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EN4trRGtrNC)' N4trD]CNE
EN4trRGENCY MtrD]CINE
rN4]]RGtrNC)' MtrD]CNE
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EN4ITRGtrNCY MtrDlCNl-
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GtrNC)' M lrDl CINE
trMtrll GlrN CY M trDl CINrI:
El\4lrRGtrNC)' MlrDl CINE
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 ENIERGENC\' ]\{EDI CINE

.A.NAPlr)'LA*X IS
Introducrion
nr:rnifes-ruonof tmnredtlle hvyrrsensiurrr.\' (r-\?e l) in tlhich e\:posutc
Anaphl.larosaccordrng to Dorlands is a
or hapen rcsulu in life-threatenrng rcspraron drsresr usuallr
of a sensiriz-edindir.irtrr,rl to a gecific anugen
and accompanied b! umflrna pnmnE and ang:oedema
follorred br. r.ascular coliapc and shak
to arurpllr'laxisbut rt ls rtol ulul)tlllologlcalh'precipiuted and t-ltusmcurs
Aruphl,laooid rs a reacrionsinillar
lacli of prolecuon due to immumzauon Your bod' creales a'l
afier thc iruual erTrosure.Anaph'laE' no*
uill qlusea reacuon
-"t"a dur $ill not dcfendvou front ccruunanuge[ but

Pathoph.r'sirlk4ricl\l echan ism

lo an irnDgenor a lnpen rrhicb produces a speci-6csensidztng
The susccpibie pcrson has an ininal e\Tnsure
uitlun orcularor-r' )gE rnrlnunop:lobu|n^s These a:tugen specttrc IgE
a:rtibodr or rcagln. Ths rcagrn s kep
re{\'posure to dre anugen bridgurg oco,'s ben'een the
conrplexes bind *it1 noo oit and bosophils. Ljpon
de'elolred on the surfacesof orc masl ceslls a'd bsophils
urrige' a'd rhe ..nsuzJ lpE compleres'tlur ha'e
decransetn o'clic. AMP' leadrng to de'eranularionand a
This bridgrng causesu .ioig. in dre cells causinga
as h-rs:inune' SR-q-'A' serolorul bradrkinm and alsc
release of pharmocologrca-tl1'acuve nred-taronsuch
platdcrs'
circnrourcucfacror lor cosurophils' ncutrophilsand
nredraton e\c@l for husanrine and SRS-A are tlrcuglrr lo have added effect on
Tire abor.e mentjorrcd
anaphriacUc rgilcDolls
u*j1:f"or. b,'r if is tusranrineand SRS-A tla are the uue causesof the
of man- ll-rsuurulr€ causes bronchial constJ.lcuoll'
llrs:rmrne ts thougjrt to bc a rra-ior med:atorof arraph'larrs carrsesconsn-ic'on
r.rodileuor, Slor,-r*cung subsnne ol arnph'larrs
rncrersed apilLo4.yrrmerbilin' and mcdlalors arc
and SRS-A along Nrrh rhc otlrcr abovc nrenrioncd
of bronchjal smootb nrusclc. lirsaminc *'hal \\'e see climcalll' and r{hat
rlranifestatjonsart
respo'sible for rhe r*anifesariors of aruphvlaxis Thcse
nrus be recontrrzedso that rreraLmerlczmbe rnslnned lmmedlalel\
anephvla$s. The nunifestatjorus of arnphrlan:s are
Tlrere is no universal poDcrnor sepb-r-sep proccss of
manifesurrons nurl occur and tlrose *Ial do nul nol app€ar rn an\
lrsted trclorr. sttt anr rcacdon not all $e
order
eves lrps or tongue)
L Cura_rreous. enilrenra pru6rus uruaria and angiocdematusualll' of the
IL Respinton'frilure: nvo D?es
tJre lanrui andror epxgJoms$'hich can cause acule
A) Urper arr$?\' Ob$ructrorLso$ing to edcma of
drstressand dcatjr br suflocauon
'rrtich leadsro lirruredairflou drat is not rcbe'ed b-r'endotraclreal
B) Lxrrver aln\").bronchocorsricuon
rurnrbuon leadrngto a problem of gas erclrange aDdht?oxemra and hrpercarbu
probobll.the mos ,..'"r. ,"ro,on shich lecdsto hrpotension- arrhrthnlas and cardtac
Ill. Cerdror.accular:
Jnest

Signsand s-\'ml)toms
rhc poucnt complar-ru of a scn-scoI aura of uncasiness' and
Thc npcal m:rniJcseuors of aruphvlavs arc tlnt
u'ithrn I to 15 mlnutes or several hours after e\T)osureto
Uo"ri.,!r rgored and flrxhed. Reacuon can Gcut
prunrus' cou-e}mg sneezln& umcaria and r+ifhcult)
anugen. Sympolns pro€ressto plpinuors. Fvesthesras.
rr:dt resplr:llor.\ dr-qress or in is absence'
breatlung Cardrova-snrlarcollapse can ocnn concomrunth'
Uruecoi&ea anephvlaxs cen leed to shock and uldmetell'&3lir

Caurtcs
are infnite' The most obrious and imponant
The causes of anaphrlaris and anaphllaooid reacuons
( uith esers than a:uides)-anobiotics (ie-
orecioiunrs *. n^r-u. analgesics local arrestlrcucs nrore prn'alent
d'e. crossreactirin'beru'een
andradroprque
ne-:rmphorerion)
anrifrurpls drugs
;Jilf,;#il"-"r-t*1.
r,.*.pio1otpoti* sf,outOnot be prescribed to a penicillln allergrc pouenl)
n-ffl,rmponanl

325
 rg:rl nrcnl
Because of the drre collsequetrc€of arnph'r'Lavvanaphvlaooid rcanron quick recopnition and imrnedrate
tnlen'entiotr is taltutnounl. ltttttledtate ucaunenl consists of 0.3 nil epureplurne (j:ltfil dilution) 6lven
tnu-alntlscularlr'-l'lretler the cljnical prfiure i-< generabzed prunnts. la4ngeal edema broncirostrtsm
or I
lrvpotellston. Funiter rsthlenl tncluchstle use of a tournrquel placrng the ptrent in a recgmbentposiuon
nronltonlU:ritej srgrs. es.ablishrnpunrernuimng an arn\?\. ox-\'genelc
l
Xe-r'Points
-drfl ercncc hru'ccn aruphrlax s and arnphti ao oid rcacu o n_. I
-aruptr'laris is t-rpeI h-t'persensiur.trr
(inunedrate)
-drug of chorcers 0.3 mJ IM eprnepirnne(l:1ffiO 61;uuon
-pslrent hrson of allerprcresfnns€sto drugs.foods. etc

AI'I'ROACTI TO C}IIST PAIN f'

Tlrere are nranl c€usesof ches patn All complainLsof clrest gtin should tr raken
seriouslr.. Empinc l
lre.:ltllrclllshould be s-rned inllnedretelr'-if therc ts anl suspicronof a cardio'r.asorlaror resDiraron. \
e'ent

