TRAUMA PART 2:

CHEST, ABDOMINAL,
ORTHOPAEDIC

Angel M Rodriguez PGY2
Mercy Catholic Medical Center
Chest Trauma
Chest Trauma
Accounts directly for or is a contributing factor in 50% of deaths
due to trauma
Early deaths are commonly due to (1) airway obstruction, (2) flail
chest, (3) open pneumothorax, (4) massive hemothorax, (5)
tension pneumothorax, and (6) cardiac tamponade.
Later deaths are due to respiratory failure, sepsis, and
unrecognized injuries.
Eighty-five percent of chest injuries do not require open
thoracotomy
The first priority of management should be to provide an airway
and restore circulation.
Types of Injuries
Chest Wall
Trachea and Bronchus
Pleural Space
Lung Injury
Heart and
Pericardium
Esophagus
Thoracic Duct
Diaphragm
Chest Wall
Rib fracture is the most common chest injury.
With simple fractures, pain on inspiration is the
principal symptom; treatment consists of providing
adequate analgesia.
Multiple fractures, intercostal nerve blocks or
epidural analgesia may be required to ensure
adequate ventilation.
Flail chest occurs when a portion of the chest wall
becomes isolated by multiple fractures and
paradoxically moves in and out with inspiration and
expiration with a potentially severe reduction in
ventilatory efficiency.
Chest Wall
An associated lung contusion may produce a
decrease in lung compliance not fully
manifest until 1248 hours after injury.
Serial blood gas analysis is the best way to
determine if a treatment regimen is adequate.
Most cases require ventilatory assistance for
variable periods of time.
Trachea and Bronchus
Blunt tracheobronchial injuries are often due to
compression of the airway between the sternum and
the vertebral column in decelerating or high-velocity
crush accidents.
80% of all injuries are located within 2.5 cm from the
carina.
Most patients with penetrating tracheobronchial
injuries have pneumothorax, subcutaneous
emphysema, pneumomediastinum, and hemoptysis.
Trachea and Bronchus
Tracheobronchial injury -> massive air leak or when the lung
does not readily reexpand after chest tube placement.
Bronchovenous fistula-> Systemic air embolism. If suspected ->
emergency thoracotomy with cross-clamping of the pulmonary
hilum on the affected side. Dx is confirmed by aspiration of air
from the heart.
In blunt injuries, tracheobronchial injury may be suspected only
after major atelectasis that develops several days later. Dx may
require flexible or rigid bronchoscopy.
Immediate primary repair is indicated for all tracheobronchial
lacerations.
Pleural Space
Hemothorax-minimal (350 mL); moderate (3501500 mL) or
massive (1500 mL or more).
In 85% of cases, tube thoracostomy is the only treatment
required
If bleeding is persistent-> more likely to be from a systemic (eg,
intercostal) rather than a pulmonary artery
If > 200 mL/h or the total hemorrhagic output exceeds 1500 mL,
thoracoscopy or thoracotomy should usually be performed.
Thoracoscopy effective in controlling chest tube bleeding in 82%
of cases. Also 90% effective in evacuating retained
hemothoraces.
Pleural Space
80% of patients with pneumothorax also have blood in the pleural
cavity
Most cases of traumatic pneumothorax -> tx with immediate tube
thoracostomy.
Tension pneumothorax-> when a flap-valve leak allows air to
enter the pleural space but prevents its escape; intrapleural
pressure rises, causing total collapse of the lung and a shift of
the mediastinal viscera to the opposite side, interfering with
venous return to the heart. Tx placement of a large-bore needle
or plastic angiocatheter in the pleural space then tube
thoracostomy.
Sucking chest wounds tx by an occlusive dressing and tube
thoracostomy.
Lung Injury
Pulmonary contusion due to sudden parenchymal concussion
occurs after blunt trauma or wounding with a high-velocity
missile.
Occurs in 75% of patients with flail chest but can also occur
following blunt trauma without rib fracture.
35% of these patients have an associated myocardial contusion.
x-ray findings may not appear until 1248 hours after injury-
>patchy parenchymal opacification or diffuse linear peribronchial
densities that may progress to diffuse opacification ("white-out)
15% of patients with pulmonary contusion die
Lung Injury
Lung lacerations are caused by penetrating injuries, and
hemopneumothorax is usually present
Tube thoracostomy is indicated to evacuate pleural air or blood
and to monitor continuing leaks.
