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Lecture

Soft tissue injury

Vascular injuryPeripheral nerve injury

Spine injury


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Primary Survey

Airway

Breathing

Circulation Disability


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Secondary Survey

Look:

Wound description

Feel :Vascular disturbance???

Move:

Active and passive movement


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Soft Tissue Injury

Soft tissue:

Muscle

Tendon Ligament

Vascular

Nerve


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Soft Tissue Injury

Strain: muscle or ligament tear

Sprain: ligament tear

NeuropraxiaAxonotmesis

Neurotmesis

Compartment Syndrome


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COMPARTMENT

SYNDROME


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COMPARTMENT

SYNDROME

Definition:

Elevation of the interstitial pressurein a closed osseofascial compartment

that results microvascular

compromise


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Occurs when pressure w/i soft tissues in afixed body compartment increases to levelthat exceeds venouspressure,compromising venous blood flow, andlimiting capillary perfusion.

Leads to muscle ischemia and necrosis. TRUE ORTHOPEDIC EMERGENCY


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Contributing Factors

External:

Conditions that reduced size of muscle

compartment (casts/splints); occlusive dressing;eschar of burns

Internal:

Conditions that increase compartment volume:bleeding, swelling, fluid extravasation into tissue


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The Five Ps

Paindisproportionate to the apparent injury

Especially with passive motion or stretch of the involved muscles

ParesthesiaOccurring in the distribution of the sensory nervetraveling in the involved compartment

Pallor

PulselessnessNot specific; Pulses remain normal in most casesunless arterial injury has occurred

Paralysis

If one waits until this sign appears, then full functionrarely returns after treatment


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CS-Recognition

Suspect with long bone fx, crush injuries

Presents as pain out of proportion to physicalfindings, +/- hypoesthesia, pulselessness

(late).


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Measure intra-compartmental pressure

when considering compartment

syndrome

Pressures >40mmHg considered dangerous


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Compartment syndrome should be suspected in

long bone Fxs and Fxs associated w/ significant

vascular injuries or pronounced swelling.

Intra-compartment pressures must be measuredonce the issue of compartment syndrome is

raised.


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ANATOMY

PERIPHERAL NERVE INJURY


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Pathophysiology

Types of injury:

Traction, stretch and contusion

Missiles (gunshot wounds)

Compression and ischemia

Thermal and electrical injuries


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Pathophysiology


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Pathophysiology

Seddon grade ( 1943 )

Sunderland grade ( 1951 )


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Nerve Injury ClassificationSeddon Sunderland Pathophysiologic Basis

Neuropraxia I Local myelin damage. Axons preserved. No degeneration.

Axonotmesis II Endoneural tube preserved. Axon degeneration.

III Loss of endoneural tube continuity. Perineurium intact. Axon degeneration.

IV Endoneural tube and perineurium disrupted. Epineurium intact. Axon

degeneration.

Neurotmesis V Complete loss of neural continuity.


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Neuropraxia

Dysfunction and/or paralysis without loss of nervesheath continuity and peripheral walleriandegeneration (Ristic, 2000; Schwartz, 1999).

Axonotmesis Result of damage to the axons with preservation of the neural

connective tissue sheath (endoneurium), epineurium,

Schwann cell tubes, and other supporting structures (Colohan,1996; Trumble, 2000; Grant, 1999).


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Neurotmesis

Axon, myelin, and connective tissue

components are damaged and disrupted or

transected (Greenfield, 1997; Ristic, 2000;

Schwartz, 1999).

Recovery axonal regeneration ( - )

Selected Muscle Evaluation for


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Selected Muscle Evaluation for

Diagnosis of Motor Nerve Injury

I. Median nerve: intrinsicA. Thumb-palmar abduction (abductor pollicis brevis)

II.

Median nerve: extrinsic

A. All flexor digitorum sublimiB. Flexor profundus digitorum to indexC. Flexor pollicis longusD. Flexor carpi radialis

III. Ulnar nerve: intrinsicA. First dorsal interosseous muscleB. Muscles of the hypothenar eminence

IV. Ulnar nerve: extrinsicA. Flexor digitorum profundus, small fingerB. Flexor carpi ulnaris

V. Radial nerve: extrinsicA. Wrist extension (extensor carpi radialis brevis and longus, extensor carpi ulnaris)B. Extension of fingers at metacarpophalangeal joint (extensor digitorum communis, extensor indicis proprius,extensor digiti minimi)


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Sensory Evaluation for Specific

