment,
with no tear to the ligaments or joint capsule. Diagnosed and treated the same as the joint
contusion.

Joint-related soft tissue injuries:

-Soft tissues are skin, subcutis, muscles, ligaments, and tendons.

-Soft-tissue injuries can be with or without bone fracture.

Different soft tissue injuries:

1-Skin injuries: -Wounds
-Bruns
-Chemical injuries
-Contusion
-Necrosis
2-Subcutis injuries: -Contusion
-Hematoma
-Decollement
-Necrosis
3-Fascia injuries: -Contusion
-Rupture
-Necrosis
4-Muscle injuries: -Contusion
-Strain
-Tear/rupture: partial or complete
5-Tendon injuries: -Strain: initial, elastic, plastic.
-Tears: partial or complete
6-Ligaments injuries: -Contusion
-Strain
-Tear: fast force, overstretch, partial or complete
-Bony abruption: Slow force or no overstretching.

BU SHEHAB HUSSAIN 25
Muscle injuries:

• Features of muscle contusion:

▪ A muscle contusion (bruise) is a basic injury to the muscle fibres. It’s often
associated with the muscles in the upper leg.
▪ Bruised muscles are typically caused by trauma or blunt force e.g. direct contact in
sports. This trauma crushes the muscle fibres but doesn’t break the skin tissue.
▪ Symptoms: Pain, discoloration, swelling, limited mobility.
• Features of muscle strain:
▪ Strains are caused by muscles over-stretching or contracting too quickly, resulting in
a partial or complete tear of the muscle and/or tendon fibres. Strain occurs mostly in
the lower back, neck, shoulder and hamstring muscles.
▪ Strains can be caused by not warming up properly before physical activity, poor
flexibility, and overexertion and fatigue.
▪ Strains cause pain and may limit movement within the affected muscle.
• Features of muscle tear and rupture:
▪ A rupture and a tear are the same thing: injured tissue that has a cut. The injury
could be partial or total.
▪ Most common symptoms are pain, swelling, loose joint, muscle weakness.
▪ Ruptures/tears occur mostly in Achilles tendon, rotator cuff, Anterior Cruciate
Ligament (ACL), biceps and quadriceps.
• Diagnosis of muscle injuries:
▪ Physical examination: swelling and tenderness.
▪ Functional tests: to test muscle functions.
▪ Ultrasonography.
▪ MRI.
• Treatment of muscle injuries:
▪ Conservative: rest, ice, compression, elevations, anti-inflammatory medications.
Immobilization in case of partial tears.
▪ Operative (suture, reinsertion): for complete tears.
• Most common muscle injuries:
▪ Upper extremity: rotator cuff, biceps, triceps.
▪ Lower extremity: Suralis, quadriceps, adductors, tibialis anterior.
• With any muscle injury or even any soft tissue injury always keep in mind compartment
syndrome. (Refer to topic 11 for details).

Tendon injuries:

• Tendon strain is the overstretching or tearing of a tendon. It can elastic or plastic. Elastic
strain is a strain which can be recovered (reversible) after removal of whatever caused the
strain. Plastic strain is a strain which cannot be recovered (irreversible) after the removal of
the deforming force, here the stress applied is more than the tendon’s elastic limits and thus
a permanent damage to the tendon occur.
• A tendon rupture/tear is a partial or complete tear of the tendon. A tear may be caused by
an injury or increased pressure on the tendon that occurs during sports or a fall.
• Diagnosis of tendon injuries:
▪ Physical examination: tenderness, swelling, mobility

BU SHEHAB HUSSAIN 26
 ▪ Functional test: to test tendon functions
▪ Ultrasonography and/or MRI.
• Treatment of tendon injuries:
▪ Strain and partial tears are treated conservatively e.g. rest, ice, compression,
analgesics
▪ Surgical (suture, reinsertion, replacement): for complete tears.
• Frequent tendon rupture:
▪ Upper extremity: long head and distal tendon of biceps, rotator cuff, extensors and
flexors of the fingers.
▪ Lower extremity: Achilles tendon, tibialis anterior tendon and patellar
tendon/ligament.

Ligaments injuries:

• Ligaments are injured when the joint stressed beyond its normal range of movement.
Common causes of a ligament injury include twisting or landing improperly.
o Symptoms: Pain, tenderness, swelling, bruising, difficulty in moving the joint.
• Diagnosis: Physical examination, checking the movement, stress X-ray, US and MRI.
• Therapy of ligament injuries:
▪ Conservative treatment (Rest, ice, compression, elevation) for contusion and strain.
Immobility for partial and complete stable tears.
▪ Surgical (Suture, reinsertion, replacement): for complete instable tears.
• Common ligament ruptures:
▪ Upper extremity: acromioclavicular, Bankart lesion, Elbow ulnar collateral, and
elbow radial collateral ligaments.
▪ Lower extremity: Ankle ligaments, Knee ligaments (medial and lateral ligaments,
anterior and posterior cruciate ligaments).

BU SHEHAB HUSSAIN 27
 7. Principles and types of non-operative (conservative) fracture treatment.

Introduction:

• The three fundamental principles of fractures treatment (Bohler’s rules):

1. Reduction
2. Retention (Stabilization)
3. Rehabilitation
• Fracture management can be divided into nonoperative and operative techniques.
Nonoperative (conservative) options: Operative options:
Closed reduction Minimal osteosynthesis (K-wires)
Splint/cast fixation Screws
Braces Rigid fixation (reamed intramedullary nails,
plates)
Functional therapy Flexible/dynamic fixation (unreamed
intramedullary nails, external fixation)
• The nonoperative approach consists of a closed reduction, followed by a period of
immobilization with casting or splinting. Closed reduction is needed if the fracture is
significantly displaced or angulated. If closed reduction is inadequate, surgical intervention
may be required.
• The most important factors in fracture healing are blood supply and soft-tissue health.
• Early fracture management is generally aimed at:
▪ Controlling haemorrhage.
▪ Providing pain relief.
▪ Preventing ischemia-reperfusion injury.
▪ Removing potential sources of contamination (foreign body and nonviable tissues).
• Which approach to choose is dependent on many factors and benefits and costs have to be
weighted to determine the best healing promoting option:
▪ Biology: Depending on the type of fracture we can determine which is the best way
of healing? Is it primary or secondary healing (topic 5), in other words do we want
absolute or relative stability?
▪ Patient: general condition, age, comorbidities, expectations and compliance all can
affect the choice of treatment approach.
▪ Hospitals: Expertise, availability of instruments, ability to deal with complications of
certain treatment approaches.
• Advantages and disadvantages of nonoperative and operative approaches:
Nonoperative Operative
Advantages Disadvantages Advantages Disadvantages
No anaesthesia (not Non-anatomical Anatomical Invasive and
all the time). reduction reduction requires anaesthesia
No risk of bleeding Long immobilization Stable fixation Risk of bleeding
No infection Weakness, atrophy Early physiotherapy Risk of infection
No need for special Stiffness Faster recovery Need special
instruments instruments
Cheaper Slow recovery No need for extra Expensive
fixation e.g. plaster

BU SHEHAB HUSSAIN 28
 • In some fractures only early physiotherapy and some medications e.g. NSIADS would be
enough for healing, this is called functional treatment. Examples are single rib fracture,
isolated fibular fracture (Polchen therapy), fracture of the proximal end of the hummers in
elderly.
• In some cases, we use combination of fixation devices together with cast/brace e.g. K-wires
+ cast fixation and this approach is called semi-conservative treatment.

Reduction:

• Fracture reduction is the term used to describe how a bone is fixed or set after a fracture.
The pieces of bone must be put in close proximity to one another so that healing can occur.
• Reduction is not needed for all fracture and it is only performed if it is necessary.
• Main goals of reduction are to restore length, alignment and rotation.
• Reduction can be achieved mainly by 3 ways:
(1) by closed manipulation
(2) by mechanical traction (pulling) with or without manipulation
(3) by open operation. (topic 8)
• Closed manipulation: A closed reduction involves using the hands to manoeuvre the
fractured bone pieces into their correct positions.
• Reduction my mechanical traction: This can be done via the skin (skin traction) or a metal pin
inserted into the bone (skeletal traction) distal to the fracture.
▪ Skeletal traction involves placing a pin, wire, or screw in the fractured bone. After
that, weights are attached to the device inserted so the bone can be pulled into the
correct position. Skeletal traction is most commonly used to treat fractures of the
femur.
▪ Skin traction involves applying splints, bandages, or adhesive tapes to the skin
directly below the fracture. Once the material has been applied, weights are
fastened to it. The affected body part is then pulled into the right position using a
pulley system attached to the hospital bed. Skin traction is used when the soft
tissues need to be repaired as this system uses less force compared to the skeletal
traction.
▪ Reduction by traction is mostly used as temporary way to stabilize a broken bone
until the definitive surgery is performed.
• Examples of common closed reductions include shoulder dislocation, Humeral shaft
fractures, and knee dislocations.

Retention/stabilization/immobilization:

• Immobilization is only indicated for 3 reasons:

▪ To prevent displacement or angulation of the fragments.
▪ To prevent movement that might interfere with union.
▪ To relieve pain.
• Immobilization can be achieved mainly by 4 methods:
▪ By a plaster of Paris cast or another external splint.
▪ By continuous traction.
▪ By external fixation. (topic 8)
▪ By internal fixation. (topic 8)

BU SHEHAB HUSSAIN 29
 • For most fractures the standard method of immobilisation is by a plaster of Paris cast.
Another type of casts is fiberglass cast. Fiberglass casts are lighter, water-resistant and more
durable than Plaster of Paris cast.
• For some fractures a splint is more appropriate e.g. for the thigh and fingers.
• Cast bracing is a technique in which a fractured long bone is supported externally by plaster
of Paris or by other plastic material in such a way that function of the adjacent joints is
preserved and use of the limb for its normal purposes can be resumed. Functional bracing is
used mainly for fractures of the shaft of the femur or tibia.

Rehabilitation:

• This step is always essential in the healing process of bone fractures. Unlike the first 2
principles (reduction, retention) which might not be necessary for all fractures,
rehabilitation is definitely necessary in all fracture cases.
• Rehabilitation should begin as soon as the fracture comes under definitive treatment. There
are two main purposes of rehabilitation (1) to preserve function so far as possible while the
fracture is uniting and (2) to restore function to normal when the fracture is united.
• The two essential methods of rehabilitation are:
▪ Active use: patient must continue to use the injured part as naturally as possible
within the limitations imposed by necessary treatment. Although in some injuries
rest may be necessary in the early days or weeks, there should be a graduated
return to activity as soon as it can be allowed without risk.
▪ Active exercises: Exercises for the muscles and joints

BU SHEHAB HUSSAIN 30
 8. Operative fracture treatment. Different types of ostesosyntheses. AO (ASIF)
principles of fracture management.

Introduction: This is an important topic as its principles might be asked generally in other topics as
well. Some of the details included here weren’t mentioned in the lecture however, I included them
as they are essential to understand the principles of this topic.

• The three fundamental principles of fractures treatment (Bohler’s rules):

4. Reduction
5. Retention (Stabilization)
6. Rehabilitation
• Fracture management can be divided into nonoperative and operative techniques.
Nonoperative (conservative) options: Operative options:
Closed reduction Minimal osteosynthesis (K-wires)
Splint/cast fixation Screws
Braces Rigid fixation (reamed intramedullary nails,
plates)
Functional therapy Flexible/dynamic fixation (unreamed
intramedullary nails, external fixation)
• The most important factors in fracture healing are blood supply and soft-tissue health.
• Early fracture management is generally aimed at:
▪ Controlling haemorrhage.
▪ Providing pain relief.
▪ Preventing ischemia-reperfusion injury.
▪ Removing potential sources of contamination (foreign body and nonviable tissues).
• Some operative treatment options:
▪ Screw fixation
▪ Tension band
▪ Intramedullary nailing
▪ Plate osteosynthesis
▪ External fixation
▪ Special devices: periprosthetic fractures
• A fracture can have different levels of stability:
▪ Load-stable: allows full weight-bearing.
▪ Motion-stable: allows full range of motion of the bone.
▪ Bed-stable.
▪ Unstable.
• Postoperative care of fracture consists of (1) adequate pain control, (2) thrombosis
prophylaxis, and (3) early recognition and treatment of complications.