Lung hematomas are the result of local parenchymal destruction
and hemorrhage.
The x-ray appearance is initially a poorly defined density that
becomes more circumscribed a few days to 2 weeks after injury.
Most resolve adequately with expectant treatment.
Cystic cavities occasionally develop if damage is extensive.
Heart and Pericardium
Blunt injury to the heart is most often from
compression against the steering wheel in
MVA
In decline with the increasing prevalence of
airbag technology

Blunt myocardial injury
Early -> friction rubs, chest pain, tachycardia, murmurs,
dysrhythmias, or signs of low cardiac output.
EKG if normal and the patient is asymptomatic, the workup is
complete.
An abnormal EKG -> echocardiogram.
IF injury on echocardiogram or hemodynamic instability (or both),
then -> ICU and managed depending the injury.
An abnormal EKG with a normal echocardiogram -> at least 24
hours in telemetry unit and daily repeat EKGs until stable or the
dysrhythmia resolves.
Standard measurement of cardiac enzymes is not useful and has
no role in the diagnosis of blunt myocardial injury.
Blunt myocardial injury
Management of symptomatic blunt myocardial injury -> same as
for acute myocardial infarction.
Hemopericardium may occur without tamponade and can be
treated by pericardiocentesis.
Tamponade in blunt cardiac trauma is often due to myocardial
rupture or coronary artery laceration.
->distended neck veins, shock, and cyanosis -> thoracotomy and
control of the injury
If cardiopulmonary arrest occurs before the patient can be
transported to the operating room -> emergency room
thoracotomy with relief of tamponade.
Penetrating
cardiac injuries


Tx-> prompt thoracotomy, pericardial decompression, and control
of hemorrhage.
Most patients do not require cardiopulmonary bypass.
The standard approach has been to repair the laceration using
mattress sutures with pledgets while controlling hemorrhage with
a finger on the heart.
Several studies have demonstrated that in most cases,
emergency temporary control of hemorrhage from cardiac
lacerations can be achieved with the use of a skin stapler
Following stabilization of the patient, the staples can be removed
after definitive suture repair is performed in the operating room.
Heart and Pericardium
Pericardiocentesis or creation of a pericardial
window is reserved for selected cases when the
diagnosis is uncertain or in preparation for
thoracotomy.
In approximately 75% of cases of stab wounds and
35% of cases of gunshot cardiac wounds, the
patient survives the operation.
However, it is estimated that 8090% of patients
with gunshot wounds of the heart do not reach the
hospital
Esophagus
well protected
perforation from penetrating trauma infrequent.
Blunt injuries are exceedingly rare.
The most common symptom of esophageal perforation is pain;
fever develops within hours in most patients.
Hematemesis, hoarseness, dysphagia, or respiratory distress
may also be present.
Hamman's sign (pericardial or mediastinal "crunch" synchronous
with cardiac sounds).
X-ray findings on plain chest films include evidence of a foreign
body or missile and mediastinal air or widening.
Pleural effusion or hydropneumothorax usually on the left side.
Esophagus
Contrast x-rays of the esophagus should be performed but are
positive in only about 70% of proven perforations.
NGT should be passed to evacuate gastric contents.
If recognized within 2448 hours after injury, the esophageal
perforation should be closed and pleural drainage instituted with
large-bore catheters.
Repair include buttressing of the esophageal closure with pleural
or pericardial flaps; pedicles of intercostal, diaphragmatic, or
cervical strap muscles; and serosal patches from stomach or
jejunum.
Illness and death are due to mediastinal and pleural infection.
Thoracic Duct
Chylothorax and chylopericardium are rare
complications of trauma but are difficult to manage
Symptoms are due to mechanical effects of the
accumulations, eg, shortness of breath from lung
collapse or low cardiac output from tamponade.
The diagnosis is established when the fluid is shown
to have characteristics of chyle.
Thoracic Duct
Tx-> fat-free, high-carbohydrate, high-protein diet and the
effusion aspirated.
Chest tube drainage should be instituted if the effusion recurs.
Lipid-free total parenteral nutrition with no oral intake may be
effective in treating persistent leaks.
Three or 4 weeks of conservative treatment usually are curative.