I. Hrston, of traurrraand/orreprcducibleprrrnrvit_lrpa.lpauon
-rrros likelv nrusculoslieleujrn on;u
a
)
I L Cerdrora-scularrnd/or Rcspinron ctrologr
a) begrn ox\ gen - 5 Umtn
b; nroniror viral sipn<
c) appropnale STAT con-sultauonrvi*t rntenils or cardiololusr u'hen possible (f evenl
I
occLusrn hospiul t
d) tr:rnsfer pJDenl to )nrcrsive Care or Cardrac Care Urur
e) e\rlrl.rne for shock increaseil'errous pressure-pulrronan edenra )
\
III shock Hvporension- lncreased'enous pressureand/or hrjmonan,edema
A) trqmrenr
l.) rnsenlarge bore IY
7
\
2.) obrain arrerial blood gas STAT
-?.)ohain ECG and chesrs-rar
4.) examrneFrjenr
5-) in-sn urinan'calhcrcrand montlor flrud snru_<
B ) diflcrcntiai dragnosrs
i
I .) mvocardial infarction
2.) prJlnorun' emboLsnr I
-i.) acur heart failurr
4.) pencarrli:l effuson
5.) others:cardiacumponade. lensionpneumothoran-aomc dissccrjon leaking aoruc )
aneun.sm
l\/. Acure drqress from rnrn or dvspne: rrirhoul slrock hvporenstorL increesed yenous
pressur€ and,ior
puJnronan'edema
A) treamtent
l.) hisoD' and ph.vsical
2.) rnsenIV and infirseD5\\;
3.) ohain ancrial blood gas
4.) obain ECG - correq severearrtrrrlutria
5.) I\i nrorphilre2-5 mg even' lCr-20minures
B) di fferential diagnoss
J.) all droselised in the abor,esecdon
2.) cardrac.respiraton- aMonriruJ and nruscuJoakeletalcauses
l. Basrcs
A) EXG gtPet
I.) usr:allr'run3t 25 lnm/ss
2.) tjun I n'rntbo.r = 0.Gl sec
-i.) tirick 5 mnt bor = 0.2 sec
B) Conrgnnenu'
l.) P uavc: rcPrescntsatrid conracuon
2.) QRS coltrpler: rsplesens ventncularconttacnon
.1.)T \\"\'e. represenBvenlncularrelaxatton
4.) P-R tnten'a]: nol to e\ceed0.2 sec
5.) QRS complex: shouldbe lessdun or equalto 0. l2 sec

Il. R.atc
A detemtinedb1'Pacemaket
l.) sinusatrium node(SA node)
a) nornulh' tlre Pacemaker
b) rronna.lrate= 60- I 00 trc:rtVnrinute
c) srJltt.(bradvcardla= lessdnn 6{) beats/nlrrlutc
d) surustachvcardra= lygtler lhen l0() bqlls/nunute
2. ) cropic ;racenral<er
a) eitherarrium
b) AV node
c) eillrert'elttricle

B. lrou lo deternrinethe rale br quick esunuuoncounl the numtrer of thick (-i nm) lines benleen trvo P,
rraveseachthick hne rs p\ en a ralue ln successlon
- 3 0 0 .1 5 0 .1 0 0 . 7 5 . 6 0 5
.0

ll l ldennfvurgarrltmthrmla<
A) deternrrnethe rate
B) icierrufl tJteplnenr or regrrlant-r''of tlre arrltrdrnua
l.) premarure bears(re-a bcat earlier than expected)
2 ) speedmgup or slo'rrrngdosn of the rh'rtlurt
3.) prcscnccof an1'Pouscs
J.) ronl irregularitv or clraos
C t recogniz.e and defitr atrial actirrn
I )rdcntifr'ilrcPsave
qill be presenl
2.) P rrave nrrt' chengeif rlrre is an ecopic pccemalrerin eitJreramrurt. lrorvevera P rrave
urrdtJre QRS conrplex rrill be nontul
.i. r ecropc AV nodepacemalierma\.havean inr,enedP rvave or no P rrzve
D) recopruzrngvenmoilar acu'\ln'
iJ ccropic pccmal<cr is in thc vcnmclc tlrcn QRS conrpler sill bc Erurler tlun 0 12 scc and P ualc u'ill bc
absent
E) detemrurerelationslilp of atrial to ventricul:u actirrn
l.) normall:1. trred
2.) prolongedl:1. fi-red
3.1nruJtipleP q?r'es lo QRS cornpleres
J.) P uaves and QRS compleresunrelated

327
 I
Ir

--?,-;
F il
t]

i_-r_
c ll=
?- t
,

^,-
I
I
t'roi ,+t ,s l
I
.Rete raw DB cslcolatqC:
E!
lgoo
b.E.'Jocn rlrr-Ilt wtva3
- rEta
T
t
l
t
t; ji
-;',-r-L'',i-..^.**L,- r
l
}|orral Sl.r:rs R.n5h= A:--:al Flbri l-l att or:

t
Tofsactof
t gu5nidlae
det Poi.rl-c5
!o).j c:=)r )
verrt:icu)gr FibriJ, l ar:on r
T
,rrg.rqy sla I vctttrJ crr,L a3 7'::;rcrrdia ^=r].a.l Plqtrt'fr
l
t
328
T
I
COA'-ATOSE PATI-LN-I
'initial
nrarugemcnlto crlsuremartmal rc'cgvenand avoid funherciemage

L AssesABC's

Il Obraitrblood for STAT arulvsrr

.A) Ioroc subsunce scrctn
r"N
B) elecuohres.pcucose'calctum BUl'- & crandtuns
C) lrrer funcdon less

lll Drugs uhich ma1'rnlprove;ntient's surtusand u'iU rrothamr

A) glucose(an:prJe of D50) - consider hrpog.lvcemrauntil pro'r'enotherurse
B) tjriul11re - gtve ll \\'ith glucose lo avoid praiprnurg acule Wenucke-Korsalioll srrtdroltre
tenccphalopo*'l) rn thianunedefrcientpouenl
C) corucoseroids - decrcise cerebral edema
Dt nrennitol- osmoucrPcnl to rcduccan clc\ztcd jnr.rcnnrd Prcssurc
E) naloxone0.4-2.0mg fv..- reverserurcotrc overciost
F.tralrrmr5-10 nrg ni - sop selTltreaqirrn
C) flunrazenillV - reversebcnzodrazcprne overdosc

)\/ ; .\orm:rlize Inetrbol i c ebnorrnel tu es and bodt' l enlpemrurt

SI.IOCX

Gcneral managemcnlof shotk

I Recogruzelhe presenceof the shrck sate
I ldentiJl the probable causeof tlre shock sate
i Earh' Luen,errtron- ur=lullelrl of slrock is drreoed touard restonnc celJular and orlart perfusion rritJr
adeguarelr oslgenated blood rather t}an lnerelr resonng prrlse and blood pressrre: thereforc.
vasopres-\ors are conra-tndrcated in hvpololemic shocll

Tlre goal of tru:rtnrenl is to rr:strtrcor?an lrcrfusion

Sfns dSbocL
I Tachlcardra:earlies sgrr ofshock
jnlant 160:presclrool l-10:schoolage 120: adull IU)
I Resprraron'ntle:u'hen tissue;xrfuson &'creases o\gen lensroncjecrsrsesand cells suitch lo anaerobic
nteubobsm. L:cnc acid is t}en produced rvhjch rnducesa nreuboltc acidosis. Respiratoryrate u'il|
mcrcasc €usng a u*drrsicnlrcspiraton'alkaloss. Tachrpnca rcprescnts ano0rer carlT sign of
shodr
i Capiliaa' 6llrng: capillan filling uill decreasecausing cold errrenuues Normal capillan' fillurg is l-!
rcconds. This sign r no considereda cnteria in the hlpothemuc p3uent
r hrls€ hessure: rhe di-flerencebetu,een q'stolic and dia-qobc pressute. This ralue sill reduce as lhe
padent enrers the shodr sate A narrou'ed trrlse press.ue ts con-sideredless than 20 mmHg. The
plrenornenon is pnmarih related to a rise in diasolrc pretsure becluse catecholamines relceseddunng tlt
shak sute rncreaseperipheral resgancr

Aigfrr or hosrilin'. ln Orelarc sages the n:enlal sunt-( rrur\ dcprade to uruesponsivenessand evenn:alll lack
of consoousness.
6 Fall is s'sobc pressure:this does not occur until a signiJicrnt antounl of blood is lost- usualll' beru'een
l -500-2000 rnl. Requiresitnnrediateirtren'etrtion

329
- -Unaan-nurtrlrson}r-aflecr
nhe-Bdollls?fr*{rnrltrorr.
- rn severe shock sates. Once flu:d replacement ha-qbeen ininared uman ouTxtt rrutv be used
as a g.augeof effefll'ettess Unlun outprt should be -50nrl,4rou-rfor aduls- 2 mV\y'lrour for infalu.
a:rd I mlAipr'irourfor pedtatric pauents
ti Herrntocnt (irenrogJobrnconcenuarion):e rmssive blood loss ma1 produce a mirumd acute decreasern
lrernatcrnl. A lou' hematmrrt suggesusiprtificrnt blocd loss or anemta*horlever a normai or near nornral
irertutocnt cioeslrot ru.leoul a siglrificant blcrd loss Therefore. henratocntrs al unreljablelrre.:sureof
blooj loss

