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CLINICAL PROTOCOL
ON
J
Karnataka Health Systems Development Project,
Bangalore
Government of Karnataka
Printed on Riso & binded at project Secretariat ’99
>
Foreword
*
Dr. S.N. Halbhavi, Specialist, District Hospital, Belgaum, conducted the first District
Level Training Programme at District Hospital, Belgaum*,' to the group of Surgeons of
Belgaum District from 10-03-1997 to 19-03-1997.
In this booklet, an attempt has been made to provide a diagnostic and management
guidelines on Trauma care, which may be informative to all the Doctors taking care of Trauma
patients in all the primary and secondary level hospitals.
With the present trend of increasing major road accidents, especially with the increased
number of two wheelers on road, younger patients with major injuries and multiple fractures
are reported to all casualty units of Govt. Hospitals, where a sound knowledge of either
managing on modem lines or to refer to higher center without enhancing the damage to the
existing conditions, is required. In this direction this booklet will be of some help either to the
trainers who have to carryout the training programmes for the doctors working at Community
Health Centres or to others who are facing the problems in their day-to-day life in hospitals. I
would like to mention that 45 Trauma Centres are being established all over Karnataka to take
care of the victims of Trauma especially of accidents.
I also request the clinicians to express their views and suggestions to improve upon the
modalities involved in taking care of large number of Trauma victims.
Dr. S. Subramanya, IAS
Project Administrator &
E/o Additional Secretary to Govt.
Health & F W Department,
Bangalore.
PREFACE
I was informed by the Superintendent and District Surgeon, District Hospital, Belgaum, in the
first week of March 1997, that I should conduct training programme to the group of Surgeons from
Belgaum District. I had lot of apprehension at that moment, because the group consisted of Surgeons
who were seniors and had plenty of practical experience and some were my contemporaries. This
training programme was the after effect of my training in St. John Medical College, Belgaum, during
the month of November ’96. My sincere attendance and the notes that I had made during the training
were of much help to me. Dr. S.L. Mokhashi, all the time encouraged me to go ahead and this was the
source of inspiration to me.
The duration of the training was of 10 days from 10-03-97 to 19-03-97. I contacted the Senior
Professors and Specialist in Anatomy, Surgery, Gasto-enterology, Dental & ENT Surgery in J.N.
Medical College and District Hospital, Belgaum and arranged few lectures. Met Dr. Joshi, former
Professor of Radiology and presently working in Disha Diagnostic Centre, Belgaum and arranged for
lecturer and demonstration in Ultrasound Scanning. \I would succeed in getting the overhead projector
and slide projector from the District Health Officer, BelgaunJ) The training consisted of pre-test on the
first day, post-test on the last day of training and lectures by me and the invitee professors with
discussion and visit to K.L.E. Hospitals and Disha Diagnostic Centre for observation in Endoscopy and
Ultrasound respectively. The trainees also visited for 2 days Surgical Operation theatres of District
Hospital, Belgaum, and observed various operations and anaesthesia procedures.
During the course of training. Dr. G.V. Vijayalaxmi, Additional Director, KHSDP and Dr.
J. A. Krishna Swamy, Joint Director (Hospitals), KHSDP, Bangalore, visited the District Hospital and
participated in the training and explained the themes of KHSDP. Her kind words of appreciation made
me forget all the trouble that I had taken to organise the training programme and conduct it
successfully.
On the last day of training, in the Valedictory function, the trainees expressed their satisfaction
and told that they could learn so many new things, which was a very high moral boost to me.
After the training, I visited the KHSDP Office, Bangalore. I was introduced to ——
Dr.
Subramanya, Project Administrator, by the Additional Director. He gave me letter of appreciation and
asked me to prepare the training module on Trauma, sharing my experiences. Thus, this booklet
originated.
I prepared the notes topic-wise which I had taught in the training period and submitted to the
Project Administrator. It took sometime to include the notes in the computer and copy was ready. This
copy was handed over to Dr. Manjunath, Senior Specialist (Orthopaedic Surgeon, K.C. General
Hospital, Bangalore), who scrutinized and suggested to add few chapters in Orthopaedics.
i
During the month of March 1998, I was deputed to training in Ultrasound and I took this
opportunity to meet Dr. Vijayalaxmi. She readily handed over the entire file to me and requested me to
go through the whole file and include whatever needed and feed in the computer. In the file I could find
the typed notes on multiple fractures from Dr. Farooque, Professor and Head of Department of
Orthopaedics, AIIMS, New Delhi. Some of the topics are included in this booklet. I hope this booklet
will be best guide for Doctors who treat Trauma patients.
Dr. Subhash N. Halbhavi
M.S. (Gen. Surgery)
Specialist, District Hospital,
Belga um.
Goals
I
1. To familiarise Surgeons and Casuality Mledical Officers, the force
acting in Trauma victims.
1
2. To anticipate and find out the injuries inflicted in traumatised
patients.
3. To make ABC resuscitations as part of routine examination.
4. To diagnose correctly and TREAT or REFER the patient in the
GOLDEN HOUR.
5. MINIMISE MORTALITY IN THE PRODUCTIVE AGE AND
PREVENT DOWN FALL OF ECONOMY OF THE COUNTRY.
i
Trauma
i
We thank
All the Officers and Staff who have contributed
their time and energy in various ways in bringing out this
book.
We acknowledge the services of
1. Teaching Faculty of J.N. Medical College, Belgaum.
2. Teaching Faculty of St. John’s Medical College,
Bangalore.
3. All India Institute of Medical Sciences, New Delhi.
4. Health Systems Project I, Andhra Pradesh
and
5. Orthopaedic Department, K.C. General Hospital,
Bangalore.
Dr. G.V. Vijayalakshmi,
Consultant,
KHSDP, Bangalore.
/
Foreword
f
Dr. S.N. Halbhavi, Specialist, District Hospital, Belgaum, conducted the first District
Level Training Programme at District Hospital, Belgaurrt; to the group of Surgeons of
Belgaum District from 10-03-1997 to 19-03-1997.
In this booklet, an attempt has been made to provide a diagnostic and management
guidelines on Trauma care, which may be informative to all the Doctors taking care ofTrauma
patients in all the primary and secondary level hospitals.
With the present trend of increasing major road accidents, especially with the increased
number of two wheelers on road, younger patients with major injuries and multiple fractures
are reported to all casualty units of Govt. Hospitals, where a sound knowledge of either
managing on modem lines or to refer to higher center without enhancing the damage to the
existing conditions, is required. In this direction this booklet will be of some help either to the
trainers who have to carryout the training programmes for the doctors working at Community
Health Centres or to others who are facing the problems in their day-to-day life in hospitals. I
would like to mention that 45 Trauma Centres are being established all over Karnataka to take
care of the victims of Trauma especially of accidents.
I also request the clinicians to express their views and suggestions to improve upon the
modalities involved in taking care of large number of Trauma victims.
1
Dr. S. Subramanya, IAS
Project Administrator &
E/o Additional Secretary to Govt.
Health & F W Department,
Bangalore.
4
I
TRAUMA AND ITS MANAGEMENT
In the present decade of this century, there is marked increase in the number of trauma
patients, mainly due to Road Traffic Accidents, because of (1) rapid increase in the number of
vehicles on the road and (2) introduction of high speed vehicles. The condition of existing roads
is not good and there is no strict implementation of rules. Alcohol is also one of the major
contributors.
4
These patients are mainly brought to the Causality Department of District and Taluka
Hospitals and Major Hospitals and to out patient department of Primary Health Centres and
Units. Here the causality Medical Officer is assisted by Staff Nurses and sometimes by a House
Surgeon in the hospitals attached to Medical Colleges. He has two tasks to perform (1) To
examine, assess and render emergency treatment and (2) to record the history and findings which
may be required to be produced in the Courts of Law in future. Hence thorough knowledge of
accident and emergency medicine is mandatory to these doctors.
After initial resuscitation, which is highly decision making to save the life of the patient,
he may be treated in the same centre or may have to be referred to higher centre depending upon
the existing condition of the patient.
4
Trauma is the leading cause of mortality and disability during the first 4 decades of life.
It is the third most common cause of death overall. It has been calculated that more than 4
million trauma cases are hospitalised in the USA annually. In the United Kingdom there are
14,000 deaths annually due to trauma; of these 5000 to 6000 result from road traffic accidents.
For each trauma death, there are more than 10 other persons that are seriously injured, and some
of these are permanently disabled.
The .direct cost to society in caring for the victims of trauma is enormous, for in many
instances trauma affects young individuals, and their loss of productivity at work is immense.
MECHANISM OF INJURY
Trauma may be broadly classified into : (1) blunt or nonpenetrating and (2) penetrating
varieties.
Injury occurs when tissues are deformed. The severity of the damage is related to the
amount of energy released and the area over which it is applied.
f
In penetrating trauma of low velocity, the energy is usually focused over a small area,
e g. injuries caused by bullets from hand guns, or due to knives, sharp instruments, spikes of
glass, wood or metal. However, in high velocity missile injuries, the energy may be dissipated
over a wide area.
1
In blunt injuries, the damage may be caused by acceleration, deceleration, rotational or
shearing forces. Victims of motor vehicle accidents may be injured by either rapid deceleration
or by deformation of the vehicle itself As deceleration occurs in.a crash, the occupant’s body is
thrown against the interior of the vehicle, whereas the vehicular deformation is caused by inward
movement of the shell, the person may be crushed and trapped inside. Ejection of an occupant
may occur, in which case rapid deceleration of the body occurs when it strikes the ground or
another vehicle.
B
When a pedestrian is struck by a moving vehicle, there is often an acceleration injury in
addition to the direct trauma at the sites of impact.
(bl
Fig 1: (a) A victim struck by a fast-moving vehicle sufiers blunt trauma (*) and acceleration (->) injuries,
(b) In head-on impaction type injuries, the victim sufiers blunt trauma (*) and deceleration injuries (<-).
Patterns of injuries in road traffic accidents :
While the variety of injuries that may occur in a road traffic accident is vast, there is a
tendency for certain patterns of associated injuries to emerge. There may be a combination of
head and cervical injuries; cervical whiplash and sternal injuries; sternal fracture and dorsal spinal
injuries; fracture of the lower ribs and rupture of the spleen or liver; intra-abdominal and
diaphragmatic injuries; pelvic fracture and urinary tract trauma and lower limb fracture
associated with either dislocation of the hip or spinal fracture.
Disaster Planning:
Disasters may be classified as being either natural or artificial. Natural disasters , embrace
events such as earthquakes, typhoons and floods. Artificial disasters include major road, rail or
air crashes, industrial accidents, rioting and explosions associated with civil disorder.
When a disaster occurs, large numbers of casualties are likely to arrive at hospital within
a short period of time and may overwhelm the facilities and services available. It is therefore
important to set priorities, not only in the management of the individual, but for organisation of
care of the totality of the injured group.
2
*
Triage :
Tnage means sorting’. The term was used during warfare when sorting out casualties at
forward clearing stations but, nowadays is frequently applied to disaster situations. Triage may
be necessary both in the field and in the hospital setting. In hospital triage may be used in three
situations .
1. On arrival of patients at Causality Department.
2. In the x-ray department.
3. In determining priorities for operative intervention.
TRAUMA SEVERITY SCORES
Glasgow Coma Scale:
are as fJlows^6
SpeCifically t0 head hlJury Patients- The three components of this scale
1. Eye opening.
2. Best verbal response.
3. Best motor response.
The coding for each of these is shown as follows :
Eye Opening
Spontaneous
To voice
To pain
None
4
3
2
1
Verbal response
Oriented
Confused
Inappropriate words
Incomprehensible sounds
None
5
4
3
2
1
Motor response
i
Obeys command
Localises pain
Withdraws (pain)
Flexion (pain)
Extension (pain)
None
6
5
4
3
2
1
Total
3-15
3
Revised Trauma Score :
Of the many severity scoring system in use, the Revised Trauma Score as devised by
Champion is widely accepted and applied. This incorporates the Glasgow Coma Scale.
Variables on three organ systems that are vital to survival are thus combined into a single score
as shown below. High scoring equates with prognosis.
Glasgow coma scale
Systolic blood pressure
~~
13 - 15
9- 12
6-8
4-5
Respiratory rate
>89
10-19
76 - 89_______>29
______ 50 - 75_______
6-9
_______ 1 -49_______
1 -5
0
0
Points
4.
2
2
1
0
Trimodal pattern of trauma deaths :
Trunkey has pointed out that death due to trauma fall broadly into three groups giving a
distinct trimodal pattern.
’ ~~ ■
1. Immediate deaths (50%) - those occurring within the first few minutes of injury and
usually due to extensive trauma to the following :
• brain or upper spinal cord,
• the heart or major blood vessels,
• rupture of major airway.
This first peak is due to injuries which are generally so lethal that little that can be done in
their management that is likely to affect the outcome. Hence, it is only accident prevention or
measures taken to reduce the severity of the injury, such as wearing of seat belts.
Lacerations 3rain
Brainstem
Aorta
Cord
Heart .
1
Epidural
Subdural
Hemopneumothorax
Pelvic fractures
Long bone fractures
Abdominal injuries
0
.
■ 2 weeks
1 hour 3 hours
'
Time
Sepsis
/ | Multiple organ
/ \ failure
4 weeks
—----------
Fig 2: Tnmodal patterns of death following trauma based on 1,500 autopsies.
(From Bailey & Love’s Short Practice of Surgery)
4
/
2. Early deaths (30%) - those occurring within the first few hours after injury due to
space-occupying collections of blood within the skull, or massive blood loss into the
chest or abdominal cavities from major vessels and organ disruption, or into soft
tissues from extensive fractures of pelvic or long bones.
3. Late deaths (20%) - those occurring some weeks
weeks after
after injury,
injury, generally
to sepsis
sepsis
generally due
due to
and multiple organ failure. Organ failure may involve the heart, kidney,, liver, lung,
brain and haemopoietic systems.
It is amongst those cases represented by the second and third peaks that potentially
preventable deaths occur.
Pre-hospital management:
The aim should be for the rapid and smooth transfer or patients from the scene of the
accident to a hospital.
Attention
Attention is
is paid
paid to
to securing
securing an adequate airway. Gloves are worn and a two-fingers
sweep is used to clear solid material from the mouth and pharynx combined with suction to
remove fluid and debns. Patency is maintained by lifting the mandible forward and, if
appropriate, inserting an airway. For emergency use, a mini-tracheostomy set is invaluable.
Cemcal spine should be protected by the use of a balloon, sandbags or forehead strapping.
Other measures mclude ensuring adequate ventilation and oxygenation, covering and sealing
open sucking’ chest wounds, controlling external bleeding by direct pressure and monitoring the
neurological status. If there is an obvious fracture of an extremity with gross deformity, the limb
should^ be gently drawn into alignment as axial traction is maintained. As axial traction is
maintained, the fracture is splinted.
If delay is anticipated intravenous fluids may be administered.
Hospital Care :
A team approach by those trained in trauma management, preferably by an Advanced
Trauma Life Support (ATLS) course, is ideal. The aim of this course, which was developed by
the American College of Surgeons and is now being introduced in many centres around the UK
and elsewhere, is to instruct doctors in the recognition of problems and in the provision of expert
resuscitative measures during the ‘golden hour’ following trauma, Since the severely injured
patient has many problems, swift and co-ordinate management requires a team approach,
Factors indicating that a patient has a high risk of multiple injuries are outlined below : (After
Champion)
1. A penetrating injury to the chest, abdomen, head, neck or groin.
2. Two or more proximal long bone fractures.
3. Bums > 15% combined with facial injury or airway problems.
4. A flail chest.
5. Evidence of a high energy impact:
5
• Falls of 20 feet or more.
• Change in velocity in crash of 20 m.p.h. or more estimated from outward
deformity of car.
• Rearward displacement of front axle.
• Sideward instrusion of 35 cm or more on the patient’s side of the car.
• Ejection of patient.
• Rollover.
• Death of another person in the same car.
• Pedestrian hit at more than 20 m.p.h.
Primary survey and resuscitation :
The initial evaluation of the patient proceeds in parallel with the ABC of resuscitation,
i.e., airway, breathing, circulation, which must be attended to in that order. Endotracheal
intubation may be required depending on the local anatomical injury and the level of
consciousness. It is important to check up by inspection and auscultation that both sides of the
chest are being ventilated and oxygenated. Blood is taken for haematocrit estimation, blood
grouping and cross-matching, electrolytes and urea analysis and blood gas analysis. Mini
tracheostomy may be required.
_•
Two peripheral intravenous lines using size 14 cannulae are set up. Central venous
cannulation and bladder catheterisation are undertaken to aid in the control of fluid balance.
Vital signs are measured and recorded. A rapid initial assessment of the brain and spinal cord is
made by requesting the patient (if conscious) to put out the tongue, move the toes and squeeze
the examiner’s fingers.
Secondary survey :
The adequacy of resuscitation is judged by the patient’s clinical response.
Increasing tachycardia, decreasing blood pressure and increasing pallor suggest
continuing blood loss into one of the body cavities.
In order to carry out a detailed head-to-toe examination the patient should be completely
disrobed. It may be necessary to cut off the clothing to avoid undue disturbance of the patient.
Head : A thorough check is undertaken for external signs of injury such as bruising,
lacerations or bony deformity. Depressed skull fractures may or may not be palpable.
Deterioration of the neurological status may indicate rising intracranial pressure, or it may be due
to hypoxia and hypoperfusion. If a patient with closed head injury becomes hypotensive, a
careful search should be made for blood loss with particular attention to the abdominal and
thoracic cavities. Hypoxia and hypercarbia both tend to compound the initial brain damage.
The nostrils and external auditory meatus are examined for any evidence of rhinorrhea or
otorrhoea. It should be remembered that the cerebrospinal fluid emerging from these orifices is
6
*
I
mixed with blood and produces a double ring if dropped on a sheet. Clotting is also delayed by
the presence of the CSF fluid.
Face : The eyes are checked for the presence of foreign bodies, perforation, visual
acuity, pupillary reflex and corneal reflex. Subconjunctival haemorrhage may suggest basal skull
fracture. An assessment is made for the stability of the mandible. Fracture of the bones of the
middle third of the face with displacement can compromise the airway, which may be improved
by pulling the mobile segment forward. The mouth is checked for retropharyngeal haematoma
and foreign bodies.
Neck : Palpate for subcutaneous emphysema. The cervical spinous processes are
carefully palpated for any ‘step’ deformity. Examination of the neck may reveal venous
distension or tracheal deviation. A lateral x-ray showing all seven cervical vertebrae is essential
in patients with multiple trauma. Care must be taken to avoid lesions at Ci, C2 and C7 levels
going undetected. Downward traction on the arms while the film is being taken will enhance the
demonstration of the lower cervical vertebrae.
J
Thorax : Inspection of the anterior and posterior chest wall is undertaken to check for
any penetrating or sucking chest wound, or for paradoxical movement of a flail segment. Impact
against an automobile steering wheel may have caused sternal fracture and cardiac contusion.
Palpation of the ribs reveal tenderness or crepitus in the case of fractures. If the lower ribs are
fractured, the possibility of intra-abdominal organ injury, esepecially hepatic or splenic, must be
borne in mind.
Percussion and auscultation may confirm the presence of pneumothorax or haemothorax.