If daily chyle loss exceeds 1500 mL for 5 successive days or
persists after 23 weeks of conservative treatment, the thoracic
duct should be ligated via a right thoracotomy.
Intraoperative identification of the leak may be facilitated by
preoperative administration of fat containing a lipophilic dye.
Diaphragm
Penetrating injuries of the diaphragm outnumber blunt
diaphragmatic injuries by a ratio of at least 6:1.
Diaphragmatic lacerations occur in 1015% of cases of
penetrating wounds to the chest and in as many as 40% of cases
of penetrating trauma to the left chest.
as many as 25% of patients are in shock when first seen.
CXR is a sensitive diagnostic tool, it may be entirely normal in
40% of cases.
The most common finding is ipsilateral hemothorax, which is
present in about 50% of patients.
Diaphragm
Passage of a NGT before x-rays will help to identify an
intrathoracic stomach.
CT scan or contrast x-rays may be necessary
A transabdominal surgical approach should be used in
cases of acute rupture.
The diaphragm should be reapproximated and closed with
interrupted or running nonabsorbable sutures.
Chronic herniation is associated with adhesions of the
affected viscera to the thoracic structures and should be
approached via thoracotomy, with the addition of a separate
laparotomy when indicated.
Abdominal
Trauma
Questions?
Break?
Key points
Damage control
Exploration
Spleen
Liver
GI
Pancreas-duodenum
Vessels
Damage control
When in intraop metabolic failure:
Hypothermia
Acidosis
Coagulopathy
More likely to cause the death- unless
bleeding.
Damage control
Hypothermia
If initial temp less than 35 or progressive
decrease->inability to control bleeding
Acidosis
Leads progressive decrease in cardiac
performance and increase susceptibility to
arrythmias.
Damage control should be practiced when pH<7.2
Damage Control
Coagulopathy
Bleeding from edges- diffuse oozing
Principles
Rapid control of bleeding
Temporizing measures for non bleeding injuries
Packing of oozing surfaces
Rapid abdominal closures
RESUSCITATION IN ICU
Packing but not
creating compartment
syndrome.
Controversy in closing
the fascia or not


Exploration
Blunt trauma
Hypotensive c evidence of intra-abdominal
hemorrhage or hollow viscus injury
Stable c ongoing bleeding, or other condition req
tx- perf-SI
Penetrating
Transperitoneal trajectory
Thoraco-abdominal trajectory c evidence of abd
injury
Exploration
Remove from backboard
Warm room-fluids
Control all external bleeding c pressure
blood products!
Coagulation devices
Exploration
Laparotomy-xiphoid to pubis
Four quadrant packing
Rapid search for arterial bleeding
Place clamp precisely
Venous
Evacuate blood and pack
Exploration
Adequate retraction!
Thorough search
Spleen- slide hand to diaphragm and feel outer
surface-assess for continuity
Liver- slide hand to diaphragm and assess
continuity- examine porta and left lobe
Exploration
E-G junction- examine anterior stomach to
duodenum
Duodenum-look for staining of peritoneum
Small intestine- ligament of treitz-follow to
ileo-cecal valve
Exploration
Colon- retract SI medially and examine right,
transverse and left for continuity, air and
staining. Sigmoid and upper rectum
Retroperitoneum- open lesser sac and
examine posterior stomach and pancreas-
zones I, II, and III for hematomas-kidneys
Spleen
Splenectomy- prefered operative technique
for grade III-V in unstable pts
Grade I and II controlled c pressure,
coagulations agents, splenorrhaphy, or mesh
wrapping.
In damage control with coagulopathy,
hyporthermia, or ventricular irritability- rapid
splenectomy must be done unless bleeding
can be stopped by other means.
Liver
In pt that cannot be managed non-
operatively-many will require damage control
Simple injuries can be controled with CUSA,
argon beam, finger fracture and ligation, deep
packing, absorbable mesh, wrapping, etc
Liver
Damage control techniques
Hepatotomy
Resectional debridement
Major resection in the face of metabolic failure has mortality
of 50%
Selective vascular ligation- ??
Wrapping takes time
Perihepatic packing
Often will not work for arterial injuries
Temporize to allow transfer to angiography if surgical
exposure of bleeding would jeopardize pt.
