Fractures. the mechanism of occurrence. formation of the osteal callositas. The first aid at fractures.
Treatment of fractures in the hospital, the care of the patients with fractures, plaster engineerin. Dislocations.
Reanimation actions at surgical patients.
Trauma is influence on the organism of outward agents (mechanic, thermal, electric, ray, psychical and oth.), which provoked the anatomical and functional breaches in the organs and tissues, which are accompanied by local and general reaction of organism.
There are distinguished the following types of traumatism:
1. Traumas of unindustrial character:
a) transport traumas (railway, car, tram);
b) everyday;
c) sporting;
d) others (traumas, which received as a result of natural catastrophes).
2. Traumas of industrial character (manufactural and agricultural).
3. Intentional traumas (battle traumas, ill-intentioned attacks, attempt of suicide).
Traumas are divided on mechanic, chemical, electric, ray, psychical, operational and others by a type provoked the damage agent.
The dividing of traumas by character of damage is very important – there are distinguished the open and closed traumas. There is a gaping of skin and mucous membranes wounds by the open damages. The microbes can penetrate through the wound of skin and mucous, that is promoted to developmental of early and later complications. There are also distinguished the penetrating damages, in the presence of which the internal organs (of abdomen, of thorax, of skull, of joints) can be affected, and unpenetrating.
In case of damages of tissue of only one type we tell about the simple trauma, if the different tissues are damaged – about the complex trauma, for example, the skin, muscles and bone.
Trauma is homogenous in those cases, if it provoked by only one factor. If the trauma is sipulated by several factors, for example, mechanic trauma with a burn, it named the combined trauma. While the single-moment lesion of various systems (for example, the contussion of the brain and fracture of skin bones) the conjuncted trauma are named.
Traumas can be direct and undirect (damages developing in the distance from the region of provoking agent influence).
The single and also plurality traumas (polytraumas) are possible. Usually the traumas are acute, however, it can tell about chronical traumas, which are provoked in some cases by professional harmfulnesses.
Peculiarities of investigations of traumatological patients
Symptomatics of patient with serious traumas is developed very quickly, state is often serious, often it is necessary for surgeon to orientate quickly, be able to specify the diagnosis and render first help. Some circumstances require the especial attention in the gathering of anamnesis and objective investigation of traumatological patient in contrast of surgical patient.
At first, the outward look of damaged place not always corresponds to the seriousness of damage.
Secondly, not always the trauma, symptoms of which are obvious, is threating for human life, the diagnostic of plurality traumas is especially hard in patients, which are unconscious, in a state of serious shock or alcoholic intoxication.
Thirdly, the serious general phenomena (shock, acute anemia, traumatic toxicosis) can to conceal traumas. It is necessary to estimate them rightly and render the proper help.
In the cases of serious traumas, when the life of patient is under the threat, at first it is necessary to render the urgent help and then to proceed, gathering of anamnesis and carrying out of more total investigation of patient.
It is necessary to elucidate by questioning of victim (or eye-witnesses, if the patient is unconscious) the complaints in present time, what the patient felt at the moment of trauma and then, what help has rendered to it. It is necessary to determine the presenting accompanying diseases.
It is necessary to examine the place of damage that is far specification of diagnosis and to represent the preliminary opinion about the methods of treatment and possible complications. For example, the fractures can be accompanied by damage of nerve and great vessels, and the wound of thorax is complicated by hemothorax and heart tamponade. Getting of a soil in the wound can provoke the tetanus later. To check the condition of all systems and organs, estimate the presence of general phenomena and degree of them seriousness. Carry out the laboratory and roentgenological investigations, if they not prevent to rendering of urgent help. It is necessary to take into account the anatomical, comparative and functional shortening of extremity and middle-physiological location of upper and lower extremities.
Closed damages of soft tissues
Closed damages of soft tissues are divided on contusions, tensions and ruptures, concussions and squeezes. Closed damages of soft tissues, organs, which localized in cavities are observed.
Contusion – (contusio) – is damage of tissues and organs without the breach of skin integrity as a result of quick and momentary action of traumating factor on the one or another part of a human body. Mechanism of the trauma can be various – fall on something object or blow.
Seriousness of damage is determined by two moments:
1. Character of traumating agent, its seriousness, consistence, quickness of action.
2. Type of tissues, on which the trauma acts (skin, muscles, fat, and bones).
Clinical picture – characterized by appearance of pains, swelling, and breach of function of contusioned organ or region. It can be observed the exfoliation of skin by the action of great force by angent, it can develope the shock of paralysis (contusion of great nerves) of a region, which innervated by contusioned nerve, by contusion of joint breach of its function, by contusion of thorax and lung – subcutaneous emphysema.
Treatment. The main task of treatment at first period after contusion is stopping of hemorrhage in tissues, which achieved by quarantee of rest, raised posture, cold, pressing bandage. On 2-3 day when the contusioned vessels thrombosed, the warmth, physiotherapy procedures are applied. In the presence of haematoma – it sucking off and antibiotics is introduction in the plevral cavity.
Tensions (distorsio) and ruptures (ruptura)
Tensions is damage of soft tissues, which is provoked by the force acting like a traction and nor breaching the continuity of tissues. However, if the acting force exceed the resistibility of tissues by such mechanism of trauma, then the rupture of ligaments, fascias, muscles, tendons, nerves etc. Clinically the rupture of ligaments is accompanied by appearance of strong pain, breach of motions, haemorrhages in soft tissues, oedema and swelling of joint. It can be determined the fluctuation by a palpation as a result of haemorrhages.