Tension pneumothorax needs immediate release. This can be achieved in the first instance using
a large-bore intravenous cannula inserted in the 2nd intercostal space in the midclavicular line on
the affected side. Subsequently a 32 French gauge chest drain can be inserted just anterior to the
midaxillary line in the 5th intercostal space. Likewise, an open chest wound or haemothorax will
require the insertion of a chest drain. While all patients who sustain severe blunt trauma require
chest x-ray, this may have to be deferred until life-threatening priorities have been dealt with
appropriately.
Penetrating chest wounds may injure the heart. Not uncommonly, the patient reaches
hospital alive, especially if the lesion involves the right side of the heart. Distant heart sounds,
distended neck veins, a rapid, thready pulse and falling blood pressure may herald the
development of cardiac tamponade. Rapid deceleration as a result of a car crash or fall from a
height may result in tearing of the thoracic aorta.
I
Abdomen : The use of a nasogastric tube reduces the risk of aspiration of regurgitated
gastric content, and is prophylactic against acute gastric dilatation. The abdominal wall and back
should be carefully inspected for signs of injury or ecchymosis. Any laceration is covered with
sterile gauze. Eviscerated bowel is covered with a large sterile pack soaked in warm saline Pain
in the shoulder during inspiration may suggest subdiaphragmatic irritation from blood or leaked
gastrointestinal content. Palpation of the abdomen may reveal abdominal distension and
7
voluntary guarding.
Blunt abdominal trauma may produce severe intraperitoneal and
retroperitoneal injuries with relatively few physical signs. Diminished or absent bowel sounds
may also be due to peritoneal irritation from intestinal contents. However, at the initial
examination, bowel sounds may still be audible in up to 30 per cent of cases with significant
intra-abdominal lesions.
Initial clinical assessment of the abdomen in blunt trauma is accurate at best in only 70-80
per cent of cases. Accuracy is likely to be less in patients with multiple trauma or concomitant
head injuries, or altered levels of consciousness due to alcohol or drugs. Diagnostic peritoneal
lavage is particularly helpful in patients with an altered level of consciousness from head injury,
alcohol intoxication or drug ingestion, in whom clinical assessment of the abdomen may yield
few clinical signs. False negative results may be obtained in patients with extraperitoneal injuries
to duodenum, pancreas, bladder or colon.
It must be stressed that extensive investigations should not be undertaken at the expense
of resuscitation. In some critically ill patients, urgent resuscitation and, in some cases,
emergency laparotomy must take precedence over investigative procedures.
Pelvis :
The pelvis is compressed and distracted manually to check for pain
enhancement and pelvic stability. Blood at the penile meatus may indicate urethral damage,
either partial or complete, and no attempt at urethral catheterisation should be undertaken. If
there is suspicion of urethral injury and a urethrogram has not yet been undertaken to clarify the
situation, the suprapubic placement of a urinary catheter is undertaken. Following severe blunt
trauma, the pelvis should always be x-rayed.
Spinal iniuries : Tests are made for peripheral sensory and motor defects. In spinal
injuries with unstable fractures, further neurological damage can be caused by moving the patient
inappropriately. However, if no spinal cord injury occurred as a result of the initial trauma when
forces at the moment of impact were greatest, then the patient can be carefully log rolled to
examine the back.
Extremities : Extremities should be inspected and examined for signs of trauma,
check is made for the presence of peripheral pulses and also that the nerves are intact,
fractures are suspected, x-rays are taken while maintaining splintage.
*
A
If
As part of the early management of the traumatised patient, consideration may have to be
given to the need for pain relief, antibiotic administration and tetanus prophylaxis.
*
8
TEACHING PROGRAMME FOR GENERAL SURGEONS
/
Topic : Diagnosis and Management of Head Injuries
1. Define Concussion / cerebral contusion
compound depressed fracture
Acute subdural haematoma
Complications
2. How to take history
3. To assess level of consciousness
4. How to diagnose each as one (1)
5. To judge who needs surgical intervention
6. How to transport
7. How to write reference letter
8. Prevention
NOTE : Doctors working below 100 beds.
Ref: C.G.S. less than 13 to higher centres.
HEAD INJURY
Objectives
1.
An account
of accident
(a) Modes of Transport
(b) Time & Date
(c) Conscious
i
2.
Diagnosis
Contents
Activities and AIDS
RTA________
FALL_______
ASSAULT
MISSILE
CALAMITIES
(a) Airwary Metal______
(b) Endotracheal tube
(c) X-rays_____________
(d) C.T. Scan__________
(e) Craniotomy Set______
'(f) Fibre Optic Head Light
(g) Suction Apparatus
(h) Bipolar Coagulator
(i) Cervical Collar______
(j) Thoraco-lumbar Brace
No Loss________
Loss___________
Lost but recovered
Continued to
deteriorate
(d) Vomiting___________
(e) Seizures _________
(f) Increased Headache
(g) ENT bleeding_______
(h) Alcohol___________
(i) Helmet_____________
(a) Concussion_________
(b) Cerebral Contusion
(c) Extradural Haematoma
(k) Knee Hammer
(l) A/v. Aid______
(m) O.H Projector
(n) Slide Projector
(o) View Box
(p) Torch_______
9
3.
Transport
4.
Examination
(d) Acute Subdural
Haematoma____________
(e) Intra-Cerebral Haematoma
(f) Compound depressed
Fracture_______________
(a) Semi-prone Position
(b) Immobilization of neck
with Cervical Collar
(a) Air way
___________
(b) Breathing_____________
(c) Pulse / BP_____________
(d) Assessment of
Consciousness by G.C. Scale
(e) Pupillary changes_______
(f) Focal deficit, sensory level
10
r
CRANIOCEREBRAL INJURIES
Introduction : In most countries, the primary and continuing care of patients who
have sustained a head injury is the responsibility of general and Orthopaedic surgeons rather than
neurosurgeons. Despite the expansion of neurosurgical services, this situation is likely to
continue and therefore the general surgeon requires a knowledge of principles and practice in
this field. Since the majority of patients do not require any neurosurgery, the major steps in the
care of such patients are medical, diagnostic and nursing, and it is these steps which will
determine the outcome far more frequently than any surgical manoeuvres. Indeed, the avoidance
of unnecessary cranial surgery is an important principle, because such surgery may be harmful.
At the same time the general surgeon must be aware of the indications for specialised intracranial
investigation, which usually requires transferring the patient to a neurosurgical department.
Finally, he or she must be able to decide when there is a clear indication for urgent surgery
without specialised investigation, either because the rate of deterioration does not allow any
further delay, or because the facilities for intracranial investigation do not exist. Thus, in many
parts of the world, patients must still be managed without CT scanning, although this situation
should become less common in future.
I
11
Injuries of the brain
r
Primary Brain Injury (Type I)
Secondary Brain Leision (Type II)
---- --------------------------- 1 +
a. Due to movement of the brain within the skull box
causing shearing forces due to deceleration and
acceleration. Ex. Road traffic Accident - when the
moving head strikes against the immovable object
like foot path or road.
b. In acceleration injury the stationary skull is struck
by a moving object. Ex. Assault in which the brain
accelerates against the stationary mid brain.
I
Head Struck
from front
In this both the
cerebral
hemispheres are
displaced
posteriorly
against
static
mid-brain,
Hypothalamus,
Brain-stem
Head Struck
from behind or in
front at one side
or the other
In this one
cerebral
hemisphere
moves against
the other so that
junctional tissues
of commissures
and corpus
collasum are
damaged.
It is due to localised injury to the brain
against rough internal configuration of
skull and flax tentorium. When the
internal portion of the skull is rough,
damage to the brain is more and when
it is smooth damage to brain is less
I
Temporal lobe of Damaged against
Head struck far the brain
Sharp
edged
away from site of
sphenoid ridge..
blow to the head
In this grey
matter of cortex
moves over the
white
matter
leading to tear
of nerve cells
and axon fibres
of that region.
Injury is
of
diffuse in nature.
Frontal lobe
Damaged
by
(Inferior surface) rough surface of
anterior
cranial
fossa floor.
Occipital lobe
Damaged due to
injury to Flax Tentorium.
Corpus callosum
Damaged against
sharp edge of
Falx.
Cerebral
Peduncle
Damaged
sharp edge
tentorium.
by
of
*
12
TYPE OF BRAIN DAMAGE IS INDICATED BY THREE TERMS
1
CEREBRAL CONCUSSION:
It is a brief physiological paralysis function of the brain without structural organic brain
damage.
Clinical Signs and Symptoms:
1. Transient loss of impairment of consciousness.
2. Dizziness or mild confusion followed by complete recovery. It may be short losting
from one minute to x/z an hour or may be long lasting prolonged for hours or even a
day.
3. Patient looks pale, pulse feeble, Temperature increases and later on pulse becomes
full and bounding.
Cause for loss of consciousness:
Cerebral Anemia is due to compression of the brain causing emptying of vessels or abrupt
stretching of anterior and posterior perforating arteries causing transient ischemia of brain.
2. CEREBRAL CONTUSION:
4
In this there is damage to nerve cells and axons with bruise and swelling of cortial gyri,
Brain odema and congestion contribute to' swelling of brain.
3
CEREBRAL LACERATION:
In this brain surface is tom or lacerated with eSusion of blood into CSF fluid. Often
laceration is most severe on the side opposite to that on which the blow is struck. This condition
is known an contracoup injury.
Changes in the brain:
Damage to the nerve cells and axons causes brain odema which leeds to giosis and
atropic changes in the brain. The damaged portion of the brain shrinks and fluid accumulates in
the subarchanoid space. Therefore it causes mental impairment. After some years scar formation
and later on causes epilepsy (Traumatic epilepsy of Jaksonean type)
i
13
CEREBRAL IRRITATION
r
It may occur within 48 hours of injury.
Signs and symptoms:
1. Patient curls up on his side with knee drawn up and arm flexed (an attitude of flexion)
2. Avoids light, interference. No interest in surroundings.
3. Recovery is complete.
Patient complaints on headache, irritability, depression, lack of concentration, defective
memory and change of personality.
Aetiology - is due to localised odems which occurs around the area of contusion or
laceration in brain.
SEQUALE OF CEREBRAL CONTUSION OR LACERATION
1. Post traumatic amnesia (PTA). This is the time between the head injury and return of
continuous memory.
•
•
•
If it is less than 1 hour, injury is regarded as slight.
Between 1 and 2 hours injury is regarded as moderate.
Between 1 and 7 days injury is regarded as severe.
2. Retrograde traumatic amnesia (RTA). This means loss of memory of events before the
occurrence of accident.
3. Cerebral Irritation - this is called as post contutional syndrome- (after recovery patient
complaints of headache, photo phobia, nausea, vomiting, depression, delerium or lack of
concentration).
4. Traumatic Epilepsy.
5. Permanent damage to an improtanf focal centre of cerebral cortex.
• Anosmia - injury to the inferior aspect of frontal lobe.
• Hemianopia, Blindness - occipetal lobe lesion.
• Ataxia and Nystagnus - cerebellar lesion.
6. Cerebral compression features due to
•
•
•
•
Acute extra dural hematoma of arterial origin.
Acute extra dural hematoma of venus origin.
Acute sub dural hematoma.
Acute intra cerebral hematoma.
14
Mechanism and pathology :
At the moment of impact, a diffuse neuronal lesion is inflicted on the brain, which is
responsible for the immediate clinical picture of brain injury. Secondary changes of brain
swelling or intracranial haemorrhage take time to develop. The rise in pressure resulting from
these causes leads to a deterioration in the patient’s level of consicousness a few hours after
injury; the clinical picture in the early stages results from the neuronal lesion alone. All degrees
of brain injury resulting in loss of consciousness, concussion, contusion, or laceration of the brain
are produced by one mechanism, namely displacement and distortion of the cerebral tissues
occurring at the moment of impact.
X
tv
/
- i
Fig 3: Lines of force acting on the hypothalamus and
brain stem as the result of posterior displacement of
the hemisphere.
Fig 4: Lines of force acting on the corpus
callosum and one peduncle as the result of
posterior displacement of one hemisphere.
Early secondary pathology
1. Intracranial factors :
Brain swelling : The brain often reacts to any insult, be it ischaemic, neoplastic
inflammatory or traumatic, by swelling due to oedema, The accumulation of fluid is both
extracellular and intracellular. Macroscopically oedema may be localised at least initially to the
part of the brain most damaged, but it may extend rapidly throughout one or even both cerebral
hemispheres, causing a severe rise in intracranial pressure and, at an earlier stage, features of a
relatively localised space-occupying or compressing lesion which may mimic a compressing
haematoma.
Brain necrosis : This is seen most frequently in the so-called burst temporal lobe
syndrome. By a combination of swelling (oedema and venous engorgement), ischaemia leading
to haemorrhagic infarction, and necrosis, there may be localised mass occupying the anterior and
middle parts of one of the temporal lobes; similar changes may also occur in one or both
anterieor poles of the frontal lobe. This produces all the clinical features of a lateralised
supratentorial mass lesion, usually presenting some hours or even a few days after injury, and
may require urgent craniotomy and temporal or frontal lobectomy.
15
Haematoma : The surgically remediable intracranial haematomas may be extradural,
subdural or intracerebral. They may be the result of arterial or venous bleeding, and therefore
vary in their time of presentation in relation to the injury. The deeper the haematoma, the more
likely it is to be associated with primary brain damage, oedema, and necrosis and therefore the
results of surgical evacuation are poorer. It is rare to have an intracerebral haematoma due
solely to the rupture of one major vessel; usually such haematomas are due to the tearing of
many small vessels, and it is often difficult to determine the relative part played by the
haematoma in the clinical problem.
Vascular changes : Consequent to rising intracranial pressure, disturbance in cerebral
blood flow may occur which causes further brain damage through ischaemia, and the ischaemia
itself may produce an increase in brain oedema. In normal life there are autoregulatory
mechanisms, which to some extent protect the cerebral circulation despite changes in blood
pressure and intracranial pressure.
When the intracranial pressure rises severely, the
autoregulatory mechanism fails and irreversible ischaemic changes occur. In addition, following
brain injury there may be dilatation and engorgement of the venous system which will further
increase the brain swelling, and therefore the intracranial pressure, and increase the brain oedema
by impeding the normal drainage of tissue fluid and worsen the cellular ischaemia.
Coning, or herniation of the contents of the supratentorial compartment through the
tentorial hiatus, or the contents of the infratentorial compartment through the foramen magnum,
may accompany a rise in pressure in the appropriate compartment. The pathological sequelae at
the tentorial hiatus include herniation of the medial part of the temporal lobe (the uncus) on the
side of the supratentorial mass, which causes pressure upon the ipsilateral 3rd cranial nerve, and
upon the midbrain. The midbrain is distorted and displaced away from the side of the mass,
where the free edge of the tentorium indents or ‘notches’ the cerebral peduncle and interferes
with the descending motor pathways from the hemisphere opposite to that which is being
compressed. In addition, the compression of the midbrain contributes to obstruction of the CSF
flow in the aqueduct, which contributes further to the rise of intracranial pressure. These changes
produce a deterioration in the level of consciousness, dilatation of the pupil on the side of the
compressing mass, and a hemiparesis on the same side as the mass. This situation is called
‘Kemohan’s notch’.
Coup and contre-coup : These words are used to indicate the types of craniocerebral
damage which may occur either on the side of the blow to the head (coup), or opposite (and
often diagonally opposite) to the position of the blow (centre-coup). Provided it is clear where,
and where alone, the head was struck, this knowledge can provide a useful guide to pathology
when used in conjunction with the lateralising signs of a compressing lesion (see Coning, above).
2. Extracranial factors :
Respiration : Respiratory failure or inadequacy is one of the most potent factors which
can aggravate or precipitate the development of severe brain oedema and venous congestion,
leading rapidly to irreversible changes. Of the two factors, the arterial pO2 and pCO2, a rise in
pCO2 is the more potent. It is therefore essential that pCO2 and pO2 are maintained at normal
16
levels in any patient who has sustained a severe head injury. Although at times hyperventilation
has been employed in order to reduce intracranial pressure, abnormally low pCO2 levels may
cause a reduction in cerebral blood flow and subsequent cerebral ischaemic damage, and it is
therefore safer to achieve normal levels.
Systemic blood pressure and blood volume : When the brain is at risk from ischaemic
damage following injury it is obviously essential that a normal cardiac output is maintained and
that blood loss from other injuries is adequately replaced. Recent work has confirmed that when
the intracranial pressure is high, protective cerebral blood flow regulatory mechanisms are
impaired and a fall in cardiac output is particularly likely to result in irreversible cerebral
ischaemic damage.
«
Fluids : Although the onset of brain oedema is usually the result of the primary brain
injury and ischaemia, the state of the vascular compartment will influence its course. Thus, if
hypotonic fluids are given intravenously, the plasma osmolality may be lowered, particularly if
there is any delay or defect in renal excretion of the excess ‘water’, and therefore by an osmotic
effect fluid may be drawn into the brain tissue and brain swelling increased. With disturbance of
the normal blood-brain barrier (which is poorly understood), these effects may be increased.
Therfore intravenous fluids should be isotonic, and the volumes used (apart from replacement of
blood loss by blood) should be dictated by normal requirements and renal function. Problems
with fluid and electrolyte balance may be exacerbated by inappropriate secretion of pituitary
antidiuretic hormone as a cerebral response to the cerebral injury. This may produce
dangerously low levels of plasma sodium.
Temperature : When the body temperature rises, the metabolic demands of all tissues
rise and the accumulation of catabolites increases. When cells or particular groups of cells are
damaged, increased metabolic demands will aggravate the cellular failure or aggravate the
manifestations of poor function. This is well seen following severe head injury when a rise in
body temperature will cause a further deterioration in neurological state.
THE ACUTE COMPRESSING INTRACRANIAL HAEMATOMAS
These are (1) acute extradural haematoma, (2) acute subdural haematoma, and (3) acute
intracerebral haematoma.
Acute extradural haematoma : The majority of cases of acute extradural haematoma
are due to an injury associated with fracture of the temporal or parietal bone whose bleeding
results in an extracranial extravasation producing a boggy swelling deep to the temporal muscle.
Although intracranial haematomas are more common (x30) when a skull fracture is present, a
remediable extradural haematoma may occur in the absence of a fracture.
The classical syndrome of extradural haemorrhage results from injuries of the anterior or
posterior branches of the middle meningeal artery. In such cases, the injuring force, which
comes from a lateral direction, is often relatively trivial, such as a blow from a golf or cricket ball
which strikes the thin bone of the temporal plate, inflicting a fracture which drives the dura
17
inwards and tears a meningeal artery or vein. In the elastic skull of children, the injury may
occur without fracture, as it may, (but less commonly), in adults.
From the tom vessel blood passes in three directions :
1. Outward through the fracture to form a boggy swelling under the temporal muscle,
the finding of which is an additional indication for the admission for observation of a
conscious patient.
2. Downwards into the middle fossa.
3. Upwards over the parietal region.
The development of the extradural compressing mass depends upon the ease with which
the dura can be stripped away from the inner surface of the skull. With advancing age the dura
becomes more adherent to the skull and, with the ‘elasticity’ of the skull, is one factor in the
greater incidence of extradural haematoma in children and young adults. During the ‘lucid’
interval (below) the haematoma gradually enlarges and it is not until it has reached a size
sufficient to cause a severe rise in intracranial pressure and critical distortion of the midbrain at
the tentorial hiatus, that the conscious level deteriorates, often rapidly, with dilatation first of the
pupil on the side of the haematoma, then of the contralateral pupil as the stage of decerebrate
rigidity is reached.
