Trauma Review

 

• Superficial wounds

  An acute skin lesion caused by external trauma.

  Types

  • Erosion: partial break in epidermis. An abrasion (aka graze) is a sub-type caused by rubbing or scraping.
  • Laceration: cut/tear in skin from blunt trauma causing shearing or crushing force.
  • Incision: cut in skin from sharp-edged object e.g. knife.
  • Ulcer: complete break in epidermis ± dermis and subcutaneous tissue. Usually describes skin lesions caused by internal pathology or with a chronic course, as opposed to acute trauma.

  Management

  Most wounds can be managed in the emergency department or primary care, using the steps outlined here. More extensive injuries require specialist referral for possible surgical debridement, grafting, or complex repairs.

  Wound closure

  1. Initial clean:

  • Irrigate with normal saline or tap water.

  2. Local anaesthesia:

  • Lidocaine (up to 3 mg/kg) directly into wound edge, subdermal (less painful) or intradermal.
  • Infiltration parallel to the wound, breaking new skin, is more painful but may be indicated for grossly contaminated wounds.
  • Adrenaline mixed with lidocaine allows higher volumes of lidocaine (up to 7 mg/kg), as the vasoconstriction reduces systemic uptake of lidocaine. It is traditionally though that adrenaline is unsafe for use on extremities (e.g. fingers, nose) due to the risk of ischaemia, though there is little evidence to substantiate this.
  • Alternatively, consider regional anaesthesia with a nerve block, or procedural sedation for more extensive injuries.

  3. Further clean once anesthetised:

  • Remove any foreign objects or dead tissue.
  • Abrasions may require scrubbing, as any particles left in may cause long-term tattooing.

  4. Wound closure:

  • Many lacerations and incisions require healing by primary intention (i.e. deliberate closure) using sutures.
  • Absorbable sutures (e.g. Vicryl, Monocryl) for internal sites such as oral mucosa, otherwise non-absorbable (e.g. nylon, silk, Prolene).
  • In the USP sizing system, higher numbers are finer: 5-0 or 6-0 for cosmetically-sensitive and low tension sites such as face and hands, 3-0 or 4-0 for high tension sites such as trunk, limbs, and scalp.
  • Remove non-absorbable sutures after 5 days (face/scalp), 7 days (arms/trunk), or 14 days (legs). Absorbable sutures can take from 1 week to several months to dissolve.
  • Alternative forms of closure for small wounds: surgical tape (Steristrips), provided there is no tissue loss, tension, or hair; or glue, applied onto opposed edges not into the wound.
  • Healing by secondary intention (conservative management): abrasions, small puncture wounds, chronic wounds (ulcers). Usually require dressing; the first layer, in contact with wound, should be non-adherent.
  • Healing by tertiary intention: delayed primary closure. Consider for large, contaminated wounds.

  Antimicrobial prophylaxis

  • Routine antimicrobial prophylaxis is not recommended, with appropriate irrigation and cleaning usually sufficient to prevent cellulitis. However, certain wound types do require prophylaxis, and tetanus status should be checked on all.
  • Large, contaminated animal and human bites require prophylactic co-amoxiclav.
  • Snake and insect bites may require specific anti-toxin.

• Tetanus

  Pathophysiology and presentation

  • Caused by tetanospasmin toxin released by the spore-forming, anaerobic Gram +ve bacillus Clostridium tetani.
  • Toxin enters spinal cord and prevents release of inhibitory neurotransmitters (GABA and glycine) at the synaptic cleft, resulting in muscle spasm and hypertonia.
  • Most commonly affects neck and jaw.

  Post-wound prevention

  Vaccine:

  • Booster vaccine required for all wounds if primary immunisation incomplete (not had first 3 doses) or boosters (dose 4 [pre-school] and 5 [high school]) not up to date.
  • If immunisation history absent or unknown, give immediate vaccine dose followed by full 5-dose course.

  Human tetanus immunoglobulin IM:

  • Added for tetanus-prone wounds if (a) primary immunisation incomplete or boosters not up to date, (b) there is heavy contamination with material likely to contain spores, or (c) there is extensive devitalised tissue.
  • Tetanus-prone wounds are those with a foreign body, contact with soil/manure, puncture wounds, compound fractures, or those requiring surgery but delayed >6 hrs.