Treatment consists in quarantee of a rest, application of pressing bandage and prolonged immobilization of a joint. After resolution of haemorrhage with third week, it is passed to the careful active movements, massage, and medical physical training. The punctions and introduction of antibiotics make by delated resolution.
Ruptures of fascies are registered rarely and developed from the direct blow in a region of fascia. The crack-like defect of fascia appeared as a result, that is lead to sticking out by the contraction of muscles.
Treatment is operative.
Ruptures of muscles – complete and uncomplete – are registered rarely and happened as a result of strong and quick contraction of them, by rising of heavinesses. The strong pain, haemorrhages, oedema, limits in motion are manifested clinically.
Treatment. In case of uncomplete rupture are immobilization, rest, cold, then the warmth, physioprocedures. In case of complete rupture is operation with following immobilization on 2-3 weeks.
Ruptures of tendons need the operation.
Concussions (commotio) – is lead to the significant breaches of function of organs and tissues. Prolonged and strong vibration of upper extremities at first provoked the breach of functions, and then leads to the morphological changes in muscles, nerves, bones, which are expressed in a development of sclerotic processes, pain, limit of capacity for work (vibrational disease).
Squeeze – is observed by squeeze of lifly important organs (heart, brain, lungs).
Traumatic toxicosis (crush syndrome) It is especial type of damages representing the distinctive syndrome, which is observed by prolonged squeeze, pressure of wide parts of soft tissues, more often of extremities, with the following general and local phenomena. It is happened by the landslides, earthquakes, bombardments, railway catastrophes; syndrome is appeared after the removal of the squeezing heavinesses. Detailed description of this syndrome is made by A. J. Pytel (1841), N. N. Elanin (1950).
LONG – TERM SMASH TISSUE SYNDROME
(CRUSH-SYNDROME)
Long – term smash tissue syndrome is a kind of traumatic pathology, which arises after long – term crushing soft tissues of limbs by destroyed buildings, stones and ground. There are other synonyms: long-term crumple syndrome, crush-syndrome, traumatic compress, also – recirculative syndrome.
During the earthquake the long – term smash tissue syndrome appears in 3,5 – 5% of all injured; crumpling of lower extremities arise in more cases (79,9%); at the same time injuring of upper and lower limbs registers in 6,1% cases. Among victims of earthquake in Armenia the long – term smash tissue syndrome was registered in 23,9% of all injured.
There is a violation of muscle entirety, other soft tissues, in the most cases (near 65%) appear bone fracture during the long – term smash tissue syndrome. On the first place an ischemic injuring of big muscles arise, as, a result of evenly forced crumpling and long – term block of regional blood flow.
There are two mechanisms in the pathogenesis of the long – term smash tissue syndrome: first is forced crumpling of soft tissues with long-term ischemia and second is destroying of anatomic structures closed or opened types.
The syndrome belongs to one of traumatic diseases and it has universal nonspecific reactions of organism on a trauma. The reaction of central nervous system and violation of microcirculation, which in the hardest cases develop as a shock are on the first place. They develop on the very beginning of factor activity and continue after its cessation; a toxemia and plasmorrhagia increasing. Generalized and long-term process of microcirculative violations cause globules formation of fat and microthrombus in the microvessels gap, after resuming of hemodynamics a large quantity of this globules spread with blood flowing in different organs and tissues. The obstruction of tissue microcirculative system promotes a disorganization of brain, lungs, liver, kidneys work – long-term smash tissue syndrome is many-sided, intricate for diagnosis.
Pathological result of direct cells destroying appears immediately, but during ischemic injuring of muscle result appears some hours later. Since middle term of ischemic death of striated muscles is near six hours, so the cause of early necrosis (first hours) is mechanical factor, but in the later period is hypoxya. Because of direct tissue destruction intra cellular substances get into blood; during the compressive-ischemic muscle injuring in the most cases ischemic toxin penetrate into system of blood flowing (metabolites of anaerobic glycolysis). In both cases appears destroying of blood circulation and breathing, but symptoms of ischemic toxins influence increase slowly.
Contents of toxins are increases after injuring of muscle tissue. However it is necessary to know, that hemolysis also increases of creatine contents, because erythrocytes contain it more than serum does. Therefore it is recommended to indicate an activity of creatin kinase.
An increasing of creatine/creatinine index is inherently in inapposite tissue destruction by means of mechanic injuring; this index can be an objective criteria a question of early amputation of limb. During the long – term smash tissue syndrome a blood flow violation arise not only in arteries, but also in veins. Disintegration of ATP appears as a result of deep ischemia of muscles; also take place a violation of carbohydrate and fat metabolism lactate and other metabolic accumulate in the blood. A large quantity of myoglobin (75%), potassium (60%), phosphates (75%), acid products (95%) penetrate into the blood. Destructive degenerative changes in the nerve structures of injured muscles appear very soon, after compressing. Contents of aldolase increase in the blood that can be an objective criterion while evaluation of last prognosis. However the main importance in the mechanism of pathological violations during the long – term smash tissue syndrome has a myoglobin. It is obdurate little vessels of kidneys, liver, lungs and other organs. It persists in gap of vessels and it’s a base in the process of hard complications development that can be finished by death. Rhabdomyolisis and accumulation of myoglobin, potassium, phosphates, uric acid, lactate and other acid products lead to metabolic acidosis formation. In this condition myoglobin transforms into hematin hydrochloride that make changes in ascenders column Henle’s arch, it even can cause necrotic changes. Because of hypoxia, hypotension and spasm of cortex vessels of kidneys acute kidneys insufficiency develops.
After long – term smash tissue syndrome the liver function is pressed during many months and even years.