T1 grci of Shock
*AlJ
fstients in shrck arc trcatcd injtiallt'as $oue}r *rev n'crc in hrpovolcnuc shock'

Cardrogcnic sltock a shock sate induced br. nrvocardial dvsfuncuon in the Faunul poDentthis form of
shock rs conunorl second onlv to hvpovolenuc shock Chenoerzed br rncreesedC\4P presnue a:rd
a iuson of chcst u?utrut.Causcsincludc qrrdrac urnr;nne& tmufllcd hcan sound.s.cngorgcdnc<* r'ciru).
,)
lenS!on llneunrodroran-cardiac conlr.slorr arr embolisnr and mr,ocardial infarcuon trareh-).
Neurogcnic shock: in gcneral. isolaredhsrd tnruma does nor qegseshrck Head and spinaj cord injuries
tnav prcrCucehrTntcnsronsecondan'to loss of srnrptheuc lone. hou,everthis onlr conrpoundsthe eflect-.
of ir1'povolenua. Clurractedzd b.r h'r'poterulonu'ithour tJre classrc sr-rru of shock and u'ide pqlse
prersure
Sepnrc shock: shock due to infeqron ts uncomnlon rn tr.rulna hou's\,s1 should be considered g'it;
pelreraung rvounds of the abdonren u'lrere trrrvel conlents are spilled Ch:rracrerizedbv nrild uchycardra.
rr:rrm skir fand a rride prlsc prc:sure
Hr'povolenuc shak: defined as an ac-uE loss of ornrlarrng blmd The normal 3r+rrhgircul3ting blood
volurtte is 7/n of bodv u'eight or in a 70 kg lrr:ul approsrnurlelr'5 liten. ln childrenthe blood volurne is 6-
f/o of bo{r' tveight or E(}-90 ml"&g Chrcc hlpovolemic sbcrk is suspecred rnrmedrareaggressr.e fluid
resusciuuon mun beprn
5 Faaors that ajtcr rascltar drrram:cs.
a) Sndent age - t}te older the patlenl &e nrore diffrcrrJn'drer hn.e in rolenung and cornpen_saring for
henrcrrhage.
b) sevenn, of irjun - specialanention to atutonrjc loqation.
c) ume laJxe - Ored-rnebcrl,een occrurcnccs of in-1u4,and ueatment is si;ruficanr.
d) prehospiuJ therapr'- fluid replacenrent or use of lr4AST tmjliun antishock rrousers) or pASG
u)neunu|uc antislrock garmens)

Cla-rscsof Flcmorrhagic Shock

I Class I lrenrorrhage:a loss of lSY" of blood volurne or 750mJ. No measurablesgrs of shock are
denton:qrated u'it-h the exceFnjonof minimal tach.r'cardia Wi0rour therapn'Ote bod' u'ill contpensarefor
tlre volume loss uithin 24 hours hou'g1,gscn'sulloid 0uid replacement is sugglcsred
2 flrq< Il hcmorrhagc: a l5-3tr/" r'olumc loss or 750-1.500mls. Characrcrizcd bt utChlcerrlie uchlpnca.
decrcased prlse pressue. S1'solic pressrre ard uman ouprt usuallr' rcnrai-n sable. Patient nur
erTreriencesrrtrle CNS changes.Tlte nujonn of yntienL<in this sage of hemorrhagenrav require blood
tran_dustonsl,snnrelll'. hou'sver. are r-qilv statilized siti cr_r,stalloidfluid
;. Cie-s III hemorrluge: a 304{f/o blood loss or 1500-2000 mls. This ch<< of hemorrlrage presenrs r}e
classical sigru of shocli (ie-nrarlied uchr,cardra uchrpnea clranpe in lnenlal zurus ard fall of sysolic
pres-sure). At leas 30ozbof blood tolume mus be losr bcfore the svsolc pressure drop. Treagnenr
regulres immedtate o1'salloid fluid replacenlenl and er,ennuJ u-ansfusion. The decjsion ro inrmediatelr'
transfuse is bosed on tlre prient's rcsponsc,

330
 Crar. IV @umeloss o-nm- nl@Eluruluon_rs-=.-'-
urinan'ourprtand
rntmolruelr.liJe- threarerungCluraseruedbv theclassicsrgnsof shocli negJtgible
urrotxarnabledrasro|c pressurc lrnlttedrate 0uid artd blood replacettteltt ard surpcrl
lntcn,enuonlo slopthe herttorrlugets rr';irranled
. Loss of -5po/t, pr:jscand blood pressuc
of blood r.olumcrcsrJrsin lossof corlscrousncss

Sofi rissucflrrid lrxs

Ntator sofi Uss:c iniunes and frasurcs aflccl $c crrcuJaUonin nro rrzr.s-
I blood loss: a fracrured tjbia/hunenrs czur lose up lo 750 nrl of blood Fetlturs can lose 3 u:uts
( I500 nrl) and tlrepclrTs can lose 6 units (3000 nil) of blcnd
2 infl:rnrnrato4' edema collstsls of pl:rsnu and elrracellular 0uid

Rouelrjr 25ri'oof lluid found at tlte inrured area is clrcuJaringvoluttte Tlrerefore the 3:l rule of fluid
rcpiacenrerrris indicared For example. nros ;ntients in lrcnronhagrc shock uill reguire 3fXt ml oJ
eiecrolrre soluuon tor each l(X)nrl of blood volume loss

lnitial nran:rgcntcntrf hcmorrhagicshrrk

I Ainrzt'/brcatlung: rcsrorurg blood volunrc docs notlung unlcrs the blcrd tcurg crrculated is o4'genated
Ir4arrrrelarceoI anerialox-\,genlensional leasl95o/"PlO2 or betterrs necessa .
I HenrorrSageconuol: bleedrng fronr anerial s'ounds is controlled uitlr dtrect pressute. Internal blecd:ng
requlres surpcal e\"luation imnredrateh
_. G.rsmc dccomprcssron:thc Gl u-Jcl stop'sfuncuorung in thc rraunrrtued ;nucnr. Thc d.rnger of agluauon
sit-h fauJ sequelaesrss
i \,ascular access.ntus be otxarnedprornpll using large trore ler gruge or larger catlreten. Uperipherai
accassannol bc oharned a saplrcnousvcu'r culdo\\rl rs pcrformed bcfore a CVP rs considered The
cutciorrnrs guickerand s'itlr lesscolnplicauons-
i l_ruualfluid tJrerapr'-c1'salloid tsororucelecuolrte solutjorx are used Ior resu-qciuuononll . Rurgen
laaarc is ilrs choice follos,ed b-r'normal saline. Normal srhne ts not prcferred due to the potential to
causr hl.pocNoremrc acidoss cspecialh rn renall'r' rnrglred IEDenLs. The initial bolus in adulls tlt'
-2
l lrtersand 20 ml/kg in childrcn
c, Blcnd reDlacenrent:once the decision to begrn rran-S:sion has been made. three npes of blmd are
available dependrngon tlre urgenq' of tlre porient'scondiuotl.
. fulll'crossmatched blood : prefcrrcd horvcr,er.u-srrrlh'l3kesone hour to prsfJare
. llpe specifc (salure srossnratched): compatible riith .ABO and Rh blood n'pes bul nunor
antrbodresexis. Arailable rrit]rin l0 tlrinules.
. r.\pe O neg?uve blood: resened for use in potient< sith ersrngurrudng hemorrhage. Rh
niganve faoor ts suggesedto avoid future sensru:uon especiallv ue6sl of chil&eanng
!cars.
. Blood \\armers should be used uith blocd and cn,sulloid fluids lo prevenl h)'pothenrua. A 16{)
mlcron fler should be u-sedto filter microscopic clos All otlrer fi.ltenng &'rices should be
avoided becausedrev do not allou'rapid 0uid adrnjnrsrauon
7 peurl:rtrc Altrjshock Gantrent (?ASG): this &rice raises srsobc prclsute bv incrsasing penplrera)
resrsunccard mr.ocardralafierload The derrce ts a prehosptal therapr'dcsgned to bu1'ume.
OnJl nvo in-hosoital indicanonsercs
o lfver€ pehic fraoure $,ith condnou heltrorrluge and h.lpotensiolt
o p{ru€115 rn-roue to the OR rvith rnu-a-aMomuuJ trautrul and so'erc hvpol'o}emia
Conra-indicadon-<
' uncontrolledienrorrlrage ouside tlre confines of tlre gamrent
. prlmonar-r edema
. sustesed or borrn ruFure of rhe diaphngm
. left ventriculardrsfuncrion
. respirao4,drsress:necessiutesthe deflaoon of the abdonurul componment