Peripheral Nerve Injury

I. Median nerve -- Pulp of thumb and index fingerII. Palmar cutaneous branch of median nerve -- Proximal palm over thenar eminence

III. Ulnar nerve -- Pulp of small finger

IV. Dorsal cutaneous branch of ulnar nerve -- Dorsal ulnar surface of hand

V. Radial nerve -- Dorsal radial hand over first web space

VI. Digital nerve -- Area of the distal phalangeal joint flexion crease


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Therapeutic Management

Acute Phase

Immobilization period

Post immobilization period

Recovery Phase

Motor retraining

Desensitization

Sensory reeducation

Chronic Phase

Surgical approach


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Acute Phase

Immobilization period ( splinting

period )

Goals : minimize tension at repair site

protect the nerve from disruption

resolution of inflammatory reaction


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Acute Phase

Plaster cast or removable plastic

splint

Positioning : avoid tension at the

repair site

Monitoring pressure sores

Post immobilization period :

Increase of range of motion

Enhancement of function

Patient education


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Increase ROM

Gradually

Begin from active ROM

If progress slow : passive ROM exercise may begin Serial adjusted of the splint


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Enhancement of function :

Splinting

Radial nerve palsy :simple wrist cock up

splint,phoenix outriggers splintMedian nerve injury : hand base splint, web

space splinting

Ulnar nerve injury : dorsal hand base splint


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Patient education:

Inform concern

Simple, realistic

Communication between therapist and

surgeon


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Recovery Phase

Motor retraining :

Control strengthening

Electrical stimulation

Nerve radial lesion : key exercise :wrist, finger andthumb extension

Nerve median lesion : key exercise : thenar intrinsic

muscle

Nerve ulnar lesion : key exercise : fingers abduction andadduction.


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Recovery Phase

Desensitization

Use of modalities and procedure designed to reducethe symptom of hypersensitivity

5-10 minutes, 3-4 times per day

Technique :

Barbers approach texture

Contac particle

Vibration

Massage

TENS

Fluid therapy


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Recovery Phase

Sensory reeducation:

A method by which the patient learns to

interpret the pattern of abnormal sensoryimpulse generated after an interruption in the

peripheral nervous system

Dellon : recovery : pain,vibration 30

cps,moving touch,constant touch, vibration

256 cps.


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Sensory reeducation

First phase : perception vibration 30 cps ,

moving touch : begin sensory

reeducation

Second phase : moving touch,constant

touch good at fingertips ,tactile

recognition : texture,shape and size

object


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Chronic Phase

Functionally limiting residual deficit.

Surgical approach:

Nerve exploration and grafting

Joint fusion Tendon transfer


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Tendon transfer

Low injury (wrist) High injury (elbow)

MEDIAN NERVE:Thumb Opposition(loss of FBP) (note

thumb opposition is combination of

flexion and adduction)1.Ring finger FDS transfer to APB

via a pulley made in the FCU

tendon at the level of the

pisiform.2.MCP +/or IP joint fusion

For index and middle finger flexion

FDP of index and middle finger sutured side to side to FDP

of ring and little fingers, +/- ECRL tendon transfer to FDP for

extra strength

For flexion of IP joint of thumb -Brachioradialis transfer to FPL

For thumb opposition-Extensor indices transfer to Abductor

pollicis brevis


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Tendon transfer

ULNAR NERVE:For Adductor pollicis and FPB (thumb

opposition)

1. Absent FPB = Ring finger FDS

transfer to APB via a pulley made

in the FCU tendon at the level of

the pisiform.2.If FPB working and adductor

not = use extensor indices

transfer through interosseous

membrane to adductor pollicis

For loss of action of interrosei and

ulnar 2 lumbricals

1.Split tendon transfers of FDS+

/- EIP & EDQ, to radial dorsal

extensor apparatus (tenodesis

procedures)

2.Or stabilise MCP joint with

Zancolli capsulodesiswhere the

volar capsule is tightened to

produce slight flexion of MCP

joint (not very successful).