*
Fig 5: Acute extradural haematoma.
(A) Impaction of the opposite crus
against the. opposite rim of the
tentorial opening. (B) Displacement of
the inner edge of the temporal lobe
(uncus) descending into the tentorial
opening (midbrain cone).
B
Clinical features : Usually, a laterally directed blow of small magnitude causes a short
initial period of concussion, followed by a characteristic lucid interval, during which the
haematoma is collecting intracranially and also forming a swelling under the temporal muscle.
An example is an unconscious footballer who has carried off the field but later recovered
sufficiently to finish the match; headache and drowsiness supervened so that he retired to bed
early and was later found dead from middle meningeal haemorrhage.
Although the ‘lucid’ interval is one of the ‘classical’ features of an acute extradural
haematoma, the ‘lucidity’ may be only relative compared to the subsequent deterioration. In
these circumstances, the clinical diagnosis is less obvious, and the consequent delay in diagnosis
18
may reduce the prospect of a favourable outcome. The practical difficulty in such cases is to
decide what degree of primary cerebral injury may be present with persisting low level of
consciousness, but nevertheless an acute extradural haematoma may yet supervene. It is the
awareness of this possible ‘nonclassical’ presentation which has prompted the move towards
greater use of the CT scan.
The next change is in the level of consciousness. The patient becomes confused and
irritable, and at this stage is in danger of being arrested if found wandering and smelling of
alcohol, therefore, beware of the patient brought to casualty in a confused state with a bruise in
the temporal region. Persons alleged to be found drunk have been locked in cells only to be
found dead in the morning, the unconsciousness and stertorous breathing of compression being
mistaken for a drunken stupor. Confusion changes to drowsiness, and there may be evidence of
a contralateral hemiparesis due to direct pressure on the cerebral cortex. At the same time,
inward displacement of the temporal lobe causes the inner portion of the lobe to press against the
3 nerve above the edge of the tentorium, causing constriction (rarely observed), rapidly
followed by dilatation of the pupil on the side of the haemorrhage. If the pressure is not relieved,
displacement of the brain stem at the tentorial opening forces the opposite crus against the rim of
the tentorium, producing a hemiparesis, which this time occurs on the same side as the
haematoma.
*
19
Extradural haemorrhage of venous origin is produced by fractures which injure the
major sinuses or by tearing of a meningeal vein. Injury of the superior longitudinal sinus
produces a massive subgaleal haematoma, together with evidence of clot compression, causing
rapid deterioration of consciousness with unilateral or bilateral leg weakness if the clot is over
the upper end of one or both motor cortices.
Acute subdural haematoma : Following severe head injury there is commonly a thin
layer of clot over the brain in the subdural space. This does not usually constitute a significant
compressing lesion, which is more likely to be produced by the underlying cerebral swelling and
contusion. A significant subdural haematoma is produced either by rupture of a large cortical
vein as it crosses the potential subdural space to reach the fixed dural venous sinuses or by
laceration of the cortex and subsequent venous or arterial haemorrhage.
Fig 6: Position of a subdural haematoma
produced by tearing of the superior
cerebral veins at the level of the
arachnoid. The diagram also shows the
partial or occasionally complete septum
which divides the superior sinus.
Cerebrospinal fluid drains into the upper
compartment through the arachnoid
granulations. The supenor cerebral veins
drain into the lower. (G.B. Northcroft,
FRCS, London.)
The presentation and management of acute subdural haematoma may be similar to that of
acute extradural haematoma, but tend to differ in certain respect.
1. There is often severe primary brain damage (e.g., laceration) and therefore initial and
persisting loss of consciousness. A truly lucid interval is unusual.
2. Deterioration tends to occur sooner than in extradural haematoma.
3. The haematoma may be ‘coup’ or ‘contre-coup’.
4. The haematoma is often extensive and may cover an entire hemisphere, extending both
subfrontally and subtemporally.
5. Effective surgical action is unlikely without special investigations (CT scan or
arteriogram, see below).
6. Effective surgery involves an extensive craniotomy; even then the results are poor due
to the primary and often widespread brain damage and brain oedema.
When the presentation is less dramatic and delayed by several days (so-called subacute
subdural haematoma) it is very difficult to determine the part played by the haematoma as
opposed to the underlying brain damage and especially increasing brain oedema. Without the CT
scan surgical opinions are frequently without foundation, and surgery ineffective.
7. Very rarely a large acute subdural haematoma may occur in the elderly following a
trivial injury or shaking of the brain with rupture of a ‘bridging’ vein.
20
Acute intracerebral haematoma : This is the least common of the siginificant and
remediable compressing intracranial haematomas. It is rare for a major intracerebral vessel to
rupture as a result of trauma and produce an expanding haematoma that is the sole cause of
cerebral compression. When there is totally lucid interval before such an event, it is more likely
that haemorrhage has occurred from a pre-existing vascular lesion such as an aneurysm or
arteriovenous malformation. If time permits, arteriography before surgery is advisable.
Usually, traumatic intracerebral haematomas are associated with cerebral laceration,
contusion, oedema and necrosis, the compressing lesion being formed by all these elements.
Therefore in these circumstances the benefit of removing the clot is unpredictable and often
disappointing. Occasionally, the removal of such traumatic masses in the anterior part of the
temporal lobe or in the frontal pole may be effective, but preoperative diagnosis with CT scan or
arteriogram is essential.
21
CLINICAL DIAGNOSIS AND MANAGEMENT
Primary and later neurosurgical management must include the following, which will be
considered in clinical sequence :
1. Casualty reception.
2. Indications for admission.
3. Radiography.
4. Continuing care and observations.
5. Deterioration.
6. Indications for surgery without special investigation (decision making)
7. Special investigations.
8. Nonsurgical therapy : osmotic diuretics, steroids.
9. Miscellaneous early complications.
1) Casualty reception : The reception of the severely injured patient is a large subject
which has already dealt with. In the following paragraphs, the essential points relate to patients
whose main reason for admission is a major head injury. There are certain general principles :
(a) Patients are more likely to die from airway obstruction than from any remediable
intacranial lesions.
(b) Surgically remediable intrathoracic and intra-abdominal lesions take precedence over
any intracranial procedures, as does general resuscitation and correction of blood loss. It is
dangerous to take decisions above active (especially surgical) intracranial management before
this has been done.
(c) In normal civilian practice patients are brought rapidly to a casualty department,
therefore compressing intracranial haematomas are unlikely to present when the patient is first
seen.
(d) The initial clinical assessment and its recording, especially of the level of
consciousnes, is of crucial importance if any later deterioration is to be gauged accurately.
(e) The immediate institution of the correct care of the unconscious patient does more to
lower the morbidity and mortality from major head injury than any other single measure.
In receiving and assessing a patient in casualty the essential steps in chronological order
can be summarised as follows :
(i) Protection of the airway : All the usual measures for the protection of the airway in
an unconscious patient should be taken immediately; removal of false teethy positioning prone or
on one side with the head low, mouth suction and insertion of a pharyngeal airway. The
presence of a compound skull fracture with exuding brain tissue is not a contraindication to
lowering the head. In the majority of patients, these measures will suffice. However, if they do
22
not a cuffed endotracheal tube should be inserted, which is in itself a test of the need for that
manoeuvre.
a
Specific indications for endotracheal intubation are :
(a) Absence of gag reflex.
(b) Maxillofacial injury; orophrayngeal bleeding; facial or oropharyngeal bums.
(c) Uncleared vomitus and / or the need for controlled ventilation.
(ii) General assessment : The general assessment is often more important than the
neurological because intrathoracic and intra-abdominal injury may require immediate action.
These aspects are dealt in the preceding section, but it should be stressed that the picture of
‘surgical shock’ should not be ascribed to the head injury unless the presence of another major
injury has been excluded.
(i)
Neurological assessment:
(a) Level of Consciousness : This is the single most important neurological observation,
and one that causes greatest difficulty in accurate description and recording. Terms and gradings
which require definition (e.g., ‘coma’ or ‘stupor’) should be avoided. A brief description in
simple words which include the degree of alertness, ability to communicate or obey commands,
and type of spontaneous or reflex limb movements is often satisfactory. The Glasgow Coma
Scale is a valuable method of recording consecutive observations, and of observing progressive
changes but without requiring previous definition of terms used.
(b) Pupils : When both pupils are small on admission and later one dilates, that provides
the most accurate clinical guide to the lateralisation of a supratentorial compressing lesion. If,
however, one pupil was known to be dilated immediately after the injury it is usually due to
direct injury related to the orbit, and neither pupil can be used later as- aguide to lateralisation.
Therefore the first assessment and recording of pupillary size is of extreme importance; size and
equality rather than reaction to light is the more important feature, and should be recored
graphically or verbally.
(c) Limbs : The types of spontaneous or reflex limb movements are an essential part of
the assessment of the level of consciousness (see above). Hemiplegia is as likely to be due to a
stroke’ prior to injury as to trauma; in the acute state it is very rarely due to a compressing
intracranial haematoma, but may be due to the primary cerebral damage. Alone it is never an
indication for urgent surgery. Of more immediate significance is the direction of paraplegia or
quadriplegia indicative of a spinal injury.
(d) Cranium : The position and nature of the external trauma should be noted
accurately, the wound over an obvious fracture should be cleaned with saline and surrounding
hair removed for a distance of at least 5 cm, and a head dressing applied. The presence of CSF
rhinorrhoea, or otorrhoea in noted, and special note made of any mandibular or facial fracture
which might lead to further difficulties with the airway.
23
(e) History of injury : With the severely injured the initial assessment and resuscitation
is usually done before a history of the injury can be obtained. However, that information is
important, particularly if a preceding medical condition has led to the injury. Information from
witnesses, ambulance attendants and relatives should be sought. Alcohol poses particular
problems, which are often greater in those who have been less severely injured, and it makes
accurate assessment of neurological lesions more difficult, and may be misleading when
deterioration in conscious level due to an intracranial haematoma occurs.
B
2. Indications for admission : Following head injury, patients are admitted to hospital
for two main reasons : (1) For continuing hospital care for those who have suffered serious
injury and who are in obvious need of care and possibly surgery. (2) For observation in case a
complication should develop, despite the patient being perfectly well at the time of admission.
The first category presents little difficulty about the indication for admission, but the second
presents considerable difficulty. Remediable complications, e.g., acute extradural haematoma,
may occur following very trival injury, but there is good evidence that they are more likely to
occur after transient change in consciousness, when a skull fracture is present and when the
patient complains of persisting headache. However, although the incidence of haematoma is
very low in the absence of these features, it is currently a matter of debate whether transient
clouding of consciousness alone should remain an indication for admission. Accepting that there
are these grounds for debate, the following are reasonable guidelines :
(a) Indication for skull radiographs after recent injury :
(i) Loss of consciousness or amnesia at any time.
(ii) Focal neurological symptoms or abnormal signs.
(iii) Suspected penetrating injury.
(iv) Scalp bruising or swelling.
(v) Alcohol intoxication.
(vi) Difficulty in assessing the patient.
(b) Indications for admission :
(i) Any degree of depression of level of consciousness on examination.
(ii) Skull fracture.
(iii) Focal neurological signs.
(iv) Persistent headache or vomiting.
(v) Other medical conditions such as patients on anticoagulants, haemophilia.
(vi) Alcohol intoxication.
(vii) Circumstances of injury unknown.
(viii) Crime.
(ix) Absence of responsible relatives or friends.
If the absence of a skull fracture is used as one of the reasons for not admitting a patient,
the radiographs must be of acceptable quality. If patients are not admitted, a responsible relative
or friend should be given written instructions about the possible complications and appropriate
action.
24
«
*
The duration of observation is arbitrary, but since it is exceptional for acute extradural
haematoma to present more than 18 hours after injury, overnight admission is usually sufficient.
In general, children should be admitted even more readily than adults because of the increased
incidence of extradural haematoma. Alcohol intoxication can lead to great difficulties because it
can mimic or mask the signs of intracranial haematomas to which alcoholics are generally more
prone.
3. Radiography : The purpose of skull radiographs includes :
(a) The demonstration* of a skull fracture whose position may provide a valuable guide to
the site of an extradural haematoma which might develop later.
(b) The presence of a skull fracture provides some indication of the severity of the injury.
and is one of the indications for admission.
(c) The demonstration of a depressed fracture which may require surgery.
(d) The demonstration of a calcified pineal gland and its position relative to the midline
which may change in subsequent radiographs, and indicate the presence of a lateralised
supratentorial mass lesion.
~
(e) The presence of intracranial air.
■V. 1
'■X-
i.
%
-
Fig 7: Skull radiograph of poor quality fails to show
fracture (arrow) properly.
Fig 8: Good quality radiograph shows fracture
(arrow).
Therefore the radiograph on admission may provide an essential baseline when later
detenoration occurs, and in the early management it can be argued that the radiographs are more
important in patients who are relatively well than in those who are deeply unconscious. Unless
radiographs are of reasonable quality, they are valueless and may be dangerously misleading
(figs, above), and in those circumstances it is wiser to defer radiography until films of good
quality can be obtained. The skull radiographs usually required are the right and / or left lateral,
tghe half-axial (35°) and the anteroposterior (20°). However, a chest radiograph is essential, as
25
is a lateral radiograph of the cervical spine to demonstrate clinically undetectable fractures or
fracture dislocation. If patients are in urgent need of intensive care, time should not be wasted in
trying to obtain skull radiographs.
4. Continuing Care : The objects of further care are : (a) by nursing and other
intensive care measures to enable the patients to survive a period of ‘unconsciousness’; (b) by
repeated observation to detect at the earliest possible moment the development of complications
which may need surgical or medical action.
Care of the ‘unconscious' patient: The quality of care given, which largely depends
upon the availability of experienced nursing staff, will determine the outcome in the majority of
patients. Attention to airway, skin, eyes, mouth, bladder and bowels, limb joints, nasogastric
tube feeding and intravenous infusions are very demanding and the surgeon must take a personal
interest in these matters if morale is to be maintained. Controlled ventilation is used widely if
spontaneous respiration is inadequate to maintain normal levels of pCOi and pCh. If the
ventilation is controlled, full sedation and total paralysis is essential because if the patient
struggles to breathe the intracranial pressure will rise. Tracheostomy is very rarely necessary in
the first few days after injury because an endotracheal tube may be used for up to 7 days;
thereafter if the airway or respiration is inadequate, tracheostamy may be required. As the level
of consciousness improves, there may be a stage of irritability which is difficult to control; drugs
are best avoided because all sedatives tend to depress respiration to some extent, which may lead
to a gradual rise in the pCO2 and deterioration due to brain swelling even 10 days after injury.
Clearly if the patient is conscious enough to experience severe pain from other injuries (e.g.,
limbs) it is inhumane to withhold analgesics such as codeine phosphate (100 mg.), but morphia is
best avoided. Because epilepsy is a major cause of deterioration (see below) all patients should
be on prophylactic anticonvulsants; adult drugs and dosages are phenobarbitone 60 mg 8-hourly,
or phenytoin 100 mg 8-hourly, and neither will depress the level of consciousness.
5. Deterioration : The most important indication of deterioration following head injury
is a decline in the level of consciousness. Its recognition requires accurate observation and
accurate sequential recording (see Glasgow Coma Scale, fig.). The major causes of deterioration
are :
(a) Airway obstruction / hypoventilation causing brain swelling causing rising intracranial
pressure.
(b) Brain swelling causing rising intracranial pressure.
(c) Intracranial haematoma.
(d) Epilepsy.
(e) Fluids and dehydration.
(f) Fever - infection - meningitis.
(g) Blood loss from other injuries.
(h) Aerocele.
Although swelling is a more frequent cause of deterioration than compressing intracranial
haematoma, it must be assumed that the deterioration is due to a haematoma until proved
26
otherwise. The exceptions to this rule are : epilepsy, fluid imbalance, infection and fever, and
blood loss. Unfortunately, airway obstruction and inadequate ventilation may not only cause
increased brain oedema, but also the addition of brain oedema in the presence of a haematoma
and, therefore, it is not always safe to assume that oedema alone is the cause of the deterioration
following airway obstruction.
Epilepsy may cause rapid deterioration in level of consciousness and if a convulsion is
not witnessed it may be difficult to differentiate this from the occasionally rapid effects of
cerebral compression. A convulsion does not necessarily indicate the presence of a compressing
haematoma.
Fever from any cause will produce deterioration. Meningitis may follow injury,
especially with basal skull fractures, and tends to present at the 3rd or 5th day after injury. At that
time, in the presence of fever and neck stiffness, diagnostic lumbar puncture is indicated.
Fluid imbalance and particularly dehydration may produce a gradual deterioration over
the course of 48 hours; clinical examination, review of fluid charts, and plasma electrolytes
should detect the imbalance, and the level of consciousness improves with correction.
6. Indications for surgery (decision making):
THE SIGNS OF CEREBRAL COMPRESSION are DETERIORATION IN
LEVEL OF CONSCIOUSNESS, SLOWING PULSE, RISING BLOOD PRESSURE and
SLOWING RESPIRATION.
In the presence of these signs, and having reasonably excluded other causes (see above),
the conclusion must be that:
This patient has a compressing haematoma until proved otherwise.
The course of action to be taken in these circumstances will depend upon :
(a) Availability of neurosurgical advice and facilities, and safety of transfer.
(b) Availability of CT scanning in the district general hospital or accident service.
(c) Speed of degree of clinical deterioration.
(d) Surgical expertise available.
Although in the majority of cases, and especially in more (developed
’
countries, surgery on
the basis of skull radiographs and clinical signs is rarely necessary, it is essential that all surgeons
should be aware of the indications for and the technique of such surgery. If there are clear
indications for urgent surgery, delay for CT scan or transfer to a neurosurgical department may
be disastrous.
Surgery without special investigations : The prime purpose of such surgery is to
locate and evacuate, or exclude an acute extradural haematoma, an essentially remediable lesion,
in a patient who is rapidly deteriorating. (The clinicopathological aspects of acute extradural
27
haematoma are described above and the reader may need to refer to this section before that
which follows.)
The major decisions before embarking upon urgent exploratory surgery concern :
(1) The presence or not of a haematoma (determined by the signs of rising pressure, see
above).
(2) The side for exploration : For this the essential guides are, in order of reliability, (a)
the shift of a calcified pineal on x-ray and (b) the side of the first pupil to dilate, provided it was
not dilated immediately after injury.
(3) The position of exploratory burr holes on the appropriate side. In order of
importance the guides are, (a) the position of a vault or squamous temporal fracture, (b) the site
of external trauma, and (c) the standard temporal position.
Preoperative : Ideally general anaesthesia with endotracheal intubation and controlled
ventilation should be used. However, if that is not available, time should not be lost, an
endotracheal tube should be inserted, and operation done under local anaesthesia. Having
determined the likely side of the compressing lesion (see above), the patient is positioned supine
with a sandbag under the appropriate shoulder and the face turned to the opposite side. It is
wise to remove all the hair, or at least that of the appropriate half of the head, and that side is
shaved. The sterile towels should be arranged in a way that allows access to frontal, temporal
and parietal regions. Blood should be available, but surgery should not be delayed if it is not.
