Episode 6

Wound less than 1 cm in length (sometimes referred to as a “poke-hole”) with minimal contamination and muscle damage. These wounds can be very small; however, the size and nature of the wound may not reflect damage to the deeper structures. As such, it is important to examine the overlying soft tissue very closely. Wounds with a continuous ooze are always more suspicious, however, any soft tissue wound in proximity to a fracture should be treated as open fracture until proven otherwise, as it can lead to infection and other complications if not properly managed.

Wound size of 1-10 cm and are associated with moderate soft tissue injury.

Wounds usually larger than 10 cm, indicating high-energy trauma with extensive soft-tissue damage and contamination. Despite the severity, there is adequate tissue available for flap coverage, making surgical reconstruction feasible. Farm injuries, due to their high contamination level and potential for severe tissue damage, are generally classified as at least Gustillo IIIA.

Wounds usually larger than 10 cm. These fractures are marked by extensive soft tissue damage and periosteal stripping. Interventions for soft tissue coverage, such as rotational or free flaps, are typically required. 

Distinguished by the presence of a vascular injury that requires repair, regardless of the degree of soft tissue injury. 

A is for airway management. It’s crucial to ensure that the airway is open and clear, a task primarily managed by anesthesia and respiratory therapy teams. However, the orthopaedic team plays a critical role in cervical spine (c-spine) protection. This includes ensuring the placement of a cervical collar, particularly in patients with high-energy trauma mechanisms, to safeguard against potential unstable c-spine injuries that could lead to spinal cord injuries and neurological deficits. Furthermore, during situations where intubation is necessary and a cervical collar may impede the process, the orthopaedic team may be called upon to manually stabilize the patient's neck, ensuring both effective airway management and c-spine protection simultaneously.

B is for breathing. The role of the orthopaedic team, while often supportive, remains important. The primary objective is to assess and manage any breathing problems, specifically identifying issues such as chest wall instability, flail chest, pneumothorax, or hemothorax. While the responsibility for addressing these conditions typically falls to other members of the trauma team, it's crucial for the orthopaedic team to be adept at recognizing these injuries. Their ability to identify and, when necessary, assist in the management of such conditions can be instrumental in stabilizing the patient and preventing further respiratory compromise.

C is for circulation. In this component of the primary survey, the orthopaedic team plays a critical role in managing conditions that could lead to significant bleeding and hemodynamic instability. Orthopaedic injuries, such as pelvic and long bone fractures, are prime examples where orthopaedic intervention is essential.

Pelvic stability assessments are pivotal in the initial evaluation of trauma patients, especially given that pelvic injuries can lead to substantial blood loss and hemodynamic collapse. The assessment involves specific maneuvers to identify types of pelvic instability—internal rotation (IR) forces applied to the iliac wings can reveal IR instability (lateral compression or LC injuries), external rotation (ER) forces can indicate ER instability (anterior-posterior compression or APC injuries), and traction to the leg or vertical forces can identify vertical instability. An anteroposterior (AP) pelvis radiograph is recommended for all polytrauma patients or those with hemodynamic instability following a traumatic mechanism of injury.

The use of a pelvic binder or sheet is a critical intervention by the orthopaedic team in the trauma bay to temporize injuries. The primary goals of applying a pelvic binder or sheet include closing the volume of the pelvis to reduce space for potential bleeding, stabilizing clots on bony surfaces and vascular structures, and providing temporary stability. This intervention is particularly indicated for pelvic ring injuries accompanied by hemodynamic instability, highlighting the orthopaedic team's role in acute management to improve resuscitation outcomes and prepare patients for definitive surgical care.

D is for disability. In this phase of the primary survey, the focus shifts to evaluating the neurological status of the trauma patient. The orthopaedic team has a dual role during this stage. While other members of the trauma team use the AVPU scale (Alert, responds to Verbal stimuli, responds to Painful stimuli, Unresponsive) or the Glasgow Coma Scale (GCS) to assess the patient's consciousness and neurological function quickly, the orthopaedic team concurrently performs a meticulous examination of the extremities. This involves identifying any limb injuries that may impact the patient's neurological status or overall outcome. Detecting extremity fractures, dislocations, and soft tissue injuries is crucial for planning further management, and it also contributes to the overall assessment of the patient's disability status.

E is for exposure. This component of the primary survey mandates the complete removal of all clothing to ensure a thorough examination and to avoid missing any injuries. For medical students involved in trauma care, being proactive by locating trauma shears before the patient's arrival can be a practical contribution to the team, facilitating rapid and efficient patient exposure.

Once the patient is fully exposed, a log roll maneuver is performed to assess the integrity of the spine. The orthopaedic team's role here includes a meticulous spine assessment with a systematic approach:

1. Look for any wounds, contusions, or deformities along the spine.
2. Feel for abnormalities along the spinal column by palpating the spinous processes from the cervical to the lumbar spine. The team assesses for any steps or gaps between vertebrae, any bogginess or crepitus that might suggest an underlying fracture or injury, and areas of tenderness that the patient may express.
3. Perform DRE (Digital Rectal Examination) to assess for sacral sparing, which includes checking for sensation, motor function (such as active or passive rectal tone), presence of blood, or a high-riding prostate, which can indicate a serious pelvic injury.

During the secondary survey, the orthopaedic team conducts an extensive assessment of the patient's extremities, which is essential after life-threatening injuries have been addressed. This detailed evaluation begins with a full 360-degree inspection for any open wounds, including the perineum. The team also looks for gross deformities that may be fractures or joint dislocations and palpates all bones for signs of tenderness or subtle deformities. Joint integrity is assessed through both active and passive ranges of motion, and each joint is stressed to check for instability.

A comprehensive neurovascular examination is also performed, encompassing both myotome and dermatome patterns, evaluation of peripheral nerve function, and a vascular assessment that includes checking for the presence and quality of pulses, as well as observing skin color, temperature, and capillary refill time.

Imaging also plays a pivotal role, with X-rays obtained for any suspected injuries. The timing and prioritization of imaging are critical decisions based on the patient's overall condition and the likelihood of injury. Once injuries are identified, the orthopaedic team moves swiftly to manage them. Wound care may involve irrigation and debridement, and temporary or definitive closure techniques. Reductions of dislocations and fractures are performed to re-establish normal anatomy and relieve pain, followed by the application of splints to immobilize the affected area until definitive surgical treatment can be performed. This thorough process ensures that no injury is missed and that all are managed effectively to promote the best possible outcome for the patient.