+For loss of FCU - Use ECRL transfer for power
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Tendon transfer

COMBINED MEDIAN &

ULNAR NERVES:For function of the

interrossei and lumbricals,

to restore flexion of MCPjoint and extension of IP

joints - Brands ECRB graft

with a plantaris graft to

increase length, attached

to insertion of intrinsics

Thumb opposition - FDS(ring finger) via FCU pulley

to EPL

Thumb adduction (pinch) -

EIP to Adductor pollicis

very difficult problemFor function of the long flexors & interrossei

and lumbricals, to restore flexion of MCPjoint and extension of IP joints - Zancolli

Capsulodesisof MCP joints, ECRL to FDP, BR to

FPL, ECU (with free graft) to EPL

Thumb fusions
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Tendon transferRADIAL NERVE:(Radial wrist extensors

functioning:)wrist extension-

Pronator Teres to ECRB

MCP joint extension -

FCR / FCU to EDCor

FDS to EDCextension and

abduction of the thumb

-PL rerouted to EPL

If radial nerve might still

recover keep EPL incontinuity and bring

palmaris longus upward
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SPINAL INJURY


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42

The Spine Composed of 33

vertebrae

7 cervical

12 thoracic

5 lumbar

5 sacral + 4

coccyx (fused)

Act to support the trunkand transfer muscularload


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Spinal Injuries

>80% occur in young males

Motor vehicle accidents, falls from height, gunshot

wound Worrisome presentations:

pain over spine in setting of trauma

loss of motor function

incontinence

priapism


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Spinal Injuries

Additional risk factors for spinal PAIN:

Metastatic cancer

Osteoporosis, rheumatic dz, steroid use

(compression fracture)

IV drug use (epidural abscess)

Spinal hardware


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Cervical Spine Injuries (CSI)

The cervical spinal column is extremely

vulnerable to injury.

The seven cervical vertebrae, whose specific

facet joint articulations allow movement in

the planes of flexion, extension, lateral

bending, and rotation, have attached at the

cephalic aspect the skull and its contents.


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Spinal Injury

Assessment

ABCs

Immobilize neck and back

GCS, motor/sensory/sphincter tone exam

Imaging

Plain c-spine films (lateral only detects >85% of

cervical spine injuries)

CT/MRI for injuries with neuro deficits and

identifiable spine fractures.


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CLASSIFICATION

Compressive Flexion (CF)

Vertical Compression (VC)

Distractive Flexion (DF)

Compression Extension (CE)

Distractive Extension (DE)

Lateral Flexion (LF)


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TREATMENT

The goals of treatment of CSI are

(1) To realign the spine,

(2) To prevent loss of function of undamaged

neurological tissue,

(3) To improve neurological recovery,

(4) To obtain and maintain spinal stability,(5) To obtain early functional recovery


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Nonoperative Treatment

Management involves treating the multipletraumas and, more specifically, treatingconcomitant neurologic injury

The use of steroids for neurologic injury has

become the standard to prevent secondarycauses of spinal cord damage Doses

within 3 hours: methylprednisolone of 30 mg/kg overan hour intravenously followed by 5.4 mg/kg/h for the

next 23 hours more than 3 hours but less than 8 hours postinjury,

the 5.4 mg/kg/h is extended for 48 hours


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For a stable CSI with no compression of theneural elements, a rigid cervical brace or halo

for 8 to 12 weeks usually produces a stable,

painless spine without residual deformity.

Stable compression fractures of the vertebral

bodies and undisplaced fractures of the

laminae, lateral masses, or spinous processes

also can be treated with immobilization in a

cervical orthosis.


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skeletal tractionthrough spring-loadedGardner-Wells tongs or

a halo ring.

Unilateral facetdislocations that are

reduced in traction maybe immobilized in a halovest for 8 to 12 weeks

l bili i ( d i k l


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Halo Vest Immobilization (Perry and Nickels

in 1959)

Many trauma patients with unstable CSI are initially

managed with cervical traction through a halo ring


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observed closely.

Because subacute instability may occur

despite adequate initial physical and

roentgenographic examinations, a second

complete evaluation should be performed

within 3 weeks of injury.

Serial roentgenogramsweekly for the first3, 6 weeks,and 1 year

Complications of halo immobilization have been


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Complications of halo immobilization have been

reported to occur in as many as 30% of patients


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Operative Treatment

Unstable injuries of the CSI, with or without

neurological deficit, generally require

operative treatment.

In most patients early open reduction and

internal fixation are indicated to obtain

stability and allow early functional

rehabilitation.


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PITFALLS AND COMPLICATIONS


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1. NEUROLOGICAscending paralysis

2. SPINAL DEFORMITYlate instability and deformity

3. PULMONARYAtelectasis and pneumonia

4. GASTROINTESTINALgastrointestinal hemorrhage

5. OPERATIVE

wound infections

massive hemorrhage.

dysphagia, fistula formation

dysphagia, fistula formation

increased neurologic deficit

retropulsion of a ruptured disc causing spinal cordcompression

nonunions

6. BRACINGskin breakdown


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Thoracic and Lumbosacral Fractures The most frequent causes are:

motor vehicle accidents (45%),

falls (20%),

sports (15%),

acts of violence (15%)

In older patients (i.e., age 75 years and older),falls account for 60% of spinal fractures

Males are injured four times more frequently

than females.