OPERATION
The exploratory burr hole : A 3 cm vertical incision is made down to bone; a self
retaining mastoid-type retractor is inserted and opened forcefully thus controlling scalp and
muscle bleeding. The incision for the standard temporal burr hole is immediately above the
zygomatic arch midway between the posterior margin of the orbit and the external auditory
meatus. At that level the squamous temporal bone lies relatively deeply, but no damage can be
done in reaching it, and it is essential to use the self-retaining retractor to control the scalp and
muscle bleeding. Using a brace and bit with first the sharp point, and, when the inner table of the
skull is pierced, the reamer which has a protective flange, a blurr hole is made. If a significant
extradural clot is present the dura will not be seen because the dura will have been separated
from the brain by the clot, which has the appearance of blackcurrant jelly. For the same reason
the responsible bleeding dural artery e.g., middle meningeal will not be seen.
28
Fig 9: Incision for standard temporal burr hole.
I
Further action:
1. Extradural clot is not present Bearing in mind that the essential purpose of this
exploratory surgery is the exclusion or evacuation of an_extradural clot it is unwise to open the
dura at this stage. If the first burr hole has been placed over or next to the fracture, it is
reasonable to make a second burr hole in the standard temporal position. If that also is negative
it is reasonable to make a frontal or parietal burr hole if the original guides have not already
mcluded those positions. If none of these burr holes on one side have revealed an extradual clot
two further questions arise :
Fig 10: Incision for frontal and parietal burr holes.
(a) Should the dura be opened ? The assessment of the thickness and therefore
significance of an acute subdural clot by inspection through a burr hole is extremely difficult.
Only specialised radiology can assess this accurately and show the extent as well as the thickness
of the lesion. Whenever there is primary brain damage (contusion, laceration) there is some clot
in the subdural space, but this is rarely a significant compressing lesion. Furthermore the
satisfactory evacuation of a significant subdural clot requires a major and often larger craniotomy
(osteoplastic flap) with a wide dural opening; these procedures require particular neurosurgical
29
expertise and facilities, and the surgery itself may lead to further technical problems such as
ermation of a swollen brain. Therefore if an extradural haematoma is not found, the dura
should not be opened, ventilation should be continued, an osmotic diuretic given (mannitol see
below) and the patient transferred for special radiology.
, ., /k) Should a burr hole be made on the other side ? If the radiologically demonstrated
shift of the pineal has been used to determine the side of the compressing lesion nothing will be
gamed by making a burr hole on the opposite side. If the side of the first dUating pupil and the
S1 tof
fracture “d 7 or SIte of external trauma conicide, a contralateral burr hole need not be
made. If, however, the fracture or evidence of external trauma, e.g., bruising and swelling on the
temporal region, is on the side opposite to the first dilating pupil, the compressing lesion is likely
to be contre-coup (see above). However, very rarely the pupil may mislead and therefore a final
burr hole should be made over the fracture and / or site of external bruising or swelling.
,.
2‘ ExtraduraI clot present Assessment of thickness of the clot is made by using a
blunt-nosed brain cannula with centimetre marks and feeling the resistance of the dura- any clot
greater than 0.5 cm thick is significant. F
’ at the
Sometimes the burr hole will have been placed just
edge of the haematoma which is not, therefore, immediately visible; only by gently inserting a
dissector and depressing the dura will the clot be detected.
Fig 11: Burr hole near edge of extradural
haematoma.
Evacuation of clot:
(1) By craniectomy : The burr hole incision is extended in a straight line to a length of
about 8 cm, a second self-retaining retractor is inserted and with bone nibbiers the burr hole is
enlarged to a craniectomy of at least 7 cm diameter. The clot is then gently lifted ofl; this and
the bone removal decompressing the brain. Small fragments of clot adherent to the dura are left
because their removal only produces troublesome oozing from the dura to which ‘Oxycel’ may
be applied.
30
Fig 12: Extension of incision for craniectomy.
Fig 1j: Craniectomy and control of meningeal
artery by dural stitch.
f a major dural vessel is bleeding it is controlled either by diathermy or by a stitch passed
under the vessel. The dura is then ‘hitched’ to the surrounding bone by passing sutures, e.g.,
ac si through the superficial layer of the dura and the surrounding muscle or pericramum’
his step is essential to prevent the reaccumulation of a haematoma. The muscles, temporal
ascia, galea and skin are then closed in layers without drainage and a fiill head dress using gauze
and crepe bandage is applied.
...
Fig 14: Dural ‘hitching’ stitches.
'i W'*W S'
31
(V By craniotomy and osteoplastic flap : In experienced hands this gives wider access
without any appreciable loss of time in decompressing the brain and is generally used in
neurosurgical departments, but does require familiarity and neurosurgical instruments. The
stages are the turning of a scalp flap, the placing of multiple burr holes which are then joined by a
Gigh saw and the raising of a quadrilateral bone flap hinged at its base upon the temporal
muscles.
.-Os
Fig 15: Incision for temporal craniotomy.
Fig 16: Burr holes and saw cuts for temporal
craniotomy.
Postoperative : As soon as the conscious level permits the patient should be mobilisedskin sutures are removed on the 2nd or 3rd day. Antibiotics are not used routinely. Prophylactic
anticonvulsant drugs (see Continuing care) should be continued for about 6 weeks in the absence
of any other indications for their longer term use.
7. Special Investigations : Once the decision is made to shift the patient to the
hospital where neuroradiological facilities are available, it is reasonable to give osmotic diuretics
to the patient, to gain temporary improvement during transer.
Computed Axial Tomography (CT scan) : This non-invasive investigation provides the
most accurate guide to intracranial pathology following injury. The head is scanned from above
downwards in a series of transverse planes like a tomograph from vertex to base of skull by
tilting the x-ray tube and detector array within a gantry at each scan.
32
Ju
I
|A
Fig 17: CT scan. Acute extradural haematoma.
Fig 18: CT scan shows left hemisphere swelling,
ventricle displaced to right, contusion,
intracerebral blood and subdural clot.
The information is fed to a computer and produces a record in which high density objects
such as bone, clot or tumour appear white, the brain substance appears grey, areas of oedema a
dark mottled colour and the ventricular fluids black.
Indications for CT Scan :
/As CT
— scan facilities
are available in non-specialised
institutions, there is a need for defining its indications. A safe general rule iis : An indication for
CT scanning is also indication for neurosurgical advice prior to CT. This avoids
unwarranted and dangerous delay in transferring to a neurosurgical department.
The indication for CT Scan are still a matter for some debate, but include :
Absence of speech or eye-opening after general resuscitation.
...
.
. 2. Deterioration in level of consciousness.
3. Skull fracture with persisting severe headache.
4. Skull fracture with confusion or neurological deficit.
. Carotid arteriography, in the abscence of CT scan, remains a valuable method of
investigation, particularly in the demonstration of extracerebral haematomas.
8. Nonsurgical therapy
Osmotic diuretics : These substances when administered parentrally, raise the
osmolarity of the plasma, fluid will be drawn from the brain extravascular compartment into the
blood, there by reducing the brain oedema and swelling.
33
Mannitol as a 20 per cent solution given intravenously to an adult as a volume of 250 ml
the over the course of 20 to 30 minutes is the agent in general use. It may be used repeatedly at
6 or 8 hour intervals but the following must be noted :
1 there should be satisfactory renal function,
2. if a diuresis has not occurred following mannitol, further administration should be
delayed,
3. fluid and electrolyte replacement should be meticulous, particularly with the loss of
electrolytes with each diuresis,
4. if hyperosmolarity of the blood is to be produced, the rate of administration is critical.
Continued or repeated use of mannitol is only appropriate within neurosurgical
departments, in conjunction with continuous recording of intracranial pressure.
There are potential dangers in the use of mannitol before either a diagnosis has been
established or a course of actin instituted. Thus although the cause of a patient’s deterioration
may well be brain oedema, giving mannitol may produce temporary improvement in the presence
of a large haematoma, soon to be followed profound deterioration. Therefore mannitol should
not be used in the acute stage following injury unless the possibility of an intracranial haematoma
has been excluded in a patient who is deteriorating, except to gain time prior to surgery. It
should never be used as a diagnostic test to differentiate between oedema and haematoma.
Frusemide (40 - 80 mg by intramuscular injection) is an alternative agent which
produces a very rapid diuresis and thereby raises the osmolarity of the vascular compartment. It
is nonirritant, but requires good renal function for its effect.
Corticosteroids (dexamethasone and betamethasone). In high doses (up to 24 mg a day)
these drugs are effective symptomatically in malignant brain tumours, the main effect being upon
surrounding brain oedema. In the management of severe head injuries they have been used
widely for some years, often in doses of up to 60 mg a day. Unfortunately this practice is based
more upon tradition than objective evidence, because at present there is no evidence that their
use improves the outcome in severe head injury.
9.
Miscellaneous complications - early
'Brain-stem injuryf: This term is used loosely to describe a clinical picture which is
ascribed to primary damage in the brain-stem (medulla and pons). It should be stressed that the
changes may follow unrelieved supratentorial compression. The patients are often children or
young adults, the latter being motorcyclists who, wearing crash helmets, suffered an acute
flexion/extension movement of the neck at the moment of impact on the vertex. Signs of
external trauma may be absent, but the patient is ‘unconscious’, with spontaneous extensor
spasms of all four limbs, arching of the trunk (opisthotonus), a rapid pulse, rapid and often
shallow and therefore inadequate respiration, small pupils, pyrexia and sweating. Any stimuli will
tend to increase the tendency to extension. If this state has been present from the time of injury
the likelihood of a compressing haematoma is remote. Prognosis depends upon intensive nursing
34
care> ayd control of respiration, the ultimate intellectual deficit may be considerably less severe
than following major supratentorial brain damage, but there is often marked spasticitv and incoordmation.
. ''S’
I
------ 4WS
7
Fig 19: Carotid arteriogram showing midline shift
and bare area over cortex due to clot.
Fig 20: Frontal aerocele and ‘spontaneous
ventriculogram fracture through frontal sinus.
Posterior fossa compression : Compression of the cerebellum and medulla by posterior
fossa haematoma is rare. However, in the presence of a fracture which passes towards the
foramen magnum and therefore crosses the lateral sinus an extradural haematoma may occur
These tend to present somewhat later than the supratentorial extradural haematoma, usually after
ours and the most important physical sign is slowing and irregularity of respiration, which
may precede other evidence of deterioration. Special investigation by CT scan or ventriculogram
is needed prior to a posterior fossa craniectomy.
CSF rhinorrhoea : FFor CSF rhinorrhoea to occur there must be a communication
between the intracranial (intradural) cavity and the
r., j
/
ii i
—J nose. Therefore CSF rhinorrhoea indicates a
of the dura (usually basal) and a fracture involving the paranasal smuses, frontal ethmoid or
sphenoid. At the moment of impact, not only does the dural tear and fracture occur but also a
plug of bram may be forced into the dural tear; although this may temporarily seal the defect it
also prevents dural healing and therefore the CSF rhinorrhoea may persist and the patient be at
nsk from meningrus, which is usually pneumococcal. CSF rhinorrhoea may occur in association
with displaced fractures of the middle third of the face.
Although there are different views on the management of CSF rhinorrhoea a reasonabel
course is :
1. Initially the patient is given prophylactic antibiotics (penicillin and sulphonamides),
mav cpaTp
mddle
Of
faCe
reducedi in manY cases the rhinorrhoea
iiiay cease.
35
3. The indications for anterior fossa exploration are CSF rhinorrhoea persisting for more
than 10 days, the presence of a fracture involving the frontal or ethmoid sinus, an aerocele, and
an attack of meningitis which has been treated. Factors such as age, neurological state and
degree of disruption of the anterior fossa floor are taken into consideration.
Aerocele : Entry of air into the cranial cavity usually occurs in association with CSF
rhinorrhoea. Air may enter the subarachnoid space and ventricular system (a ‘spontaneous
ventriculogram’) or the substance of the frontal lobe because the brain is adherent to the margin
of the dural defect. This occurs particularly if the patient blows his nose. Rarely a frontal
aerocele may cause compression and therefore deterioration 2 or more weeks after injury.
Surgery is similar to that for CSF rhinorrhoea.
Meningitis : Apart from its association with CSF rhinorrhoea and otorrhoea, meningitis
may occur after any major head injury particularly if a basal skull fracture is present but often
undetected. Bleeding into the subarachnoid space is common with head injury, and neck
stiffness immediately after injury is not an indication for lumbar puncture. Meningitis when it .
occurs does so after the first 48 to 72 hours and, therefore, provided there are no signs of
cerebral compression, fever and neck stiffness are, at that stage, an indication for lumbar
puncture. If there are also signs of cerebral compression, the patient should be transferred for
urgent intracranial investigation before lumbar puncture.
Pituitary failure : Occasionally, basal fractures may pass across the pituitary fossa
causing acute pituitary damage and endocrine failure. This may lead to a profound fall in blood
pressure, tachycardia, pallor and hypothermia with deterioration in level of consciousness. Once
the condition is recognised high doses of steroids should be given (hydrocortisone 200 mg 6hourly for the first 24 hours, followed by reduced and then maintenance dosage).
Fat embolism : Systemic fat embolism may cause diagnostic difficulties when patients
with multiple injuries, which include a head injury, show neurological deterioration at about 48
hours after injury or surgery for limb fractures. Neurological features which suggest fat
embolism rather than an intracranial haematoma are the time of deterioration, the delayed onset
of features of a brain-stem injury, pupils which vary in size from moment to moment but which
remain equal, the presence of small retinal haemorrhages, and the absence of any firm lateralising
signs. The finding of fresh petechiae over the upper part of the trunk and in the axillae is of help.
However, in the absence of positive signs of fat embolism, it is usually wise to check the position
of the pineal if it is visible, or to obtain a CT scan.
36
FRACTURES OF THE SKULL
Fractures of the vault and base of the skull are produced : (1) by compression of the
Sr i
by l0Cal indentatl0n’
(3)
tangential injury. A traditional primary classification
of skull fractures is :
Closed: The scalp is not breached, but there may be bruising or grazing of the scalp
as distmct from a full thickness laceration.
fr ctu ''D') Open : There 1S 311 °pen laceration of the scalp
exP°sure of the underlying
Fig 21: Sharp bone spicules penetrating the
dura. Probing of an open wound to determine the
type of fracture is potentially dangerous because
a spicule of bone plugging a laceration in a large
vein or dural sinus may be dislodged, and cause
uncontrollable bleeding.
This snnple classification, which is analogous to that of fractures elsewhere, gives some
guide to the likelihood of foreign tissues being present in the wound and the relative danger of
subsequent infection at any depth. However, given that the primary management of the scalp
injury is satisfactory, the differentiation between closed and open fracture is of less surcdcal
importance than the classification of the type of fracture, which can only be established
radiologically Unless there is a very obvious skull defect beneath an open wound in which brain
tissue is visible, attempts to a differentiate between simple and depressed fractures clinically are
rarely accurate. Furthermore, probing of such wounds to determine the type of fracture is
potentially dangerous.
1. Simple and comminuted linear fractures of the vault : These are the most
common tyyes of fracture, and m themselves do not require surgery. The surgical management
is simply that of the overlying laceration if present. The significance of such fractures (apart
om those in special sites) is that their presence gives some indication of the severity of the
injury, the degree of deceleration or acceleration primary brain injury, and the likelihood of
e ayed complications. Indeed, extradural haematoma is more common in the presence of a
simple linear fracture than with depressed fractures. A linear fracture of the squamous temporal
bone is of special significance in that respect, and should make very frequent observation of the
patient, particularly a child, obligatory.
37
2. Linear fractures of the skull base : The clinical indications of the presence of such
fractures include bruising within the orbital margins involving the eyelids and conjunctiva
(anterior cranial fossa), and bruising in the mastoid region. Battle’s sign (middle cranial fossa and
petrous bone). Such fractures are the result of skull distortion, and indicate that a considerable
force was applied to the skull at the moment of impact. These fractures may be difficult to
demonstrate radiologically, unless special skull views are taken. Since accurate diagnosis of such
fractures is rarely essential for management, basal views of the skull should be- done with
circumspection because the position of hyperextension of the neck is potentially dangerous in the
presence of any degree of cervical instability, or in the presence of cervical spondylosis.
Skull base fractures may be associated with immediate and often irreversible damage to
cranial nerves, e.g., olfactory, optic, oculomotor, facial and auditory. A delayed lower motor
neurone facial weakness may be due to contusion and swelling of the facial nerve in continuity
within the facial canal. Anterior fossa fractures may be associated with CSF rhinorrhoea.
Middle fossa and petrous bone fractures increase the risk of meningitis, which may occur after an
interval of several days. CSF otorrhoea indicates a basal fracture with disruption of the dura
over the petrous bone, and rupture of the tympanic membrane. Management is by prophylactic
antibiotics for Gram-negative and Gram-positive organisms until the otorrhoea stops; meningitis
due to continued leakage of CSF from the middle ear through the Eustachian tube is very rare.
3. Linear fractures of the posterior fossa and foramen magnum : These are rare and
can be seen clearly only on the half-axial skull radiographs. Their significance lies in the rare
association with a posterior fossa extradural haematoma, of which the presenting clinical feature
may be a decline in respiration which precedes deterioration in level of consciousness. If such a
fracture is present, it is wise to observe the patient for at least 3 days.
4. Linear fractures involving the frontal paranasal sinus : If such fractures are
associated with a linear tear of the dura, CSF rhinorrhoea may occur. Even if CSF rhinorrhoea
is not present, it is wise to check that it cannot be provoked by positioning the patient with his
head low, before he is dischargedfrom hospital. The indications for surgery in the absence of
CSF rhinorrhoea are debatable, as is the prophylactic use of antibiotics.
5. Depressed fractures : Traditionally, a fracture is said to be ‘significantly’ depressed
if the degree of depression is greater than the depth of the inner table of the skull. The possible
complications of depressed fractures are :
(a) Dural tear : This is the most important indication for surgery. The greater the
depression of the bone fragments, and the more the fragments are angled inwards, particularly a
spicule, the more likely is the dura to be tom; even in the absence of such features it may be very
difficult to exclude a dural laceration by the radiological appearances of a depressed fracture.
(b) Underlying haematoma : It is unusual to have a significant compressing clot
beneath a depressed fracture. If there are clinical indications, investigation, e.g., CT scan, should
be done before elevating the fracture.
38
(c) Pressure upon the cerebral cortex : In practice this very rarely contributes to the
clinical effects of a depressed fracture.
(d) Epilepsy : A depressed fracture may be one of several factors contributing to early
or late post-traumatic epilepsy. Elevation of the fracture may diminish the risk of epilepsy,
although in individual cases this may be debatable.
(e) Cosmetic defects : In the adult this is rarely a problem; but the simple depressed
‘pond’ fracture of infants following obstetric manoeuvres may need elevation for cosmetic
reasons, although such fractures often undergo spontaneous elevation.
(f) Pressure upon dural venous sinuses : Very rarely a depressed fragment of bone may
compress and obstruct the superior sagittal or lateral sinus, leading to raised intracranial
pressure. Of greater importance is the risk of severe haemorrhage if depressed fractures over the
sinuses are elevated; therefore fractures in these sites should not be elevated.
SURGERY OF DEPRESSED FRACTURES
When the injury is compound prophylactic antibiotics covering Gram-positive and Gram
negative organisms should be started on admission, and continued for 10 days after surgery.