One of the main factors in the pathogenic destroying, which exist during long-term smash tissue syndrome, is a loss of plasma.
Overdosage causes not desired anesthesia till time of patients getting into the hospital. It hardens diagnostics by loss of contact with patients, changing of clinical picture of possible craniocerebral trauma, intracavital injuries. In specialized «emergency» car it is possible to provide blockades (conductive) using local anesthetics and also inhalation of nitrogenium oxydulatum with oxygen (through the mask), trichlorineethylene and inhalation (through special sets). In case of opened injuries local anesthesia is provided; to solution of novocainum there might be added modern antibiotics of wide action spectrum. It considerably improves fight with infection. In large injuries of soft tissues, and especially in fractures immobilization of all injured limb is necessary. It’s good to use pneumatic immobilizers, which help to prevent plasma loss by moderate pressing on limbs. Last time «anti-shock pants» are used with the same aim. During their usage pressure in abdomen and lower limbs is near 80 mm Hg that decreases blood loss in intra-abdominal bleeding. It is considered that these pants are effective measure in shock elimination.
In case of future long-term transportation it is needed to start cooling of injured limbs. It is not effective to put jute on the limb in crush syndrome, because in kept life ability of tissues it doesn’t prevent toxaemia, severest ischemia and intoxication of the organism. Of course, these recommendations aren’t for cases with large bleeding, total destructions and considerable injures. Here there’s no doubt iecessity of amputation by primary indications. Jute in those cases must not be put off till the moment of amputation higher than put jute.
Nowadays in system of pre-hospital measures during crush syndrome special accent is put on early base infusion into the organism. But there must be excluded solutions containing potassium (Ringer’s, Hartmann’s solutions, “Lactasolum”).
Special attention to infusion anti-shock therapy must be put during not fast enough transportation of medical group to focus of catastrophe that leads to late of these measures. It is needed to continue infusion therapy and during transportation (especially long-term). During evacuation by air transport it is needed to use special apparatus for infusion because during changes of pressure infusion therapy in air by usual way practically stops. During combination of crush syndrome with overcooling infusion therapy must be provided by solutions heated to 38-40°C; is provided body and limbs massage by special tampons with alcohol, used hot water bottles.
On the stage of hospital treatment elimination of hyperkaliemia it is needed to make an urgent intravenous infusion of hypertonic (40%) solution of glucose (50 ml) with insulin, 10% solution of calcium chloride or gluconate (30 ml for 20 min). If the level of potassium in blood plasma is more than 7 mmol/liter, glucose with insulin and calcium preparates is except. It is indicated to use absorbents (polystiren-sulfonate, haemo- or peritoneal dialisis). Special attention should be paid to diuresis control.
During period of diuresis forcing into urinary bladder there is inserted constant catheter for every hour measuring the quantity of excreted urine, its pH and quality composition (presence of myoglobin, erythrocytes, cylindres). Concentration of urine and electrolytes in blood must be defined every 6 hours. Base infusion of the organism is continued by systematic addition of 44.5 mmol of NaOH (93 ml of 4% solution) on every 2 liters of infused fluid for keeping of urine pH higher than 6.5. Indication for diuretics infusion appears when diuresis becomes less than 300 ml/hour. Adequate speed of infusion during crush syndrome is 300-500 ml/hour. During this hypovolemia is liquidated and haemodynamics is stabilized. At the same time the other task of infusion therapy – reparation of oncotic blood pressure by infusion of plasma, albumin solution, and polyglucin – is solved. For organism detoxication in early time (first hours) you prescribe haemodes (neocompensanum), rheopolyglucin. For “basing” there may be used 0.3 mmol/liter buffer of trisaminum, which has high and constant buffer capacity. If the patient has normal swallowing during first 2-3 days you prescribe NaOH (2-4 grams after every 4 hours). Before diuretics infusion hypovolemia has to be eliminated by active diffusion of blood plasma, solutions of albumin, crystallates.
Intensive therapy during crush syndrome must be started in the earliest time, because the characteristic changes are formed during 5-6 hours after trauma.
If the response on diuresis stimulation is absent, you should not prescribe furosemidum (lasix) or mannitum one more time, because there is already tubular necrosis in kidneys. For saving such patient there are needed haemoabsorbtion, haemodialisis. Large attention is paid to simple and safe method of detoxication – haemo- and lymphosorbtion. During sorbtions the content of potassium, magnesium, phosphorum and some toxic substances is decreased. During regional haemosorbtion there are absorbed “acid” metabolites.
Crush syndrome of medium and high severity is an indication for haemosorbtion providing and development of acute renal insufficiency – to start haemodialisis. During treatment of patients with severe form of syndrome it is necessary to provide both procedures. Absorption helps to eliminate encephalopathy, improves general condition, but it hardly changes level of urea and kreatinine in blood; haemodialisis effectively eliminates hyperazotemia and hyperhydration. Haemodialisis must be early, regular and individual depending on catabolism level; dangerous hyperkaliemia and hyperhydration are absolute indications for “artificial kidney” usage.
Usage of hyperbaric oxygenation in complex therapy of crush syndrome helps to eliminate blood hypoxia, increase quantity of thrombocytes, decrease intoxication, and improve kidneys’ function. Experience of early and wide usage of plasmapheresis in complex treatment says about its high effectiveness of liquidation of DIC-syndrome (Dissemination Intravessel Coagulation – syndrome), providing of organism’s detoxication.