331
 -The-&rrcgcannu-tcrcmored-until-the-fruenrlurs-teen-.rdequstelr-manaprcd-and-rs-srable-or-uiren
lhere ts adequau prepanDon for rmmedratesurgrcalrnlen'enuon. The de0anon proc€ssls gmrlrral.
begututittgtti0r tJre\\?rsl conlpdnntentatrd proce'rlne ro srclr leg corlrpan1llenl Arr is reiqr-sedu'til
a -: mmH€r drop in blood pressureis nored

Compliutions in tructmcnt of h1'povolcmicshnck

A) Agc: tlc oldcr ptjent ha-cdrfficuln'compensaung and rolcrau-nghrpuension from hcmorrhagc
B) Atjrleres: tJusgroup of peuens lraveFrlse ratesof 50 and rncrL:l-ses ix blood volunte br l!20ozi, Cardjac
outFrt incrsases6 fold arxj snoke t,olurne bt' -i0p.,oAssessmenlof tlus p€Denl LqdifforjL
C) Medicauoru: beu-adrenerpc recepor blocken and calcrum chsnnel b)ockers sigruircanth a1rer thc
;reucnl's ]rcmodrmmic rcgonsc to hcmor*ugc
D) H-rpothentua: lenrlEEllure is estrenrelv inrponant to raord rn rlre suspecredslnck paoenl.
El Facemakers:hcan rate rentainsconslanlin theseFrrrenl^< unril blcxxj Ioss causesmr.ocardialfailure This
gJoup should bc monitored bv CVP prc:srre
F) Condnued henrorrirage:il henrorrluge ennol tr conrrolled bv ininal treamren1-rmmedrate
srrgicel
rrrlen,enuoltL< reourred
G) Fluid overlcnd once ilre yrtient nran:tcenrenl is cornplereddte risil of fluid overioad rs nrilurrrizedb1.C\?
monrtonng or Ftlnronan'\'edge pressurE. A fu.lnrorun' r,r,ecig€pressure is technjc"ll]. difficult
to
prrform in drc cnrcrgenc! rmm sning t}crcfore C\P pressurecen be emploved much nrore simplr
:= Central \'enous pressurenronilors onlr LJrerig-lrrlreart'sabilrtv lo accep fiuid
Tlre precrs.
mcrlsurEof cardrac funcuon is the relatronshrptrcnr.eenend dia-qolic renmcular yolume
and
sroke volume. Therefore rigfrt hcrn pressurero qrrdrac ouq)ut as deremlned by C\? pressure
is
indlrcct and inscnsinvc csdmalc of cardjac lunaron hoNc|cr- it is rucful for
6ross cvaluarion of
*"t]t"t-ottffill,
no in rlre initial lo*'c\rp rarues indicare need for furrler flud
replac€ment
o -a declining CVp tzlue indrcaresconlrnuedhemorrirage.
' -rn abrug elereuon in CVP relue suggess repleccmenl
rs loo much or roo rapid end

H) Acid-Brse
-r.,*-*il'iTHil,.", "-t"J:T.tt.r ronreubolic
acidos,s
or a mirdrormin the
earh' stages of shock and does not reguirt lrutml€ru, ln prolonged late sage shoc]i a se'ere nreubobc
acidosts qrn ocant. This is treatedonll' uith increasedflujd rror bicarb Bicarbondare 0lerat\-rs indrcsred
rvhcn thc pH drcrp'sbclou'7.2
l) Recognition of othel problenx: l hen OreFuent fai)s to respond properlv to tJrerapt..consider odrcr caus6.
J) Consanlll re-erahute tlre grarienr
lnitial Assr-ssment
Exrernrn u?unu rs rarelr life-thrsrerung but a-rsociatedintunes can bc potentiall'r' snous. Cenain injunes and
disabL:rgif not properlr recoErzed
contbiladors of i:liunes to ilre skeletonrtul be pentu:tentJ'r'

l. Pnman' Sunrr': life-thrcetenmg condirionsare identifed nith tlu-sexaru

$rnra1' nrai:tteturtce u'itlr cen'rcal spi:te collrrol
p re.rthing and venrii auon
Crranlarjon uith hemonhage conuol
Qisabilin': quick neurologic checli rrsirlg d1sA\PU nretlrod
A: alen
\': respondsto rrsual srimul
P: respondsrc najllfill stutlull
U: unresponstve
Er:lnsure of ;nuent ren)oveall clotJdng

2. Secondan'Sun'o'.
The second.an'su^,evts a hard to toe Errlu:rjon of the traunu Intlent- u'hich doesnol beprn until tlre priman' sun'a'is
col:rplerealrd tlre pouetrl ts sLabiiized Each re6lon of tJletrrdr'- begrruungrritlt tlre head and endurg ltith tlre feet lttust be
ilrorougpl examined.Specialprcreduressuchas laborato4'st'trdres and raciroeraphic are condused in this
ex:rmtnatiotr-s
sun'e\.

3 Hison-.
the drrecrionand srengh of the defornringforces. A
of rhe in-;un'rrill help cjeternrine
lnformar.ionconcerninglhe cau-se
huson' can be obuuned al anv ume dunng the e\ahnuon of tlre p3Denl but cannot tnterfere uith t}te pnman' and
scondan'sun'Q.

4 Dcf nitive Care Plu-se

ln flus phase.aU t}e pouenl's ur.iuneszuenwuged Tlus pha-seincludes colttpreheluive lllalugen)enl- fi-aflure
subilzarion and anl' neccssa ofErali\€ inten'ention 6 ueli as sabiliz-atjonof the poltenl m pre;xrarion for appropriate
ransfer to a faciljn' that can provide a hiEfrer lo'el of medjcal care

Fracturt Atrcssnrcnl
Fraoures are generallr.classifiedinro nro rnajor proups. opcn or closed fracnres. An)'obrrous or suspeoedfracrure nean
a u,ound should be ansumedro br an open fraaure. even if $e fiaqure cannol be seenin the u'ound

Life-threatenine fraoures
cmslr injuries of tJrepelus and abdomen
rraunratic anlFruuons of t}le arrn forearrn rhigh or leg massiveopen long bone f-asures

Limb threatenine iriuries

vascular injuries uith or u'ithoul fracrure
crush injuies
comFrBnent $rdromes
dislocation of nrajorjoutt-.
open fraoures

