Principle Management of Wound and Fracture in Emergency Department
dr. Tedjo Rukmoyo, SpOT (K) Spine
Presented in Clinical Update Seminar January 15th 2011
Initial Management ATLS Procedure A : airway B : breathing C : circulation D : disabilities E : exposure
Compressive dressings for hemorrhage
Check Cervical Chest Abdoment
X ray
Head Pelvis Neurovascular
Wound Inspection & Palpation
Concentrate ony Hemorrhage y Locationy Sizey Border y Wound typey Exudatey Infectiony Dressed or undressed
Wound management Evaluate the wound NeuroVasc status Joint Movement X-RAY ! Sterile saline dressing Irrigate with NS 1 or 2 litres
Tetanus status immunity IV antibiotics Prepare minor set Needle Suture material instruments
Wound irrigation
Irrigate with NaCl 0,9 % 1 2 litre Brush, evacuate foreign
body Use : Povidon iodine Savlon Perhidrol
(hidrogen peroxide) Irrigate with NaCl to
cleanse
Debridement
Excision:y Wound Edgey Skin Abrasion y Dead Tissuey Dirty Bone
Evacuate:y Foreign body
Re-Irrigation / Spoel Irrigation Temporary
Primary Closure
Secondary closure & Packing
Dressing Types and Assistive Devices
Dry Dressings dry wound
Wet-to-Dry Dressings wet wound
Packing deep wound
Vacuum Assisted Closure
Compression Elastic Bandage
Principle Wound and Skin coverage
Without skin lossy Primary clossure
y Contraindication :
1. Contamination
2. NV injury
3. Tension
Principle Wound and Skin coverage
With skin loss :y Secondary intention
y Release / counter incision
y STSG, FTSG
y Flap fasciocutaneus, rotational
Fracture Classification
Close (simple) Openy Gustillo Anderson Grade I Grade II Grade III a Grade IIIb Grade IIIc
Gustillo Anderson
> Grade III B
Vascular disruption Arteriography If can be repaired? Possible Limb salvage Failed? amputation?
Debridement and Irrigation
As soon as possible Scrub and brush
wound dirt Superficial
debridement: Identify and explore
-> extend wound Excised non viable tissue
Debridement and Irrigation
Deep debridement : When in doubt take it out Check muscle : 4 c Color Capacity to bleed Contractility Consistency Cover by tissue or moist dressing Remove Foreign body
Debridement Procedure
Irrigation
Use NS, high volume low pressure lavage
For grade II-III : y 6 10 l
Use antiseptics, perhidrol, antibiotic, etc
Upper extremity ImmobilizationOn Accidental Site At the primary health care
(puskesmas or clinics)
Lower extremity ImmobilizationOn Accidental Site At the primary health care
(puskesmas or clinics)
Skeletal Stabilisation
Evaluate vascular status, limb salvage, debridement and irrigation
Stabilize the bone : Restore length Angular alignment Rotation
Will promote healing Decrease pain and
further damage
Method Skeletal stabilisation
Cast : y splint, circular cast
Traction : y skin, skeletal
External fixation : y steinman or K wire
Internal Fixation
Plate and screwy Accurate anatomicaly Mantain /w platey Various types
IM nailsy Restore alignmenty Callus healingy Minimize soft tissue damage
Compartment syndrome
Rehabilitation
Early Range of Motion Isometric, isotonic, isokinetic excercise Motor Power excercise Non weight bearing Partial weight bearing Full weight bearing Return to normal activity
Slide Number 1Initial ManagementWound Inspection & PalpationWound managementWound irrigationDebridementPrimary ClosureSecondary closure & Packing Dressing Types and Assistive DevicesPrinciple Wound and Skin coveragePrinciple Wound and Skin coverageFracture ClassificationGustillo Anderson > Grade III B Debridement and IrrigationDebridement and IrrigationDebridement ProcedureIrrigationUpper extremity ImmobilizationLower extremity ImmobilizationSkeletal StabilisationMethod Skeletal stabilisationInternal FixationCompartment syndromeRehabilitationSlide Number 26