AO (ASIF) principles of fracture management:

1. Fracture reduction and fixation to restore anatomical relationships:

▪ Some fractures are reduced to restore:
➢ The bony anatomy and morphology, when perfect anatomical reduction is
required. This is anatomical reduction.

BU SHEHAB HUSSAIN 31
 ➢ The relationship between the proximal and distal main fragments. Length
alignment and rotation are restored. This is functional reduction.
▪ Reduction methods depends on the location of the fracture:
➢ Reduction of diaphyseal fractures: Within the diaphysis, length, alignment
and rotation must be restored but anatomical reduction is not necessary.
➢ Reduction of articular fractures: These fractures demand anatomical
reduction and absolute stability to enhance the healing of articular cartilage
and make early motion possible.
2. Fracture fixation provides absolute or relative stability depending on the personality of the
fracture, the patient, and the injury requires:
▪ Goal of fracture fixation is (1) to main the reduction and (2) to create adequate
stability which allows early function of the injured limb and minimizes pain.
▪ There are two types of stabilities that can be achieved:
➢ Absolute stability: achieved by interfragmentary compression e.g. lag
screws, compression plate.
➢ Relative stability: achieved by splinting or bridging e.g. elastic nails.
➢ Hybrid fixation involves a combination of absolute and relative stability
principles.
3. Preservation of the blood supply to soft tissues and bone by gentle reduction techniques and
careful handling.
4. Early and safe mobilization and rehabilitation of the injured part and the patient as a whole.

BU SHEHAB HUSSAIN 32
Open reduction and internal fixation (ORIF):

• Operative or internal fixation may be indicated in the following circumstances:

▪ Displaced intra-articular fracture.
▪ Axial, angular, or rotational instability that cannot be controlled by closed
methods.
▪ Open fracture.
▪ Polytrauma patients.
▪ Associated neurovascular injury.
• Benefits of internal fixation:
▪ Earlier functional recovery.
▪ More predictable fracture alignment.
▪ Potentially faster time to healing.
• The objectives of internal fixation are:
▪ Adequately exposing the fracture site.
▪ Minimizing soft-tissue stripping.
▪ Obtaining a reduction of the fracture.
▪ Stabilizing and maintaining the reduction that has been achieved.
• Types of internal fixation include: Screws, plates, intramedullary nails/rods, and K-waires.

Screw fixation:

• A screw can be applied to compress a fracture surface (lag screw), fix a plate to the bone by
producing compression between the plate and the bone, or it may be used to fix an external
fixator or internal fixator to the bone.
• Screws come in different sizes for use with bones of different sizes. Screws can be used
alone to hold a fracture, as well as with plates, rods, or nails. After the bone heals, screws
may be either left in place or removed.
• Types of screws: (1) Cortical, (2) Medullary, and (3) Compression (lag) screw.
▪ Cortical screws are designed for placement in cortical bone.
▪ Medullary screws are designed for placement in the medullary cavity.
▪ Compression screws compresses the fracture fragments together.

Tension band:

• This technique uses the mechanical principle of converting the tensile stresses of the
muscles acting on the bone fragment, into a compressive force that keeps the fragments
together at the fracture site.
• Indications: olecranon fracture, patella fracture and acromioclavicular joint dislocation.

Intramedullary nails/rods:

• Intramedullary nailing of shaft fractures of the femur, tibia, and humerus is generally a
standard treatment. These nails operate like an internal splint that shares the load with
the bone and can be flexible or rigid, locked or unlocked, and reamed or unreamed.
▪ Reaming is done to enlarge the medullary canal of the bone so it can accommodate
the nail. Reaming gives us the advantage to place the nail the exact way we want but
the cost if reaming is that it destroys the blood supply so, in some conditions
reaming is contraindicated.
• Advantages of intramedullary nailing include:

BU SHEHAB HUSSAIN 33
 ▪ Indirect reduction and fixation without opening the fracture site.
▪ Implant insertion along the mechanical loading axis of the bone.
▪ Good bone-implant interface.
▪ Early load sharing to allow weight bearing.
• Many types of nails exist including:
▪ Kuntscher nail: this is unreamed, no locking nail that can fit in the narrowest part of
the shaft. It is used for simple midshaft fractures.
▪ Universal nail: these has interlocking screws, and this enhance the mechanical
properties of the intramedullary implant. It widened the range of indications to
include more proximal or distal fractures, as well as more complex and unstable
fracture patterns.
▪ Marchetti-Vicenzi nail: this is a nail which locks proximally and distally has spreading
pins. It is used for humeral shaft fractures.
▪ Gamma nails: used for the treatment of trochanteric fractures.

Plate fixation:

• Plate is a load-bearing device that is most effective when placed on the tension side.
• Plates provide strength and stability to neutralize the forces on the injured limb for
functional postoperative aftercare. The plate is fixed to the bone by application of screws
on both sides of the sides.
• Indications of use of bone plates are:
▪ When anatomical alignment must be restored accurately.
▪ Where the use of screws alone is inadequate.
• Functions a plate can have:
▪ Compression: Plates compress together the main fragments of a single plane
fracture which can result in absolute stability.
▪ Neutralization: Plates neutralizes any force which may disrupt the stability of a
fracture.
▪ Buttressing (supporting): a plate can act like a thumb that is pressing fracture
fragments into a reduced position.
▪ Bridging: a plate can be applied so it spans the multifragmentary zone to restore
length, axial alignment, and rotational alignment.

BU SHEHAB HUSSAIN 34
 • Plate designs vary, depending on the anatomic region and size of the bone the plate is used
for. All plates should be applied with minimal stripping of the soft tissue. Different plates
exist for different purposes:
▪ Buttress (antiglide) plates:
➢ The buttress plate is always fixed to the larger main fracture fragment but
does not necessarily require fixation through the other smaller fragment,
because the plate buttresses (support) the small fragment into the larger
fragment. This is the most common way that plates are used around the
joints.
➢ Examples of indications: tibial head fracture, distal radius fracture.
▪ Compression plates:
➢ Compression plates counteract bending, shear, and torsional forces by
providing compression across the fracture site.
➢ These plates are commonly used in the long bones, especially the fibula,
radius, and ulna, and in non-union or malunion surgery.
▪ Reconstruction plates:
➢ These plates have notched edges to permit bending. These plates are very
adaptable to shape.
➢ They are useful in complex anatomical sites such as the distal humerus, and
pelvis.
▪ Bridge plates:
➢ These plates achieve adequate reduction and stability without disrupting the
soft-tissue attachment to the bone fragments.
➢ Bridge are useful in the management of multifragmented diaphyseal and
metaphyseal fractures.
▪ Dynamic compression plate:
➢ In this plate screw holes were modified to achieve better results. With this
plate the soft tissues are not irritated and stress on fracture is minimised.
▪ Locking compression plates (LCD):
➢ LCD has got screws with threaded heads which lock themselves when
inserted to threaded plate holes, thus locking the screw with the plate.
➢ Advantages of LCD: sparing of periosteal blood supply and improved holding
power.
➢ Used in e.g. communicated metaphyseal fractures.

Kirschner wires:

• K-wires are commonly used for temporary and definitive treatment of fractures.
• K-wires resist only changes in alignment; they don’t resist rotation, and they have poor
resistance to torque and bending forces.
• K-wires are commonly used as adjunctive fixation for screws or plates and screws that
involve fracture around joints.
• When K-wires are used as the sole for fixation, they are supplemented by casting or
splinting.
• K-wires fixation is adequate for small fragments in the metaphyseal and epiphyseal regions,
especially in fractures of the distal foot, wrist, and hand, and in displaced metacarpal and
phalangeal fractures after closed reduction.

BU SHEHAB HUSSAIN 35
External fixation:

• External fixation provides fracture stabilization at a distance from the fracture site,
without interfering with the soft-tissue structures. This technique provides the stability for
the extremity, maintain bone length, alignment and rotation without the need for casting.
Another advantage of this technique is that is allows us to inspect and treat soft tissue
structures and as well as wounds.
• Indications of external fixation are:
▪ Open fractures.
▪ Septic conditions.
▪ Comminuted fractures.
▪ Bone lengthening.

BU SHEHAB HUSSAIN 36
 9. Multiple trauma, polytrauma. Management of severely injured patients.
Damage control. ATLS guidelines.

Introduction:

• The initial evaluation of a person who is injured critically from multiple trauma is a
challenging task, and every minute can make the difference between life and death.
Mortality can be grouped into immediate, early, and late deaths.
▪ Immediate deaths are caused by a fatal injury of the great vessels, heart, or
neurological system. Immediate mortality occurs at the scene of injury.
▪ Early deaths may occur minutes to hours after the injury. Injured patients frequently
arrive at a hospital before death which usually occurs because of haemorrhage and
cardiovascular collapse.
▪ Late trauma mortality peaks from days to weeks after injury and is primarily due to
sepsis and multiple organ failure.
• Organized systems of trauma care e.g. ATLS are focused on saving the patient from early
trauma mortality, whereas critical care (ICU) is designed to overcome later trauma
mortality.
• The objectives of the initial evaluation of the trauma patient are as follows: (1) to rapidly
identify life-threatening injuries, (2) to initiate adequate supportive therapy, and (3) to
efficiently organize either definitive therapy or transfer to a facility that provides definitive
therapy.
• Many terms exist do describe type of trauma a patient has:
▪ Polytrauma: Combination of injuries with the involvement of at least one the body
cavities whereas each injury by itself or their combination is a life-threatening.
Examples are injury of two cavities or injury of a body cavity and two long bones
fractures. Spine injury with neurological deficit or complex pelvic fracture equals to a
cavity injury.
▪ Multitrauma: Combination of injuries without the involvement of the body cavities
whereas neither the injuries themselves, nor their combination are life-threatening.
▪ Monotrauma: Single, isolated injury of one of the extremities.