3. Associatedor occult fracrutes

333
 -RsAUMAT€LOGY-
TRAIJMATOLOGY
TRAIJMATOLOGY
TRAUMATOLOGY
TRAUMATOLOGY
TRAUMATOLOGY
TRAIJMATOLOGY
TRAIJMATOLOGY
TRAI]MATOLOGY
TRAL]MATOLOGY
TRATJMATOLOGY
TR,AIJMATOLOGY
TRAIJMATOLOGY
TRAIJMATOLOGY
l-K.^,Lr\,1.Al-OL ilil 1
-|-n -
I
j r \._*,. L.,r \_\,.!
it i,7-{'-- a-:/"-'.i
,- ' ' I i.- .1l__t j' - - : :
':
Ti?..{l_l\4.4 T t}i_i-ii_i
.:'
T it,j:, l_r\4 .4 T O L.(_'ii*i
TFi q i-l\,i.l,TO i,-.( ]l':
TFLiLi\I-,ft iit-( ii:-ji
.l
TFiAl_llr1,{T OI_C,,_i
 t
of a traurna
ln the rrdratnc a-ss€ssnlenl
fracrureshave assaiatedLtru4 pon€rns
mcult fracturesare easilr' overlooked C€nain nyrs of accidcnts and/ol
i
:= Conrpressionfraoures - tlus Dpe of f:raurc ls nlosl conrntonll seenin a Fitrenl siro llas fallen from a beig|r and
fracturesare assaiated uith tibial piateaufraclures alrd venebral bodr'fuacnrres
larded on theu feet Calca.rreal
Spirnl radrographsare reguued on all
'tunr;rn''
I
4. Neuro'r:rsuclar iniuries
P
\
Assessnrenlof neurova-scularsuru-sis tlte firs sep in n'aluauon of exrenun futtun
a) rascular inirrnes: 'rascularin-iunesdisrup the mlegnn'of tlrevesseluall. u'i*r bleedrngor thrombosisres:lrrng
ln unfrilrn)ent of drsal circulatron and ischerrua.Bone ts an exrenrelv rz-scu.larorgarr. Fraoures un'olring long
bone ard prlus cal resrJt il ln'povolertricslrock Tlre pelrnscan lose sur urrru of blood the ferrrur tlrree uuts a1d tJre ,
tibra one and one-halfuruts. Dopplen and anso-trr.rrns providelhe nros accumlemearlqof rascrrlar erzluadon
b) conrfrgnnrenl srndromes. a contFxlrultenlsndronte Gcurs Nhen the rnremjrjal pressurc nses abort l}rat of the
capillan'hed local ischertriao{ tterve and nrusie occurs. Conrfr,rlrurenlsurdronres take several lrours lo fornt. Thc
;rrienr nrav have ercelient puises-hou'q'st. the pnrn the;nuent rs erpcnencrngrs oul of proponton lo lhe inJun'
l'
su-qarned Cennuladonand nrce-surenrenl of conr;nrunenlprssure is d:agrrosoc.Pressures€yealerthan 30 nrmHg arc
irrdrcauveof coniFrrunerrl srndronte. honrp fa-rciotorrn'ls ne€ssan'.
c) nen,e inrun': in-lu1'lo ncn'esma)'rcprctnt asual dirision of the nen,eor a phvsiological disrupion. ln general.
srrerchin-iunes have a poor prognosiscorqrued rritlr compressionin-iunes
r
d.1arnnrrutjons: fFUenL<u'iilt antpumrjorxreguirerapid assessrrrerrland coltsuluuon u'ith a specializedcellel r
The anrprtaredfrrn shouldbe clean-sed of anr grossdebnsand urap;red rn a serile rou€l morsened uith salire and t
placed in a cmshed ice ccnler and t}e paDcntshould tJrentre rarsferred ro a ccnrer cr;-nble of nricrorascular re-
aruslollosrs. A.rnpuutedpans rertrairt'riablefrorn 4{ iroun al roornlentperalureor up 10 I8 lrours il cooled
propcrlr. i'
Classifiqrr ions of Closcd Fracru res
Rockl,crd arrd Green derised a cla-<siltcauonsvslerlt hB-sedon fi'acnrre nre[a:risnr rr]rich help deremrine subseouelr
trezrtmenl
I
l. Drrect Traurru: closedfracnrresq:used b^'direcl blous of valing velocln \
a) Tappurg fractures:lou'r'elain'blou u'lijch res-rluin no cormilnutron ard little soff rissuedqrlugs
b) Crush fr:rcurcs:hig:hvelocrn'blou'n'hichcre.ltesexcnsive soff ussueinjun'and comminurron r
)
2. lndireq Trauma: closedfragures resrlung fom forcesacdng at a disance to tlre fraoure site
a) racdon {rzctures:uzul$;ersearrrlsion fracnrreat the sire of rendon or lrgartrent anac}urrent i
b) a:rgularion fraqures: uz[Lsvers€fi-acnrrecausedb-rtrndrng forces on a iong bone. The convex side
)
u:rLsvcrseh'fraoures u'hile t}e conca\Eside splinrcn
c) spiral fraoures. an obbguefracrute 45 to tlre long ar:s of bone. causedbv rouuonal forces
d) crrrnpresson fraqures. resuh from rmpacuonof the shafi into the sofi ancellous honc
)
e) angr:latlon and axjal compressionfraqu-res:qluse u-art.sverse fraflures uitlr buner0r'fragment
f) angulauon and routiorr fi-acnrres.causeobljgue fi-aqure lines
)
t

334
 Trcarmcnt of Clrncd lracnrrer
Prior to definiove ucauttenl ilre pmun and ssondan sun's\ nrus be conrplered rhe rreurovascu.larand tenool
funcrion are firs prionn

L Conrra-indiations to closedreducrion
- no drsplacentent
=, no reducuon is possrbledue lo comnlnuuon
= rcduaion srnnot be held bl exernal immobili'.6on
- tJ?rcuonforces producedtlte fraclulr
=3 open fracture
2. lndiqrtions for orrn reduction
=. closed reductron tecluriguelur.e failed to approxirrute fraEnrenL<
=. anicular surface involr'enrenl arulomlc reducuon ls necessan
= rraaion force fraoures resJting in largea.rulsionftactures
3 Technique of clos€d reduflion
: anesthesiaIs necess;an'lo prevenl Ftuenl ntusculiu guardmg. guardrnp carLsese\cesst|e reductive force to
tr used res:hing rn eyezllerdssuedenuge
= revieu' of fraoure nrechanisrttis rtecessrn'to unciersandproper reduaive nrovelnen6
= slou. seadl uzlcuon applied aJongtlre aus of the bonesitJr counler-u?cllon applied br. an assisrant
-- resorarion of lenglr
-) correflion of routon'deformin
: apposiuon of bone fi-agmenl.
- correcrjon of arguJational defornun
=, appbcruort of Jolresconrpressivedressrng
' tissue st'elhng usualh'peals approrimateh'6$ hours follou.ing ln1ul
= rinrelr applicatjon of a compressivedressrngrvill reducesoff Dssueedenra
: erzluate neurovascularsurnL(
: foliourng a 3-1 dav couse of elnzdon rviti contpressivedressrngapplicauon- a "hard" casl rut\-be applted

Fracturcs in Childrr-n and Adolcsccnts

Children's lrcnes reafl rnuch nrore qulckJ)-tofi-aquresthan tlrose rn l.beadult R/jthrn a feu dars- the fragnrens are toined
bv callus Reduqion of the fnqure is easiesu'ithin rhe firs 24 hours

li Indicarjors for oprrarive or nonoperarh'eusrunenl:

In gerreral.closed reducrion is preferredfor children's fracrures. J11sheelirlg capacrn'of grou.ing bone is
consjderableand pscrrdanluosisseldom occurs. Malunion mav be correaed bv subsequenrgrou'th. Qperan'e
trajtnlenl should be con-sideredu'hen closedreducoonfails or surgerl'u'ill pra'ent a poor resuJt.

2. A:ms of fi-aqure rrcaonenl in children

a.)prevenuon of malunion: the abilin'of boneto sponuneoush'correctpos-traumadc deformin'
decrea-qes siOr age. Anatomic reducr-ionis indrcaredrn tlre adolescenr
b) prn,endon of grourh dim:rbances: s€pafilDonof tre epiphrsis heals perfecrJl'follouing precise
rert"ction lf closed technigues carrnol preciseh' reduce the epiphl'sis. operarive reducuon is
reconuuended ExcessivelongirudiruJ grou'tb is regularh' seenfollouilg fiacnue of rJrediaphrsis. lt is
conrpen-s^atedfor b.r'aUosr-ogtlre faoure to unjte uit}r slJgfrtinitial shonening.