Push together- not down-
Finger fracture
Packing-
Foley and penrose
GI tract
SB injuries can be resected and
reanastomosed in almost all situations
Multiple within a short segment- should be
resected en-bloc and re-anastomosed
Careful closing holes
Narrowing/strictures
Inadequate closure
Staple when feasible
SI damage control
Dont waste time putting bowel together
Stop further soilage
Will be back in 2-3days
Techniques
Rapid one layer closure or reanastomoses
Staple ends
Umbilical tape
Control mesenteric hemorrhage
Colon
Recent studies- most wounds can be primarily
reanastomosed
Comfort decreases as you approach rectum
Deep shock, massive soilage, massive hemorrhage
may prompt diversion
Unwise to bring out ostomy during initial damage
control
Vascular supply may be compromised
Will likely be removed later
Duodenum
Lacerations
Where lumen will not be compromised- primary
repair is indicated
If unable to close pyloric exclusion should be
performed with some drainage procedure
Obviously complete duodenal resection can only
yield survivors in stable pts
Consider t-tube feeding tube drain area
Pancreas
Contusion/laceration not involving duct
Omental plug
Multiple drains
Head of pancreas
Resection in stable pts
Other opts
Sphincterectomy
Operative ERCP
Post op stenting
Pancreas
Injury to body or tail
Stable- distal pancreatectomy
Unstable- distal pancreatectomy and splenectomy
Can pack and reassess once condition has
stabilized at second surgery
Arteries
Celiac artery
Ligation
Renal artery
Nephrectomy in most cases
SMA
Shunt
Iliac
Shunt if feasible
If ligated- need fasciotomies
Venous
Iliac, infrarenal IVC, smv, portal
Ligation can be tolerated in most cases
Pelvic veins
Packing will likely be the only method of control
Retohepatic vena cava
Pack
Extensive surgery in this area in an unstable
patient will be fatal
Skin closure
Abdomen must be closed in some fashion to
place pressure
Rapid skin closure with towel clips or running
suture
Can use temporary silos

Non-operative considerations
Blunt trauma- Spleen
Grade III or higher have 25% overall of failure
Arterial blush on CT have increase risk of failure
Patients should be stable
No more than 2 units of blood
No hypotension
Benign abd exam
Unstable pts with minor injuries require operative
intervention
Non-operative- Liver

Degree of injury on CT does not correlate
well with need for OP intervention
Decision made on hemodynamic status
Almost any liver injury can be observed in a
stable pt
Arterial blush in stable pt may warrant
arteriographic intervention
Non-operative
Free fluid- no organ injury
Very bothersome
Recommendations
Peritonitis->OR
Benign exam-> repeat CT in 6-8 hours
If fluid increases, or free air-> OR
Make sure oral contrast is given!
Non-operative
Pancreas
Controversial
Definitive transection seen in CT-> OR
Contusion and hemorrhage around pancreas
Rpt ct in 6-8 hours
If increased fluid, increased inflammation->OR
ERPC?
Conclusions
Splenorrhaphy or splenectomy acceptable
depending on degree of injury
Large liver resections not warranted on initial
operation
Si can be resected and put together in most
situations
Colon can be closed or put together in >90% cases
Pancreas distal resection for severe injuries
Otherwise pack or drain.
Orthopaedic Trauma
Questions?
Break?
Open fractures
fracture that is exposed to the outside
environment
high-energy injuries
immediate irrigation and dbridement
combined with skeletal stabilization
Pelvic Fractures
If hemodynamic instability occurs, stabilization of the pelvis
combined with possible arteriography and embolization can be
life saving.
Stabilization of the pelvis can consist of formal application
of an external fixator, emergent application of a pelvic
fixator clamp, or simple pelvic binders.
Continued, unexplained blood loss despite fracture stabilization
and aggressive resuscitation is an indication for angiography.
In patients who are hemodynamically stable, an emergent
external fixator is not required. Atomic and definitive fixation with
open reduction and internal fixation should improve the outcome.
Classifications
Tile
Type A fractures- stable
Type B fractures - rotationally unstable but vertically stable
Type C fractures - rotationally and vertically unstable.
Burgess and Young- according to the mechanism of
injury
lateral compression
anterior-posterior compression
vertical shear or combined mechanism injuries
Acetabular Fractures
Any degree of incongruence involving the
weight-bearing surface of the acetabulum is
unacceptable and is an indication for surgical
treatment.