Advanced Trauma Life Support (ATLS):

• ATLS is the standard of care for trauma patients, and it is built around a consistent approach
to patient evaluation. This protocol ensures that the most immediate life-threatening
conditions are quickly identified and addressed in the order of their risk potential.
• The algorithm of ATLS consist of the following:
1. Preparation & Triage
2. Primary survey
3. Resuscitation
4. Adjuncts to primary survey and resuscitation
5. Secondary survey
6. Adjuncts to secondary survey
7. Post-resuscitation monitoring and re-evaluation
8. Definitive care

BU SHEHAB HUSSAIN 37
1. Preparation & Triage
▪ The objective of triage is to prioritize patients with a high likelihood of early clinical
deterioration.
▪ Triage of trauma patients considers vital signs and perihospital clinical course,
mechanism of injury, patient age, and known or suspected comorbid conditions.
▪ Findings that lead to an accelerated workup include multiple injuries, extremes of
age, evidence of severe neurologic injury, unstable vital signs, and pre-existing
cardiac of pulmonary disease.
▪ Many scoring systems have been developed to help us prioritize patients:
➢ Revised Trauma Score (RTS)
➢ Injury Severity Score (AIS / ISS)
➢ Glasgow Coma Scale (GCS)
▪ Triage system categorize the patients into the following groups:

2. Primary survey: Primary survey can be repeated until the patient is stable.
▪ In the primary survey, airway, breathing, and circulation are assessed, and
immediate life-threatening problems must be diagnosed and treated.
▪ The primary survey consists of 5 steps (ABCDE) that are performed in order:
A: Airway and c-spine protection:
-Patients who answer questions appropriately have a patent airway.
-Signs of respiratory distress can indicate compromised airways.
-Mouth and larynx should be inspected for any sign of obstruction.
-Unconscious patient should be intubated.
-Assume cervical spine injury in blunt trauma patients until proven otherwise.
B: Breathing and ventilation:
-Assess oxygenation status with pulse oximetry.
-Inspect and auscultate chest wall for injuries.
-If hemodynamic instability is apparent then immediately suspect tension
pneumothorax or massive haemothorax.
C: Circulation with haemorrhage control:
-Check and stop and any present bleeding.
-Restore the hemodynamic stability by any means.
D: Disability/ Neurologic status:
-Assess the patient’s Glasgow Coma Scale score: GCS score less than 8 is an
indication for intubation.
-Assess the pupillary size. (Can indicate focal neurological lesion).
E: Exposure/Environmental control:
-Patient is fully undressed and environment is controlled to protect from
hypothermia or hyperthermia.
BU SHEHAB HUSSAIN 38
3. Resuscitation:
▪ This step focuses on the management of life-threatening problems identified in the
primary survey.
▪ It includes e.g. oxygenation and ventilations, shock management, intravenous lines,
warmed Ringer’s lactate solution, etc.
4. Adjuncts to primary survey and resuscitation:
▪ Radiography of the cervical spine, anterioposterior (AP) chest and anterioposterior
(AP) pelvis. This can provide information about potentially dangerous conditions in
minimum amount of time. eFAST and DPL (diagnostic peritoneal lavage) can also be
performed.
▪ Laboratory studies: CBC, electrolytes level, renal functionals, hCG levels in females.
▪ Blood preparation: contacting the blood bank and making sure that blood is
available in case it is needed.
▪ Urinary and gastric catheterization.
▪ Temperature, ECG and oxygen saturation monitoring.
▪ At this point, the physician should have enough knowledge of the patient’s status to
consider transfer to a higher level of care if needed.
5. Secondary survey:
▪ The secondary survey is performed only after the primary survey has been finished
and all immediate threats to life has been addressed. The secondary survey is a head-
to-toe examination designed to identify any injuries that might have been missed.
▪ The so-called AMPLE history is obtained: A: Allergies, M: Medications, P: Past medical
history, L: Last meal, E: Events prior to accidents.
▪ The patient then should be physically examined from head to toe, including rectal
exam.
▪ During all steps the vitals of the patient should assessed frequently.
6. Adjuncts to secondary survey:
▪ Specialized diagnostic tests are performed to confirm potentially life-threatening
injuries. These tests are done after the patient hemodynamic and ventilation status is
normalized. These tests include CT scanning, MRI, X-ray of extremities, Endoscopy and
ultrasonography.
7. Post resuscitation monitoring and re-evaluation:
▪ Basically, re-checking everything e.g. the vital signs and urinary output.
8. Definitive care:
▪ This step is carried out after identifying the patient’s injuries and their definitive
treatment plan.

BU SHEHAB HUSSAIN 39
Therapeutic approaches: Early Total Care (ETC) vs Damage Control (DC):

• Imagine a trauma patient with serious bone fracture comes to you, you evaluate the patient
and then decide what options do you have to treat that serious fracture. One solution is to go
immediately to the OR and surgically fixate the fracture, and that would be ideal to the patient
regarding recovery and other aspects, but what if the patient is unstable then operating on
such a patient is not an option, instead you try another approaches first stabilizing the patient
and you do external fixation to the fracture. Later, after the patient is stabilised you can do a
surgical fixation and that would be a definitive treatment.
• From the scenario above there are two mean therapeutic approaches that a doctor must
consider for a trauma patient. One is called Early Total Care (ETC) and this approach focuses
on providing early definitive treatment and it is a gold standard approach in
hemodynamically stable patients. The other approach is called damage control and it
focuses on delaying definitive treatment that might harm the patient more. It is the gold
standard approach in hemodynamically unstable patient e.g. shock patient.
Early Total Care (ETC): Damage Control (DC):
Consist of Life-saving operation +Definitive Consist of Life-saving operation – temporary
care treatment
Definitive treatment is delayed until
physiology is improved.
Indicated in hemodynamically stable Indicated in hemodynamically unstable
patient. patient.
Priority is early definitive treatment unless it Initial priorities: haemorrhage control, soft
is contraindicated. tissue management and provisional fracture
stabilization.

Shock: The pathophysiology of Sepsis was mentioned in the lecture, but it is not included here for
simplicity.

• Phases of shock:
1. Compensated: Blood pressure is still maintained, there is oligo-anuria, tachycardia
and the patient is confused.
2. Decompensated: The blood pressure starts to drop, the patient is pale, with
tachycardia, anuria, coagulopathy, metabolic acidosis, respiratory insufficiency and
even loss of consciousness.
3. Irreversible: the circulation collapse, and there is progressive cell death.
• In shock patients an aggressive crystalloid i.e. fluid therapy should be started as soon as
possible, and the response is dependent on how much blood the patient already lost:
▪ Fast response: in 10-20% blood loss.
▪ Transitory response: in 20-40% blood loss.
▪ No relevant effect: in severe blood loss more than 40%.
• Management options of shock complications:
▪ Complex ICU therapy.
▪ Monitoring hemodynamic parameters.
▪ Sufficient respiratory support.
▪ Fluid balance.
▪ Careful wound and fracture management.
▪ Wide-spectrum antibiotic.

BU SHEHAB HUSSAIN 40
 10. Management of the septic condition of soft tissues, bones and joints.

Introduction:

• Skin and superficial tissues can usually get infected by microbes, but the infection is simple
and superficial and easier to manage. In case of trauma the infection is deeper and more
complex and more difficult to treat.
• Basically, any structure along the injured site can be infected including skin, subcutis,
muscles, tendons, ligaments, joints and bones.
• The infection usually starts as a local focus and then spreads to surrounding structures and
possibly to the blood.
• The basic principle of the treatment is the removal of infected nonviable tissues and
administration of antibiotics.

Septic arthritis:

• Septic arthritis is an inflammatory condition of the joints that is caused by microbial agents,
i.e bacteria or less commonly fungi.
• Bacterial septic arthritis is commonly described as gonococcal or non-gonococcal. Niesseria
gonorrhoea and staphylococcus aureus among the most common bacteria causing septic
arthritis.
• Risk factors of septic arthritis:
▪ Age: older than 80 years.
▪ Comorbid conditions, especially diabetes.
▪ Joint damage from arthritis.
▪ Prosthetic joint.
▪ Skin infections.
▪ Immune suppression.
▪ Cirrhosis (due to impaired immunity and metabolism).
▪ Chronic renal failure and haemodialysis.
▪ IV drug abuse.
• Pathogenesis of septic arthritis:
▪ Organisms may invade the joint by direct inoculation (e.g. in therapeutic procedures
or from penetrating damage), by contiguous spread from infected periarticular
tissue (e.g. osteomyelitis), or via the bloodstream (the most common route).
▪ The normal joint has several protective components e.g. synovial cells with
phagocytic activity and bactericidal effect of the synovial fluid. Any other condition
which compromise these protective factors (e.g. rheumatoid arthritis) can be in the
background of septic arthritis.
▪ After successful invasion there will be direct aggressive damage to the joint and
aggressive host inflammatory response.
• Clinical features of septic arthritis:
▪ Joint swelling and pain.
▪ Pain with reduced range of motion, immobility.
▪ Fever.
▪ Signs of sepsis.
▪ Distribution usually monoarticular (affecting one joint at a time).

BU SHEHAB HUSSAIN 41
 ▪ Large joints are mostly involved.
▪ Signs and symptoms of infection may be muted in people who are elderly,
immunocompromised, and in those who abuse IV drugs.
• Diagnostic tests in septic arthritis:
▪ Synovial fluid analysis: high WBCs count.
▪ Blood test: WBCs, ESR, CRP can all be increased.
▪ Gram stain and culture.
▪ Blood culture.
▪ Radiography and ultrasonography (specific changes usually are seen later in the
course of the disease).
• Management of septic arthritis:
▪ Joint drainage: e.g. repeated needle aspiration, surgical drainage and open
arthrotomy or synovectomy.
▪ Antibiotic therapy.
▪ Synovial fluid and blood cultures to evaluate the efficacy of the treatment.
▪ Serial synovial fluid analysis.
▪ Extended duration of treatment (6 weeks).

Infection of prosthetic joints:

• Two major types of prosthetic joint infections exist, early onset and late onset infection.
▪ Early onset infection occurs directly related to surgical wound. Mostly caused by
staphylococcus and streptococcus species. Symptoms tends to be acute.
▪ Late onset infection occurs through hematogenous spread and symptoms tend to be
indolent.
• Therapy includes prolonged courses of antimicrobials and surgical intervention.

Septic bursitis:

• Septic bursitis is bacterial (staph aureus) infection of bursa (fluid-filled sac). Pre-patellar and
olecranon bursae are the most affected.
• Etiology: acute or repetitive trauma.
• This condition is very painful.
• Therapy include drainage/ synovectomy and antibiotics.

Osteomyelitis:

• Osteomyelitis is inflammation of the bone caused by an infecting organism.

• Bone normally is resistant to bacterial colonization but events such as trauma, surgery, the
presence of foreign bodies, or the placement of prostheses may disrupt bony integrity and
lead to onset of bone infection. Osteomyelitis can also result from hematogenous spread
after bacteraemia.
• The major cause of bone infections is staphylococcus aureus.
• Osteomyelitis can be acute or chronic and sub-acute:
▪ Acute osteomyelitis:
➢ In children and young adults.
➢ Children younger than 1 year often have osteomyelitis, septic arthritis and
septicaemia together.
▪ Chronic and sub-acute osteomyelitis:
➢ Mostly follow trauma or surgery.

BU SHEHAB HUSSAIN 42
 ➢ Needs prolonged antibiotic treatment and surgical debridement.
• Risk factors of osteomyelitis:
▪ Comorbid conditions (especially diabetes).
▪ Corticosteroid treatment.
▪ Prosthetic joint.
▪ Skin infections.
▪ Immune suppression.
▪ Cirrhosis.
▪ Chronic renal failure and haemodialysis.
▪ IV drug abuse.
• Pathogenesis of osteomyelitis:
▪ Osteomyelitis tends to occlude local blood vessels, which causes bone necrosis and
local spread of infection.
▪ Microabscesses form inside the bone cavity and later form abscess.
▪ Abscess may expand through the bone cortex and spread under the periosteum,
which can result in subcutaneous abscess formation.
▪ The abscess keeps on expanding into the soft tissues until it is in the joint cavity
(progression to septic arthritis).
▪ Spreading of abscess causes ischemia and osteonecrosis.
• Clinical features of osteomyelitis:
▪ Swelling, pain, redness, etc.
▪ Pain with motion, immobility.
▪ Fever (not always).
▪ Signs of sepsis (in the late phase of the disease).
▪ Systemic symptoms: fatigue, loss of appetite, etc.
• Diagnostic tests of osteomyelitis:
▪ Blood test: elevated WBCs, ESR, and CRP.
▪ Blood culture: mostly staph aureus.
▪ Radiography: negative findings in the early course of the disease.
▪ Scintigrapgy (WBCs labelled with technetium-99m): scan detect the disease in early
stages.
▪ CT scan: useful for guiding needle biopsies, preoperative planning, to check for
lesions in sternum and spine.
▪ MRI: sensitive and excellent from very early to late stages.
▪ Biopsy and histology.
• Differential diagnosis of osteomyelitis:
▪ Tumors: chondroblastoma, Ewing-sarcoma, metastasis, and lymphoma.
▪ Trauma.
▪ Myositis ossificans.
▪ Erythema nodosum.
▪ Cellulitis.
▪ Eosinophil granuloma.
• Treatment of osteomyelitis:
▪ Wide-spectrum, then specific-spectrum antibiotic treatment for 6-8weeks.
▪ Surgical intervention (especially in chronic cases): rapid debridement, antibiotic-
impregnated PMMA-chain, cancellous-bone graft, pedicle-bone graft, tissue flaps,
etc.