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Introduction A few very minor cases can be treated with

bed rest and physiotherapy;

60 % of lesions can be managed with closed

treatment;

Only 30 % will require surgery.


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Classification of Thoracolumbar Fracture

COMPRESSION FRACTURES

BURST FRACTURES

FLEXION-DISTRACTION FRACTURES

FRACTUREDISLOCATIONS


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Dennis Fracture Classification

B t F t


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Burst fractures, according to Denis. A

type A burst fracture (A) involves both end plates,

type B (B) involves only the superior end plate.

type C fracture (C) includes the inferior end plate,

type D (D) injury entails rotation.

type E fracture (E) is characterized by lateral wedging of the vertebral body

Burst Fractures

Flexion Distraction Fractures (Seat Belts)


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( )

Seat belt-fractures.A: Injury to soft-tissues only.

B: Bony chance fracture.

C: Mixed injury.

Fractures Dislocation


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Fractures Dislocation

Fracture dislocations.A: Flexion-rotation.B: Shear.

C: Flexion-distraction.


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Three-column model of

Denis.A: Anterior column.

B: Middle column.

C: Posterior column.

Algorithm for


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Algorithm for

Treatment Thoracolumbar Fracture

The goals of treatment operative or


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The goals of treatment, operative or

otherwise are:

1. Protect neural elements, restore/maintainneurological function

2. Prevent or correct segmental collapse anddeformity

3. Prevent spinal instability and pain

4. Permit early ambulation and return tofunction

5. Restore normal spinal mechanics

Non Operative Treatment


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p

Only 20% to 30% of spine fractures require

surgery.

Nonoperative management may consist

bed rest,

casting,

application of an orthosis,

often some combination of these

Indication


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Indication

for Non Operative Tretment:



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Single-column injuries (e.g., compression fracture,laminar fracture, spinous process fracture) aretreated in an off-the-shelf bracethat encouragesnormal spinal alignment and limits extreme motion

More significant compression fractures may betreated inmolded orthosis.

Two-column injuries, including severe compressionfractures, mild to moderate burst fractures, and

bony Chance fractures, are too unstable to bebraced but may well be reduced and maintained atbed rest or in ahyperextension cast


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Surgery

Indication1. Greater than 50% axial compression.2. Greater than 20 angular deformity.

3. Multiple contiguous fractures.

4. Neurologic injurycomplete, incomplete, orroot.

5. Three-column injuries and dislocations.

6. Patients with extensive associated injuries.

7. Greater than 50% canal compromise at L-1and 80% compromise at L-5.

Surgery


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1. Timing

Still controversial.

Most authors agree that in the presence ofa progressive neurological deficit,

emergency decompression is indicated Complete spinal cord injuries or static

incomplete spinal cord injuries, someauthors advocate delaying surgery forseveral days to allow resolution of cordedema, whereas others favor early surgicalstabilization


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The indirect approach to decompression

of the spinal canal generally involvesinsertion of posterior

Instrumentation (Harrington, Edwards,

Cotrell-Dubousset, or Texas Scottish RiteHospital implants)


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Stretch the spinal cord, causing serious neurological injury. Posterior reconstruction of severe burst fractures without restoring

the anterior weight-bearing column exposes instrumentationsystems to excessive cantilever-bending forces, resulting in acutepedicle screw-bending failure, or late collapse and fatigue failure.

If the normal thoracolumbar lordosis is not restored at the time ofsurgery, the forces of weight bearing will fall anterior to the lumbarspine and pelvis, imparting an exaggerated flexion moment on thefracture and fixation construct,predisposing to instrumentationfailure.

Finally, failure to expose the thecal sack completelyfrom pedicleto pedicle and endplate to endplateduring an anteriordecompression may result in persistent neurologic impairment.


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Endoscopic splitting of the diaphragm also

made it possible to open up the upper

sections of the lumbar spinethat the area

between the third thoracic vertebra and thethird lumbar vertebra is now accessible to

endoscopic surgery

T h i l R i


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Technical Requirements

1. Image Transmission

The image transmission system consists of a rigid 30

angled optic linked to a threechip camera with remote

release of the digitally recorded image

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