At the same time with conservative therapy surgical treatment is provided. One of the most serious possible mistakes of surgical procedures is not taken into the account in wound infection factor and local tissue changes, especially in places of their long-term pressing. Sometimes there is provided relatively economic cutting of injured soft tissues, and after amputations primary surgical procedures on the wound – putting on of primary stitches. It can lead to appearing of severe purulent processes. For future disease course in such cases is characteristic increase of severe condition in patients after operation (for 6 days after trauma) due to crush syndrome and progressing of wound purulent processes. Very often despite of massive antibacterial therapy there are developed typical non-clostridial and clostridial anaerobic phlegmones and deep myositis. During this period there are needed repeated wide surgical introductions and wide usage of afferent methods of treatment (haemosorbtion, plasmopheresis and haemodialisis).
Early amputation have to be provided in ischemia of limbs of III degree when there is edema of injured limbs, there are absent all kinds of sensitivity, active and passive movements, despite of kept arterial pulsation. You cannot amputate the limb on the place of catastrophe not freeing it, if time of crush is less than 15 hours.
Not enough wide primary surgical procedures even in correct active surgical treatment may finish badly. In such cases sometimes we cannot even save patient’s life.
After operation the limb must be in horizontal position, because in higher position arterial blood supply is hardened and metabolic disorders of ischemic nature are severed.
Maximally full and early elimination of not living tissues from the wound, foci of destruction and places of ischemic necrosis being an ideal environment of microbial reproduction, is basis in infection liquidation. Any antibiotics will have no action if necrotized tissue will be in the wound.
From first stages of treatment systematic injection of highly effective antibiotics without nephrotoxic properties is needed. Effective antibiotic prophylaxis may be by usage of equal combinations of antibiotics, effective for most causative agents of wound infection. Combined antibiotic therapy is an important method of effective treatment improvement. During crush syndrome there is recommended usage of two antibiotics combination because injection of more remedies may have not desired consequences.
A principle speciality of combined antibiotic therapy is usage of preparations with different spectrum of antimicrobial activity including action on anaerobes, which helps to influence on most causative agents of wound infection.
The most adequate in crush symdrome are such combinations of antibiotics:
1. Modern aminoglycosides (gentamycini sulfas, tobramycinum, sizomycini sulfas, amykacinum) with penicillines (benzylpenicillinum-natrium, ampicillinum, carbenicillinum, oxacillinum), cephalosporines (excluding ceporinum), macrolides (erythromycinum), tetracyclines (rondomycinum), antibiotics of different groups (rifampicinum, linkomycinum, laevomycetinum).
2. Polymixinum B combined with penicillines, cephalosporines (excluding ceporinum), macrolides, tetracyclines, and antibiotics of different groups.
Despite of relative equalness of those combinations each of them has specific peculiarities which lets use individualize antibioticotherapy. Thus, in appearance of clinical symptoms of Pseudomonas aeruginosa infection we will use combinations of aminoglycosides with carbenicillinum or ureidopenicillines.
Risk of anaerobic infection development during crush syndrome is very high; that’s why into combined antibiotic therapy must be included derivatives of metronidazolum (flagilum, clion, metrogyl), remembering about necessity of antifungal drugs’ prescription.
Excreted with urine metabolites of metronidazolum may color it to reddish-brown color. You must remember during treatment of patients with crush syndrome for differential diagnostics of this symptom with haemolysis and myoglobinemia.
For decrease of eikosanoides level (products of arachidonic acid metabolites) – mediators of inflammatory reaction – there might be used hormones of adrenal cortex. There is indicated also effectiveness of usage of protease inhibitors (trasilolum, tzalolum, contrikalum) which also decrease activity of kalikrein-kinin system decreasing level of spontaneous esterase activity.
For prophylaxis and fight with secondary immunodeficiency there might be used immunomodulators like thymalinum, T-activinum, immunoglobulines.
As a result of plasmorrhagia a hem concentration, decreasing of chemical and osmotic erythrocyte resistance, intracellular hemolisis and anemia appear; very important is an indication of mioglobinemia, resistance of erythrocytes. Processes of hem coagulation activate during the long-term smash tissue syndrome, the concentration of heparin goes down, but fibrinogen concentration increases. Hypercoagulation aggravates reological properties of blood.
During first hours getting out from under ruins victims complain on pain and violation of moving – joint of injured limb. Hypoanesthesia or anesthesia, absence of reflexes are typical locally changes.
However general condition is stable during some time. But then feebleness, headache, pallor of skin, cold sweat and tachycardia are increased.
There are three stages of limb ischemia, and each of them has its own help.
I. Compensative ischemia. There are no violations of micricirculation and metabolism. All movements are kept. Pain sensitivity is saved too. A tourniquet that was put on a pressed limb should be taken off immediately.
II. Uncompensative ischemia. Pain sensitivety is absent. Passive movements, are free, but active are absent. A tourniquet must be taken off, because ischemia continues by its pressing, and death of extremity observed (during 6 – 12 hours from the beginning of crumpling).
III. Unreverse ischemia. Pain sensitivity is lost; there are no active movements. Pay attention: there are no passive movements. Don’t take off a tourniquet. An amputation of a limb upper of a tourniquet is necessary.
Every long-term crumpling, which makes an ischemia, finishes by necrotic changes of muscle.
The versions of the long-term smash tissue syndrome are the following:
1. By influence mechanism:
– crush;
– direct pressing;
– positional pressing;
2. By localization of force:
– Thorax;
– Abdomen;
– Pelvis;
– Hand;
– Forearm;
– Brachium;
– Foot;
– Crus;
– Femur;
3. By combinations of injures:
– Internal organs;
– Bones;
– Joints;
– Main arteries;
– Nerves;
4. By complications:
– Limb ischemia (compensative, non-compensative, non-reverse);
– Inner organs and systems (pneumonia, heart infarction, lungs swelling, fat embolism, etc).