• Describing fractures on X-ray

  First note patient details, study date, and X-ray type. Then describe the fracture, covering 5 points.

  1. Which bone and which part of it:

  • Proximal, middle, or distal third.
  • Note relation to or involvement of landmarks such as trochanters.
  • Formal terminology: in adults, diaphysis is the shaft and metaphysis is the ends. In children, the epiphysis sits at the ends, separated from the metaphysis (i.e. distal diaphysis) by the cartilaginous physis (growth plate).

  2. Fracture type:

  • Transverse, oblique, or spiral.
  • Skull fractures can be depressed, when they press down into the brain.
  • Note if there are signs suggesting open fracture: soft tissue injury, debris, surgical emphysema.

  3. Number of fragments:

  • Two or three, multifragmentary (>3), or comminuted (too many to count).

  4. Displacement i.e. when the distal segment is in an abnormal position:

  • Shortening usually implies impaction. Lengthening is called 'distraction', and usually results from the bone being pulled out by a muscle.
  • Translation: same height, but medial/lateral or anterior/posterior displacement.
  • Angulation
  • Rotation
  • There may also be dislocation if joints are involved.

  5. Intra-articular:

  • Does the fracture line extend into the joint line?
  • This is commonest in wrist and ankle fractures, but rare in proximal femoral fractures.
  • Suggests risk of cartilage damage and osteoarthritis.

  Summary sentence:

  • "This is a {displaced/non-displaced}, {transverse/oblique/spiral}, {intra/extra-articular} fracture of the {left/right bone name}, in {X number of parts}, with {description of displacement}."

  To complete, you would also like to see another view (if not already given) and X-rays of the joint above and below.

• Fracture management

  Basic approach

  The 4Rs:

  • Resucitation and initial care, including assessment of neurovascular status and analgesia. Open fractures need antibiotics, cleaning, and possibly debridement. Tetanus booster ± immunoglobulin if indicated.
  • Reduction of any clinically-significant displacement.
  • Restriction (immobilisation) until fracture heals.
  • Rehabilitation: promote fracture healing and encourage early movement. Usually led by physios and OTs.

  Reduction

  Involves alignment (most important) and opposition.

  Methods:

  • Manipulation (closed reduction). May be done under anaesthesia (MUA) if complex and/or very painful.
  • Traction: needed when large muscles are maintaining the displacement. May be skin traction using tape and bandaging, or skeletal traction using a pin.
  • Open reduction: done in theatre. Usually needed for intra-articular fractures.

  Restriction

  Indications

  • Fractures which may displace again after reduction are known as unstable fractures, and need to be held in place.
  • Many stable fractures also need to be held in place due to the risk of being knocked.

  Methods

  Splinting:

  • Often the initial management, providing symptomatic relief and reducing neurovascular injury.
  • May be kept on for prolonged period, or be a bridge to definitive immobilization through casting or surgery.

  Sling:

  • May be sufficient for minimally displaced fractures.

  Casting:

  • Usually with plaster of paris or fiberglass.
  • Usually 6 weeks for upper limb or ankle malleolus fractures, and 12 weeks for lower limb fractures. Shorter period in children.
  • Need to be kept dry.
  • May have half a cast for first 24-48 hrs ('back slab') to allow swelling and not cause compartment syndrome.

  Functional bracing (cast bracing):

  • Separate casts on two bones either side of a joint, with a hinge between them to allow joint movement.
  • Usually used for lower limb fractures after 6 weeks in a normal plaster cast.

  Internal fixation:

  • Pins, plate, and screws all sit under the skin.
  • May be part of open reduction and internal fixation (ORIF).
  • Metalwork usually left in permanently.

  External fixation:

  • Pins in bone with external frame to join them.
  • Uses include open fractures where there is a high risk of infection from internal fixation.

  Continuous traction:

  • Rarely used, but may be seen for young children with femoral fractures.

• Fracture complications

  Immediate

  • Bleeding
  • Neurovascular injury.
  • Muscle damage.
  • Fat embolism (esp. long bone injuries), presenting with classic triad of SOB, CNS symptoms, and petechial rash.

  Nerve injury types

  • Neurapraxia: temporary injury from stretching.
  • Axonotmesis: axonal damage but with surrounding connective tissue preserved. Wallerian degeneration occurs on distal segment. Can recover if cause removed.
  • Neurotmesis: nerve cut, with recovery unlikely.

