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