Nondisplaced fractures may be treated with a
period of traction followed by progressive
weight bearing.
Hip Dislocation
The most common mechanism of injury is
motor vehicles accidents.
Posterior dislocations are often associated
with a fracture of the posterior wall of the
acetabulum.
Prompt reduction of hip dislocations is
essential in minimizing the incidence of
osteonecrosis of the femoral head.
Anterior Hip Dislocations
10 to 15% of all hip dislocations
Femoral head fractures may occur in a significant
percentage of these cases and late osteonecrosis
may occur in approximately 10%.
abducted and externally rotated
Closed reduction is possible under adequate
sedation by longitudinal traction and subsequent
flexion and internal rotation.
Intra-articular fragments or inadequate reduction are
an indication for arthrotomy and open reduction.
Posterior Hip Dislocations
associated with posterior wall fractures
adducted, internally rotated, and flexed
once the hip has been completely dislocated
posteriorly, it may appear shortened and externally
rotated.
Sciatic nerve injuries are present in up to 15%
Closed reduction is usually accomplished by
longitudinal traction, followed by gentle abduction
and external rotation
If the reduction is unstable and associated with a
posterior wall fracture, open reduction and internal
fixation is indicated.
FEMORAL NECK FRACTURES
complains of pain in the groin or thigh and is
unable to bear weight on the injured
extremity.
shortened and externally
rotated
Garden classification
FEMORAL NECK FRACTURES
Internal fixation is indicated in nondisplaced
fractures.
treatment of displaced femoral neck fractures is
controversial.
best functional outcome and the least number of repeat
operations are performed when these patients are treated
with initial total hip replacement.
Displaced femoral neck fractures can also be
treated with reduction and internal fixation.
high incidence of probable embolic disease
Intertrochanteric and
Subtrochanteric Fractures
mechanically less stable than femoral neck fractures
varus deformity of the proximal femur
shortening, external rotation of the lower
extremity, and often swelling or ecchymosis
about the hip
may have more significant blood loss related to the
hip fracture.
the sliding hip screw with a side plate continues to
be the preferred implant for most stable and
unstable intertrochanteric hip fractures
Fractures of the Femoral Shaft
pain with motion, external rotational deformity,
and shortening of the affected lower extremity.
injury to the sciatic or femoral nerve or femoral
artery
Open femur fractures are associated with a 10%
incidence of limb-threatening vascular injury.
Any signs of distal ischemia should be evaluated by
vascular surgeons and is indication for immediate
vascular exploration.
Fractures of the Femoral Shaft
Traction used as a temporizing measure until
patients are stable enough to undergo
definitive surgical stabilization.
The gold standard of treatment of these
fractures is reamed, locked, antegrade
intramedullary nailing performed through a
closed technique.
Distal Femur Fractures
pain, swelling, and deformity
(1) anatomic reduction of the fracture
fragments, particularly intra-articular
reduction; (2) preservation of the blood
supply to the fracture fragments; (3) stable
internal fixation; and (4) early, active, pain-
free motion.
Patella Fractures
Disruption of the extensor retinaculum will
make active extension of the knee
impossible.
Nondisplaced fractures of the patella require
immobilization in extension.
Displaced fractures require open reduction
and internal fixation.
Tibial Plateau Fractures
articular step-off of greater than 3 mm or a
widening of greater than 5 mm are indicators
for surgery
Nonsurgical treatment consists of short-term
immobilization with a long leg cast followed
by bracing or immediate cast-bracing with
delayed weight bearing.
Tibial Shaft Fractures
30% of fractures are open injuries->result of
the subcutaneous position of the bone
Nondisplaced fractures may present with
localized pain and swelling, and an inability to
bear weight
compartment syndrome
Tibial Shaft Fractures
Closed tibia fractures, in general, can be treated
successfully with closed reduction and cast
immobilization.
Management of open tibia fractures remains a
challenge
salvage of the limb may be impossible
Stabilization of open tibia fractures can be performed with
internal fixation or external fixation.
External fixation ->limit any further devascularization of the
leg while providing needed stability.
Studies comparing external fixation with intramedullary
nailing conclude that intramedullary nailing gives better
results.
Calcaneus
lumbar fracture
Those with minimal displacement are treated
closed.
