ORTHOPAEDIC TRAUMA

Principle of Management
 The Goals
• To understand the principle of orthopaedic
trauma management
• To be able to work together as a team with
physician or orthopaedic surgeon
• To understand the rationale of operative and
nonoperative care
• To educate patients
 The Outline
What we will discuss today …

• Introduction
• Type of injuries
• Special consideration
• Summary
 The Outline
What we will discuss today …

• Introduction
• Type of injuries
• Special consideration
• Summary
 Definition
Orthopedic trauma:
injury to the elements of the musculoskeletal
system:
- bones
- muscles
- joints
- ligaments
- other soft tissue (skin, nerve, vascular)
 Introduction
- Epidemiology -

Based on mode of injury

There is difference between
dominant cause of injury
between developed and
developing countries

Based on location
 The Outline
What we will discuss today …

• Introduction
• Type of injuries
• Special consideration
• Summary
 The most familiar is FRACTURE
A fracture is …
a break in the structural continuity of bone
 What to do ???
• Patients with suspected fractures require urgent and
sometimes emergent evaluation to determine if
serious complicating conditions exist
• The acute management of uncomplicated
fractures are:
1. Initial clinical assessment
2. Radiographic assessment
3. Immobilization
4. Pain management
5. Patient education and follow-up care
 What to do?

1. Initial Clinical Assessment

• Begin the assessment by looking for life-
threatening injuries using the basic approach of
Basic/Advanced Trauma Life Support
• History – for patient without life-threatening
injuries → may begin with a focused history:
– Mechanism of injury
– Localization and characterization of symptoms
– Concomitant injuries
• Examination – do systematically, comparing both
sides if necessary
– LOOK: deformity? Swelling? Bruise? open wound?
bone exposed?
– FEEL: tenderness? distal neurovascular?
– MOVE: false movement?
 Important!!!
• Avoid checking for crepitation or passive range of
motion or manipulation of the affected area to
prevent exacerbation of pain, fracture
displacement, soft tissue damage, or
neurovascular compromise

• General rule: “splint it where it lies”,

Exception: when distal neurovascular function is
compromised, you should promptly reduce any
apparent dislocation or reposition of the injured
extremity followed by proper splint application
for immobilization
 Deformity

Swelling & bullae

Open wound
 What to do?

2. Initial Radiologic Assessment

• Plain x-ray
The rule of 2’s :
1. 2 joints (proximal and distal of the fracture site)
2. 2 views (combination of AP & lat, or oblique views)
3. 2 limbs (the injured limb and the healthy one)
4. 2 sites (commonly in severe trauma)
5. 2 Occasions (by the time of injuries and sometimes after that)
• Obtain advanced imaging when clinical
findings suggest fracture but plain x-ray are
unrevealing, e.g: CT-scan, MRI
Common pitfall : normal physeal line might be misinterpreted as fracture in
pediatric patients
Example of AP, lateral, and additional oblique view
 What to do?

3. Immobilization
• Why is so important?
– Reduce pain
– Protect from further injury
• Several methods to immobilize: splinting,
casting, bracing, buddy tapping, sling-and-
swathe, skin traction
• Remember to always check for distal
neurovascular BEFORE and AFTER the
application of immobilization
 SPLINTING
• Can be done using simple
splint or slab made of PoP
or fiberglass
• Important rules:
– Rigid enough
– Long enough (to fix 2 joints or
2 limbs)
– Always apply soft and thick
padding on surface with bony
prominent
– Splinting in two planes
stabilize better compared to
single plane
 CASTING
(Circular cast) BRACING
BUDDY TAPPING SLING & SWATHE
SKIN TRACTION
 What to do?

4. Pain Management
• Pain is the 5th vital sign!
• Adequate analgesia is
mandatory for effective pain
control
• Acetaminophen or NSAID is
often sufficient for minor to
moderate fractures
• More severe pain require
treatment with opioids
• Always consider the history of
drug allergy of patients
 What to do?

5. Patient Education & Follow-up Care

What to do next once a fracture and any
associated injuries have been stabilized?

The physician must be able to educate the

patients on the following issues:
– The definitive treatment options
→ consult or refer to orthopedic surgeons
– The complications
→ early, intermediate, and late complication
Fracture Complications
 Remember! Do not let patients suffer more!

• Many patients get misleading information into

doing something harmful and devastating
 A real story of preventable disaster:
a boy, 7 y.o, simple fracture, brought to Mr. Sangkal Putung

Compartment syndrome Volkman’s ischemic contracture

(irreversible!!!)

It is YOUR DUTY to educate the patients to get

the proper treatment, in the right place, by
the right man
 The Outline
What we will discuss today …

• Introduction
• What to do as primary physician?
• Special consideration
• Summary
 Special Consideration
1. Open fracture
2. Dislocation
3. Compartment syndrome

What to do???
 Open Fracture

“When the fracture

makes contact with
outside world”

• Must be able to identify and

to classify
• Look for the TRIAD of the
flowing blood:
• Oozing
• Dark-coloured
• Fat-bubble sign
Open Fracture
 Open Fracture
• This is an emergency
• Treatment is determined by
the type of injury and the
nature of the wound
• All open fractures, no matter
how trivial they may seem,
must be assumed to be
contaminated
WHAT TO DO?
1. Check distal neurovascular
2. Give broad spectrum
antibiotic and anti-tetanus
3. Irrigate the wound with
copious amount of saline
4. Never attempt to insert
back any bone fragment
5. Cover and bandage the
wound
6. Immobilize the fracture
7. Consult or refer for
immediate debridement
 Dislocation
• A dislocation is an
abnormal separation of
two adjacent bones
within a joint
• Check for distal
pulsation and
neurological status
• This is an emergency
• Reposition of dislocated
joint must be done
immediately
Anterior shoulder dislocation
Posterior hip dislocation
Cervical dislocation Elbow dislocation
 Dislocation
WHAT TO DO???
• If you are in remote place
Attempt closed reduction
• If you feel confident and
capable then immobilize

• If you are in doubt

• Referral to orthopedic surgeon Immobilize and refer
is possible
 Compartment Syndrome
• Fractures of the arm or leg can give rise to severe ischaemia
even if there is no damage to a major vessel. Bleeding,
oedema or inflammation (infection) may increase the
pressure within one of the osteofascial compartments
• There is reduced capillary flow which results in muscle
ischaemia, further oedema, still greater pressure and yet
more profound ischaemia - a vicious circle that ends, after 12
hours or less, in necrosis of nerve and muscle within the
compartment.
 Compartment Syndrome
• The classic features of ischaemia
are the five Ps:
– Pain on passive movement
– Paraesthesia,
– Pallor,
– Paralysis
– Pulselessness

WHAT TO DO??
The threatened compartment (or
compartments) must be promptly
decompressed:
- Remove all cast, bandage, dressing, etc
- Close observation of distal perfusion
- Elevate the limb
- Report and refer immediately
Compartment Syndrome
 The Outline
What we will discuss today …

• Introduction
• What to do as primary physician?
• Special consideration
• Summary
 Take Home Message
• Proper management in initial treatment might
prevent severe morbidity or even mortality in
patients
• Good teamwork between primary physicians,
nurse, and orthopedic surgeons is the key to
bring the best result to the patient
Thank you