5. By degree of critically:
– Easy;
– Middle;
– Hard;
6. By periods of compression:
– Early;
– Middle;
– Late.
7. By present of combined injuries:
– Blood loss;
– Burns, frostbite;
– Barotraumas;
– Radiation sickness;
– Intoxication (poisoning) of chemical substances.
It’s necessary to distinguish in the crush syndrome a compression period (fig. 1).
Manifestations of long-term smash tissue syndrome, which are acute renal insufficiency, traumatical local neuritis should be considered as regular, because they have similar pathogenetic mechanisms with crush syndrome.
Middle and difficult stage of long-term smash tissue syndrome accompany with acute renal insufficientia. An extracorporal detoxication is necessary for its treatment.
A tumor of injured area of a limb and a stage of ischemia manifestate expressively after 12 – 24 hours, at the same time inflammational changes manifestate which are rubor, dolor, calor, tumor, functio laesa. First portion of urine is brown (mio- and hemoglobinuria); there is albumen in urine (6 – 12%), cylinders. A hemoconcentration arise even after hemorrhagia; a biochemical analysis is the following: contents of serum urea, blood serum, urea nitrogen, creatinine, potassium and phosphate increase.
Anemia is obligatory phenomenon of long-term smash tissue syndrome, but it is absent first days as a result of hemoconcentration. It becomes stable because of intoxication.
An acute hepatical insufficiencies that join up later manifistate by hyperbilirubinemia and increasing of blood enzymes – alkaline phosphatase, creatininkinase, asparagines transaminase, lactatedehydrogenase and others.
There are three periods of long-term smash tissue syndrome, those are distinguished in a clinics:
· Early – shock manifestation (till third day after trauma);
· Intermediate manifestates by acute renal insufficiencia;
· Late, or a period of recovery (a beginning of second week till 1 – 2 month).
A sudden change for the worse during pathological process is observed immediately after getting out from ruins or stones. During period of shock a violations of circulation manifestate conveyly with vessels insufficient.
Shock accompanates only a heavy forms of crush – syndrome; it is characterized by pain, emotional stress, hypovolemia and hemoconcentration.
After shock an intermidiate or light period begins. It can be also in a hard form, and those can lead to death. A condition of a patient getting better, there is no pain, normalization of a pulse and blood pressure are observed, body temperature is 37,6 – 38,5 C; an olyguria registates.
Next period of long-term smash tissue syndrome manifestates till 4 – 5 day after trauma with acute renal insufficient (dyshydria, hyperazotemia, hyperpotassiumemia, increasing of metabolic acidosis). Diuresis gets shorter till critical level (30 – 20 ml/h). Also there are anemia, hyposodiumemia, hypocalciumemia, and albumen contents get down till 5 ± 0,1 g%. An acute renal insufficient can be observed also at those cases, when there is no shock.
At the end of long-term smash tissue syndrome during a convalence period functions of kidney renew other organs, a water-electrolytic balance are normalizes.
Anaesthetization should be given at first medical care, before getting out from ruins and stones. Ketaminum is used very often in prehospitalic anaesthetization; it combines with seduxenum effectively; an analgesic effect manifests in a doses 0,1 – 1 mg/kg of the body weight after intravenous introduction.
The first specialist who had singled out shock was Le Dran (1737). He described the symptoms and introduced the term “shock” (stroke, shake and jolt) and treated the patients with rest, alcohol and opium.
Extremity, which liberated from squeeze, is pale, with a cyanosed spots. Pulse on it is not felt, sensitivity loosed, the movements is impossible. The clinical picture of serious shock with a breach of functions – agitation, fear, anxiety, and then, apathy, and sleepiness – is developed through the 3-5 hours. Disorder of hemodynamics, plasmorhea and toxical damage of the liver and kidneys are present. Degenerative changes in kidneys and liver are developed in the serious cases – oliguria, hematuria, albumen, and cylinders in a urine, anuria, and uremia. Oedema of the brain, lungs are present. Extremity is sharply swollen on 3-5 day, become compact, and paralyses are developed. There are serious degenerative changes in kidneys and liver, oedema of the brain, lungs and others are observed after death by the post-mortem examination.
Fractures of bones and dislocations. Clinic, treatment
Fracture. A fracture is a structural break in the normal continuity of bone. This structural break, and hence fracture, may also occur through cartilage, epiphysis and epiphysal plate (see appendix 14).
Dislocation. A dislocation is a total disruption of a joint with partial remaining, but abnormal, contact between the articulating surfaces.
Subluxation. A subluxation is a partial disruption of a joint with partial remaining, but abnormal, contact between the articulating surfaces.
The treatment of fractures and dislocations requires knowledge of the anatomy, physiology, and biomechanics of the musculoskeletal system. While a fracture represents a disruption in the continuity of a bone, it also represents a major soft tissue injury. In case of fracture the surgeon must be aware of the soft tissue structures adjacent to a fracture site and be alert for neurologic and vascular components of the injury. Since many fractures occur in a setting of violent trauma, full evaluation of each patient is necessary, and the surgeon must be prepared to deal with major injures in other tissue systems.
Classification of fractures
Fracture – is a partial or total breach of integrity of the bone, which is provoked by quickly – acting force and accompanied damage of soft tissues. The fractures are divides on inborn and acquired depending on the origin. Each of these groups, in one’s turn, divided on open and closed, and the acquired fractures are divided on traumatic and pathological.