335
 t
-O t efl*l-#tlD SESAnt O ID A b
Pedal djgiEl and ses;amoidalfractures arc nol inodenul. u-i'rial inlunes. The seguelafrom rnisreamrenr of tlesc fracrurcs
crn resrlt in iong term parnfuldrsabilrrr

I lallut lractures: Corsidered to be tie nrosl comnron fracture in tlre forefoot Mos halju; fraqures occur al the drstal
r
plurlanx and result from a mtbbutg itt-tun or a cnrsiung injun'fiom a heavv oliecr falirng on lhe loe.
Crushrng iniunes
GtLsecomnllnudon of the drsul phaiarrr and are ofren assocratedrrith subungualhem:toma due ro a tacerarJnai
Pressurecru-sedb\. the henutolrl, can drnuge the nail nrarir il not relieved rrithin 6-12 hours. If the hemaroma
UeO
inroh,es
T
ntore lhan 2-59irof the nail plare.arrulsionof rite entire nail plate shouldbe cnn-sideredU a nai1bed lacerarionis nored
u;nn renroral of the nail plate. tlre jn-tun' should be trearedas an open fraqurc.
I
Scsanroid fraclures: Usuallv qrused bv re;retiuve. high-impaa afll'\.jues or br cnxhi-og in-iul'to t1.,efoot Sesamoid
tzcrure nru-srfrrsl be diflerenuared fronr a brpnrute or nrultiparute sesanoid
Frndrng:<suppnmng a dragrrosisof sesamoidfraqure-
t
>l:aoure Lne usualll'lagged rrre6nrjaror uneven
>large spacebcnveen fragrnerrE is corursenl uith fraaure
>anaromi ca\' abnormal f-agmenr fnsi u ons indj care fncnrre
>bone callus formarion is suggrcsureof frasure
r
>rnuluperure seranroidsare usualll larger tlu-n rronnal
>contralateral r.ret,s denron-qnlleno evidenceof simjlar fiodrng. on tbe umniured
foor
>if funJrer dragnosuc sudies neces:ir '- consider techneuum 99-ntdp bone scan dorsif
l
exon sress radrograpbs of

=
the fim MTPjourr- CT scau or MRI

Fraqure of the obial scsamoidmav be nlore common due to grearcr lcnd during ga:r.
I
l-ctrcr digital fractures: Fraqure to tlre fifflr digir due ro nighr ualking is rire nros corrrmon lesserdigiral
fracn-'e- The
t
proxrtuJ phal:inr is usuallv aflecred derrtorrstralilg an obligue or spiral oblique panerl

Tn::rlmrnl
t
Haliur fractures. Commrnuted nrfi fnqures usuallv respond to immobillzauon in a u,eightbeanng crs
lnrra-arucular condr'lar fraqures maY respondto consenative marugement ('N\\IB ca-qimmobilization;.
or surscal shoe I,
r
U,rt ^A,requre
ORlFdcpndurg on tlre size of the frasure fraprnent. lf consenaol'e rlrempr'laiJs. surgical excision mar be necessar-\

Sessmoidfraoures: Con-senzuvelranagement consisu of cas immobihza:on ($'ith er-rensionro end of hallu)

NWB
for 14 u'eekS- Surgical shoepaddedto alle\iate pressue under tlre firs meuursal head and ualking cas
are o*rer
opuons-but mav be nrore appropriarefor ssanoidiris rllan for fraoure ruuueemenl. ln some casesof se'ere
injul
7
surgrcalexcison of the allecred sesamoidand long terrn managemenl u'i0r funcuonal onhoses rru),6p required t
l-esrr dieital fnoutEs. lf nondrsplaced suppnn via truddr' glinr and avoidrng naryo\\'roed shoesis usr:alh,adeguarc.
dspiaced reducuon is required This reducuon mat'bc mainu.ined u.itlr a sr,mplebud4'splint- pera:raneous
modrf ed cast. Ser,ereiniu+'nul'necessiure oRIF or excision of fracnrre fasnents.
K-uire. or
lf
t
I
)

r
T
336
1,.
 of Flrsl l\lTP Joint Disloetion In.iuq
Jahss'Cla-ssification

Tr'E l: dorsal dislocauonof t}e pro>cmd phalanx and sesamoidsruth the inlgrsesarnoidal
lreamenl rntact. Tirc
mechamsm of in-1u4's hlperexen^sronof the hrUur
'Ireatrttent:
= oEn reducuon

Trrr IIA: dorsaj dislgcauon of tlre proximal phalarui and the sesamoidsn'itlr rupture of the intersesamoidalbpament
= Treautrent:closedreduction

l.rpc IIB: dorsaj d:slocarronof tjre proxinnJ phalanr- and tlre seslmoids rr"it]rtrarsverse fraqure of one of tre
sesatrroids.
= Trearnenl: closedrcducuon

Trrr llC dorsal drslo;:rron of proxmal phalarui and sesr.moidssith cornpler disruprion of tle inrersesamoidrl
rse fracn:re of eitl rer sesarnoid
nent ai)d tiil! Ls\re
I Erar
=. Treatment:oprenreducuon

Jrrr ll rariant: dorsaldisloqrtronof prorrmal phalaru'uitJt conrpleted:srupdonof sesnroid-plantarplate

conrpler and sepnrarronof previous bipanite tibial sesattloid
=' Treatmenl. closedreducuon

Jahss'Classificanonof Frst hdT?-'i

Dislocatorrl::run'
t {

t4 fi
t \ fi
AA,\
\ / oPo
t
t
l
i
\ t l l

/ \ / \
I I
LJ
Ty1re TypeII.A. Tlpe IIE

]\JITA TARSAL FRACTURES

Classilrcarion of Meurarsal Fraoures: thesc in-iuries sharc the ssnrc classificatjon as long bones. u'hich have been
descnbed b' Saier
=, ste: diapbl'seal meuphvseal epiphvsealor ilua-anicular
- exenl: compler or inconrPiete
- confguraoon: u-ans\rerse-obUque.spiral or comminuted
-r relatiorsbip of fracnue fagmens to each other: shiied sideuans. angulated rotated disraoed orerriding or
impaoed
- corrpbcatedor uncompUcated

rGudas funher classif ed meutarsaj facnres into irternal rnetararsal(2-3-4) and e:nernal meutarsal (1,5) f-acnues.
He suggesed tlut funJrerconsidentjon be giren lo dre exernrl meuulrsrls due to tbe efleos of eruinsic muscles
and independ€nlnuges of motjon.

337
 Trtamrent of
t
fracn:re a-<rteU ac deEve€of displacerrrent. Sagrrnalplalre deforuun'nlusl be nnni-rruzedLr order to pre'eul
subsequenr
nreratarsa.lElaandrorfracrrueof tre adtacenrmemtarsais

Dpp!:SSaunctues: ucatn)enl raries bv dte arttounl of displacenrent. Nondrsplacediracrures are genemliy placed
t
irt a ttotlrrtiglttbcarurgcas Displacedfracturesregurreanenrptedclosedreducuon folJou,ed
b'cas rr'nrobiliza66r.,
Shouldthe reduoion not be maintainedin a c:rsl ofrn reduqion u'ith rnrernalfixarjon rs reguired

Mstlp]ffl93l-fmqu95: u-sualh'Eansversern nrmre. these frasures can be maruged con-senari\,eh.r'ith a cas

t
Unstablefuagrnerru. horvever.mat reguue urrenul flrauol
I
t
t
t
l
l.