BU SHEHAB HUSSAIN 43
▪ After prosthesis implantation:
➢ Early stage associated infection treated with antibiotics.
➢ Late stage associated infection are treated by the removal of the prosthesis,
later revision arthroplasty or resection arthroplasty.
➢ Prosthesis-associated infection is usually difficult to treat because bacteria
form biofilm on the prosthesis (Antibiotics cannot really reach the biofilms).

BU SHEHAB HUSSAIN 44
 11. Inactivity-induced atrophy, reflex dystrophy, compartment syndrome.

Compartment syndrome: NOTE you shouldn’t go to the trauma exam if you do not know this one,
it is almost a complication of all trauma cases and they can it ask in any topic.

• Compartment syndrome occurs when the tissue pressure within a closed muscle
compartment exceeds the perfusion pressure and results in muscle and nerve ischemia. It
typically occurs subsequent to a traumatic event, most commonly a fracture.
• Compartment syndrome may affect any compartment, including the hand, forearm, upper
arm, abdomen, buttock and the entire lower extremity. Almost any injury can cause this
syndrome and it thus it should be kept in mind in every traumatic case.
• Etiology of compartment syndrome:
▪ Any internal or external event that increases pressure within a compartment can
cause compartment syndrome.
▪ Long bones fracture.
▪ Damage of circulation.
▪ Muscles injuries.
▪ Burns. (Because of the swelling of tissues)
▪ Haemorrhage.
• Pathophysiology of compartment syndrome:
▪ Normal myocyte metabolism requires a 5-7 mmHg oxygen tension, which can be
obtained with a Capillary Perfusion Pressure (CPP) of 25 mmHg and an interstitial
tissue pressure of 4-6 mmHg.
▪ In trauma we usually have bleeding or increased fluid extravasation due to
inflammation. When fluid is introduced into a Fixed-volume compartment,
interstitial pressure starts to increase (30 mmHg is considered critical) and
eventually exceeds the CPP, as a result the capillaries collapse, and muscle and
tissue ischemia occur.
▪ After 6-10 hours of ischemia, the myocytes begin to die and lyse and release their
components such as myoglobin, potassium, etc. Released components are toxic
especially to the kidneys and result in acute renal failure.
• Clinical features of compartment syndrome:
▪ Deep aching pain that is worsened by passive stretching of the involved muscles.
Pain is out of proportion to the actual injury.
▪ Paraesthesia or numbness.
▪ Reduced or diminished pulse in the affected limb. If this sign exists, then the
situation is already severe.
▪ Swelling.
▪ Pallor.
▪ Paralysis (late).
• Diagnosis of compartment syndrome:
▪ Presence of the clinical features after typical cause of compartment syndrome e.g.
long bone fracture should raise the suspicion of compartment syndrome.
▪ The suspicion is confirmed by direct measurement of the pressure inside the
affected compartment. A needle with pressure monitor device attached to it is

BU SHEHAB HUSSAIN 45
 inserted into the suspected compartment. A plastic catheter can also be inserted to
monitor the compartment pressure continuously.
• Management of compartment syndrome:
▪ The treatment of choice is early decompression, and this achieved by fasciotomy.
Fasciotomy is an emergency procedure and should be performed within 6 hours.
▪ After decompression, repair of whatever was injured is initiated e.g. repair of vessel,
fracture, etc.
▪ After fasciotomy, Vacuum-assisted closure (VAC) can be performed to promote and
enhance wound healing and closure.
➢ Vacuum-assisted closure (VAC) is a type of therapy to help wounds heal. A
device decreases air pressure on the wound, and this can help the wound
heal more quickly. Advantages of VAC are reduced swelling, remove
bacteria, pull edges of the wound together, and stimulate the growth of new
tissue that helps the wound close.

Reflex sympathetic dystrophy:

• Reflex sympathetic dystrophy (RSD) is a clinical syndrome of variable course and unknown
cause characterized by pain, swelling, and vasomotor dysfunction of an extremity. RSD is
now known as Type 1 Complex Regional Pain Syndrome.
• RSD is usually posttraumatic or postsurgical; however, it can occur in a previously healthy
extremity with no known trigger.
▪ Penetrating wounds associated with RSD: lacerations, abrasions, gunshot wounds.
▪ Other traumatic cases associated with RSD: Crush injuries, neck or shoulder injuries,
chest trauma, sprain, fracture, or dislocations.
▪ Surgeries associated with RSD: fracture repair, arthroscopy, cervical rib resection.
▪ Other disorders associated with RSD: nerve compression syndromes, arthritis, tissue
ischemia.
▪ Systemic disorders associated with RSD: myocardial infraction, stroke, pancreatic
cancer and Herpes zoster.
• Pathophysiology in unknown yet but three conditions has to exist in order for RDS to occur:
▪ A persistent painful lesion.
▪ A predisposition or susceptibility to developing the syndrome.
▪ An abnormal sympathetic reflex.
• Clinical presentation of RDS:
▪ Acute stage (last for 3 months): Burning pain, swelling, redness, vasomotor
instability, hyperhidrosis, demineralization of the underlying bony skeleton.
▪ Subacute stage/dystrophy (4-6months): Persistent severe pain, fixed oedema,
cyanosis, paleness, dry skin, loss of function progresses, and demineralization of the
underlying bony skeleton becomes pronounced.
▪ Chronic/atrophic stage (6-12 months or more): Pain is variable (comes and goes),
oedema subsides, skin is pale, dry and cool, stiffness and loss of function is marked,
and osteoporosis is extreme.
• Diagnosis of RSD is suspected when the patient’s symptoms develop after 4-6 weeks after
one of the associated factors mentioned above e.g. fracture. Actual diagnosis is made
solely on the history and physical examination of patient. There is a diagnostic criteria
established for this condition and it is called the Budapest criteria.

BU SHEHAB HUSSAIN 46
 • Treatment of RSD:
▪ The goal of treatment is to manage the pain and to increase mobility of the affected
limbs.
▪ Physical therapy.
▪ Pharmacological therapy of the symptoms: pain, bone loss, depression
▪ Anti-inflammatory drugs can be used too.
▪ If the patient is not responding to any of the abovementioned options, then we
might consider induction of sympathetic or somatic nerve block either
pharmacologically or surgically.

Inactivity-induced atrophy:

• Muscle atrophy is when muscles waste away. It is usually caused by a lack of physical
activity.
• When a disease or injury makes it difficult or impossible to move an or leg, the lack of
mobility can result in muscle wasting.
• You may have muscle atrophy if:
▪ One of the arms or legs is noticeably smaller than the other.
▪ When you experience marked weakness in one limb.
▪ When you have been inactive for a very long time.
• Typical history e.g. long-term immobility and exclusion of other conditions causing atrophy is
enough to diagnose inactivity-induced muscle atrophy.
• Therapy:
▪ Exercise
▪ Physical therapy
▪ Ultrasound therapy
▪ Proper nutrition
▪ Electric therapy

BU SHEHAB HUSSAIN 47
 12. Replantation, revascularization, microsurgery.

Microsurgery:

• Microsurgery uses the operating room microscope or high-powered loupe magnification to

facilitate the microvascular surgical techniques used to anastomose small vessels and
nerves. Delicate tissue handling and the use of atraumatic suture materials are other main
principles of microsurgery.
• Microsurgical reconstruction is used for complex reconstructive surgery problems when
other options (e.g. primary closure, healing by secondary intention, skin grafting, and local
or regional flap transfer) are not adequate.
• Indication for tissue transfer utilizing microsurgical techniques include the following:
▪ Need to cover exposed vital structures such as joint surfaces, tendon, vessels, and
bone.
▪ Need to restore shape, as in the breast after mastectomy.
▪ Need to restore function, as in the muscles of the face.
▪ Finger/toes reimplantation.
• Under microsurgery in trauma we have 2 important procedures (1) replantation and (2)
revascularization:
▪ Replantation: Re-attachment of a completely amputated body part by re-
establishing arterial inflow and venous outflow.
▪ Revascularization: Re-attachment of incompletely (partial) amputated parts
requiring restoration of both arterial inflow and venous outflow.

Replantation:

• Not all patients with amputation are candidates for replantation. Decision is based on the
importance of the part, level of injury, and expected return of function. For example, hand is
severely compromised if thumb or multiple fingers are lost so replants of these should be
attempted.
• Some of the strong indications for replantation include, multiple digits amputation, thumb
amputation, whole hand amputation, and any amputated part in a child.
• Recommended ischemia times for realiable success:
▪ Digits: 12 hours for warm ischemia and 24 hours for cold ischemia.
▪ Major replants: 6 hours for warm ischemia and 12 hours for cold ischemia.
• A very essential part in the preoperative management of replantation operations is a proper
transfer of the amputate. A proper transportation of the amputate include:
▪ The amputate should be thoroughly washed.
▪ Wrapped in a saline moistened gauze.
▪ Placed in a dry, watertight plastic bag.
▪ Placed in ice. (should Not be in direct contact with the ice).
• At the same time, the patient should be managed in the ER according to the ATLS protocols.
X-rays of amputated part are performed, and the patient should receive tetanus and
antibiotic prophylaxis.

BU SHEHAB HUSSAIN 48
• The Sequence of the operative procedure is:
1. Debridement.
2. Bone fixation e.g. with k-wires, plate, or screws.
3. Tendon re-attachement: first the extensor tendons are repaired then the flexor
tendons.
4. Arterial anastomosis.
5. Nerve re-attachement.
6. Venous anastomosis.
7. Skin closure and dressing.
• If any of the structures above is not viable or not enough for replantation, then a graft
should be used.
• After the operation, the patient should be anticoagulated against thrombi. The patient
should be on antibiotics for 5-7 days.

BU SHEHAB HUSSAIN 49
 13. Head and spine injuries.

Traumatic brain injury (TBI):

• TBI is a traumatically induced structural and/or physiological disruption of brain function as a

result of an external force that is indicated by new onset or worsening of one of the
following clinical signs:
▪ Loss of or a decreased level of consciousness.
▪ Loss of memory for events immediately before or after the injury.
▪ Alteration in mental state (confusion, disorientation, etc.).
▪ Neurological deficits (weakness, loss balance, change in vision, etc.).
▪ Intracranial Lesion/s.
• TBI is the leading cause of mortality in the active population (primary cause of death under
the age of 40 years).
• The most common causes of TBI are motor vehicle accidents, Falls, sports, and firearms.
• TBI can manifest clinically from concussion to coma and death.
• A TBI can be described as being a closed or open brain injury:
▪ Closed brain injury occurs without the skull being broken or penetrated and the
brain has not been exposed. For example, when the rapid movement of the head
backward and forward (acceleration-deceleration movement) causes the brain to
move inside the skull and slam against its hard-inner bone.
▪ Open/penetrating injury is a head injury in which the dura mater is breached. Open
injuries can be caused by high-velocity projectiles e.g. bullets or low-velocity such as
knives. Open injuries can result in open skull fracture, compound fracture or skull-
base fracture.
• There are 2 main types of potential forces that may cause TBI, and by knowing the type of
the force caused the injury one can predict which injury might be caused.
▪ Static force(rare): occurs when a slowly moving object traps the head against a fixed
rigid structure and gradually squeezes the skull, causing many comminuted
fractures that may be enough to deform the brain and lead to fatal injury.
▪ Dynamic forces: occurs when the force is suddenly applied to the head. It has 2
subtypes:
➢ Impact injury: the force delivered to the head at rest e.g. a bullet or a ball
hitting the head. Impact injuries usually result in focal injures (coup-
contrecoup contusion, epidural haemorrhage or subdural haemorrhage).
➢ Acceleration-deceleration injury: here we have sudden motion without
significant physical contact e.g. in motor vehicle accidents. This type of
injury often results in diffuse brain injuries (Diffuse axonal injury, hypoxic
brain damage, brain swelling, diffuse vascular injury, and diffuse neuronal
somatic injury).