Any displacement of an articular fragment
involving the subtalar joint should be
reduced.
Metatarsal Fractures and Toes
Metatarsal Fractures
result of direct trauma
easily treated by nonweight bearing for 4 to 6
weeks
Toes
Treatment is almost always only taping to the
adjacent toe.
If the great toe has a displaced fracture, pin
fixation may be indicated.
Clavicle
80% occur in the middle third
managed nonoperatively as long as there is
not gross displacement
Fractures that occur in the middle third of the
clavicle are treated by placing the injured arm
in a sling
In the past, a "figure-of-eight" splint was used
but it is uncomfortable and is no longer felt to
be needed.
Anterior Shoulder Dislocation
most commonly dislocated large joint in the body
95% of cases
generally occur after an indirect trauma with the arm
abducted, externally rotated, and extended
painful shoulder held in slight external rotation
and abduction
axillary nerve is the most common nerve injured-
>sensation over the lateral deltoid region
Reduction of the dislocated shoulder should be
performed expeditiously with sedation
Chronic Dislocation
If a shoulder joint has been dislocated for a few
days, becomes much harder to reduce by closed
techniques.
Open reduction is the only means to reduce the
shoulder joint in this circumstance- very difficult
In elderly patients with low functional demands and
minimal pain with a chronic shoulder dislocation,
conservative treatment leaving the shoulder joint
dislocated may be the best option.
Posterior Shoulder Dislocation
direct trauma to the anterior humerus or
indirectly from seizures or electric shock
pain, the shoulder held in internal
rotation, and adduction.
prominent coracoid process, fullness of the
posterior shoulder, and limited external
rotation and elevation of the shoulder.
Reduction is performed using the Hippocratic
technique with longitudinal traction.
Humeral Shaft Fractures
pain, swelling, and difficulty moving the shoulder
and elbow
crepitus and motion at the fracture site
Radial nerve palsies are commonly associated
injuries, particularly with fractures of the middle third
of the humerus.
Operative stabilization of humeral shaft fractures is
recommended when-> inability to obtain an
adequate alignment with a splint or brace, open
fracture, floating elbow (fractures of humerus and
radius/ulna), fracture with vascular injury,
polytrauma, and pathologic fracture.
Elbow Fractures
Open reduction and rigid internal fixation is
recommended in the adult.
In children with supracondylar fractures,
closed reduction can almost always be done.
Those with minimal initial displacement can
be treated in a cast; however, those with
complete displacement (unstable
supracondylar fractures) are best treated with
percutaneous fixation after the closed
reduction
Forearm Fractures
Monteggia-fracture of the ulna with an
associated dislocation of the radial head
treated with a closed manipulation and cast
immobilization for children and open
reduction and internal fixation in adults.
Displaced, both-bone forearm fractures in
adults are usually unstable and are best
treated with open reduction and internal
fixation
Distal Radius Fractures
lower-energy fall from ground level onto an
outstretched hand with the wrist extended
Colles-Pouteau-> fracture of the distal
radial metaphysis with dorsal
displacement of the distal fragment->
most common fracture of the distal radius
Most tx with closed reduction
Spinal Injuries
most devastating
rigid backboard and with a rigid cervical collar
Both acutely unstable and chronically unstable
spines need to be stabilized.
general rule, if two or more columns are injured, the
spine is considered unstable.
anterior column -> vertebral body.
middle column ->posterior cortex of the vertebral body and
posterior longitudinal ligament
posterior column -> facet joints and posterior processes

Cervical Spine
Stable injuries without nerve deficit can generally be
treated with a cervical orthosis or a halo vest.
The presence of spinal cord compression with
incomplete nerve injury generally necessitates
operative decompression of the spine to facilitate
recovery and prevent further damage to the cord.
In cases of complete spinal cord injury,
decompression may allow for recovery of the nerve
roots at the level of injury although there is usually
little functional recovery distally.
Cervical Spine
Atlas fractures are axial
loading injuries and are
generally stable injuries
without spinal cord injury.
They can usually be treated
with a rigid cervical orthosis
or a halo vest.
Patients with neurologic
injuries seen within 24
hours of their injury are
started on 30 mg/kg
methylprednisolone, then
5.4 mg/kg per hour for 24
hours.


Questions?