FIF]'E NIETATARS.ALBASE FRACTURES

r
Radjoloeic Classification (aier I.M. Steuart) as rans)ated tom Coun-ier des Pdic-ure.sRononds
Trrrc I: supra-anicular fracrure occurrure at tJrerneuphvsealdiaphvseal-iuncuon
b* Mrss M Soufljet MCiLs
t
>this inju4'corres;nnds lo a lrue Jonesfraoure mechanjsm - venical and
fired foot t},at cannot inven
lransverseforces aq upon a

nonunlons colnnlon due lo Ole drrnmic forces of soii ussueanachmens. tle fifi]r rneurarsal's
l
indeoendcnt
runge of morion and rzscular supll'ro fifth meuursal
=' TrslrnenFit nondrsplaced 6-8 u,eeksN\\ts immobilizarion
surg:cal retret rn competidve aOrletesand rn cxes r|hen consen'arivetherap. tails consisr of
ORIF u,ith
I
prns. scrrus. plare uith scrs\rs. uire or bone grai rritb plate f,ranon
Trrr II: rnra-aJdcuiar aru.lsionfracnrre *it} one or n1,ofracn:re hnes
TrPe III: errra-anjcular artlsion fracture ir rvhich tbe peroneusbrevis tears a small fra-emenr
from the
T
m'loid process
::i Treamtenl for arulsion fracn:res irvolves consenztj'r'e themp.r'a-.ourlined abovc
surgcal inren,ention is requjred
Trpe fV: rnra-anin-rlar. comminued fiacurre
and rensionband uirine il
I
Trr:e V: errn-arrinrJar arr-rlsiontracrure of the epiphvsis in children
l

33E
T
T
 FifthIf etatarsal
baseFracrr:reClassiicaborr

/Kl
( ir,
IDi iln
/ YI lv(
Fo
lv{
iln
#
J l I

r\t)
t_-/
/AS 'V
LJ L,
l I] J\r \i

Ste$art Classificatronfrotn: Jones'sFracnrre: Fnflure of Ba-seof Fifllr l'4eraursalbr'1.]r4-Sre$anN.{B-FRCSE

Clinical Ortlropedrcs. 1960. T'lis is the preferred classif cauon

Tlpe I A Tlpe I B

339
 t

I
t
t
l
t
t
TlplA Trpe Il B
I

Classificationof Fiflh Jr4eurarsal

BaseFracruresfiom 5I cases

Fracrureat tlreiuncrion of shai and base(IONES) - T IA

Cases
E
r
Conrrninuted-TvnclB r
Fraqrue of the sn'loid \
WiOr loirt in'olrmcnl - Trnc Il B
Sresarl Classf carion from: Jones'sFracnrre. Fraqure of Base of Fifth
Meuursaj br'l.M.Srerran MB- FRCSE-Clinical Onlropedrcs.1960. i'
t"\

7
Fraoure/dislq:arion to this.ioinr s rare and diffculr ro diagnose.The confgurauon of the.ioinl is errremel1.sable duc \
to a recessedsecondmeuursal ba-seand suong planrar/dorsalligamenu

TsrloclassifcaooD svsems basedupon radiographic aryilance are mos common1r,emploved-

A) Quenu and Kusc

- Homolateral: fracn-ue/dislocadonuith all the meuursals drqplacedrn one drrecnon @rresponds ro Tlpe A Hardcastle
classif cadon lsolated: ilvolvement of a singJemeuursal. usuallv disicrcauonof rlre flrs meuursaJ
: Dversent: fracnrre/dislocarionu'hich forces tlre first meuursal medialll and the lessermeuursals lareralh

340
r\
- B) Ilardsts:tlc

=' roul incongruin' of the entirelarsomeuursal.ioint

: uit} displacenrenlin the saprnalor trarr.sverse planes
TlgqlrgnJ =
r closedreduclion if nondisolaced
. ORIF if sa'erc
. stabiLtzalion rrith 2 I'-uires is colnnron bur depends on the snbiln. of tlre
arsrrnremnrsa]-iornl (te-oneuire mediall acrossfirs nreuursocuneiJorm iornt and one
rrrre larerallv acrossfi.flir nreuursocuboid iorntt
Trpe B: nanial urconenrin
pnial drsplacentent irn'olving panial incongrurn'of the_iointcompiexrn eirhersagnaj or trrrt.sers{
planes or both
Bl - rnedial dislcrauon
=:) drsplacenrentof tle fim nreuursal in isolaton or rn combinruon rrith drspiacementof tlre lesser
nletruvsals
El_- lateral di slocauon
:' firs meuursal uatreged
Trurtment =
r surgical stabilizsfion ofjornt conrpler
r closedreducuon dependrngupon s€\'enn

Ipcl-drsecst
dlvergent displacetrtentsi:r,olvutg ponjal or total urconprurq'of tJre-iornr
the firs ntcmursal is displaced medialll' and anv combi-nadonof the lareral four meuursals are
displaced larerallv in t}le sagrnalor u:rnsvers€pianesor bot-h
lateral pliurur ane4r'is conrprorrilsed
Cl - panial drsplacement
C2 - total displacenrent
Tre.rurrenl=
== surgical rcpu due to rnsabilin'ofjoint complex
tie-threeor more K-uires)

T1pe.P.

TypeBI

341
 7
t

//w> 7

r-{
\
t { (
'il
r)
Tlpe C
)ffi
<#Q
/ l
U I'
)
t
K'j 7

]\,]D} OO T FRA CTUIi ES ( CTINEIFORM. CTIBOID A\D NA \T CLII-AR

)
)
\
Cunciform and Cutxlid Fracrrrrcr
lsolared fracnrres of tlre cuneifornl( or cuboid are rare and u-cualh caused dir"o inrpao
b, lraurra. Fracrures to tlrese
hnnes can also occur a-sassrriated iniunes $'it} ursomeuursal fracnrres. fifi} meuursaj
base fraqures and naricular
fragures )

}.
Classific-rtionof cunciform and cuhoid fracn:rqs
I ) arulsion facnue
2) bodv fracn:re (srmple. comminured or cnrsh) )
3) franure u'ith djslocauon

v
!
TrBlmenl: these iniuries u-suallvrespond to cas immobilt:tjon srncethe bonesare srongh,bound
b' inrenarsa;
lipantrentsattd surroundilg born' $ruqrues. lf arulsion fiacnue doesnot respondlo correnati'e
tlrerapr.. surp€l
excision of fragmenr should be considered

I
342

I
,-
 NA \'I CTJI-AR FRA CTURES

Tvr I: tuberosn'fraaurc

ffio
Trrr III: fiaaure of the boch'urth or u'itlrout displacernenr

Trcatnrenl: trsltnrenl rzries according to locadon

Tire ruberosr.r'factures are usuallv s'atidactorilr'rnamged s'jdr cast urunobilizatjon. Pull of rhe ubialis posenor czul
dclar or prevcnl healing necessitau-n-e the suryical excison of t}e fra-snent Chip fraaures respondu,ell ro crsung. Bodr
lraoures. dcpndrng upon t}e depreeof rri:placemenLu'ill require closedreducuonand fiequenth, open reducrion gith
mtenral flrauon.

TALAR FRACTI.]RES

The nlus is almos u'holll arucular and has a unique blmd suppll rrhich pcdisposclsit to s€vereposl-trarururDc
comphcations including cripphng anlrirjs. delavedor nonunion and ava-scularnecrosis. Fracruresof rhe ular head are
frequentll sesn in suddendonifleson'force iniuries. however.usualh' havea good prognosx u'i$ cas immobi1;zarjon

Due to tlre large amounl of arricular surface-blood can on\' sr-pplv the nJus through three main sources: rluougb rhe
necii tluouglr the siru-s ursi. tJuough tlre ursal carul ard throug:h tJremedial side of rlre bodr'. The rluee main aneries
rt'hich supph' Oe ulus. in order of sip:nifcance.are - the poserior u-bial-antenor nbiai and perforadng pcroneal. Haukin-q
sip LsfreguentJl'used to gaugetbe riabili4'of the talus follouing fracnre/dislocarion: it appean as a s:bcbondral
radioluceno' on tlre AP r-jeu'of the ankJeapprorimatelr' 6-8 rveeksalier inju4 and occutls,n,henno at,ascularnecrosis is
present. lt has been posrulatedthat Ha'ukjns sign is causedbl drsuseoseo;rnia or rzsctilar congesrion u'hich zugeests
nrrnrenance ofblmd s-ppl1'to talar bod.r'.

343
 lr

B an'k i n s Cl :rssific.:rti on of Ta I ar Fraou rclD i slnsrr ions

@T.trA
bod-r'of the taius reuins ils normal posirionin the STJ and ankje-ioinr
Tr're II:'r'erucal fuaqure of the talar neck rvith STi sublurruon or dslocauon
Trrre III:r'enical fracure of the talar neckuith STI and ankle.iornrdislaauon
all three sourcesof blcrd supplv are drsn:ped
Trc A/: r'erucal fraoure of the ular necks"ith STJ.rnk-leand ulonr.i'icular-jorntdislocauon
I
all rlrree sourcesof blood suppl).are drsrupred
\

H aw'kinscI a-ssifi
cati on of TaJar Ne ck Fractures
I
| -:.