  Early

  • Compartment syndrome.
  • Infection
  • Complications of bed rest: DVT, pneumonia, UTI, pressure sores.

  Late

  • Poor union: delayed union, non-union (if not healed after several months), malunion.
  • Avascular necrosis.
  • Pain, including complex regional pain syndrome (CRPS) type 1. CRPS type 1 is a sympathetic-mediated injury that presents weeks post-injury with tender, pink, warm skin.
  • Reduced joint use.
  • Growth impairment in kids. Usually follows epiphyseal plate (aka growth plate) injuries, classified using Salter-Harris.
  • Myositis ossificans: soft tissue calcification which may limit movement. Commonest site is elbow.

  Causes of poor union

  Injury-related:

  • Vascular impairment. Due to original injury or later swelling.
  • Infection (may also be surgery-related). Higher risk if open.
  • High energy impact.

  Treatment-related:

  • Poor reduction.

  Patient-related:

  • Co-morbidities: PVD, diabetes.
  • Steroids
  • Smoking

• Major trauma

  Definition and epidemiology

  • Severe or multiple injuries with a high risk of death or permanent disability.
  • Blunt trauma most commonly follows falls or motor vehicle collisions.
  • Penetrating trauma is when an object passes through skin into underlying tissue or body cavity. May result from stabbing, gunshot, or some other trauma e.g. impalement.
  • Affects 1/2500 adults annually in the UK, with 25% mortality. Commonest cause of death under age 45.
  • Fatal injuries are often immediate and irreversible e.g. catastrophic brain or chest trauma. The commonest cause of preventable deaths is haemorrhage.

  Management

  Overview:

  • CABC may be used instead of ABC, to prioritize Catastrophic haemorrhage. See the critically ill patient for more on the ABC approach.
  • Patients should be transported to an appropriate specialist trauma centre ('major' or 'level 1-2'), even if it is not the closest hospital, where definitive care (usually surgical) can be provided. In cases with very long transport times to specialist centres, initial resuscitation may be appropriate at a smaller centre.

  Haemorrhage control:

  • Initial: direct pressure (most external haemorrhage), tourniquets (major limb trauma), pelvic binders (suspected pelvic trauma causing bleeding), resuscitative endovascular balloon occlusion of the aorta (REBOA, for refractory haemorrhagic shock from non-compressible abdominal or pelvic bleeding).
  • Fluid resuscitation should be with blood products, in a 1:1:1 ratio of RBCs, PLTs, and FFP. Crystalloids should only be used pre-hospital, where blood components are unavailable, and even here they may be harmful in excess.
  • Tranexamic acid IV as soon as possible (max 3 hours post-injury).
  • Rapidly reverse anticoagulation.
  • Definitive control of ongoing bleeding may require surgery or interventional radiology. Some patients may proceed directly to damage control surgery before CT in refractory shock.

  Imaging:

  • Immediate CXR and/or eFAST (extended focused assessment with sonography for trauma) in patients who are haemodynamically unstable.
  • Immediate CT if haemodynamically stable. Whole body (head-chest-abdo-pelvis) in adults with blunt trauma and suspected multiple injuries, but try and be more focused in children given the higher radiation risks.

  Penetrating trauma:

  • Most penetrating wounds require surgical exploration in theatre to look for deeper injury.
  • Cardiac arrest resulting from penetrating chest trauma requires resuscitative thoracotomy, allowing release of cardiac tamponade (from haemopericardium), control of bleeding vessels, cross-clamping of aorta, and/or direct cardiac massage.

• Compartment syndrome

  Definition and causes

  • Bleeding or inflammation within a closed muscle compartment, leading to muscle and nerve ischaemia.
  • Usually due to a fracture, most commonly tibial, but can occur at any location.
  • May also result from an overly-tight plaster cast.

  Signs and symptoms

  • Presents with pain out of proportion to appearance. This can sometimes be subtle e.g. increased use of patient controlled analgesia.
  • Swelling, redness, and warmth.
  • Altered sensation from nerve injury.
  • Late signs: weakness, rhabdomyolysis, vascular compromise.

  Management

  • Position limb at level of heart and remove any bandaging or cast.
  • Surgical decompressive fasciotomy is needed for most.
  • If fracture is not yet reduced, this should be done.