BU SHEHAB HUSSAIN 50
 • Pathophysiology: Injuries are divided into 2 subcategories: Primary and Secondary brain
injury: NOTE: I will not write about intracranial haemorrhage and other injuries such as
contusion and diffuse axonal injury. However, I think you need to at least know the basics.

Primary Brain Injury: Secondary Brain Injury:

-Primary brain injury is induced by mechanical -Secondary brain injury is not mechanically
force and occurs at the moment of injury. It induced, and it occurs some time after injury.
result from dynamic forces (impact injury and -Secondary brain injuries are attributable to
acceleration-deceleration injury). further cellular damage from the effects of
-Primary injuries can manifest as focal injuries primary injuries.
(e.g. skull fractures, intracranial hematomas, -Characterized by hypoperfusion/hypoxia,
contusions.) or they can be diffuse as in diffuse altered autoregulation and edema (impaired
axonal injury. cerebral blood flow).
-Primary brain injuries are refractory to most -Secondary brain injuries include increased
treatments. intracranial pressure (ICP), cerebral edema,
hydrocephalus, and brain herniation.
-Secondary brain injury is preventable and
treatable. It is mainly prevented by maintaining
appropriate cerebral perfusion pressure (CPP).
• Since, this is a traumatic case, TBI can be associated with other injuries e.g. C-spine injuries,
or injuries outside the CNS.
• Clinical presentation TBI patients:
▪ Cognitive problems: Memory, learning, decision making, etc.
▪ Physical changes: spasticity, weakness, paralysis, loss of sensation, etc.
• Clinical assessment of TBI patient:
▪ The initial management of patients with TBI is identical to that of all trauma
patients, focusing on the Advanced Life Support (ATLS) principles (topic A9). This
include the primary survey (ABCDE) and the secondary survey. In the primary survey
the brain injury is evaluated by using the Glasgow Coma Scale (GCS), which assess
the person’s ability to follow directions and move their eyes and limbs.

Eye opening: Motor response: Verbal response:

Spontaneous 4 Follows commands 6 Oriented to person, 5
place, and date.
To speech 3 Localizing movement to 5 Confused 4
pain
To painful stimulation 2 Withdrawal movement 4 Says inappropriate words 3
to pain
No response 1 Flexor (decorticate) 3 Says incomprehensible 2
posturing to pain sounds
Extensor (decerebrate) 2 No response 1
posturing to pain
No response 1

▪ The severity of TBI according to the GCS score is as follows:

➢ Severe TBI = 3-8.
➢ Moderate TBI: 9-12.
➢ Mild TBI 13-15.
➢ Patients with GCS score of 8 or less should be intubated immediately.

BU SHEHAB HUSSAIN 51
 ▪ So, obviously TBI varies in severity and thus there has to be system which prioritize
which patients need the most attention and medical care. The triage system
classifies the TBI patient based on the probability of intracranial haemorrhage after
TBI into low, medium, and high-risk patients:
➢ Low risk patients do not need CT and discharged with warning notices e.g. if
they have headache, they should come back immediately.
➢ Medium risk patients need CT scan but it should be delayed for 4h (because
early CT may not detect the injury), if it is normal then they are discharged
with warning notices, however if it is pathological then send the patient to a
neurosurgeon.
➢ For anticoagulated patients, the story is different:
❖ In patients taking vit k antagonists or novel oral anticoagulants
(NOAs), the INR should be checked and if it is above 1.5, urgent CT
must be ordered. If haemorrhage is present, then administer
prothrombin complex (for vit k antagonists) or idarucizumab (for
NOAs) and refer the patient to a neurosurgeon. Also, patients who
take platelet-aggregation inhibitors should have immediate CT.
➢ Factors which increase the risk of post-TBI intracranial haemorrhage include
GCS under 13, neurological signs e.g. seizures, penetrating head injuries, and
severe maxillofacial trauma.
▪ As far as it concerns trauma, management of TBI should involve ATLS and
identifying/predicting immediate threats. After that management is carried in the
neuro-intensive care unit.

Spine injuries:

• Most spinal fractures occur in the thoracic and lumbar spine. Fractures of the thoracic and
lumbar spine may result from high-energy trauma such as a car or motorcycle crash.
• Spinal fracture patterns are classified into 3 major types:
▪ Flexion fracture pattern:
➢ Compression fracture: Fracture in the anterior aspect of the vertebrae, but
the posterior aspect is intact. This fracture is usually stable and rarely
associated with neurologic problems. Compression fractures commonly
occur in patients with osteoporosis.
➢ Axial burst fracture: Here the fracture is on both anterior and posterior
sides. It is often caused by landing on the feet after falling from a significant
height.
▪ Extension fracture pattern:
➢ Flexion-distraction (Chance) fracture: Anterior wedge fracture of the
vertebral body with a horizontal fracture through the posterior elements or
distraction of facet joints and spinous processes. This type of fracture result
from excessive flexion of the spine and this can be seen e.g in car-collision
when the upper body is thrown forward while the pelvis is stabilized by the
seatbelt. It mostly affects the upper lumbar vertebrae and can be associated
with abdominal injuries.

BU SHEHAB HUSSAIN 52
 ▪ Rotation fracture pattern:
➢ Transverse process fracture: this fracture is uncommon and results from
rotation or extreme sideways (lateral bending). It does not affect the
stability.
➢ Fracture-dislocation: this is an unstable injury involving bone and/or soft
tissue in which a vertebra moves off an adjacent vertebra (displacement)
result in serious spinal cord compression.
• Clinical presentation of spinal injuries:
▪ Pain.
▪ Neural deficits: weakness, numbness, tingling.
▪ Neurogenic shock.
▪ Bowel or bladder dysfunction.
• Diagnosis of spinal injuries:
▪ Typical history and physical examination.
▪ Neurological tests e.g. checking reflexes.
▪ Imaging: radiography, CT, and MRI (the study of choice to determine the extent of
damage to the spinal cord).
• Management of spinal fractures:
▪ Nonsurgical treatment: minor fracture or those with column stability are treated
without surgery. Nonoperative management of unstable spinal fractures involves
the use of a spinal orthotic vest or brace to prevent rotational movement and
bending.
▪ Surgical treatment: the goal of operative treatment is decompression of the spinal
canal and stabilization of the disrupted vertebral column. Types of stabilization
procedures are:
➢ Posterior lumbar interspinous fusion by screws.
➢ Posterior rods: effective in stabilizing multiple fractures or unstable
fractures.
➢ Z-plate (anterior thoracolumbar plating system): used for the treatment of
axial burst fractures.
➢ Cage: it serves as a space holder between the affected vertebrae and allows
bone to grow though it, eventually becoming a part of the spine.

BU SHEHAB HUSSAIN 53
 14. Injuries of the chest.

Introduction:

• Thoracic traumatic injury is any type of injury that happens to the chest, because of blunt or
penetrating trauma.
• Structures which can be affected in the chest are ribs, sternum, lungs and pleurae,
tracheobronchial tree, oesophagus, heart, great vessels of the chest, diaphragm.
• Motor vehicle accidents are the most common cause of blunt thoracic traumatic injuries.
Gunshots and stabbing are among the most common causes of penetrating thoracic
traumatic injuries.
• Based on the nature of the point of contact with the thorax, thoracic injuries can be
classified as either blunt or penetrating.
• The common thoracic traumatic injuries are traumatic pneumothorax, rib fracture and flail
chest and pulmonary contusion.
• Traumatic cardiac injuries include cardiac arrest, myocardial contusion, pericardial effusion
and tamponade. The ascending aorta, and thoracic aorta might be injured in patients
sustaining a penetrating chest trauma. Blunt trauma of the chest might result in dissection of
the aorta. Airway injuries include tracheobronchial injury.
• Pulmonary injuries include lung contusions, hematomas, and lacerations. Pulmonary injuries
might be associated with pneumothorax, haemothorax, hemopneumothorax.
• Chest wall injuries include rib fractures, sternum fractures, and fractures of the shoulder
girdle. Flail chest is another example of a chest wall traumatic injury. Chest wall contusions
and bruises are seen after blunt chest trauma.

Blunt and penetrating chest injuries:

Blunt: Penetrating:
• Blunt injury to the chest can affect any • Conditions caused by penetrating chest
one or all components to the chest wall injuries are eventually the same as in
and thoracic cavity. blunt injury. The clinical consequence
• By far the most important cause of depends on the mechanism of the
significant blunt chest trauma is motor injury, the location of the injury,
vehicle accidents. associated injuries and underlying
• The major pathophysiologies illnesses.
encountered in blunt chest trauma • The mechanism of injury may be
involve derangements in flow of air, categorized as low-, medium-, or high-
blood, or both. velocity, as follows:
• Blunt trauma commonly results in ▪ Low-velocity injuries (only
chest-wall injuries e.g. rib fracture. The penetrating) include
pain associated with these injures can impalement e.g. knife wounds,
make breathing difficult, and this may which disrupts only the
compromise ventilation. structures penetrated.
• Blunt trauma can result in space- ▪ Medium-velocity injuries
occupying lesions e.g. pneumothorax (penetrating + blast) include
which interfere with oxygenation and bullet wounds from most types
ventilation by compressing otherwise of handguns and are
healthy lung parenchyma. characterized by much less

BU SHEHAB HUSSAIN 54
 • Blunt trauma that causes significant primary tissue destruction than
cardiac injures e.g. chamber rupture or wounds caused by high-velocity
severe great-vessel injuries frequently forces.
results in death before adequate ▪ High-velocity injuries
treatment can be instituted. (penetrating, blast, and burn)
• For the great majority of patients with include bullet wounds caused
blunt chest trauma, outcome and by rifles and sounds resulting
prognosis are excellent. from military weapons, and
they result in extensive
damage.
• The outcomes of treating patients with
penetrating chest trauma are directly
related to the extent of their injuries
and the timelines with which treatment
is initiated.
Musculoskeletal injuries in chest trauma:

Rib fractures: Flail chest:

-Simple rib fractures are the most common -A flail chest is defined as at least two fractures
injury following blunt chest trauma. per rib in two adjacent ribs which would
-The ribs 4 through 10 are the most commonly produce a free—floating unstable segment. It
injured. interferes with breathing and causes ventilatory
-Rib fractures may compromise ventilation by insufficiency.
a variety of mechanisms. Pain from rib fractures - Flail chest is a clinical anatomic diagnosis
can cause respiratory splinting, resulting in noted in blunt trauma patients with paradoxical
atelectasis and pneumonia. Fragments of or reverse motion of a chest wall segment
fractured ribs can also act as penetrating while spontaneously breathing. This clinical
objects leading to the formation of a finding disappears after intubation with
haemothorax or a pneumothorax. positive pressure ventilation, which
-Symptoms: inspiratory chest pain and occasionally results in a delayed diagnosis of
discomfort, local tenderness and crepitus. the condition. Pain, dyspnoea, tachypnoea and
-Diagnosis: X-ray, (CT). tachycardia can be frequently seen.
-Treatment: Effective pain control, early -Treatment: treatment measures of simple rib
mobilization, Aggressive pulmonary toilet fractures are also applied here. Endotracheal
(exercises that help to clear your airways of intubation and positive-pressure mechanical
secretions), chest physiotherapy and incentive ventilation is applied if respiratory distress
spirometry. develops. Surgical stabilization of chest wall can
provide definitive treatment; however, this is
usually not needed.
Sternal fractures: Scapulothoracic dissociation:
-Sternal fractures are predominantly associated -Scapulothoracic dissociation is a rare injury
with blunt anterior chest injury e.g. motor that is usually the result of severe trauma with
vehicle accident. lateral scapula displacement, clavicular
-Fracture usually occur at the body or the disruption, and severe soft-tissue injury. The
manubrium. displacement is the result of disruption of the
-Clinical presentation: Local tenderness, muscular attachments of the scapula.
swelling and ecchymosis. -This condition is associated with serious
-Sternal fractures are commonly associated debilitating complications such brachial plexus
with rib fractures, long-bone fractures, closed injury and subclavian or axillary artery
head injuries. vascular disruption.