There are different views about the timing of surgery for depressed fractures. Emergency
elevation is not required, but as soon as the patient’s general condition is stable, especially in
respect of other major injuries, operation for the compound fracture should be done. When the
fracture is simple, i.e., closed, operation may be delayed for 2 or 3 days, particularly if there is
doubt over the patient’s neurological progress, and intracranial investigation may become
necessary.
Important points in surgical technique are :
1. The hair should be shaved widely round the wound.
2. Care is taken to remove all foreign material from the laceration.
3. A wound may be extended in a linear fashion, or be made part of a skull flap.
4. Because the scalp is the most important of the tissues covering the brain, scalp should
not be excised, and debridement should be kept to an absolute minimum.
5. The pericranium is detached from the bone using a rougine, and preserved for closure.
6. A burr hole is made in the normal skull next to the depressed area, but away from the
midline of the vault. Bone is nibbled away towards the depression, the underlying dura is gently
separated from the overlying bone fragments using an Adson’s elevator.
7. The depressed fragments are cautiously lifted out and kept, so that the dura beneath
the depression is fully exposed and any dural tear can be seen.
8. If there is a dural tear, the edges of the dura are gently separated from the underlying
brain using the Adson’s elevator.
39
9. Any indriven fragments of bone or foreign bodies are cautiously removed, but only
obviously necrotic and extruding brain tissue may be sucked away.
10. Any bleeding from the brain can be controlled by diathermy or tantalum clips.
11. The edges of the dural laceration are brought together using interrupted sutures. If
there has been loss of dura, a free graft of pericranium may be inserted.
12. If the area of exposed dura is greater than 3 cm diameter, ‘hitching’ stitches should
be inserted.
13. The removal bone fragments should be cleaned and replaced in a mosaic fashion, and
the pericranium and scalp closed carefully in layers without drainage.
Skull reconstruction : Areas of skull defect are restored at intervals of 3 to 6 months
after injury, by the insertion of moulded tantalum plates or acrylic inlays. Concealed horseshoe
or traverse incisions within the hair line are used for these purposes.
Head wounds due to missiles : The outcome depends on the explosive impact of the
missile in the cranium, which is the commonest cause of fatality, and the relation of the wound
track to the great vessels and the ventricles. Through-and-through tracks, from side to side or
front to back, may be survived. Survivable injuries can be transported to a suitable hospital.
Projection of the swollen brain through the dura at the site of entry or exit forms a hernia cerebri,
which seals off the subarachnoid space during transport. A pressure dressing is applied.
Immediate controlled ventilation has reduced the mortality from missile injuries.
Operation
consists
of the excision
of the surface wound and suction, cleansins
and
♦
■ «
.
':-,7
removal of foreign material from the track. The dura is closed by suture or grafting at entry and
exit points. CT scanning is of great value in identifying in-driven foreign material and / or bone
fragments.
J_____________ l-r’C.
Fig 22: Formation of burr hole beside a
fractured area to allow unlocking of the bone
fragments.
Fig 23: Transverse penetrating wound, entry at (A)
showing : (1) protrusion of brain through the dura at
the entry site forming a hernia cerebri; (2) pupled
brain and bone close to entry; (3) a metal fragment at
(B) has crossed the open superior fissure.
Penetrating wounds produced by sticks are always to be regarded very seriously.
Although scissors or pokers may enter the roof of the orbit when a child falls and thereafter be
successfully withdrawn, a stick which goes in through the orbital roof, or backwards behind the
orbit into the temporal lobe, cannot be withdrawn intact; portions which are left behind may,
from previous contact with the ground, be infected with gas gangrene or tetanus, with probable
fatal effects.
40
LATE EFFECTS OF HEAD INJURY
Chronic subdural haematoma
This is produced by rupture of the veins passing from the cerebral hemispheres to the
venous sinuses as the result of displacement of the brain inside the skull. Usually, the superior
cerebral veins are ruptured, producing haemorrhage over the convexity of the hemispheres; very
rarely veins passing from the temporal lobe to the sphenoid or petrosal sinuses may produce
clots which collect on the under-aspect of the brain. This complication, which is potentially fatal,
is produced particularly by blows of small magnitude applied to the front or back of the head
which may be insufficient to produce even transient concussion, but which are sufficient to move
the brain suddenly. Cerebral atrophy renders this displacement easier, and hence the condition
becomes commoner with advancing age. The superior cerebral veins pass from the convexity of
the hemispheres and pierce the arachnoid membrane before crossing the potential subdural space
to joint the inner aspect of the dura 2.5 cm or more from the midline; they then run inwards to
drain into the lower compartment of the superior longitudinal sinus. Sudden displacement may
snap the vein at the level of the arachnoid, allowing blood to pass downwards into the potential
subdural space between the arachnoid and dura. Frequently, corresponding veins on both sides
are affected and the condition is bilateral in 50 per cent of cases. The haematomas are often
large, bilateral collections up to 60 ml a side or unilateral collections of 120 ml being quite usual.
There is a progressive change in the nature of the subdural fluid, which becomes thinner, lighter
in colour and eventually is similar to CSF.Clinical features : The symptoms may follow a concussion, but owing to the slight
nature of the force required to produce displacement, this complication may occur without
preceding loss of consciousness and without the head being even struck. It can follow a sudden
jolt, as when a driver is thrown against the steering-wheel of a car, or be produced by knocking
the head against the lintel of a door, or landing heavily on the feet when jumping from a height; it
has followed dental extraction and electroconvulsive therapy. The interval between ‘trauma’ and
onset of symptoms may be of weeks or months.
The symptoms are undramatic and consist of mental apathy, slowing of cerebration,
slowness of response to questions, merging into stupor. When the stupor develops, it comes and
goes as the brain volume varies, the patient being inaccessible at times and then rousing
sufficiently to answer questions accurately, but very slow and after a considerable pause. When
the level of consciousness deteriorates further the operative mortality rises to 30 per cent; hence
the significance of the early symptoms.
Physical signs vary. In older patients, where more room is available and if the fluid
collects slowly, there may be no signs, or at most a unilateral or bilateral extensor plantar
response from pressure on the motor cortex, or brain-stem displacement. Pupillary changes
occur last when the brain-stem is affected and pressure-cone formation is imminent. Lumbar
puncture shows a fluid at low pressure with protein increased to 120mg / 100 ml (1.2g/l), often
stained yellow from the transudation of pigment, but no cells. Papilloedema is exceptional.
Success in treatment comes from acting on suspicion and employing skull radiographs for the
41
position of the pineal, CT scan, or exploratory burr holes.
avoided in the elderly.
Carotid arteriography should be
Treatment. Bilateral posterior parietal burr holes are made under local anaeshtesia to
expose the dura, which often has a blue-green tinge. On incising the dura there is gush of brown
uid. This should be allowed to flow out of the burr hole spontaneously, aided by lowering the
head. The brain surface will frequently remain at a considerable distance from the dura. If the
CT scan has shown a large collection of fluid, but only a small amount has been obtained from
t e posterior parietal burr hole, another burr hole should be made further forward on that side.
(a)
_
r
•
Fig 24: Site of clot
’
(5)
Fig 25: Incisions for burr holes for chronic
subdural haematoma.
Postoperatively the patient is nursed flat initially and the subdural space can be re-tapped
using a blunt-nosed brain cannula through the closed burr hole wounds. -
Burr-hole aspiration of a chronic subdural haematoma, especially in the very elderly, may
cause added fresh haemorrhage into the haematoma cavity. Therefore an alternative to surgery
is the use of steroids (dexamethasone), but this should be reserved for patients who are not
showing rapid or severe neurological deterioration.
42
Post-traumatic epilepsy : Epilepsy occurring soon after injury does not indicate the
presence of a compressing intracranial haematoma. It reflects degrees of primary brain damage,
which may be trivial and from which total recovery occurs. Children are more susceptible to
early epilepsy than adults, and it is probably a reflection of an inherent epileptic tendency.
Epilepsy within one week of injury occurs in about 10 per cent of all cases admitted to hospital
with a head injury, factors which tend to increase the incidence are prolonged post-traumatic
amnesia, intracranial haematoma and depressed fracture. In these circumstances prophylactic
anticonvulsants should be given for about 6 weeks, but for up to 3 years in those who have
suffered from any post-traumatic epilepsy.
Late post-traumatic epilepsy has an overall incidence of about 5 per cent, but of up to
25 per cent in those who have suffered from early epilepsy, and therefore similar factors are
involved. It probably represents cortical scarring and reactive gliosis. The epilepsy may be
focal, general or essentially temporal, and although in the majority of patients its onset is within
the first year, in about 20 per cent the onset is delayed for more than 4 years. When the onset is
very late, e.g., 10 years, it may be wiser to investigate the patient as a case of ‘late onset
epilepsy’ rather than assume that the epilepsy is post-traumatic. The use of a long-term
prophylactic anticonvulsants, e.g., for 3 years, is advisable in those who have suffered early
epilepsy, major compound fractures with dural and cortical laceration and intradural compressing
haematomas.
Post-traumatic hydrocephalus : Late deterioration with apathy and mental retardation
may rarely be caused by post-traumatic hydrocephalus requiring the insertion of a ventricular
shunt.
Post-traumatic headache is not always cerebral in origin. Referred pain of spinal origin
resulting from associated strains in upper cervical joints may be referred through the great
occipital and posterior auricular nerves to the vertex, forehead, or temple. The post-traumatic
state, with vertigo, defective memory and concentration, abnormal fatigue, irritability, and
defective emotional control, may result from temporary or permanent cerebral lesions.
Patients with minor injuries recover speedily, but in serious cases prolonged
convalescence is needed. Usually, some symptoms of the post-contusional state consisting of
headache, giddiness, defective memory, defective concentration, irritability, impaired emotional
control, impaired sleep, or susceptibility to alcohol, persist for a period of 18 months. Posttraumatic dementia constitutes a permanent handicap sometimes necessitating institutional care.
Schizophrenia is a rare complication of even a minor injury.
43
HEAD INJURIES
1. Maintain airway patency by keeping the patient in the lateral position to prevent the
tongue from falling back. Clear the mouth and oropharynx of secretions by means of suction.
Introduce an oro-pharyngeal or naso-pharyngeal airway. Perform endotracheal intubation if
necessary.
2. Ensure adequate gaseous exchange by providing oxygen,
Give positive pressure
v<entilation using the Ambu bag if necessary.
3. Check the vital signs. The presence of hypo-tension is more likely to be due to
injuries other than head injury. These may be external or internal injuries. Therefore it is
essential to do full physical examination.
4. Evaluate the severity of the head injury using the Glasgow Coma Scale.
Eye Opening
Verbal Response
Motor Response
El No eye opening_______
E2 Eye opening to pain
E3 Eye opening to call_____
E4 Spontaneous eye opening
VI No verbal response
V2 Incomprehensible
V3 Inappropriate words
V4 Confused_________
V5 Oriented
Ml No motor response
M2 Abnormal extensor
M3 Abnormal flexion
M4 Withdraws______
M5 Localises________
M6 Obeys commands
A GGS RATING OF LESS THAN 7 OR 8 DENOTES COMA
5. The presence of pupillary asymmetry denotes incipient herniation. This requires urgent
management with anti edema measures. In such a case rule out direct optic nerve or III
cranial nerve injury.
6. Start an IV line. Anti edema measures and anticonvulsants may be given in consultation with
the neurosurgeon.
7. Raise the head end of the cot by 30 degrees.
8. In case of local scalp injury - shave the area liberally, wash thoroughly with saline and probe
the area gently with a gloved finger. Do not use any sharp instruments or probes for this
purpose. Do not try to dislodge fractured fragments of skull. Suture the wound after
lavaging with hydrogen peroxide and povidone iodine (Betadine / Wokadine).
9. In paraplegic / quadriplegic patients - do not try to extend or move the neck eg., during
intubation. Put the patient on a flat board with sand bags on either side of the head to. prevent
movement. Put a cervical collar before shifting the patient anywhere.
10. Before doing any investigations - Eg. X-ray, CT Scan, consult the Resident on duty in
Neurosurgery or the Neurosurgeon, if available or refer the patient to neurosurgeon unit.
Prepared by Neurosurgical Department,
St. John fs Medical College Hospital, Bangalore.
44
NEURO CHART
Data and Time
EYES
OPEN
C
O
M
A
S
C
A
L
E
4
Spontaneously
4
To Command
3
To Pain
2
No Response
1
Obeys Commands
6
Localizes Pain
closed
by
swelling
5
BEST
Flexion-Withdrawal
MOTOR
RESPONSE Flexion(abnormal)
Record
best
arm
response
4
3
Extension (abnormal)
6
C—
eyes
2
No Response
1
Oriented
5
Confused
BEST
VERBAL Inappropriate Words
RESPONSE
4
T-Endoracheal
5
Tube or
T racheostomy
3
Incomprehensive Sounds
2
No Response
1
A= Aphasia
TOTAL SCORE
Size
P
u
p
I
L
S
R
Reaction
B= Brisk
Size
S= Strength
L
N= No Reaction
C= Closed
Reaction
Name of the Nurse
1MM
2 MM
3MM
4 MM
5 MM
6 MM
7 MM
8 MM
9 MM
Courtesy: St John’s Medical College Hospital, Bangalore
45
SPINAL INJURIES
In recent years spinal injuries have become common as a result of high velocity
automobile accidents. Injury to spine involves bony elements, soft tissues (including muscles,
ligaments, intervertebral disc and capsule of apophyseal joints) and quite often spinal cord and
nerve roots. The aim of treating spinal injury is to restore the painless, stable spine and ensure
recovery from neurological damage. The nature of initial injury may at times preclude this
achievement in some patients. In order to manage these injuries adequately, comprehensive
knowledge of anatomical features, stabilising structures of spine, mechanism of injury and
radiological features is necessary. Above all there should be high index of suspicion of presence
of spinal injury as the symptoms may be few, develop insidiously later on and quite often patient
may be unconscious due to concomitant head injury.
SPINAL STABILITY
Spinal injury can be stable or unstable depending upon whether stabilising structures have
been damaged. A stable fracture or dislocation is not liable to displacement greater than that
produced at the time of injury, whereas an unstable fracture or dislocation is liable to further
displacement with serious consequences to the spinal cord. The unstable injuries therefore
require very careful handling of patient, prolonged immobilization, external splintage and
sometimes internal fixation also.
Throughout spine, stability between two vertebrae depends upon following structures :
1. Intact ligaments, particularly posterior ligament complex comprising of supraspinous,
interspinous, posterior longitudinal ligament, ligamentum flavum and capsule of
lateral apophyseal joints. Disruption of posterior longitudinal ligament complex
occurs mostly in flexion injuries. Anterior longitudinal ligament also provides
stability during extension and is injured in extension injuries of spine.
2. Intervertebral disc is an important stabilizing structure between two adjacent
vertebrae and its disruption makes spine, particularly cervical spine, very unstable.
Disc may be injured in both flexion and extension injuries.
3. Muscles which are attached to vertebrae not only provide motor power for various
movements but also protect spinal column and its contents. Both during flexion and
extension injuries muscles get severely attenuated and tom.
Cervical spine is a flexible column with wide range of mobility which has developed at
the expense of stability. In cervical spine lateral articulations are small and flat with very little
upward inclination and therefore it is easy for the upper face to slip forwards on the lower facet.
There is normally some lordosis in cervical spine which disappears in flexion. Greatest mobility
occurs in lower cervical spine where intervertebral discs are thicker and wedge shaped. Injuries
are also commonest in this area of greater mobility.
46
The thoracic spine is more stable than the cervical and lumbar spine. The increased
stability is due to reinforcement provided by rib case and shape and size of articular processes of
facet joints. Articular processes of facet joints are flat and upright facing almost backwards and
forwards so that continuous processes lock together securely and dislocation is extremely rare.
Lumbar spine is mobile but less than cervical spine. The articular processes are massive
and curved. The are directed inwards and outwards and are vulnerable to dislocation. Lumbar
spine is more stable than cervical spine but much less stable when compared to thoracic spine.
47
CERVICAL SPINE INJURIES
DIAGNOSIS
Cervical spine injury should always be suspected in patients injured in violent road traffic
accidents and fall from height, in multiple injury patient and in unconscious patients (due to head
injury). Sometimes symptoms develop insidiously and therefore to be aware of possibility of
Cervical spine injury is most important factor in the diagnosis. Cervical spine injury should also
be suspected in patients complaining of suboccipital, shoulder and arm pain, paraesthesia or
motor weakness in upper or lower limbs following injury.
Very careful examination of neck is required. Patient may be holding the neck still or in a
deformed position. Neck muscles may be in spasm. There may be localised tenderness over
Cervical spine. Do not test for movement. Motor or sensory deficit may be present in limbs.
Location of wounds, bruises and abrasions on head and face, along with history of type of
accident may give an idea about the direction of damaging force.
Diagnosis is confirmed by X-rays which must be of good quality and show whole of
cervical spine. An open mouth AP view for C-l vertebra is also required. If facet joint
dislocation is suspected, oblique X-rays are also taken to decide as to which facet joint is
dislocated. When no bony injury is detected on X-rays then in order to identify subuxation
without fracture or spontaneously reduced dislocation, lateral X-ray is taken with neck in slight
flexion. For this purpose head should be moved very gently by the doctor himself and if patient
experiences pain or paraesthesia in limbs, neck movement must be stopped immediately.
EMERGENCY TREATMENT
In suspected cervical spine injuries until the diagnosis has been firmly excluded or when
injury is diagnosed, before proper treatment is instituted following care should be taken.
1. Patient should be placed face up on a firm stretcher.
2. Sand bags, rolled bed sheets or blankets are placed on either side of head to maintain neck in
neutral position.
3. Never move the neck or test for movements.
4. As soon as possible head halter traction with 5 kg. weight should be applied to keep cervical
spine steady.
5. Respiratory embarrassment should be treated by oxygen inhalation and by performing
tracheostomy when necessary.
This may be required in cases of cervical spinal cord injury when vital capacity may be
markedly reduced due to muscle paralysis.
48
THORACOLUMBAR SPINE INJURIES
DIAGNOSIS
As with cervical spine injuries awareness to the possibility of thoraco-lumbar spine injury
is the most important factor in diagnosis. History is often helpful as the patient may complain of
pain in back and (if neurological damage has occurred) inability to move lower limbs and
anesthesia. Thorough clinical examination of the patient is necessary. All clothing should be
removed so that entire trunk can be inspected. Patient must be rolled on to his side in one piece
with the help of 2-3 persons (like log rolling). Inspection may show abrasion or bruising which
indicates levels of injury. Spinous processes of entire thoraco-lumbar spine are carefully
palpated to detect local tenderness, swelling, gap or step between spinous processes. Normal
thoracic kyphosis and lumbar lordosis may be altered with paravertebral muscle spasm.
Complete neurological examination is performed to detect any evidence of spinal cord damage.
Following clinical examination X-rays of spine should be in A.P. and lateral planes. After
examining these X-rays if necessary oblique views may have to be taken. It must be understood
and borne in mind that spinal cord may be transacted without X-ray evidence of fracture or
displacement if spontaneous reduction has occurred. In such case clinical examination forms the
mainstay of diagnosis.
EMERGENCY MANAGEMENT
In suspected thoraco-lumbar spine injury following care should be taken until the
diagnosis has been established or firmly excluded.