Intrauterine fractures are registered rarely: there are developed in connection with inferiority, fragility of bones of a fetus.
Acquired are the fractures, which provoked by outwards violence, contraction of muscles or in connection with pathological process in the osseous tissue.
Open fractures are accompanied by damage of integrity of soft tissues and skin integuments. Closed – are the fractures, in the presence of which the skin and mucouse are intact. Clased fracture is the barrier for the penetration of infection.
1. Traumatic fractures are happen as a result of influence of mechanic force. They divide by a mechanism of force action on the fractures as a result of direct blow, squeeze, bending, twisting and tearing off of a bone.
By the direct blow – is transversal fracture, fracture with a dislocation of peripheral osseous piece.
Squeze is lead to a compessional fracture, for example, body of a vertebra by the strong bending, and by fall.
It can be developed the oblique and transversal fracture by bending.
The twisting of a bone by fixing one end is lead to the development of helical fracture by spiral.
The breaking off fractures is happened by the sharp and strong contraction of muscles.
2. By localization the damages are divided:
· epiphysial fractures are unfavourable for the processes of consolidation and quite often accompanied by dislocation of osseous piece of a joint, which is hamper the comparison and fixation of osseous parts.
· metaphyseal – are the damages of a spongy part of bone. The important symptoms of a fracture (crepitation, abnormal mobility and others) are absent quite often by such fractures.
· diaphyseal – the important symptoms of a fracture (crepitation, abnormal mobility and others) are present quite often.
3. The fractures are divided on transversal, oblique, longitudinal, spiral, splintered.
4. There are total and incomplete fractures.
5. There are simple, complex and combined fractures.
6. There are single and plural fractures.
Morphological changes in various dates after the fracture
Formation of a callus
It can be divided the pathological changes the pathological changes by the fractures and them unions of three periods:
a) changes, which connected directly with a trauma and development of aseptic inflammation;
b) period of osteogenesis;
c) period of reconstruction of a callus.
A callus is formed by the way of reproduction of the periosteal cells, cells of bone marrow, Haversions canals, and connective tissue. Each of these sources of osteogenesis is lead to development of special layer of a callus.
Callus consists of some layers: periosteal, outwards callus is developed from the cells of periosteum enveloping the ends of bones from the outside as a muff.
The proliferation of cells is started from the side of a cambial layer of periosteum on the place of fracture from the 2nd day, large quantity of embryonal cells. Young forming again vessels and osteoblasts are to the 3-4 day. These osteoblasts are main cells, which formed the new osseous tissue.
Osteogenesis can go on two ways: by the way of immediate development of a callus from osteoid tissue or by the way of preliminary formation of cartilage. The more perfect reposition of osseous fragments and immobilization of damaged extremity the more facts for the development of a callus without formation of cartilage.
Endostal or internal layer of a callus is developed from the cells of endosteum, bone marrow of peripheral and central osseous fragments. Young cells, which fell the defect between osseous fragments, are merget in a united endostal layer of a callus.
Intermediary or interventing layer of a callus is developed from the cellular elements of Haversian canals of osseous fragments and occupy, the interval between periostal and endostal layers. The better reposition, i. e. the more compactly osseous fragments adjoin one to another.
Periostal layer of a callus is developed from the tissues, which surrounded the place of fracture.
Fig. 2. Components of a bone callous:
1 – periostal; 2 – endostal; 3 – intermediary; 4 – paraossal.
As result, the following development of a callus is happen by two ways:
1) by the way of immediate formation of a callus from osteoid tissue.
2) by the way of preliminary formation of hyaline or fibrous cartilage from the osteoid tissue.
The dates of a union (consolidation) are different by the fractures.
Formation of a primary callus, i. e. the cohesionness of osseous fragments by osteoid tissue, is happening during 4-5 weeks. Then the sediment of a lime is take place, i. e. (the process of ossification, formation of secondary callus, which is continued during 5-6 weeks.
The process of architectural reconstruction of a callus is started simultaneously with osteogenesis and sediment of calcium salts in the osteoid tissue. Osteoclasts are resolved the ends of osseous fragments, splinters, abundance of a callus.
Architectonical reconstruction is very prolonged process, which can continued some years.
Regeneration of the bone depends on:
1. Character and force of traumatic agent, serious trauma makes the less favourable conditions for consolidation.
2. Anatomy-physiological state. Different bones have various abilities to union. Bones are united quicker in young people.
3. Character of fracture:
a) accompanied by large destruction and breach of nourishment of periosteum;
b) accompanied by breach of innervation;
c) breach of a blood supply;
d) fractures in region of bone, which have not the periosteum, for example intraarticulate fractures.
Clinic of fractures
It is very various by the fractures and not always expressed well. Basic symptoms of fracture are:
1. Pain – is observed at once after the fracture; it abates in a rest and reinforced by any movement of extremity. But the pain doesn’t decisive symptom, because it take place by injuries, tensions.
2. The breach function is not always typical symptom of fracture. It is typical, for example, for the fracture of lower extremity when a patient does not stay on the legs after trauma.
3. Sometimes the deformation is acutely expressed on the place of fracture, and sometimes expressed little and can be recognized only on R-gramm.
There are some types of displacement:
a) Displacement under the angle, when the axis of osseous fragments formed the angle of the place of fracture. Angle depends on the direction of the fragments.
b) Lateral displacement is observed by the divergence of osseous fragments in a direction of diameter of the bone.
c) Displacement by the length, longitudinal displacement – more often type of displacement, when the one fragment slip along another.
4. Mobility of osseous fragments along the bone length is very sure sign of the fracture. It can be expressed well by the diaphysial fractures.