BU SHEHAB HUSSAIN 55
 -Treatment: Analgesics, in case of severe pain -Patients require resuscitation and immediate
and displacement the sternum can be fixed surgical management to identify and repair the
with a plate (ORIF surgery). site of haemorrhage. Shoulder girdle is
stabilized surgically.
Sternoclavicular joint dislocation: Diaphragmatic injuries:
-Sternoclavicular joint dislocation may follow -Diaphragmatic injuries are relatively rare and
direct trauma to the anteromedial aspect of the result from either blunt trauma or penetrating
clavicle that drives it backward and causes trauma.
posterior dislocation. -Diagnosis: chest radiograph and ultrasounds
-In case of this type of injury one must rule out -Treatment: Surgical treatment e.g. suturing the
injuries to the trachea, subclavian vessels, or diaphragm and maintain proper ventilation and
brachial plexus. circulation.
Pneumothorax:

• Pneumothorax is defined as the presence of air or gas in the pleural cavity, which can impair
oxygenation and/or ventilation.
• It is most frequently caused by fractured rib.
• A pneumothorax may be simple, tension, or open.
▪ A simple pneumothorax is often asymptomatic or might cause some mild to
moderate dyspnoea.
▪ A tension pneumothorax is the result of air trapped in the pleural cavity under
pressure resulting in compression on the heart, the major veins, and the normal
lung.
▪ An open pneumothorax occurs in the presence of wound in the chest wall, which
allows airflow to and from the pleural cavity and results in the collapse of the lung.
• Generally, the patient present with inspiratory pain or dyspnoea. On physical examination
the breath sounds are decreased and hyperresonance to percussion.
• Diagnosis: As a doctor one of your basic duties is to recognize pneumothorax from the
physical signs and the history of the patient without the need for any imaging modality.
However, X-ray and CT can reliably diagnose pneumothorax if the case was suspicious.

Tension pneumothorax: Open pneumothorax:

-Tension pneumothorax occurs when there is - An open pneumothorax occurs in the
too much air in the pleural space that results presence of wound in the chest wall, which
in decreased venous return to the heart. allows airflow to and from the pleural cavity
Therefore, a patient with tension and results in the collapse of the lung.
pneumothorax will be in circulatory -Commonly, occur with penetrating chest
compromise. trauma.
-The clinical findings may include a restless -It results in collapse of lung, chest wall
and panicky patient in respiratory distress, defect and significant-to-complete loss of
tachypnoea, hypotension, tachycardia, breath sounds.
distended neck veins, deviation of the -The immediate management is an occlusive
trachea, absent breath sounds, and dressing taped only on three sides in order to
hyperresonance on the affected side. create a valve permitting one-way airflow
-Tension pneumothorax is a life-threatening from the chest cavity to the outside. A chest
condition and requires immediate drain (tube thoracostomy) should be placed
decompression by either needle as soon as possible. After stabilization,
thoracostomy (immediate), or tube operative wound debridement and closure
thoracostomy (definitive) depending on the should be carried on.
circumstances.

BU SHEHAB HUSSAIN 56
Haemothorax:

• Haemothorax is defined as the collection of free blood in the pleural cavity and is diagnosed
in about 50% of major trauma victims. The source of the bleeding is usually the lung
parenchyma and less often the thoracic wall, heart, and great thoracic vessels or the
diaphragm.
• Diagnosis: chest X-rays (should be done in upright position in order to diagnose small
haemothoraces. In supine position significant haemothoraces can be missed).
• Definitive treatment is insertion of a chest drain. This allows drainage of extravasated blood
and allows re-expansion of the collapsed lung. Large clotted haemothorax is evacuated by
thoracotomy or thoracoscopy to prevent fibrothorax and empyema.

Injuries to organs and great vessels:

Lung contusion: Tracheal injuries:

-The most common cause of lung contusion is -Tracheal injury is mostly caused by penetrating
blunt trauma to the chest. However, high- trauma. It represents a life-threatening airway
energy penetrating injuries can also result in problem; most patients die before reaching the
pulmonary contusion. hospital.
-The underlying pathology in lung contusion -Clinical signs: respiratory distress, inability to
consists of alveolar and small blood vessel phonate, stridor. It might be associated with
injury with flooding of the interstitial and pneumothorax and massive subcutaneous
alveolar spaces. This leads to perfusion without emphysema.
ventilation. -Diagnosis: Bronchoscopy
-The clinical presentation may vary from minor -Therapy: Establishment of an adequate airway.
or no symptoms to severe respiratory distress, Done by bronchoscopy-guided endotracheal
hypoxia, and haemoptysis. intubation is feasible. Emergency tracheotomy
-Diagnosis: clinical picture and x-ray or CT. or cricothyroidotomy are another option.
-Treatment: Supportive and vary from
observation and oxygen administration to
mechanical ventilation support.
Bronchial injuries: Esophageal injuries:
-Bronchial injuries mostly caused by -Esophageal injuries are transmural disruption
penetrating injuries. of the esophagus that subsequently lead to
-Clinical signs: respiratory distress, leakage of intraluminal contents into the
haemoptysis, massive pneumothorax, surrounding mediastinum. It can be caused by
ipsilateral breath sounds are diminished or either blunt or penetrating (more common)
absent, hyperresonance upon precision and injuries.
hemodynamic instability due to tension - It can be associated with subcutaneous
pneumothorax or massive blood loss from emphysema, pneumomediastinum,
associated injuries. pneumothorax, and intraabdominal free air.
-Diagnosis: Bronchoscopy if possible. -Diagnosis: Esophageal injuries are investigated
-Therapy: ipsilateral thoracotomy after single- by many techniques including radiography,
lung ventilation is established on the uninjured endoscopy, and thoracoscopy.
side. Debridement of the injury and end-to-end -Complications: Sepsis
anastomosis. -Therapy: Broad-spectrum i.v antibiotics.
Surgery within 24 hours to close the affected
part and to enhance drainage of secretions.
Feeding jejunostomy tube might be needed.

BU SHEHAB HUSSAIN 57
 Cardiac injuries: Thoracic great vessels injuries:
-Cardiac injuries can be caused by blunt injuries -Great vessels injuries can result from both
e.g. crush injuries, acts of violence, or sports or blunt and penetrating injuries.
penetrating injuries. -Injuries to the great vessel are fatal and many
-Clinical signs of blunt cardiac injuries range dies at the scene.
from transient arrhythmias to valve and/or -Patients can present with hemodynamic
myocardium rupture. Patients can be instability signs e.g. hypotension, loss of pulses.
asymptomatic or can manifest signs and Cardiac tamponade and haemothorax can be
symptoms ranging from chest pain to cardiac present too.
tamponade and shock. Patients with blunt -Diagnosis: Helical CT, angiogram.
cardiac trauma may be stable initially, and -Treatment options: emergency thoracotomy,
diagnosis may be delayed as a result. endovascular stent grafts, cardiopulmonary
-Penetrating cardiac injuries on the other hand bypass techniques.
are most of the time lethal.
-Pericardial tamponade present with Beck triad:
high venous pressure(distended neck veins),
low arterial pressure(hypotension), and muffled
heart sounds.
-Treatment options: pericardiocentesis,
diagnostic and therapeutic echocardiography,
thoracotomy, bleeding control with using finger
occlusion, sutures, or staples.
Workup of thoracic injuries:

• Laboratory studies:
▪ A Complete Blood Count (CBC) is a routine laboratory test for most trauma patients.
CBC help us determine volume of blood loss.
▪ Arterial Blood Gas (ABG) important later in the management as it is an objective
measure of ventilation, oxygenation, and acid-base status.
▪ Coagulation profile can be help in patients who receive massive transfusions.
▪ Cardiac enzymes to rule out any cardiac injury.
▪ Urine drug and pregnancy test.
▪ Blood typing.
• Imaging techniques:
▪ Plain and contrast radiography: the study of choice in patients with thoracic blunt
trauma. (Although it can reliably diagnose tension pneumothorax, we shouldn’t
really use it for that purpose because this an emergency situation and there is no
time for imaging).
▪ CT scan: CT of the chest is frequently performed in the trauma patients who are
hemodynamically stable. Helical CT and CTA are used if vascular injuries are
suspected.
▪ Ultrasonography: Can diagnose pericardial effusions or tamponade or haemothorax
(eFAST).
▪ Echocardiography: Transoesophageal Echo can diagnose blunt rupture of the
thoracic aorta, Transthroacic echo can diagnose pericardial effusions and
tamponade, valvular abnormalities, disturbances in cardiac wall motion.
▪ Esophagoscopy: Study of choice for esophageal injuries.
▪ Bronchoscopy: Used to diagnose tracheobronchial injuries.
▪ Electrocardiography (ECG): can rule out blunt cardiac injuries.

BU SHEHAB HUSSAIN 58
The major lethal six conditions to recognize in chest trauma patient:

1. Airway obstruction
2. Tension pneumothorax
3. Cardiac tamponade
4. Open pneumothorax
5. Massive hemothorax
6. Flail chest

BU SHEHAB HUSSAIN 59
 15. Injuries of the abdomen.

Introduction:

• The abdomen can be injured in many types of trauma; injury may be confined to the
abdomen or be accompanied by severe, multisystem trauma. The nature and severity of
abdominal injuries vary widely depending on the mechanism and forces involved.
• Injuries are often categorized by the type of structure that is damaged:
▪ Abdominal wall
▪ Solid organs (liver, spleen, pancreas, and kidneys)
▪ Hollow organs (stomach, small intestine, colon, ureters, and bladder)
▪ Vasculature
• Abdominal trauma is typically also categorized by mechanism of injury:
▪ Blunt trauma: may involve a direct blow e.g. kick, impact with an object e.g. fall on
bicycle handlebars, or sudden deceleration e.g. fall from a height, vehicle crash. The
spleen is the most commonly injured organ in this type of trauma.
▪ Penetrating injuries may or may not penetrate the peritoneum and if they do, may
not cause organ injury. Stab wounds and gunshot wounds are classic examples of
this type of injury. Small bowels are the most injured by penetrating injuries.