1. At the site of accident and while transferring the patient from ambulance to stretcher,
patient should be lifted in one piece with the help of at least three persons.
2. Never attempt to test the spinal movements.
3. Chest, abdominal and head injuries should be carefully looked for and (if present)
respiratory embarrassment should be promptly treated.
4. Unaccompanied patient should never be sent to radiology department for X-rays. A
doctor should accompany the patient. Patient must not leave X-ray department until
a thorough X-ray examination has been completed.
5. Neurological assessment should be repeated after 6-12 hours as the signs of cord
compression may be delayed at times.
Type of injury varies according to the direction of force which has produced the injury.
Here again it is crucial to decide if the injury is stable or unstable. However if in doubt, these
cases should be sent to specialized centres for further management. Thus it is important to
diagnosis these injuries at primary health centre level or at district level hospital, which not only
reduces the mortality, also reduces the morbidity.
49
Introduction to Thoracic Injury
Trauma is amongst the leading causes of death and disability at all ages. Twenty five
percent of all trauma deaths are due to chest trauma alone, and respiratory problems contribute
significantly in upto 75% of all trauma deaths. Fortunately, 85% of the life threatening thoracic
injuries can be managed by simple interventions which can be carried out easily by the emergency
room medical personnel. The chest trauma produces a number of situations which need
immediate attention to save life. These are :
THORACIC TRAUMA
Airway Obstruction :
1. Establish Adequate Airway
• Oral Suction
• Insert Airway
• Intubate if necessary (Oro-tracheal or naso-tracheal). If intubation is not
possible, an emergency crico-thyroidotomy or tracheostomy may be
performed.
2. Look for signs of shock
• Blood Pressure
• Pulse
• Pallor
• Peripheral pulses
• Cold extremities.
3. Look for external wounds
• If sucking wound is present - apply sterile pad and strap
• Bleeding points if easily seen - to be ligated. If not, apply pressure dressing.
4. Look for associated injuries
• Head
• Abdomen
• Spine
• Long bones and pelvis.
5. Resuscitate
• I V line : Using 18 gauge branulae start Ringer Lactate and / or Haemaccel
• Establish Airway
• Oxygen mask
• Prop up the patient (45 degrees).
50
6. If the patient is extremely dysponeic
• Do not send for Chest X-Ray
• Insert an intercostal Drainage Tube in the 4th Intercostal space in the midaxillary line on the side of diminished air entry.
7. Chest X-ray
• In the erect position (only if the patient is haemodynamically stable and spinal
injury has been ruled out)
• There is no need for Oblique or Lateral views.
Lookfor
a) Tension Pneumothorax and Pneumothorax.
b) Haemothorax and Massive Haemothorax.
c) Mediastinal shift and widening.
d) Fractured ribs and Fractured Clavicle.
e) Massive Flail Chest.
f) Subcutaneous emphysema.
g) Massive Air Leak.
h) Increased cardiac size.
.
i) Elevated diaphragm and Diaphragmatic Injuries.
j) Loss of Aortic definition.
8. Inform the Thoracic ward. Resident Doctor in Cardiothoracic surgery to see the case
URGENTLY.
IF THE RESIDENT DOCTOR IS NOT
CARDIOTHORACIC SURGEON ON CALL.
AVAILABLE
INFORM
THE
Management of Chest Injuries :
1. Airway Obstruction :
• Clear the airway of Mechanical Debris and secretions.
• Oro or Nasotracheal intubation.
• Tracheostomy.
2. Fractured Ribs and Clavicle :
• Strapping by adhesive plaster and assurance.
3
Tension Pneumothorax is an extreme emergency which can lead to collapse of the
ipsilateral lung, shift of the mediastinum and compression of the large veins which can
lead to sudden death due to decreased cardiac output. The immediate release of the
tension by placement of a large-bore needle in the second Intercostal space in the Mid
Clavicular line followed immediately by insertion of intercostal underwater drainage
at second intercostal space is life saving.
51
4. Open Pneumothorax : The sucking chest wound leads to pneumothorax and collapse
of the ipsilateral lung. These patients can be sterilised by any mechanical covering
over the open wounds (strap the wound immediately with sterlize gauze and pad with
adhesive plaster, and wound to be sutured in the Operation Theater as far as possible.
A chest tube is put in simultaneously and connected to an under-water seal. When
the patient is sterilised, debridement and formal closure of the chest wound can be
performed.
5. Haemo Pneumothorax : Insertion of the Intercostal underwater drainage at 7/3^
Intercostal space at posterior axillary line.
6. Haemothorax : A small haemothorax that produces little more than blunting of the
costophrenic angle on the chest X-ray does not require any treatment. When the
haemothorax exceeds an amount that fills the costophrenic sulcus, or when there is
associated pneumothorax, intercostal drainage tube may be put and connected to an
underwater drainage system.
7. Massive Pneumothorax (>1.5 liters of blood in pleural cavity on initial insertion of
chest tube) should have thoractomy immediately as a surgically correctable cause is
likely to be found in a large number of these cases. In addition, after initial chest tube
placement, if the bleeding continues at a rate of over 100-200 cc/hr. for over few
hours, thoracotomy should be undertaken.
8. Massive Air Leak : Tracheobronchial injuries - often caused by steering wheel
compression of the chest in cases of road traffic accidents are increasing in number.
The injury is often fatal but may be surprisingly well tolerated for a brief period.
Massive air leak is present along with collapse of the lung on the affected side. It
needs immediate thoracotomy and repair of the injury.
9. Injury to Lung Parenchyma (by Flial and Stove in chest) : Prevented by strapping
with white plaster and refer to higher center.
Apart from the “life threatening” situations mentioned above, there are many other
injuries which require treatment. These are :
Diaphragmatic Injuries :
Urgent repair of massive diaphragmatic injuries may sometimes be required if herniation
of abdominal contents into the chest prevents lung expansion - left hemi-diaphragm is ruptured 9
times more often than right hemi-diaphragm. More often, the herniation of the abdominal
contents happens slowly and patients present later with various symptoms. Thoracotomy,
reduction of abdominal contents and repair of the diaphragm are required in such cases.
52
MANAGEMENT OF THORACIC TRAUMA
Assessment and Resuscitation
j__________________ 2_______________
Watch and listen to the Monitor vital signs.
patient breathe.
Restlessness,
Estimate tidal volume. cyanosis, or
Watch for flail chest.
bradycardia indicate
Look for signs of
hypoxia. Confirm
haemothorax or
that finding with
pneumothorax and
arterial blood gas
tracheal shift. For
determination.
tension pneumothorax, • Give respiratory
decompress chest by
support as
large-bore needle or
appropriate :
similar emergency
endotracheal
measure in anterior
intubation with
axillary line second or
positive
third intercostal space.
pressure
• Clean out upper
assistance.
airway.
• Remove patient’s
clothing.
• Determine injuring
mechanism.
• Seal sucking
wounds.
3_______________
Start intravenous
(IV) fluids through
large-bore (10-15
gauge) catheter in
arm opposite to
chest injury.
• Run crystalloid
fluids fast
enough to keep
blood pressure
at 80 to 100 mm
•
4_____________
Obtain upright or
lateral decubitus
chest X-ray.
Insert largebore (36F to
4 OF) chest tube
in cephalad
direction for
haemothorax or
pneumothorax
in fifth
ng.
intercostal space
Send blood for
type and
(nipple level),
crossmatch. Use
just anterior to
mid-axillary line
typespecific
blood for
(see figure 1).
protracted or
• Avoid trocar
recurrent shock
chest tubes.
after infusion of • Give systemic
2000 ml
antibiotics to
crystalloid
patients with
solution.
penetrating
injuries.
53
•
5______________
Monitor the EKG /
CVP.
6______________
Perform other
diagnostic studies :
A. Evaluate
persistent air
leak with
unexpanded
lung, confirm
bronchial
rupture by
bronchascopy /
gram.
B. Conduct
radiographic
studies for
potential great
vessel or
esophageal
injury.
Midaxillary
incision at 5lh
interspace.
Tunnel to 4th rib.
Pleura explored.
pl
ASr?
I
I
I
Tube directed
posteriorly and
superiorly.
#0 suture
wrapped around
tube and secured
to skin.
From patient
To wall suction
Lr“w
fi
Fig (a) : Insertion of Chest Tube
54
Indications for
urgent thoracotomy
in operating room
1. Over 1500 ml
blood in chest.
2. Ongoing bleeding
at 100 ml/hour.
3. Cardiac
tamponade
(distended neck
veins,
supraclavicular
cyanosis, low
blood pressure)temporize with
aspiration through
pericardiocentesis,
push IV fluids
(see fig. b)
4. Traumatic
thoracotomy (loss
of chest wall
substance)
5. Massive air leak.
Indications fof
immediate
thoracotomy in
emergency room
by personnel
experienced in
technique (rarely
indicated)
Fig. & PericaKiocentesis
Relative contra
indications for
immediate thora
cotomy in
emergency room
Radiographic
findings to
suggest need for
aortography
1. Lateral
7. Anterior
1. Obvious,
deviation of
displacement
extensive injury
nasogastric
of trachea
to the central
tube in the
(lateral x-ray)
1. Hypovolemic
nervous
esophagus.
8. First and/or
cardiac arrest
system.
2. Widened upper
second rib
inspite of blood 2. Prolonged
mediastinum
fracture.
volume
external
greater than 8
9. Massive
replace-ment,
cardiac
cm.
chest trauma
closed chest
massage (>5 to 3. Loss of aortic
with multiple
massage, and
10 minutes)
knob.
rib fractures.
defibrillation.
with electrical
4. Left apical
10. Fracture /
2. Cardiac arrest
asystole and no
pleural
dislocation of
with
response to
haematoma.
thoracic
penetrating
cardiopulmo
5. Depressed left
spine.
injury to chest.
nary
main stem
resuscitation.
bronchus
3. Blunt chest
greater than
trauma.
140 degrees.
4. Unavailability
6. Right lateral
of surgical
displacement
personnel for
of trachea.
continuing
surgical
therapy.
55
ABDOMINAL TRAUMA
Abdominal injuries are common in patients who have met with road traffic accidents.
These are frequently associated with head, chest or limb injuries.
A smaller group of patients present with penetrating abdominal injuries due either to
assault or industrial accidents. In both cases, and more so in blunt abdominal injuries, a thorough
evaluation of all systems is required. This can be conveniently thought of under two heads.
1. Physiological status.
2. Anatomical injuries.
EVALUATION OF PHYSIOLOGICAL STATUS
The three vital functions can be quickly assessed as
1. Circulation
A fast and thready pulse, pale mucous membranes and a cold and clammy skin,
WITH or WITHOUT a fall in blood pressure (note that intense vaso construction can maintain
blood pressure in the presence of shock) denotes SHOCK DUE TO HYPOVOLEMIA most often
due to INTERNAL OR EXTERNAL BLOOD LOSS.
Once shock is identified (which should be within 2 or 3 minutes of arrival of the patient)
the following protocol is to be followed strictly.
Shock Protocol:
a) IMMEDIATELY LARGE SIZE VENOUS ACCESS
It is wise for two persons to start resuscitation, one to start a peripheral line as
quickly as possible and another to do a Basilic vein cut-down to insert a large bore
catheter.
b) COLLECT BLOOD FOR GROUPING, TYPING AND CROSS MATCH.
c) INFUSE SALINE / RINGER LACTATE / COLLOID.
d) INSERT FOLEY’S CATHETER PER URETHRA.
e) REASSESS AFTER ADEQUATE VOLUME INFUSION FOR URINE OUTPUT
f) DO NOT SHIFT THE PATIENT TO RADIOLOGY.
56
Generally this resuscitation procedure corrects shock and provides some more time for
evaluation and investigation. However, if SHOCK PERSISTS after initial resuscitation, a major
vessel injury or massive solid organ injury is likely. THORACENTESIS (aspiration of the pleural
cavity) and ABDOMINAL PARACENTESIS on either side will reveal the possible site of
bleeding. Quick transfer to the operation theatre with group specific blood is of essence to
control bleeding.
If there is no shock or if shock has been corrected, further evaluation is undertaken.
2. Respiration
The respiratory rate and effort, the presence or absence of cyanosis must be noted.
3. Central Nervous Functions
The Glasgow Coma Scale is the best evaluator of this and must be used in all cases
at initial and subsequent serial observations.
Evaluation of Anatomic Injuries :
This must proceed in sequential and logical order to include the body region divisions
accepted internationally viz..
a) Head and Neck.
b) Thorax.
c) Extremities and Girdle injuries.
d) Skin and superficial tissues (eg., bums, avulsions, etc.,).
e) Abdominal and Pelvic injuries.
Look : For telltale abrasions, contusions which indicate the site of impact and the
possible organ injured. For movements with respiration.
Feel: For tenderness, guarding, rigidity and rebound tenderness. The site of maximum
tenderness may indicate the possible organ injured. Increasing tenderness or rebound tenderness
implies a need for exploration.
Percuss : Is there free air under the diaphragm ?
Is there free fluid in the flanks ?
External Genitalia :
urethral injury.
Look for the presence of blood at the meatus which indicates
Pelvis : Compression and distraction tests for evidence of pelvic fracture must be done.
A pelvic fracture implies that a massive force is involved in the injury and this is frequently
associated with injuries to the bladder and urethra, pelvic haematomas and diaphragmatic rupture.
57
Flank Tap: On either side, is done when bleeding into the peritoneal cavity is suspected.
Free flow of non-clotting blood proves haemoperitoneum. A Negative tap is of no clinical
significance.
INVESTIGATIONS :
I. X-rays : Do not contribute much to the management of the injured abdomen. Hence,
shifting to the Radiology department should be done only if :i) The patient is not in shock.
ii) There is no suspicion of internal bleeding.
iii) Accompanied by a doctor.
Remember always that when a spinal injury is suspected the patient should be moved AS
LITTLE AS POSSIBLE. A cross table lateral X-ray of the abdomen is the best film to look for
free air in the peritoneal cavity. If it can be taken, a Chest X-ray is usefill to look for
pneumoperitoneum and diaphragmatic hernia.
2. Urine : The presence of macroscopic or microscopic haematuria should alert one to
the possibility of injury. If there is no urethral injury, a Foley catheter should be passed. If there
is haematuria, the kidneys and bladder should be evaluated.
3. Blood: Hemoglobin and PCV should be done to assess the amount of blood loss.
Serum amylase : To look for pancreatic injury.
Standing Instructions :
1. ALL CASES OF SUSPECTED ABDOMINAL INJURY SHOULD BE
EVALUATED BY THE SENIOR RESIDENT ON DUTY IN GENERAL SURGERY
BEFORE BEING DECLARED TO BE NORMAL.
2. IN ALL SHOCKED PATIENTS CALL THE GENERAL SURGERY TEAM ON
DUTY AFTER STARTING RESUSCITATION.
3. SUTURING OF WOUNDS, MEDICO LEGAL FORMALITIES AND X-RAYS ARE
SECONDARY TO RESUSCITATION AND CLINICAL EVALUATION.
58
ALGORITHM FOR ABDOMINAL TRAUMA
TRAUMA
SHOCK
NO
YES
LARGE VENOUS ACCESS
RUSH RINGER LACTATE / SALINE
BLOOD CROSS MATCH
ASSESS HEAD, NECK, CHEST, EXTREMITIES
PELVIS AND SKIN
ABDOMEN:
abrasions ?
Stab wounds ?
lower rib fractures ?
respiratory movements ?
tenderness / rebound tenderness ?
guarding / rigidity ?
free fluid ?
flank tap positive ?
pelvis / urethra injured ?
DECISION : ABDOMINAL INJURY
YES
NO
ADMIT TO SURGICAL I.C.U.
AWAIT SENIOR RES.
DECISION
59
MANAGEMENT OF ACUTE ABDOMINAL PROBLEMS
(TRAUMA & NON TRAUMA)
MANAGEMENT OF ABDOMINAL TRAUMA
Initial Assessment:
3 Phases
Primary Survey including resuscitation
Secondary Survey
Definitive management
Primary Survey including resuscitation
To detect lethal injuries immediately and manage at highest priority (ABCDE)
Ainvay :
To have an open, unobstructed airway free of blood and secretions.
• Jaw thrust
• Chin lift
• Finger sweep
If necessary intubate.
Breathing:
Respiratory rate and depth.
If inadequate intubate.
Take care of Cervical Spine stabilization.
Check for crepitation, flail chest, sucking chest wound, absence if breath sounds, deviation
of trachea.
Interventions necessary may be
•
•
•
insertion of needle to relieve pneumothorax
occlusive dressing for sucking chest wound.
insertion of chest tube if large haemothorax or pneumothorax is suspected.
60
Circulation :
Check pulse and heart.
Cardiac arrest - External cardiac massage.
Exsanginuating bleeding - External compression.
2 large bore (14 - 16 G) intravenous cannulae.
Blood group and cross matching.
2 litres of crystalloids (Ringer Lactate)
Blood pressure is low and there is no evidence of blood loss - rule out cardiac
tamponade.
Look for elevated venous pressure, low blood pressure and muffled heart sounds.
Disability:
Level of consciousness.
(Glasgow coma scale)
Exposure:
Adequate exposure of patient from head to toe.
** Take care of cervical spine.
Secondary Survey
Detailed history.
Thorough clinical evaluation of patient from head to toe including per rectal examination
and examination of back.
Continue Resuscitation.
Definitive Management
It depends on the general condition of patient and nature of injuries detected at primary
and secondary survey.
61
Blunt Abdominal Trauma
Haemodynamic instability inspite of resuscitation
Evidence of hollow viscous injury: Clinical
Radiological
Haemodynamically stable.
No evidence of hollow viscous injury,
equivocal clinical signs
Laparotomy
Diagnostic peritoneal lavage
Diagnostic Peritoneal Lavage (DPL) by Open technique
> 10 ml unclotted blood
> 10,000 RBC/mm3
>500 WBC/mm3
Presence of bile, bacteria vegetable matter
_RBC < 50,000 / mm3
WBC<100/mm3
Absence of bile, bacteria or vegetable
matter and patient is stable
Laparotomy
Conservative treatment
Requisites for Conservative Treatment:
Adequate blood bank facilities.
Adequate personnel for repeated, frequent clinical evaluation of patient.
Intensive care unit monitoring when necessary.
62
Management of Stab Injury Abdomen
▼
Haemodynamic unstable
Evidence of hollow viscous injury
Haemodynamically stable.
Exploration of wound in
theatre under good lighting.
Laparotomy
operation
Peritoneum not breached
Peritoneum breached
Conservative treatment
DPL
* DPL Positive
DPL Negative
Laparotomy
Conservative treatment
* RBC 1000 / mm3 is taken as positive for stab injury of abdomen.
Management of Gun Shot injury Abdomen
Laparotomy
Management of Splenic Injury
Actively bleeding
No active bleeding
Splenectomy
DPL
I
▼
▼
positive
negative
laparotomy
conservative treatment
▼
63
Management of Liver Injury :
Active bleeding
I
▼
Laparotomy
▼
Pringle’s maneuver
I
▼
Laceration : Ligate individual blood vessels, approximation of laceration edges with
horizontal mattress of continuous sutures using absorbable suture material.
More severe injuries : perihepatic packing and referral of a tertiary care centre (needed in
5% of cases).
Note : Ensure safe transfer of the patient to a higher centre after providing basic medical care
and adequate fluid resuscitation.
