My thoughts of McRae
A book about orthopedic trauma and emergency fracture management
Ronald McRae
trauma is the principal cause
of death and disability in the young ?!!!
Part one " general principles "
1-Fractures and fracture management
ORTHOPAEDIC TERMINOLOGY
Fracture types and patterns
aetiology
morphology
severity
location
displacement
Traumatic fractures
Pathological fractures
Insufficiency fractures
Fatigue (or stress) fractures
Transverse and oblique fractures
Spiral fractures
Avulsion fractures
Impaction fractures
Paediatric fractures
Open fractures
Intra-articular fractures
Comminution
Joint dislocation
Fracture-dislocation
Sprains
Displacement in length
Displacement by angulation
Displacement by rotation
Displacement by translation
Classification systems
AO comprehensiveclassification system
AO classification of shaft fractures
AO classification of metaphyseal fractures
ASSESSMENT OF A FRACTURE
History
History of injury
Medical and drug history
Social history
Examination
Look
Feel
Move
Neurovascular assessment
Swelling
Bruising
Abrasion
Laceration
Incised wounds
Deformity
Radiological assessment
Radiographs
rule of twos
Two orthogonal views
Two joints
Two time points
Two limbs
Ultrasound
Computed tomography (CT)
Magnetic resonance imaging (MRI)
Aspiration
Blood tests
PRINCIPLES OF FRACTUREMANAGEMENT
1. Is the fracture position acceptable or does it need to be reduced?
2. Is the fracture stable or does it need to be
held?
3. When can the patient begin to use and move the limb?
Reduce Hold Move
Direct reduction
Indirect reduction
Stable fractures
Unstable fractures
BONE STRUCTURE AND HEALING
Bone anatomy
Cortical bone
osteons
Haversian canal
osteocytes
Volkmanns canals
diaphysis
Cortical bone
medullary canal
central nutrient artery
bone marrow
cancellous bone
metaphysis
Fracture healing
Perrens Strain Theory
strain of the tissue at the fracture site is more than 10%, granulation tissue
forms
at between 2% and 10%, fibrous tissue
forms
while, at under 2%, bone formation is
possible
Secondary bone healing (healing with
callus)
four phases:
1. Inflammation (week 1):
2. Soft callus (weeks 2-3):
3.Hard callus (weeks 4-12):
4. Remodelling (months to years):
haematoma
granulation tissue
rubor, calor, tumor and dolor
intramembranous ossification
endochondral ossification
Wolffs Law
Primary bone healing
ruffled border
Howships lacunae
cutting cone
Assessment of healing
In general, a fracture is said to have united when the signs of afracture have
resolved
demographics of the radiograph:
radiographic view provided
patient name
date of radiograph
skeletal maturity whether the physeal plates closed.
ABCS of the fracture:
Adequacy and alignment
Bone quality and fracture configuration
Cartilage (joint involvement)
Soft tissues.
Management of the injured patient
MAJOR TRAUMA
The anatomy of the traumasystem and team
The trauma system
The trauma team
Primary survey
airway with cervical spine control
breathing with 100% oxygen
ATOM FC
Airway obstruction
Tension pneumothorax
Open pneumothorax
Massive haemothorax
Flail chest
Cardiac tamponade
A supine AP chest radiograph will normally be carried out as part of the primary
survey
circulation withhaemorrhage control
central pulse
blood pressureand peripheral oxygen saturation
two large-bore cannulae
venous blood for cross-match, full blood count, biochemistry, lactate and
coagulation screen.
Grades of hypovolaemic shock
I
II
III
IV
a previously fit young patient may compensate more for hypovolaemia by
physiological vasoconstriction, and may not develop clear
clinical signs of shock until 2 L of blood have
already been lost.
The site of the blood loss must be identified
Intrathoracic cavity
Intraperitoneal cavity
Retroperitoneal cavity
Thigh compartments
Floor
disability
Awake
Verbal
Pain
Unresponsive
Glasgow Coma Scale
exposure
Secondary survey
urinary catheter
Glasgow Coma Scale
Eye opening 4
Verbal 5
Motor 6
In the intubated patient, add the annotation ?t?
when scoring verbal response, e.g. ?V-t1?.
Tertiary survey
Imaging in trauma
Radiographs
Cross-table cervical spine (C-spine)
AP chest
AP pelvis
Some of these plain radiographs may be
omitted if an early trauma CT scan is anticipated.
CT
CT scan extending from the
vertex of the skull to the symphysis pubis
(?trauma scan? or ?pan scan?)
INTRAVASCULAR FLUIDREPLACEMENT IN MAJORTRAUMA
Traditional teaching
Permissive hypotension
Blood
Universal donor O negative blood
Type-specific blood
Fully cross-matched blood
Blood products
Antifibrinolytic drugs
Major haemorrhage protocolsand packs
DECISION-MAKING IN TRAUMA
Response to resuscitation
physiological values
laboratory measurements
non-responder, transient responder and
responder
The lethal triad
Coagulopathy
Hypothermia
Acidosis
Disposition from the resuscitation room
Operating theatre
thoracotomy, a laparotomy or pelvic packing
emergency neurosurgery
CT scan
Interventional radiology
Intensive care
wrap ?em up, warm ?em up
and fill ?em up
Orthopaedic decision-making:
early total care and damage
control orthopaedics
Early total care
Damage limitation surgery
Stabilization of an unstable pelvic ring fracture
Stabilization of a femoral fracture
Decontamination of open wounds.
Amputation of unsalvageable, dysvascular
limbs.
Decompression of limb compartments for
compartment syndrome.
Early appropriate care
The stress response to trauma
Nociception (afferent pain pathways)
local tissue injury (cytokine release)
higher centre (cognitive) responses
activation of autonomic, immunological, endocrine and haematological responses.
tachycardia and tachypnoea, vasoconstriction, pyrexia, a raised white cell count
and increased concentrations of hormones such as cortisol, and cytokines such as
the interleukins.
persistent hypoxaemia, peripheral tissue hypoperfusion (identified by a raised
lactate and base excess), a hypercoagulable
state that may manifest as DIC, fluid retention,and the development of a catabolic
state with muscle wastage and negative nitrogen balance.
Multiple organ dysfunction syndrome (MODS).
Acute respiratory distress syndrome (ARDS)
Fat embolism syndrome (FES)
FES is rare except after femoral fracture or polytrauma.