5. Crepitation and abnormal mobility of osseous fragments is defined, if the bone fixed by one hand below and by another hand above the place of fracture and does carefully moved in a opposite side.
Principles of treatment, reposition and immobilization
The basic problem of treatment of fractures is a restoration of anatomical integrity of a damaged extremity and physiological function of the damaged organ.
As far back as 2000 years ago Hippocrates’ used the reposition and immovable splint bandages. The main aim was the anatomical restoration of integrity of the bone by the treatment of fractures. N. I. Pirogov widely used the gypsous bandages for the treatment of fractures in 50th years of last century. However the study of results of gypseous bandages use shown, that prolonged preting of the bones, not always lead to the restoration of function of suffered extremity: atrophy of muscles, hard -mobility, immobility of joints are remained.
Berdengeer proposed the treatment of fractures by drawing out in 1880.
Russian scientist K. F.Vegner elaborated the original method of treatment by drawing out with the help of adhesive plaster.
Modern treatment of fractures direct at restoration of anatomical structure and physiological structure of a fractural bone. This purpose is attained by successive application of such measures as:
1. setting of osseous fragments – reposition;
2. retention of them in a right posture till the union -immobilization;
3. acceleration of the union processes (consolidation) and restoration of function of the damaged organ by the way of:
a) functional treatment with the application of a medical physical training;
b) improvement of a general state of a patient (nourishment, vitaminization, blood transfusion).
Reposition. Setting of osseous fragments must be made at once after the fracture till the development of a traumatic oedema and reflectory contracture of vuscles. Osseous fragments must be compared exactly.
Success of the reposition depends on following moments:
a) knowledge of the type of fracture and displacement of central and peripheral fragments;
b) by well anasthetization – 2% solution of a novocaine in the place of fracture;
c) by relaxation of muscles, which fastened to the osseous fragments;
d) by right comparison of osseous fragments – the peripherial fragment is placed to the central;
e) use of arm methods for reposition and different apparatuses (Sokolovsky’, cug-apparatus and others)
Fixation or immobilization of osseous fragments in a right posture can be practicable by different methods:
a) plaster bandage;
b) drawing out;
c) operation.
Plaster bandages: circulary, longetic, longetic-circulary, fenestrated, bridge-like, folding, and gypseous bedstead.
Plaster is a calcium sulphate like a small powder. It is able to harden, when connecting with water. Became damp gypsym loss this ability, so it is necessary to keep the dry powder of gypsum in a dry place after the tempering to 120-130°.
The splint-plaster bandage is for setting of bone fragments, wooden or wire splints into a plaster bandage. Plaster bandages are applied in a physiologically advantageous posture, that is important in a case of development of ankylosis or hard – mobility of joints. The modelling is made by contours of extremity by palm stroking by the application of plaster bandages. The edges are cliped carefully after application of bandage that they should not provoke the pressure. The bandage, which made from well plaster, is dry out during the 10-15 minutes. Patient is needed in observation after application of plaster bandage: the pressure can lead to the breach of blood circulation along all extremity, breach or nourishment, necrosis. It is necessary to remember: to cut the bandage if the squeeze is observed.
Plaster of Paris bandages, which are applied on extremity with already developed traumatic oedema, with the hematoma, through 7-14 days in connection with decrease of oedema become free. It is necessary to take off it and apply a new bandage to avoid the secondary displacement. Gypseous bandage immobilize the extremity on date, which is necessary for consolidation.
Method of drawing out – widely used for treatment of fractures, because it allows keeping the relative immobility of joints and function of muscles by the securing of immobility of osseous fragments. The extremity doesn’t squeezed by bandage and blood circulation doesn’t breached, that is hasten the formation of a callus, prevent the atrophies, bedsores etc. All extremity is accessile examination and observation to the doctor in charge of the case, and movement is started from the lust days of treatment.
Inconveniences of the method: it demands the maintenance patient on the bed, hamper the roentgenological control.
Method is realized by application of adhesive plaster or skeletal drawing out.
Technique of the adhesive plaster drawing out When wiping dry the skin of damaged extremity by the spirit, the lateral surfaces are smeared by a cleol and the sticking plaster or pieces of a flannel 6-8 cm wide are glued to them, then they are threw over the joint like a loop and glued to the outward surface, change the dressing on is after that. The suffered extremity is packing up on the splint (Beler’s etc.). The cord, which is threw over the blocks of splint and the necessive weight is suspensed to it, is fastened to the loop of adhesive plaster in a plywood distance piece. Splint is setted in such posture that peripherial osseous fragment should localized by the direction of axis of central fragment.
It is necessary to take into account the following peculiarities by the application of a sticking plaster drawing out:
a) it must be used at the first hours after the fracture till the appearance of muscular retraction and traumatic oedema;
b) stripes of adhesive plaster are fastened to all segment of extremity independently of level of fracture, that is secure the even relaxation of muscles;
c) the joints are remained mobile, that is make possible the early movement, begining from 2-3 day.
Fig. 3. Sceletal traction in femur (a) and shin (b) fractures
Skeletal drawing out (fig. 1) is realized from the bone by the way of puting of metallic spoke through it or retention of the bone by crampon. This method allows applying the significant weights (till 16 kg) for the stretching of muscles and comparison of fragments, taking the spokes through the condyles or tuberosity of a shinbone.
Operative method is allowed to realize the reposition and fixation of osseous fragments. The assistant stretches the peripherial part of extremity for reposition and simultaneously the surgeon carry out the comparison of osseous fragments.