Management of Retroperitoneal Haematoma
▼
▼
Active bleeding
No active bleeding
▼
Laparotomy
Conservative treatment
Decision making at Laparotomy :
Blunt Injury
Penetrating Injury
Location
Mid line
Supramesocolic
Haematoma explored
Haematoma explored
Inframesocolic
Haematoma explored
Haematoma explored
Lateral
Perirenal
Not explored if
functioning kidneys.
Pelvic
Not explored if haematoma is not or Not explored if haematoma is not or
slowly expanding, arterial pulsation slowly expanding, arterial pulsation
in groin are normal.
in groin are normal.
IVP
64
shows Not explored if
functioning kidneys.
IVP
shows
Management of Small Bowel Injury :
Small perforation
Closure in 2 layers
Larger involvement of bowel wall
circumference
:
resection and EEA 2 layers
Vertical tear in messentery with viable
small bowel
suture ligation of bleeding vessel.
Transverse tear in mesentery with non
viable bowel
resection and EEA.
Management of Colonic Injury :
Small perforation due to stab wounds / low velocity wounds :
<4-6 hours old
No gross contamination
No severe blood loss
No evidence of prolonged shock
Young patient.
-
=-
Right colon - Freshen the edges
Primary closure.
Trasverse colon - Freshen the edges
Primary closure
Exteriorise the sutured part of colon if necessary.
Left Colon - Freshen the edges
Primary closure with proximal colostomy.
Large perforations due to high velocity or blunt injuries
Right colon
right hemicolectomy
Contamination not much and
Gross contamination prolonged shock
other criteria as for primary closure
ileostomy and mucous fistula
Ileo transverse anastomosis in 2 layers
Left Colon
Resection and Hartman’s procedure
Transverse colon -
Resection and End Colostomy and mucous fistula.
65
Management of Stomach Injuries :
Perforation - closure in 2 layers
Look for injury on posterior wall, pancreas etc.
Antibiotic Cover:
All patients operated for trauma should receive perioperative antibiotic cover for 3-5 days
consisting of ampicillin, geramycin (if urine output is > 30 ml / hour) and metronidazole.
Management of Duodenal Injuries :
Small perforation (< 2 cm)
without gross contamination - primary closure
Blunt / high velocity injuries / stab injuries
Mild:
Stab injury, < 75% of duodenal wall involvement
Duodenal site 3 or 4th part injury
repair interval < 24 hours, No CBD / Pancreatic injury
Debridement and primary closure with gastrostomy and retrograde jejunostomy.
Severe:
Blunt or missile injury, >75% wall duodenal wall involvement, 1st or 2
injury repair interval > 24 hours, CBD or pancreatic injury.
part,
Debridement and Roux en Y anastomosis, duodenal diverticulization or pyloric
exclusion and gastrojejunostomy (for protection of duodenal repair).
Sever injury with uncontrollable bleeding from associated pancreatic injury pack,
attain haemostasis and refer to a higher centre.
Management of Pancreatic Injury :
•
•
•
•
•
Contusion and laceration without duct injury - external drainage.
Distal transection or distal duct injury - distal pancreatectomy and drainage.
Proximal transection or duct injury - distal pancreatectomy and Roux en Y pancreatico
jejunostomy
Combined pancreatic and duodenal injury - ampulla / blood supply intact - treatment
same as that of severe duodenal injury.
Ampulla destroyed / devascularisation - pack, attain haemostasis and refer to a higher
centre.
66
Mi
GENITOURINARY TRAUMA
MANAGEMENT OF RENAL TRAUMA
Introduction :
Emergency urological management may vary according to type of Trauma :
• Anatomic site
• Documentation or suspicion of associated injuries
• Clinical status
• Stability
• Availability of specialty personnel and facilities.
Criteria for suspected Renal Trauma :
Penetrating trauma to the flank or abdomen regardless of the degree of haematuria.
Blunt trauma to abdominal with gross haematuria.
Blunt trauma associated with microhaematuria and shock (BP < 90 mm Hg)
Bruising or tenderness over abdomen.
Radiographic demonstration of fracture lower rib or lumbar transverse process
fracture.
6. Deceleration trauma, RTA and fall from a height may produce
• Traction or Avulsion injury to renal pedicle.
• Blunt injury may cause major or minor renal injury.
• Perinephric or retroperitoneal haematoma.
1.
2.
3.
4.
5.
CLASSIFICATION OF RENAL TRAUMA
Grade I
Grade II
Grade HI
Contusion
Laceration - Extravasation
Pedicle Injury Shattering of kidney
Grade I
Grade II
Grade III
- Conservative
- Requires removal owing to severe haemorrhage (removal of kidney)
- Laceration, extravasation will recover spontaneously and requires
operation or embolotherapeutic intervention only for haemorrhagic or
extravasation complications.
67
(70%)
(20%)
(10%)
Investigations required for staging of Renal trauma :
1.
2.
3.
4.
Excretary urography.
Nephrotomography.
Computed tomography (CT).
Angiography.
Indications for Renal Exploration :
I
♦
♦
Absolute-persistent bleeding
Major parenchymal or renal vessel laceration
II
♦
♦
♦
♦
Relative-urinary extravasation
Nonviable tissue
Incomplete staging and
Arterial thrombosis usually coexist with bleeding.
Total Renal exposure is necessary to
• Evaluate the injury full.
- —
• Excessive bleeding may require that the renal vessels be clamped. If warm
ischemia time is expected to exceed 60 minutes, ice slush should be used for
cooling.
• The renal pelvis, vessels, parenchyma and ureter must be inspected carefully, as
should the site of injury for nonviable tissue and entry into the collecting
system.
A) Debridement: Removal of nonviable tissue is important and done by sharply incising
the margins. Approximately 30% of viable kidney will provide sufficient function to
avoid dialysis, a useful guideline while considering renal salvage.
B) Haemostasis : Blood vessels within the renal parenchyma are sutre-ligated with 4-0
chromic sutures. Large veins coursing within the parenchyma can be ligated without
worry, owing to the well developed intrarenal collateral circulation.
C) Defect Coverage: Ideally, the cut parenchymal surface is covered with renal capsule,
which provides a seal over the defect to help, prevent delayed bleeding and urinary
extravasation. Failing this a pedicle flap of omentum or free grafts of peritoneum can
also be used.
D) Partial Nephrectomy : When the upper or lower portion of the kidney is extensively
damaged, partial nephrectomy is called for.
E) Renorrhaphy : When the middle portion of the kidney is injured or when polar
injuries have resulted in only small amounts of devitalized tissue, renorrhaphy can be
68
undertaken. The nonviable tissue must be excised, the collecting system closed and
haemostasis obtained.
F) Vascular Injuries : The repair of injuries to the main renal pedicle can be difficult.
Venous injuries are difficult to diagnose with current imaging techniques. Injury to the
main renal vein can be repaired with 5-0 vascular sutures. There are no symptoms or
signs specific to this injury, and haematuria is absent in one third of the cases. Severe
multiple associated injuries are present in almost all cases, with a mortality rate of
44%. Radiologic evaluation with intravenous urography shows non-appearance of the
involved kidney. CT reveals nonenhancement of the kidney except for the periphery
of cortex from collateral circulation (rim sign), and renal arteriography shows
occulusion of renal artery or its branches. Even with vascular repair, the function of
the kidney is not restored to normal. Even with vascular repair, the function of the
kidney is not restored to normal. Late hypertension is found in 50% of patients with
main renal artery thrombosis managed conservatively.
Renal Trauma : Management Protocol
Probable Grade
of injury
Haemorrhage (flank, urine)
Transitory
Sustained
Intermittent / delayed
Extravasation
Transitory
Sustained
Urography
Function present
Segmental (polar)
Function absent
1 -2
2-3
2-3
Management
Observation
Embolization / surgery
Bedrest; embolization / surgery
2
3
Observation
Drainage; surgery
1
2
Observation
Observation; embolization / surgery
Observation; surgery
3
The potential deleterious consequences of renal trauma are well known,
complications of renal trauma are as follows :
•
•
•
•
Various
Unnecessary exploration / repair; erroneous staging; unexpected retroperitoneal
haematoma.
Haemorrhage (persistent, delayed).
Extravasation (fistula, urinoma, pseudocyst, hydronephrosis).
Infection (pyonephrosis, pyelonephritis, abscess, sepsis).
69
POST TRAUMATIC
Flank mass / ecchymosis
Rib / Spinous process fx
Liver / Spleen / Colon injury
Renal exposure / repair
Immediate <
Laparotomy
(for non-rcnal
injury)
Suspected
Renal
Injury
> Excretory Urography
(IVP)
> No exposure
Normal
> Intraoperative
|
IVP
|
arteriography
Unsuspected retroperitoneal
haematoma
Explore / repair
Abnormal
Selective embolization
Contusion -----Minor laceration
> Observation
Severe laceration
> Observation ---------(serial isotope scanning)
Extravasation
Selective embolization
or
Exploration / repair
>Non-Function
Improved
* Follow
> Recurrent
haemorrhage
Unimproved
Observation
(serial IVP)
Improved
Severe haemorrhage
k Abdominal CAT scan
(multi-system appraisal)
Follow
> Explore
> Minor haemorrhage
Observation
Exploration
Isotope flow study
Pedicle interruption
Traumatic
hacmaturia
Silhoutte of management of suspected renal trauma.
70
•
•
•
•
•
•
•
Hypertension (Vascular, infarction, compression).
Renovascular (thrombosis, aneurysm, arteriovenous fistula).
Infarction (segmental, total).
Calcification (Calculi, dystrophic).
Pain.
Death (Haemorrhage, sepsis) 0.8-4%.
Association with non renal injury (pancreas, liver, spleen, colon, bowel, vena cava).
Management of Urethral Injuries
Urethral trauma can be divided into two parts : (i) Management of proximal (anterior)
rupture of the urethra; (ii) Management of distal (posterior) urethral rupture.
Proximal rupture of the urethra :
Partial tears and complete dismemberment of the prostatomembranous urethra can
accompany pelvic fractures or may be without it. When a patient arrives in the emergency room,
having suffered enough trauma to fracture the pelvis and tear the posterior urethra, other obvious
injuries often take precedence in management, such as shock and intrabdominal injuries. When
someone notices blood from the urethral meatus, or is unable to pass a urethral catheter, the
possibility of a urethral rupture is appreciated. Since there is a high morbidity associated with
rupture of the posterior urethra, the patient deserves the best possible approach and the initial
evaluation should be performed with care so that the situation will not be further complicated.
Post urethral injury is seen in 5-10% male patients with fracture pelvis. A clinical classical triad to
diagnose the urethral injury is blood at the urethral meatus, inability to void, a palpable bladder.
The usual mechanism of injury is a violent force that disrupts the soft tissue rather than to
laceration of the urethra or prostate by a bony spicule. The posterior urethral injuries are
classified in three types :
Type I
Intact, but stretched posterior urethra, may be associated rupture of pubo-prostatic
ligament;
Type H
Rupture of membrano-prostatic urethra above the uro-genital diaphragm;
Type HI
There is a disruption of membranous urethra and may be extension in to proximal
bulbous urethra with disruption of urogenital diaphragm itself or both. In the
evaluation of a patient suspected of posterior rupture of urethra, one is often unable
to palpate the prostate, since it is in a “high-riding” position on rectal examination.
There may be boggyness in pelvis, presence of perineal haematoma and swelling of
genitalia. Public and ischial rami are fractured with a shearing action which cleaves
off the urethra at the junction of the prostatic urethra and superior edge of the
urogenital diaphragm.
71
Diagnostic catheterization is to be condemned because it may convert partial tear in to
complete disruption, particularly if a catheter guide is used. It also increases the risk of
haemorrhage in prostatic bed and there is also a possibility of infecting sterile haematoma. The
most important diagnostic step is the retrograde urethrogram. If there is doubt of combined
bladder and urethral injuries, intravenous urogram followed by cystogram, would be worthwhile.
In an isolated urethral injury bladder is often full, therefore trocar cystostomy should be. done, so
as to divert the urine without instrumenting the urethra. A cystogram can then be performed.
Commonly there is a teardrop or parachute deformity of the bladder due to a pelvic haematoma
and extravasated urine. There is a greater controversy over whether to pass a catheter,
immediately operate to pass a catheter, attempt primary reapproximation, or simply wait for a
delayed repair. The devastating morbidity arising from a posterior urethral tear includes stricture
formation, incontinence and impotence. The various opinions concerning the proper management
of this trauma have arisen from attempts to reduce the incidence of its sequalae.
Stricture :
Stricture formation is common even after skilled and careful management. The usual
indications for primary realignment are when prostrate is attached to displaced pubic fragment,
bladder lies high in pelvis with large pelvic haematoma and wide urethral gap, concomitant rectal,
bladder and bladder neck injuries. Stricture formation results because of a gap between the two
ruptured ends of the urethra and a filling-in of fibrous tissue. To prevent this, muscular layers and
adventia of the urethra must be brought in to contact. Simple trocar cystostomy and delayed
urethroplasty is another option. It is our experience that the difficulty of achieving a satisfactory
primary repair, even in the best hands, justifies a no-touch technique.
Incontinence:
Urinary incontinence has been variously reported after this injury with the vesical neck
being the primary source of continence. Incontinence may be avoided with correct initial
management.
Impotence :
Impotence occurs after rupture to the posterior urethra, but the incidence and exact
mechanism are not well known. Patients may experience a return of erections 6 to 19 months
after injury, so final assessment should probably delayed at least two years. Emission and
ejaculation are even more likely to be impaired than erections. Approximately 25 percent of those
with complete posterior urethral tears will end up with permanent impotence and various levels of
partial impotence may afflict others. One of the series has compared results of various methods
or repair.
72
Repair of Urethral Rupture :
Method
No. of Patients
Stricture
Incontinence
Impotence
I.
II.
III.
128
119
36.
11%
5%
16%
16%
5%
0%
26%
8%
4%
I
Two stage urethroplasty in failed cases of conventional realignment or primary E-E
anastomosis.
n Initial SPC + Delayed two stage urethroplasty.
m Initial SPC + Delayed one stage urethroplasty.
In AIIMS, we follow the protocol of initial trocar suprapubic cystostomy, followed by
assessment of urethral injury at 3-4 weeks and then definitive urethroplasty is performed.
Distal Urethral Rupture:
Trauma to the anterior urethra occurs infrequently. Even with multiple severe injuries to
the pelvis, it is unlikely that the distal urethra will be traumatized due to its lack of fixation.
Straddle-type injuries account for most trauma to the bulbous portion of the urethra. A laceration
or incomplete separation of urethral mucosa allows extravasation of urine during voiding. Buck’s
fascia represents the first line of compartmentalisation and prevents the wide damage of the
periurethral phlegmon due to urine dissecting to the limits of Colle’s fascia. When Buck’s fascia
is intact, the urine is confined to the penile shaft, but if it has been ruptured the extravasation can
spread widely in to the scrotum and perianal regions as well as into abdomen. It is prevented
from going in to the thighs because of Scarpa’s attachment to the fascia lata. Anterior urethral
injuries may be due to blunt trauma (straddle) or because of penetrating trauma. These are
classified in to three categories :
I. Contusion : Clinical features of urethral injury but the result of urethrography normal.
II. Partial : Extravasation of contrast from the mid bulbous urethra but continuity
maintained.
JU. Complete : Continuity is completely disrupted.
The usual mechanism in straddle type of injury is that bulbous urethra and surrounding
corpus spongiosum get crushed against inferior aspect of pubis. Initial recognition of the extent
of injury to the distal urethra is difficult. There may be blood at the tip of penis accompanied by
swelling and bruising and voiding is usually difficult, but, frequently a clear urine may appear.
Patients often do not seek medical care until the swelling and discomfort are severely disabling,
often as long as 72 hours after the trauma, so it is not unusual to be dealing with septic patient by
that time. Coverage with antibiotics and drainage of extravasated urine are basic to management.
If there is no clinical evidence of extravasation, a retrograde urethrogram may define a small tear
and then treatment would consist only of a urethral catheter and antibiotic coverage. If there is a
bridge of urethral tissue intact across the laceration or rupture of the urethra, spontaneous
73
regeneration and reformation of the urethra will occur. Trocar cystostomy to drain the urine will
suffice to treat the more extended but nonpenetrating tear. However any penetrating injury with a
missile or sharp object deserves open depridement with suture reapproximation of the urethral
tissue. Spatulation of the ends of the tom urethra often will prevent stricture formation. Some
urologists observe a trocar suprapubic cystostomy is still better alternative for complete urethral
disruption and partial tear. After 2 to 3 weeks retrograde urethrogram should be done to assess
the situation, then accordingly definite plan should be made. On following strategies subsequent
management should be done according to situation :
1.
2.
3.
4.
5.
Excision of stricture and end to end anastomosis
1 cm)
Excision with patch graft (1 cm +)
Full thickness tube graft (x cm)
Two stage urethroplasty
Optical Internal urethrotomy / core through visual internal urethrotomy.
The problems involved in definitive urethral reconstruction should never be
underestimated. The potentially complicated nature of a pelvic fracture urethral injury is entirely
apparent. Thus, surgeons with a general urologic training who do not have both a special
additional and ongoing experience of reconstructive procedures and a particular aptitude for the
problems involved must be advised that “having a go” is not in the best interests and is essentially
a personal matter because many contrarily conceived procedures work quite satisfactorily in the
hands of others.
74
BLADDER TRAUMA
Usually there is a high incidence of associated injuries with bladder rupture from external
trauma. In many instances, treatment of other injuries must take precedence over management of
the urinary tract.
Extraperitoneal Bladder Ruptures
Extraperitoneal bladder ruptures secondary; to blunt trauma are caused by fractures of the
bony pelvis 95 percent of cases.
Blunt Trauma :
In the cases of blunt trauma associated with bladder rupture, the amount of force
necessary to cause the injury may be quite small, especially if the bladder was full. Intra
peritoneal rupture usually results with direct trauma to full bladder, but in those cases associated
with pelvic fractures, extraperitoneal rupture is more common. The most likely mechanism
through which the bladder is ruptured in pelvic fractures is either a sudden increase in intravesical
pressure or compression against the bony pelvis with perforation by bony fragments.
Penetrating Injuries :
Penetrating injuries to the bladder are usually intraperitoneal and have a high incidence of
associated injuries, the most common being colon and small bowel. It may also be associated
with urethral injuries.
Diagonosis :
Usually patient complains of lower abdominal pain and tenderness. Examination often
reveals bruising in the lower abdominal region, and on palpation, there is abdominal tenderness
and muscle guarding or rigidity. With contusion injury, the patient can void, and haematuria is
present. With a bladder rupture, the patient is usually unable to void and a specimen obtained by
catheter reveals haematuria. In a severely injured patient who has a fracture pelvis, a urethral
catheter should be passed to determine if haematuria. In a severely injured patient who has a
fracture pelvis, a urethral catheter should be passed to determine if haematuria is present. If blood
is seen at meatus, a retrograde urethrogram should be done to rule out urethral injury.
A delayed presentation may be as acute abdomen, absence of voiding and elevated blood
urea nitrogen. Macroscopic or microscopic haematuria is the indication for radiologic evaluation
of urinary tract. The intravenous pyelogram is performed first, so that an occult lower urethral
injury is recognised before a large amount of dye has extravasated from the bladder obscuring the
urethral injury. In male, a retrograde urethrogram should be performed prior to the cystogram to
75
rule out urethral rupture. A stress cystogram with post emptying films. The technique consists of
filling the bladder through a foley catheter under gravity until the contrast material ceases to flow.
