Principle Management of Wound and Fracture in Emergency Department

dr. Tedjo Rukmoyo, SpOT (K) Spine

Presented in Clinical Update Seminar January 15th 2011

Initial ManagementATLS Procedure

A : airwayB : breathingC : circulationD : disabilitiesE : exposure

Compressive dressings for hemorrhageCheck

Cervical ChestAbdoment

X ray

HeadPelvisNeurovascular

Wound Inspection & Palpation

Concentrate onHemorrhage LocationSizeBorder Wound typeExudateInfectionDressed or undressed

Wound managementEvaluate the woundNeuroVasc statusJoint MovementX-RAY !Sterile saline dressingIrrigate with NS

1 or 2 litresTetanus status immunity IV antibioticsPrepare minor set

NeedleSuture materialinstruments

Wound irrigation

Irrigate with NaCl 0,9 % 1 – 2 litreBrush, evacuate foreign bodyUse :

Povidon iodineSavlonPerhidrol (hidrogen peroxide)

Irrigate with NaCl to cleanse

Debridement

Excision:Wound EdgeSkin Abrasion Dead TissueDirty Bone

Evacuate: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 lossPrimary clossure

Contraindication :

1. Contamination

2. NV injury

3. Tension

Principle Wound and Skin coverage

With skin loss :Secondary intention

Release / counter incision

STSG, FTSG

Flap fasciocutaneus,

rotational

Fracture Classification

Close (simple)Open

Gustillo Anderson○ Grade I○ Grade II○ Grade III a○ Grade IIIb ○ Grade IIIc

Gustillo Anderson

> Grade III B

Vascular disruptionArteriographyIf can be repaired? Possible Limb salvage Failed? amputation?

Debridement and Irrigation

As soon as possible Scrub and brush wound dirtSuperficial debridement:

Identify and explore -> extend woundExcised non viable tissue

Debridement and Irrigation

Deep debridement :When in doubt take it outCheck muscle : 4 c

ColorCapacity to bleedContractilityConsistency

Cover by tissue or moist dressingRemove Foreign body

Debridement Procedure

Irrigation

Use NS, high volume low pressure lavageFor grade II-III :

6 – 10 lUse 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 irrigationStabilize the bone :

Restore lengthAngular alignmentRotation

Will promote healingDecrease pain and further damage

Method Skeletal stabilisation

Cast : splint, circular cast

Traction : skin, skeletal

External fixation : steinman or K wire

Internal Fixation

Plate and screwAccurate anatomicalMantain /w plateVarious types

IM nailsRestore alignmentCallus healingMinimize soft tissue damage

Compartment syndrome

Rehabilitation

Early Range of MotionIsometric, isotonic, isokinetic excerciseMotor Power excerciseNon weight bearingPartial weight bearingFull weight bearingReturn to normal activity