Blunt abdominal trauma:

• Blunt abdominal trauma is a leading cause of morbidity and mortality among all age groups.
• Pathophysiology of blunt abdominal trauma: Three mechanisms explain the occurrence of
blunt injuries:
▪ Deceleration: A differential movement between adjacent structures due to rapid
deceleration. Shear forces can cause hollow or solid organs and vascular pedicles to
tear along their lines and points of attachment. Example is in injury of the liver teres
along the ligamentum teres are common.
▪ Crushing: The solid organs trapped between the anterior abdominal wall and
posterior thoracic case are susceptible to crushing injuries. Examples are liver,
spleen and kidneys.
▪ External compression: Compression could be a result of a direct blow from external
compression against a rigid fixed structure. Hollow organs are especially affected by
this mechanism.
• Signs and symptoms of blunt abdominal trauma:
▪ Pain
▪ Tenderness
▪ Gastrointestinal haemorrhage
▪ Hypovolemia
▪ Evidence of peritoneal irritation
▪ Sometimes large amounts of blood can accumulate in the peritoneal and pelvic
cavities without any significant early sign. Presence of bradycardia may indicate the
presence of free intraperitoneal blood.

BU SHEHAB HUSSAIN 60
• Physical signs of blunt abdominal trauma:
▪ Lap belt marks: Correlate with small intestine rupture.
▪ Steering wheel-shaped contusion.
▪ Ecchymosis involving the flanks (Grey Turner sign) of the umbilicus (Cullen sign);
indicates retroperitoneal haemorrhage but is usually delayed for several hours to
days.
▪ Abdominal distension.
▪ Auscultation of bowel sounds in the thorax: may indicate diaphragmatic injury (topic
14).
▪ Abdominal bruit: may indicate underlying vascular disease or traumatic
arteriovenous fistula.
▪ Local or generalized tenderness, guarding, rigidity, or rebound tenderness; suggests
peritoneal injury.
▪ Fullness and doughy consistency on palpation: may indicate intra-abdominal
haemorrhage.
▪ Crepitation or instability of the lower thoracic cage indicates the potential for splenic
or hepatic injuries.
• Diagnosis of blunt abdominal trauma:
▪ Assessment of hemodynamic stability is the most important initial concern in the
evaluation of a patient with blunt abdominal trauma. In the hemodynamic
unstable patient, a rapid evaluation for hemoperitoneum can be accomplished by
means of diagnostic peritoneal lavage (DPL) or the Focused Assessment with
Sonography for Trauma (FAST).
➢ DPL is a diagnostic test of choice for detecting bleeding within the
abdominal cavity after trauma. In this procedure the clinician aspirate
intraperitoneal fluid and wash out the cavity with normal saline (lavage).
▪ DPL is indicated for the following patients in the setting of blunt trauma:
➢ Patients with a spinal cord injury.
➢ Those with multiple injuries and unexplained shock.
➢ Obtunded (low-consciousness state) patients with a possible abdominal
trauma.
➢ Intoxicated patients in whom abdominal injury is suggested.
➢ Patients with potential intra-abdominal injury who will undergo prolonged
anaesthesia for another procedure.
▪ The current FAST examination protocol consists of 4 acoustic windows (pericardial,
perihepatic, perisplenic and pelvic) with the patient supine. An examination is
interpreted as positive if free fluid is found in any of the 4 acoustic windows,
negative if no fluid is seen, and indeterminate if any of the windows cannot be
adequately assessed.
▪ Radiographic studies of the abdomen are indicated in stable patients when physical
examination findings are inconclusive.
▪ CT is the standard for detecting solid organ injuries. CT scans provide excellent
imaging of the pancreas, duodenum, and genitourinary system. CT provides detailed
images of the pathology and thus it can be useful in the operative interventions.
Unlike DPL or FAST, CT can determine the source of haemorrhage.

BU SHEHAB HUSSAIN 61
 • Management of blunt abdominal injury: Management may involve nonoperative measures
or surgical treatment, as appropriate:
▪ Indication for laparotomy in patient with blunt abdominal injury:
➢ Signs of peritonitis
➢ Uncontrolled shock or haemorrhage
➢ Clinical deterioration during observation
➢ Hemoperitoneum findings on FAST or DPL.
▪ Nonoperative management involves closely monitoring vital signs and frequently
repeating the physical examination. Nonoperative management are based on CT
scan diagnosis and the hemodynamic stability of the patient. Patients who are
treated nonoperatively are:
➢ Paediatric patients.
➢ Hemodynamically stable adults with solid organ injuries, primarily the liver
and spleen.

Penetrating abdominal trauma:

• Penetrating abdominal trauma typically involves the violation of the abdominal cavity by a
gunshot wound or stab wound.
• Pathomechanism of penetrating abdominal trauma:
▪ Gunshot wounds: while a gunshot wound involves a high energy transfer giving rise
to an unpredictable pattern of injuries, additional damage is done by the bullet and
bone fragments. The severity of gunshot varies according to the distance of the
victim from the weapon.
▪ Stab sounds have a more predictable pattern of injury.
• Signs and symptoms of penetrating abdominal trauma:
▪ Signs and symptoms of penetrating abdominal trauma depends on various factors,
including the type of penetrating weapon or object, the range from which the injury
occurred, which organs may be injured, and the location and number of wounds.
• Diagnosis of penetrating abdominal trauma:
▪ Initial examination (primary survey) in patient with penetrating abdominal trauma
includes assessment of the following:
➢ ABC: Airway, Breathing, and Circulation.
➢ Level of consciousness.
➢ Location of the wound(s).
➢ Type of the penetrating object.
➢ Amount of blood loss.
▪ Secondarily (secondary survey) is a complete head-to-to physical examination in
hemodynamically stable patients.
▪ Immediate surgical exploration can be indicated in hemodynamically instable
patient.
▪ Lab studies such as CBC, electrolyte level, glucose level, ABG, coagulation profile,
etc.
▪ Imaging studies: Chest and abdominal radiographies (to rule out penetration to the
chest), FAST examination, Abdominal CT (the most sensitive and specific).
• Management depends on the type and location of injury and on the general condition of the
patient and it can range from supportive therapy to surgery.

BU SHEHAB HUSSAIN 62
Blunt splenic injuries:

• The spleen is the most commonly affected organ in blunt injury to the abdomen in all age
groups.
• Clinical presentation:
▪ A detailed history regarding the anatomical location of the injury gives a clue to
splenic damage.
▪ Lower left rib fracture must not be ignored as they are often associated with splenic
rupture.
▪ Severe chest or neurological damage makes an assessment of minor splenic trauma
difficult.
▪ History of malaria, lymphoma, and haemolytic anaemia is important as in these
conditions the spleen is enlarged, and even minor trauma can cause excessive
damage.
• Investigations:
▪ Lab studies: CBC is the most useful indicating deteriorating hemodynamic stability.
▪ The most specific and sensitive study of splenic injury a CT scan of the abdomen
(triple helical scan). CT scan is contraindicated in hemodynamically unstable
patients.
▪ Other investigations include: FAST, DPL, and angiography.
• Management:
▪ Splenic rupture management is either conservative or operative depending on the
hemodynamic stability of the patient.
▪ In hemodynamically unstable patient the management is operative (laparotomy):
➢ We do complete splenectomy in patients with severe multiple injuries,
splenic avulsion, extensive hilar injuries, failure of haemostasis.
➢ Sometimes we can save the spleen and one of these options can be used:
parenchymal suture, use of fibrin glue, use of lase, use of omental patch, use
of mesh bag and partial splenectomy.
▪ Hemodynamically stable patients are treated conservatively (hospital observation
with frequent ultrasound examination).
▪ All patients who undergo splenectomy should be vaccinated against pneumococcus,
Haemophilus influenza type b, and meningococcus.

BU SHEHAB HUSSAIN 63
B – series:

1. Pelvic and acetabular fractures. Traumatic hip dislocations.

2. Femoral neck fractures and their complications. Femoral head fractures.

3. Trochanteric, diaphyseal and distal fractures of the femur.

4. Proximal and middle shaft lower leg fractures.

5. Ligament and meniscal injuries of the knee. Patellar fractures.

6. Pilon fracture. Fractures and ligament injuries of the ankle.

7. Foot fractures and dislocations. Achilles-tendon injuries.

8. Scapula and clavicle fractures. Dislocation of the AC, SC and shoulder joints.

9. Proximal and middle shaft humeral fractures.

10. Elbow fractures and dislocations.

11. Forearm fractures. Distal radius fractures.

12. Carpal and metacarpal injuries. Basic principles of immobilization of the hand.

13. Nerve injuries of the hand. Immediate and delayed nerve repair.

14. Tendon injuries of the hand.

15. Treatment of the septic hand.

BU SHEHAB HUSSAIN 3
 ACETABULUM
Isling A-non-comminuted
Letournel ASIF Associated comminuted
surgay
- B-
extrart both columns
ant wall 1 . -

L 1 column
post wall + post colum
ant column
-

2-part intraart - T-type

Post wall
.

column"transverse
-
ant post hemitransvers
+

post
transverse post wall
+

intraart
-

transverse
PROX RADIUS
-

.
3 :
.

L 2 columns

MANSON

amwa mmm undisplaced

I

margin. displaced
#

#I comminuted
# dislocated

B
AO/ASIF
·
33A-extra-artic .

artic .
TX nail 33B- partial
:
Gamma ,
intermedullary 33C-full artic

YAStable
Spiral
oblique
comminuted

=
43B/C

TALUS : HAWKINS CLASS -

I : talus neck fracture

# :
I + subtalar dislyn
# : # + tibiotalar diskyn

# : Ill + talonavicular diskn

 ↑ & ↑

e force
a + B1 C1 + C1

compleneed

ring ring

* -
antring disruptedaverticalrotational
"-
a
Themipelvis puse
>

>
-
both hemipelvises involved
Pelider
 long

·
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Il

·
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posterolat
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5 simple
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foot fixed to sudden rotation

>
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ground ,
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4 IB

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 contraction
.
3 Indirect : sudden violent guads
 without flexion the posterior
,
capsule
can protect against
the varus
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,

Avulsion rupture
-MCL Fo 12 worse blood
supply
injury
-

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 for MM flex Knee , rotate tibia laterally
Thessaly
-

test 3 for LM- " ", " "

medially
 =
43B/43C

open
reduction - int fixation

a
distaltibiaface proximaLibuatsyndems

lankle fractures
 tendons of :

See

Positive Thompson test. In this test

the patient lies prone with his feet
over the end
of the table. The examiner squeezes
the calf muscles which should
normally result in
contraction of the Achilles tendon,
resulting in plantar exion. If the
Achilles tendon
is completely ruptured, there will not
be any apparent plantar exion.
v
chance of
S
better for better for
younger
patients
older patients ↑ wound complications
↓ wound complication

I
/

Blo
fl
fl
 Don Juan

O
fracture

20-40

120-140

if pieces of broken bone have

-
not been displaced

3 displacemena tracture
meta-diaphhe

avulsion

noctor >
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Inc - hardest to heal >

- 6w/
cast for
nonunion
screw fixation
-last
 in case of

openfractureo
ered

↓ (navicular,cuboid
or sal bones

not displaced

displaced- >
 #
distal

glenoid &

↑
BODY
&
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Acromioclavicular
 glenohumeral

-preparia
n
spike
Neurovascular
damage !

Other
injuries
Boug
Baukart
(Hill-Sack

Solt tissue
Rotator cuff
Neurovascular
·
 /sports
of
elderly-major cause

younger
morbidity

*
g
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go

3
no or minimal
displacement

I displacement ,
fragmentation
13
Supracondylar

Condylar
Absolute stability
-

erior

young
S
 Scapula
Rockwood
Tossy
W
intact
Isling
AC strain CC

I
+

ribssicle
·

neca + - AC torn + CC strain

vertebrae # AC torn C2 town

=
glenoid surgery
+ -
.