Complications of fractures
The early complications of fractures:
Local Sequelae of immediate local complications: skiecrosis and gangrene, Volkmann’s ischaemia, gas gangrene, venous thrombosis, visceral complications, joint infection, bone infection, avascular necrosis, fracture blisters.
Remote Are fat embolism, pulmonary embolism, pneumonia, tetanus and delirium tremens.
The late complications of fractures:
Local Joint stiffness, secondary osteoarthritis, bone malunion, growth disturbance, chronic infection, difuse osteoporosis, Sudeck’s atrophy, refracture, muscle myositis ossificans, late tendon rupture, tissue atrophy, tendonitis.
Remote Are renal calculi, accident neurosis.
DISLOCATION
Dislocation is a steady abnormal displacement of articulate surfaces, with respect of one to another. If the articulate surfaces are stop adjoin, the dislocations are named total, by partial contiguity -incomplete or subdislocation. Tell dislocation is usually accompanied by rupture of articulate surface capsule and going out of one articulate surface through this rupture. Depending on the damage of joint we tell about the dislocation of a humeral joint etc.
There are distinguished the inborn dislocations, which arise at the time of intrauterine life of a fetus, and acquired, which are developed as a result of trauma or pathological process in a region of a joint.
Pathological picture – the rupture of articulate capsule, rupture of a ligamental apparatus, tendons, nerves and large vessels is observed.
Clinical picture The questioning of a victim is allowed to elucidate the circumstances of a trauma, mechanism of damage. Pain in a joint and impossibility of movement in it become stronger by movement. Numbness of extremity is by squeeze of a nerve. Deformation in a joint is present.
X-ray film is confirming the diagnosis of a dislocation.
Treatment: urgent qualified aid. First aid are – transport splint or fixing bandage and analgetics. Immediate transportation in a hospital is needed. Setting is carried out easier and results are better, if it is realized at first hours after trauma. Dislocations of 2-5 days are set difficulty, and 3-4 weeks later are often required the operation.
The setting of dislocations must be carried out under the anaesthetization without fail. The complete relaxation of muscles is necessary for quick setting of dislocation that is achieved by total anaesthetization. Use of rough, physical force is result in the complementary damages of capsule of a joint and development of recidivations of dislocation (habitual dislocation), which are more often met in a shoulder and maxillotemporal joint.
There are some methods used of setting of a dislocation for the restoration of normal anatomical correlations in a joint, which are based on the relaxation of muscles of articulate region, and setting of dislocated articulate surface. With use of a number of motions, which are typical for every joint. Tills movements in a damaged joint as though repeat the motions in reserve succession, which provoked the dislocation.
Kocher’s method – consist of 4th stages (fig. 2):
Fig. 3. Reducing humeral dislocation by Kocher’s method
a. crooking in the elbow joint with a putting of shoulder to the trunk.
b. Traction downward and simultaneously rotation of a shoulder.
c-d stages – raising of arm upwards and simultaneously rotation of a shoulder with the following throw of hand on the healthy supershoulder. Control X-ray photograph is made at once after setting. Extremity is fixed on 6-10 days in a functionally advantageous posture by bandage or stretching and then the LFC complex is carried out.
Pathological dislocations are result of destructive pathological processes, which lead to the destruction of capsule and ligaments (tumour etc.)
PAIN MANAGEMENT BASIC PRINCIPLES
· Pain management regimens must be tailored to individual patient requirements. Where appropriate the combined use of different analgesics (multimodal analgesia) should be used. This is more effective, limits the dose of any one therapy and helps to minimise serious side effects. It is necessary to review the patient’s response to therapy and then tailor ongoing analgesia to their needs.
· In acute pain it is anticipated that the worst pain will be present initially and steadily improve with time. It is therefore essential to have an appropriate level of maximum therapy instituted at the outset of treatment and gradually stepped down.
· Regular assessment of pain scores and the side effects of therapy is necessary to ensure effective and safe treatment.
· Pain management should aim to control pain to a tolerable level. Remember it should be possible with appropriate interventions as above to control acute pain for most hospital patients to a level with which the patient is comfortable. However, it is inappropriate to aim for complete analgesia in all patients since this is likely to lead to problems with treatment side effects.
· • Pain relief from any analgesic regime is balanced against side effects. In some situations a compromise is necessary, where less effective analgesia is acceptable to avoid complications of therapy which may be distressing or which may lead to morbidity and even mortality.
· Regular analgesia is more effective than “as required” dosing. “As required” prescribing should only be used for the mildest pain or to relieve breakthrough pain in addition to regular analgesia.
· When converting from a more complex analgesic regime eg epidural, adequate step down analgesia must be prescribed.
· Analgesic prescriptions should be reviewed regularly, giving consideration to changing requirements and possible drug interactions.
· Where a patient can take oral medications, analgesia including opioids should be given orally unless severe uncontrolled paiecessitates iv titration.
SUMMARY OF PRINCIPLES OF ACUTE CARE
· Assess and treat simultaneously.
· Give enough oxygen to correct hypoxaemia.
· Establish adequate IV access. Take blood for urgent tests, including ABG and cross-match.
· Commence continuous monitoring.
· Perform illness severity assesment: SEWS scoring and look at the patient!
o risk of deterioration/cardiac arrest.
o where to admit.
o co-morbidity.
· Get help as indicated.
· Write iotes and prescribe drugs (incuding oxygen and fluids).
· Communicate with patient, family and significant others.
· Re-assess repeatedly and act on findings.
· Treat pain, nausea and other symptoms appropriately.
· Make a diagnosis, institute definitive treatment and assess response.
· Communicate the above and the plan with the patient, the ward team and the patient’s relatives.