A picture is taken to evaluate the presence of extravasated dye. If none is present, a further 50 ml
is introduced into the bladder, an additional films are made in the anterior-posterior and both
oblique projections. The bladder is then copiously irrigated with sterile water or saline, and a
repeat film is taken to make sure that no dye has extravasated either in front or behind the
bladder. With extraperitoneal ruptures the dye will extravasate around the bladder in the pre and
perivesical spaces. With intraperitoneal rupture the dye extravasates in to both paracolic guters
and can outline loops of bowel.
Treatment:
Isolated extraperitoneal bladder rupture especially small one, can easily be handled by 2
weeks of Foley catheter drainage. If there is large rupture or patient is to be explored for
associated injuries, open the bladder, do not disturb pelvic haematoma, repair the rupture, and
insert a surprapubic tube. A cystogram should be done after 10-14 days before removing the
suprapubic tube.
Intraperitoneal rupture of bladder
This is an injury of violent deceleration. Road traffic accident, penetrating wounds from
knives or gunshot injury, comprise the most of intraperitoneal rupture. It may also be associated
with pelvic fractures. The abdomen may be diffusely tender. A voiding cystourethrogram in a
conscious patient or a static film of bladder with 250 ml of contrast, often reveal the picture.
Delayed picture leads to prerenal azotemia, individual may show a slight acidosis with a higher
than 10:1 ratio of the blood urea nitrogen to the creatinine. Exploration of bladder and repair in
two layers is desired. A cystogram is done at 2 weeks, if no extravasation, the suprapubic tube
should be clamped and patient is asked to void normally.
EXTERNAL GENITALIA INJURY
Injuries to the external genitalia (the penis, scrotum and / or testicles), can present
complex problems to the urogenital surgeon. Therapeutic goals include adequate cosmetic repair,
the preservation of fertility, and the preservation of sexual potency.
Penile Injuries :
Most traumatic injuries have occured to the erect penis as a result of direct blunt trauma
that bends the organ abnormally. It usually occurs during sexual foreplay or intercourse when the
penis is suddenly deviated either laterally or downward, in the erect state. A cracking noise is
usually heard with subsequent pain and swelling of the shaft of the penis secondary to haematoma
formation and deviation of the penis to the side opposite the fracture. In the most of cases, the
diagnosis is easily made on the basis of typical history and physical findings. However an accurate
76
diagnostic tests i.e., cavemosography, ultrasonography, MRI may be required in few cases.
Blood at the meatus, any degree of haematuria, and difficulty in urination are suggestive of
associated urethral injury, which occurs in 10 to 20% of patients. A review of literature suggest
that early surgical repair of the tunica albugenia defect is associated with lower risk of penile
angulation, a shorter hospital stay and more rapid functional return. If there is minimal
haematoma and no extracorpal extravasation, conservative treatment may be warranted.
Complete urethral disruption is best managed by primary repair, whereas partial disruption
can be treated adequately by trocar cystostomy.
Complete transection of part or all of the penis is a rare occurrence. The treatment
depends primarily on the amount of time that has elapsed from time to injury to the time of
surgery and how much of the penis has been transected. Micro vascular reimplantation procedures
give good result with minimum postoperative complications. Although microreplantation offers
the best results in the case of penile amputation, if it is not available the older corporal
reattachment techniques should be offered.
Avulsion of all or part of the penile skin can occur in mechanical accidents, infections,
bums (electrical, chemical or thermal) or be self inflicted. For minor loss of the skin of the penis,
a scrotal flap has been used with good results. For more extensive skin loss, split thickness skin
grafts have yielded the most consistently satisfactory results. It is important in applying the grafts
that the penis be in the erect state or stretched so that a chordee will not develop with inadequate
skin coverage.
PENILE SKIN LOSS
Partial
Primary
closure
Thick split
thickness skin
graft
Total
Meshed split
thickness skin graft
(impotent patient)
Thick split thickness skin
graft or full thickness graft
(potent patient)
Scrotal Injuries :
Loss of scrotal skin is found in similar situations to that causing loss of penile skin. When
the amount of scrotal skin lost is small and the edges can be approximated over the testicles,
primary closure is performed since the scrotum has enormous powers of regeneration. When the
scrotal skin has been totally avulsed, several options are available. Firstly, the testicles can be
placed in to thigh pockets. Secondly, the testicles with their neurovascular bundle and the vasa
deferentia can be pushed up and fixed in the inguinal canals. In both cases, the testes can either be
left in position or brought down at a later time and placed in a scrotum reconstructed from split
thickness skin grafts or flaps of skin rotated from the medial thighs.
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SCROTAL SKIN LOSS
Partial
Complete
Primary
closure
Testis in high pouches
(temporary)
Meshed split
thickness skin
graft
Thigh
flaps
Testicular Injuries :
The tunica albuginea of the testis can be violated with extrusion of the seminiferous
tubules by either blunt or penetrating trauma. Any patient with this type of injury should have
immediate exploration with excision of the extruded portions of seminiferous tubules and closure
of tunica albuginea. Rupture of testis secondary to blunt trauma is a violent and immediately
painful event. Nausea and vomiting are frequently associated as occasionally is syncope.
The definitive diagnosis of testicular rupture depends on surgical exploration, which is
called for, whenever there is question of a rupture. Scrotal ultrasonography can demonstrate
whether disruption has occured (useful for surgery) and it can evaluate the testicular parenchyma.
The objectives of surgical exploration are testicular salvage, prevention of infection, control of
bleeding and reduction of convalescence. Complete avulsion of one or both testicles can also
happen rarely with accidental trauma.
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PELVIC FRACTURES
Depending on whether or not the pelvic ring is disrupted to produce a loss of its integrity
and capacity as a basin.
PELVIC FRACTURE
Avulsion fracture
Isolated pelvic ring fracture
(Simple fracture)
Pelvic ring disruption
(Double fracture)
Avulsion fracture :
A portion of bone which gives attachment to the concerned muscle becomes fractures and
detached from parent bone. It mainly occurs in Athletes and adolescents.
Mechanism : Violent contraction of muscle attached to the bone.
• Anterior-superior iliac spine - Saratorius.
• Anterior-inferior iliac spine - Rectus femoris.
• A portion of Ischeal tuberosity - strong hamstring muscle contraction.
Clinical Features : Local tenderness, pain in the fractured site.
X-ray shows avulsion of apophysis
Treatment: Few days of bed rest.
Isolated pelvic ring fracture (Simple fracture) :
It breaks the continuity of pelvic ring and the integrity of the pelvis is not disrupted.
Sites:
(1) Unilateral fracture of the pubic rami one or both on one side only.
(2) Fracture of the body of ilium.
(3) Minimal sub luxation of symphysis pubis or sacro-ileac joint. Displacement is slight
and intrapelvic viscera hardly damaged.
(4) Fracture of the acetabilum with central dislocation of the hip.
Mechanism : Direct blow to the side of pelvis or front of the pelvis.
Clinicalfeatures : Patient cannot walk after the injury with or he can walk with extreme
pain.
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On Examination :
Bruising of the affected side, tenderness over the affected region
present.
Treatment: (a) Fracture of ilium and pubic rami - bedrest.
(b) With central dislocation of the hip - skeletal traction should be applied.
(c) When acetabular fracture with large portion of the roof or posterior wall
detached, open reduction and screw fixation is necessary.
Pelvic ring disruption (Double fracture) :
In this, displacement is considerable, the chance of injury to intrapelvic organs is more.
Mechanism : 3 types of forces cause this injury. They are
(a) Compression force :
Lateral force from both sides may fracture the side wall of pelvis on both sides.
This injury may be associated with medial displacement of hip.
•
•
Anterioposterior compression force may fracture both pubic rami on both sides.
The central segment will be pushed back wards damaging the urethra.
(b) Hinge force : This force is applied from front to one side of the pelvis. Such force is
seen in RUN OVER ACCIDENTS. One half of the pelvis is usually affected and the
symphysis pubis is forced apart in front where as in the back there is usually fracture at
Sacro-iliac region, so that the whole pelvis is opened up and the other half of the pelvis
remains intact.
(c) Vertical force : Like previous force, this comes from down upwards. Such force
usually occurs when an individual FALLS FROM A HEIGHT on ONE LEG. The
affected side of the pelvis fractures on two places, the pubis in front and ileum behind.
The portion of the pelvis lying in between the two fractures is pushed upwards.
Clinicalfeatures :
•
•
•
•
Patient is unable to move after injury,
The patient is not able to pass urine after injury,
Patient complains of pain on movement even on coughing,
Internal haemorrhage is considerable so much so to produce SHOCK.
On Examination :
1) Affected area will be seen with bruisings and swelling of the affected region.
2) Tenderness will be diffuse, that is not of diagnostic value, Suprapubic tenderness will
be there.
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3) The urethra and urinary bladder should be investigated properly to exclude any
damage to these organs in those regions.
4) In Hinge force fracture, the gap may be felt in symphysis which is abnormally large.
5) In Vertical force, there is possibility of damage to nerve roots and particularly to
Sciatic nerve. This should be excluded.
X-ray pelvis is diagnostic and indicates the type of fracture. From the type of fracture
one can assess the type of injury force.
(a) In compression injury, both pubic rami are fractured on both sides.
(b) In Hinge force fracture, there is an abnormal gap at the symphysis pubis and there is a
fracture near or sub luxation at the sacro-iliac joint.
In vertical force fracture, the pubic rami and post portion of ilium are fractured on same
side with upward shift of the segment of pelvis between the fractures.
(1) Treatment of Shock : Corrected immediately
saline
I V fluids
dextrose
Blood transfusion
Plasma expanders
(2) Treatment of Pelvic vascular injuries : Mainly the urinary bladder and urethra are
ruptured, when pubic rami are fractured. This can occur even when the symphysis
pubis is forced apart as in the hinged type of injury.
•
•
Patient is asked to pass urine, if can pass urine and if urine is clear - watch the
patient for subsequent changes in urine.
If patient is not able to pass urine - pass a catheter.
Intrapelvic rupture urethra is the commonest injury in intrapelvic in case of pubic rami
fractures.
Treatment : Suprapubic cystostomy, sound is passed from above. By rail reading
methods a self retaining catheter is introduced into bladder. The ruptured urethra is now
approximated and sutured. Bladder closed a d kept retropubic space s closed in layers.
Urinary Bladder supture :
Extraperitoneal
Repair
Introperitoneal
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Treatment of Fracture :
1) Compression type of fracture - only bed rest for 3 weeks, No reduction, hip joint
movements allowed, after 3 weeks allowed walking. Later on spinal exercise is
allowed.
2) Hinge type of fracture - requires reduction under General Anaesthesia and is rolled to
affected hole. A compression force is applied to the affected pelvis so that it gradually
closed. After reduction a firm binder or lumbosacral corset applied.
If reduction fails, open reduction, internal fixation. The wire is passed through drill holes
or through obtrutor foramine to bring the 2 pubic bones together. Patient remains in bed for 3
weeks. Lower limb movements allowed during this period. Then patient is allowed to walk with
crutches. Union take place 6 weeks. Corset is worn for another 3 weeks.
Verticle force fractures
Under general anaesthesia fracture is reduced by pulling the leg of the affected side. This
will bring down the fractured segment in line with the other side of pelvis. Skeletal traction is
applied and is continued for 6 weeks till the fracture unites’. Traction is removed and the patient is
allowed to move with crutches. Weight bearing is not allowed for 3 months from the date of
injury.
Complications of fracture pelvis :
1) Intrapelvic haemorrhage - oligemic haemorrhage to injury.
2) Paralytic ileus - pelvic veins, shock
3) Urogenital damage (Urinary bladder and urethra damae) most important complication.
4) Persistent sacro iliac pain.
5) Sciatic nerve injury particularly in vertical force fractures. Such nerve injury usually
recovers.
6) Malunion of fracture results pelvic deformity and difficulty in labour.
Sacro - coccygeal injuiy
Fracture sacrum.
Fractur coccyx.
Sprain in SIJ.
Mechanism : Blow from behind usually causes fracture sacrum fall on the buttocks
causes fracture of coccyx and sprain of SIJ.
X-ray : Highly significant and diagnostic.
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No displacement
Fracture of sacrum
Displacement
lower segment is pushed forwards.
Fracture of coccyx - the lower segment is angulated forwards.
X-ray does not reveal the fracture - then sacro-coccygeal sprain.
Treatment:
If displacement present - displacement should be tried per rectum.
Pain during sitting - sorbo cushion used while sitting.
If pain not relieved - local anaesthetic injection to the tender spot or
excision of coccyx should be done.
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FRACTURE & DISLOCATIONS OF THE LOWER EXTREMITY
TRAUMATIC DISLOCATION OF THE HIP JOINT
It is one of the type of Acquired Dislocations.
Traumatic Dislocation
r
Anterior Dislocation
Posterior Dislocation
(Constitutions 80% of all
Dislocations of Hip)
Central Dislocation
Dislocation of hip is relatively uncommon because -
1. The head of the femur is well covered by acetabular cavity, which is further deepened
by the acetabular labrum
2. There are strong ligaments reinforce the capsule of hip joint, particularly
ILIOFEMORAL LIGAMENT.
3. There are strong muscles outside the joint to protect it.
Mechanism : The posterior dislocation of the hip is flexed and adducted as in this
position, the head of the femur lies against the posterior part of the capsule which is relatively
weak and posteriorly the acetabular cavity is also deep. In this position, if a force is applied along
the long axis of the femoral shaft, the head will be dislocated over the posterior lip of acetobulum,
internally rotating the head of femur at the time of impact.
Eg. (1) This type of force may occur in CAR ACCIDENT, when after applying sudden
break or after the CAR HAS HIT AGAINST A TREE OR AN IMMOVABLE OBJECT, the
FRONT SEAT PAS SANGER in a CAR is thrown forwards so that his knee strikes against the
dash board and the HEAD OF FEMUR, DISLOCATES POSTERIORLY.. This is known as
‘DASH BOARD DISLOCATION’.
If the hip is adducted, dislocation may occur without fracture.
If the hip is in only flexed position and not adducted, the impact is liable to fracture the
rim of the acetabulum.
(2) Eg. Posterior dislocation may occur if a weight falls on the back of a person in
stooping position, due to fall of roof.
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Types of posterior dislocation of hip :
(a) Gluteal Type : In this, head of the femur lies above the piriformis muscle and under
cover of glutei.
(b) Sciatic Type ; Below the piriformis, near the greater notch. Sciatic nerve may be
injured.
(c) Regular Type : In this, the Ileofemoral ligament, (the strongest ligament in the body)
may remain intact even, when the dislocation of the hip has taken place.
(d) Irregular Type : In this there is slight tear of the lateral limb of the ileofemoral
ligament and when the ileofemoral ligament is COMPLETELY TORN - it is called
IRREGULAR TYPE of post dislocation.
Clinical Features ofpost dislocation :
•
•
•
Shortening of leg.
Hip is held slightly FLEXED, adducted and internally rotated.
Pain is less - if acetabulum is fractured.
Pain is more - if acetabulum is not fractured.
Signs:
(1) The head of the femur lies on the dorsum ilii. The kidney of the head is noted by the
fact, that it moves with the rotation of the shaft. The Medial Condyle looks to the
same direction as the head of femur.
(2) Palpation is femeoral artery at groin is difficult in this case due to absence of head of
the femur behind the artery.
(3) If the Bryants Traingle is drawn - the base of the triangle is shortened in the posterior
dislocation.
(Bryants triangle is drawn by joining the Anterior superior, iliac spine with the greater
trochanter and by a line drawn vertically downwards from the anterior superior iliac spine). The
greater trochanter is raced towards the anterior superior iliac spine due to internal rotation of the
limb.
*
(4) The tip of greater trochanter lies above the ‘NELATONS LINE’. A line drawn from
the most prominent part of the ischial tuberosity to the tip of anterior superior iliac
spine. Normally this line touches the tip of the greater trochanter.
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(5) Moris Bitrochanteric test indicates the distance between the outer border of greater
trochanter to the symphysis pubis. This will indicate the medical displacement of the
greater trochanter in posterior dislocation of hip.
(6) Sciatic nerve function must be tested as injury to the sciatic nerve may occur in post
dislocation of hip, particularly in sciatic type.
(7) Movements at hip are restricted.
X-ray confirms diagnosis. Look for associated fracture of the posterior acetabular rim or
not, femoral head, neck, shaft - SHENTONS LINE is always disorted.
Complications:
(a) Avascular necrosis of femoral head occurs with in 8 hours of injury, occur
approximately in 15% of cases, incidence increase sharply with delay in reduction. Xray appearance of avascular necrosis reveals it self about 2 to 3 years after injury.
(b) Sciatic Nerve injury - occurs in 10% of cases, peroneal part of sciatic nerve commonly
affected, recovery is usual and treatment is a foot drop splint should be given.
(c) Post dislocation hip with other fractures post (rim of acetabulum, head of femur, neck
of the femur), open-reduction and internal fixation.
(d) Late oesteoarthritis of hip following dislocation.
(e) Myositis ossificans - passive movements at hip should be prohibited after injury. Hip
joint should be rested in hip spica.
(f) Unreduced dislocation - if not reduced more than a few weeks, its reduction becomes
difficult even by operation, and a vascular necrosis of head is inevitable. Then the
choice remains between replacement of the head by a prothesis and subtrochanteric
oesteolomy.
Treatment:
Reduction
Anaesthesia - general anaesthesia with muscle relaxant key to success, is
complete muscle relaxation. Position of the patientTransfer the patient on a stretcher canvas on the floor.
Procedure :
An assistant studies the pelvis of the patient when the patient is fully relaxed after giving
the muscle relaxant. The knee and hip are flexed gently to right angle. At the same time the
adduction and internal rotation deformities are corrected, so that the head of the femur is now
lying directly behind the acetabulum what is needed is a pull to the thigh vertically upwards. This
can be best performed by griping the patients leg between the surgeons knees and resting the
surgeons forearms on his thighs with his knees and thigh flexed to 45°. During the pull of the
86
thigh upwards, an attempt should be made to gradually externally rotate the femur and to abduct
is to slightly. Reduction usually occurs with a ‘clunk’.
After reduction, it is always necessary to examine the stability by pushing the femur
downwards. Gross instability is an indication for open reduction and internal fixation of
acetabular fracture.
Check radiographs - patient should always be taken in 2 planes to confirm perfect
reduction and to know about the associated fracture in post-reduction film.
Other methods of reduction : If the above method fails, Bigelow’s method may be tried.
It is popular. After flexing the abduction of the hip joint, it is smoothly externally rotated. It is
then gradually extended and pulled steadily. As extension progresses, the externally rotated limb
is turned into neutral position.
Immobilisation :
Whether or not the dislocation has been properly reduced, a skeletal traction is applied
through the tibial tubercle to give rest to the hip joint. This pull is given usually with 15 pounds
weight and is maintained for 3 weeks.
Rehabilitation :
Active use of hip should be encouraged as soon the patient is relieved of pain even with
traction. After the traction has been taken off the patient may be allowed up with crutches.
Weight bearing is not allowed before 8 weeks.
Oesteo-orthrosis usually develops irrespective of treatment.
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