·
I 80% middle
Allman 15 % lateral
humeral head #I

mean · III 5% medial

Brace & I nondisplaced

ORIF

[if displaced
I
oriF
-

Distal -
radius
Colles
Smith Forearm ↑ -MAYO
Barton simple radial I undisplaced non-comminuted
A
displaced
=
+
#
Chauffer complex B =
comminuted
Galleazi # dislocated
L
Montegia
↓ Essex
Lopresti

&
placed
located
radius ulna at diff levels associated elbow / wrist
injury
+ +

distal
joint diskn

from elbow joint

distal

joint

[
↑

-
 she looks too
pretty
try to catch her

physical exam >

X-ray
if
X-ray regative ,

cast for 2-3 weeks

>
-
Spicca cast and deck again

Compression
-

>
- Bone
graft

non-union
more unstable !
Surgery !

mediaena
lig/
 Seddon

>
-
segmental demyelination

days weeks

Axonotemesis devyelination + axou

damage
distaltodamage
proximed to

regenerates
damage
= Jagrades W

weeks
years warst !
>
-
damage to axou , epi- peri-
=
,

and endo neusium

 use of crutches
proximal humerus fracture
>
-

difficulty extending

fracture
suprocondylar
decranous fracture
legion in elbow

/
from axilla to wrist
any injury
carpal tunel syndrome
perile dislocation
distal radial fracture
 repair is required for any return of function. The time required for return of function
after repair depends on the location of the lesion and other variables.

Tests that measure nerve functions:

§ Subjective measurement:
o Pinprick test
§ check for pain sensation
o Fine tactile test
§ test for ability to discriminate between touch sensation
o 2-point discrimination tests
§ map out all areas of paresthesia
o Moberg Pick Up test
§ test the ability to perceive constant touch (to locate), precision grip (to
pick up) and cutaneous feedback (to grip)
§ Objective measurement:
o Ninhydrin test:
§ chemical test and it is usually used to detect fingerprints. This test
detects substances that are only produced if the nerves are intact.
Therefore, we can use it to determine the nerve integrity and
function.
o Electrodiagnosis: EMG, ENG

Principles of nerve repair:

The questions involved with nerve repair involve two main areas, (1) when to do the repair and (2)
what type of repair to perform. Surgically, the most favorable form of repair is the end-to-end
approximation. Other options include e.g. nerve graft placement. The repaired nerve should be
without tension.
§ Primary repair (within 5 days)
o Primary repair should always be chosen if the conditions are favorable, however, if
the criteria are not met then we should wait and perform delayed primary closure or
secondary closure
o Primary repair is attempted when
§ lesion is limited
§ the wound is clean and free of contamination that may compromise healing
§ the wound is adequately vascularized to aid nerve healing
§ Delayed primary repair (within 3 weeks)
o Delayed repair should be attempted when
§ The wound defect is big
• wait until there is enough fiber production and mechanical support to
the wound
§ Other concomitant injuries require immediate care
§ Secondary repair (after 3 weeks)

14. TENDON INJURIES OF THE HAND.

Tendon injuries of the hand:

Tendon injuries may include complete or partial tear, strain or avulsion injury. They can be caused by
lacerations, crush injuries, avulsions, burns, animal or human bites.
Tendon injuries in the hand are divided into flexor and extensor tendon injuries. Tendon injuries can
be diagnosed by checking the movement of all joints in the hand. Treatment is important to prevent
contractures.
 Damage to extensor tendons will make the patient unable to straighten one or more fingers
- zone I-VIII

Damage to the flexor tendons will make the patient unable to bend one or more fingers. It is the injury
of the flexor digitorum superficialis (flexes PIP) and perfunda (flexes DIP) and floxor pollicis longus. To
evaluate if the tendon is damaged it is important to go through each one and examine its function.
Extension in one of the fingers during wrist extension suggest flexor tendon injury. Check the FDP by
asking the patient to flex the DIP joint while holding its finger extened. Check the FDS by holding all
the other fingers extended except the finger evaluated, then ask the patient to flex the finger.
- zone 1
- zone 2 = no mans land à often poor outcome & & Neurovasc
poor outcome
- zone 3 = lumbrical origin à often seen with neurovascular injury Injury >
- .

- zone 4 = carpal tunnel injury

zone 5 = wrist - > forearm &

Boutonniere deformity: PIP flexion DIP extension ,

Boutonniere deformity is when the finger exhibits pathologic flexion at the

proximal interphalangeal (PIP) joint and hyperextension at the distal
interphalangeal (DIP) joint. This deformity can be a sign of extensor tendon
damage with subluxcation and migration of the lateral bands. It can be seen in
rheumatoid arthritis. The treatment is a splint which hallows movement of the
DIP joint.

Mallet finger: PIP extension DIPflexion ,

Mallet finger is a deformity of the finger caused by disruption of the terminal

extensor tendon distal to the DIP joint. In this deformity the injured finger bends
towards the palm. The treatment is a splint.

Jersey finger:
Mallet finger is a deformity of the finger caused by disruption of the terminal
flexor tendon distal to the DIP joint. In this deformity the injured finger bends
away the palm. The treatment is a splint.

Tendon repair:
The goal of repair is to restore tendon continuity and function, with a Suture techniques used in
secondary goal of allowing early motion of the injured digit. A tendon can be tendon repair include:
repaired early or late. Although early repair seems to have the best outcome. § Bunnel suture
It has been showed that delayed repair produce significantly worse tendon § Kessler suture
functions. § Adelaide technique
§ Primary repair (<24h) § Kleinert technique
§ Delayed primary repair (<1 week)
§ Secondary reconstruction (2-5 weeks)
verve
Repais
r ubre o One stage tendon reconstruction = tendon transplantation
Delayedany Sc-3wks § Indicated in case of segmental tendon loss and delay in primary repair
2ndary > 3wks (n groft)
.

-suraln .

that lead to scar in the tendon.

§ Tendon used in transplantation can be from palmaris longus, plantaris or
endonRepair
· short foot extensors
o Two stage reconstruction = silicon rod implantation + tendon transplantation
Delayetany Twh
<

Indary 2-Swks
§ Indicated when there is lack of sufficient donor tendon material or for any
I
stage
>
- Tendon Transplantation (Palman's longus other reason that contraindicate immediate tendon transplantation like
I
stage silicone rod transplant Lany
->
+ .
excessive scarring of the tendon bed
contraindic to
t 1stage)
Takeneventually
 15. TREATMENT OF THE SEPTIC HAND.

Septic hand:
Infections of the hand are common, and can lead to significant morbidity if not treated properly. Most
infection results from a neglected wound. The most common causative agent of hand infections is
Staphylococcus aureus.
Surgery is the mainstay treatment for most hand infections and include necrotomy, debridement,
immobilization (for as short as possible, meaning rehabilitation should be started when is possible)
and antibiotic therapy.

Hand infections:
§ Paronychia = infection of the lateral nail fold
§ Cutaneous abscess = localized collection of pus in the skin
§ Felon = fingertip abscess deep in the palm side of the finger
§ Purulent tenosynovitis = infection of a tendon and its sheath
§ Septic arthritis = infection in the joint (synovial) fluid and joint tissues
§ Osteomyelitis = infection of bone
§ Pandactylitis = nonspecific inflammation of a finger or toe
§ Dorsal phlegmone = dissemination of a subcutaneous infection of the back of the hand

Paronychia:
Paronychia refers to the infection of the lateral nail fold. The infection occurs when there is violation
of the seal between the nail plate and nail fold allowing the inoculation of bacteria. It present with
erythema of the skin around the nail, tenderness, pus-filled blisters, changes in nail shape, color or
texture and eventually the detachment of the nail. Complications include spread, which can cause
serious hand infections like infectious tendonitis and osteomyelitis.
§ Treatment:
o If there is no abscess, then frequent hot soaks and possibly a short course of
antibiotics may result in the resolution of the infection
o If pus is present, drainage of the area is required. Drainage is done by making an
incision with a scalpel blade between the nail plate and nail fold
Felon:
A felon is fingertip abscess deep in the palm side of the finger. The infection is typically due to
direct inoculation of bacteria by penetrating trauma. It presents with a throbbing pain and tense
swelling localized to the finger pulp. Complications include edema and increased pressure within
the closed compartment. This in turn, can impair venous outflow and lead to a local compartment
syndrome and myonecrosis. Invasion of the bone can lead to osteomyelitis.
§ Treatment:
o Surgical decompression by incision
o Continuous cleaning
o Antibiotics for 5 days Kanavel sign:
▪ Finger held in slight flexion
Purulent tenosynovitis: ▪ Fusiform swelling of the digit
purulent tenosynovitis refers to the inflammation of a ▪ Tenderness along the
tendon and its sheath caused by bacteria. It can present at tendon sheath
any time following a penetrating injury, with complaints of ▪ Pain with passive extension
pain, erythema, fever and disruption of normal tendon of the digit
function in the hand. The diagnosis is clinical with a positive
kanavel sign, plus culture of the suppurative synovial fluid.
§ Treatment:
 o Nonsuppurative infectious tenosynovitis is treated nonoperatively when
detected early à IV antibiotics and RICE
o Suppurative infectious tenosynovitis is treated surgically à incision followed
by drainage and irrigation with saline and antibiotics

Osteomyelitis:
Bone infection is called osteomyelitis. It is an acute, subacute or chronic inflammatory process
involving the bone and its structures secondary to infection with pyogenic organisms, including
bacteria and fungi. The major cause of bone infections is staph. aureus. The infection is caused by
pyogenic organisms that spread through the bloodstream, trauma, surgery and adjacent infections.
Microabscesses can form inside the bone cavity and later form an abscess. The abscess may expand
through the bone cortex and spread under the periosteum, which
can result in subperiosteal abscess formation. The infection can
expand into the joint cavity leading to septic arthritis and
osteonecrosis.
Treatment of osteomyelitis:
▪ Wide-spectrum
▪ Surgical intervention (especially in chronic cases):
- Rapid debridement
- Antibiotic-impregnated PMMA-chain
- Cancellous-bone graft, pedicle-bone graft, tissue flaps

Septic arthritis:
Septic arthritis is joint inflammation secondary to an infectious etiology, usually bacterial, but
occasionally fungal, viral or other uncommon pathogens. N. gonorrhea, staph. aureus and group A
strep among the most common bacteria causing septic arthritis.
Septic arthritis is usually monoarticular involving one large joint such as the hip or knee; however,
polyarticular septic arthritis involving multiple or smaller joints may also occur.
The infection can occur via hematogenous seeding from systemic infection. it may also result from
direct injury like puncture wounds and intra-articular injections, surgery, soft tissue infections and
adjacent osteomyelitis. After successful invasion there will be an aggressive host inflammatory
response with destruction of the joint, osteonecrosis.
Treatment:
▪ Antibiotic: broad spectrum à narrow spectrum
▪ Joint drainage

Pandactylitis:
Pandactylitits is a nonspecific inflammation of a finger or toe affecting all the tissues. It presents with
signs of inflammation and blisters. It can lead to osteomyelitis.
§ Treatment:
o incision and drainage
o careful cleaning and warm compresses
o antibiotics

Dorsal phlegmone:
Dorsal phlegmone is a dissemination of a subcutaneous infection of the back of the
hand. It may produce extensive maceration. As with any form of inflammation,
phlegmon presents with inflammatory signs like localized pain, warmth, erythema and
diminish function. There may be systemic signs of infection, such as fever, general
fatigue, chills, sweating, headache and loss of appetite.
§ Treatment: drainage by one or several longitudinal incisions over the back of the hand