).

INCIDENCE
OF A\/ASCULAR INCIDENCEOF l
T)?E NECROSlS STJARTHRINS
1 200/,, rare
D >
4V/o 6fJ-'l5V'
m
U t0ui6 lOffi'o
nr l(nol, lW.'

A
Suee l: small are: of subhondral bone conroression \
StaeeIl: paniallv deuched oseochondral fragmenr
su ee In : conrplereh' deu ched- n ondisplaced os eochondralfragr'en r
Suee fV: drsplacedoschondral faprenr I

Trgetmenl
suge ) observe.urlnobilize. N\18 x
sugeIl cas immobilizanon NWB
medialsuge IIJ 8-12 s'eekscas rmmobilizauon
;
lateral sage III surgcal inten,endon
sage A; surpcal inrenenuon
A
:= small lesion- excisefragment L
drilVcurenesubchondralbone
earh'ROMexercices
cas immobiliz-adonNWB 2 weelcs.rhen
P\\ts 4 ueelc-s
:= large lesion- ORtr
::> anlroscotr - recommendedlo remo\€ loosebodres >
pneumonic= ..DlAl -A-pIN{p
>
344

h
 donifle rersion cJus€san arterolatcmjleson
slrell6q. rrajer shapedlesron
planur0e.von-inversion causesa nredialFnsenor iesron
deep. cup shapedleston

i U r
I { '.\
KEY III\i\
.ls:ec€
( ..-=;'it
y'nterolateral
Lesrons
449/o Posteronled:al
LB'-,'
Lesions
56o.,b

lrlisccllaneous Talar Fraoures: fr.toures of the uriar lread are fequenth' s€cn rn sudden dorsillexon' Iorce inlunes.
hou'ever. usulll hare a good propurosr rvidt cas irrrnrobilizadon. Areas of l-rganrenrousanaclunenl such as tlre dorsal
ular neck and medial talus are stcs of arulsron chjp fraoures. These. tcn- rcsfnnd u'eU ro consenzrjve therapr'. Thc
lateral nlar processis a colnnron fiacrure sir- referredlo as a Shcphard'shaoure and nrust be proprrlf inurobilized to
prevenl prolonged pair due to delavedor nonuniorr

Snctrtrcnclassificationof talar br>dvf nrcrures

Group l: transclrondral or conrpressionfracture of talar donre
tinc|uding oseochondrirjsdessrc:nqof nlus)

Grouo Il: corornl- sapnal or lronzonul shearurgfraqures i:n,olvi.rrgdre endre talar bodr
Trc l: coronal or saginal fraclurt
lA nondisplaced
IB: dtsplacementof trochlear aniculal surface
IC: drsplacementof ucrhlca-r aninriar surlaceu'ith associatedsrhaiar joinr dislocauon
ID. toul dislostion of ular bodr

GroupII: Tipe I

IA IB IC ID

Tra II: borizontalfrasure

345
 IIA nondrs:]aced
IIB:dtsplacei

GroupI]: Tlpe Ii
{
It
I

trA

Groun II . fiaoure of lhe rpslenor rubercle of ulu-'

Gr-oupr\i
,Fl
Group fV: fracnrre of lateral prcess of talus / r'-- i
(F.')

Group \i
Group V: cn:sh fraqure of ular bod-t'

346
 Calqanealfuacruresaccounlfor approxinutelr'609'oof all ma.iorursal in-iuriesand 1-2%"of aLldiapnosedfracnrres
Calcrneal fraoures are arguablv the mos d:sabirngof pedal fraoures The mos cotnmon ntecharusmof rnluf is a
fall from a heipfrr of as linle as nvo feet. The urlus i-sdnven throug:frthe calcaneus.cre.lnng fraoure lines of Ouec
tlpes - arulsion conrprersionand slrear. Assrrciatedfraqures of the tibial plateau femur, lup and lunrbar spine rrrus
also be consrdered

f)iagnosis.potienLsconrplainof srverepaur uporru'ciehbcarhg and uiJl usualll give a luson' of a fall fronr a height
Claracrerimc ecchrmosrsnu)'occr[ belou'the medrai and laterai ma]leob as ueU as exendtng to t]e planur aspectof
"lr4ondr's
rlre heel. referred to as sigrt".

R:rdirryraphiccrantinalion shouldinclude tre follorrrnglreus

{S4pplaJfta1:fg\1': assssnrerll of calcatteocuboid -ioint
-lareralvieu'. asscssnrenl of:rnteriorbcak tuberosin'and poserior facet
-arial .ries': denton-strareslarcml corucal bdgc and tJrcprescnceof a superomedjalfagntent
-Brcden I vreu'. a-ssessnlenl of posenor facet
- ccnrral tram is cephalad 90 fmt/leg angle sitlr fcnt and leg rnternalll' rotated 45: radiognphs taiien at l0
20. 30.40 angles
tcenral bea:n is caudalrvit}l Broden Il vieus)

Rrdiographic mc:rsrrrcmcnls:inte4preuruon deprcssionLcconrmonh derivedfrom the measurenrenlof

of subtalar-lornt
r*o anglesfonued on the lateral vieu

l) Bohlcr's Angle (CnrcialAncJe:Anqle of incidence): fornredbv a lure_ioiningthe hiphes pnint on the

posenor arucular srriace to ilre nros zuperiorpoint of ttre calcanealruberosin'a-nda h:re.ioitung tJrelilgjt point
of rle ;nsenor anicr.rlarsurfaceto tlre higlt poi-nton tlre antenor beak
Normal=2OJO
Lltun'causrng depressionof t}e srbtalar-ioirt u'ill causeilus atg:Jeto decrease.
2) Gissane'sAnsle G1lca! aldg: angieformed bctu'senthe anteriorlateral conjcal shelf and the poserior
mat€rD of tlre;rosenot {aet
Nornral=l2Gl40
Inju4'causi:lg depressronof tre srtmlar-ioint s'ilJ cruse this angle to rnctease.

Grssane'sAr,.ele

/' Pr([ 5St tR I

LAMILLA€

Botrier's.ir:tele

347
 Classificat ion of Calc.:rncalFracrurcs

ir4an.r cla-ssificarion s'slems have been suggesled_tto\\'ever.no one s-\'sem conrpleteh

rnte_g?tesmechanism u,itl,
lreSmrent. Tn,o conrnron]v used svslerl.s uill be dercribed u'hich gnoup celqrneal iraoures
rnlo e\tr:l- and intra-anicu.lar
fraoures.

RoncCiarsincauol
Tr.reLA:fracrureof ntedialrubercle
Trr IB: fraqr.reof suslenuculumu}
Trr:elC: fraaureof anrenorproces(

-\--.
f
l--
\l
\-/

\
l "'I:
c]/
it^ ]F 1C

TrrceIIA: arulsion fiacrwe of ;rosenor sufEnor calcrneel process

Troe IIB: arulsion lnrcrureoI;nsenor beak uir} in,r,olvemenlof tendo Achilles

e - BeakFracturr
----r.z-II
,\=4+
-_.'---*--z-ll B - Avr:lsionFracture
\, 't
\r-----'t-/

T'rpc III: extra-anicular fraflure throupt bodv of calcaneu-q

l+
N
Trc A/: intra-anjo.rJarfraoure rhrougfr bodv of calcaneusuit}rout joint depression

i-Z-,a
-o;, IC"
t5
348
Trrr \/: comnlltluled. inrr.l-tnrail@ffi

Essr- - Ionresti ciirssifi cati o

Tlus classi_ficauon svsern rs conulronll utilzed ro describeRou'e Iv- or V fraqures. BotJt tlle tottgue and.iotnt depresston
1.pes conrain a pnnun'and secondan'fraorrrchne. The prinun'franure lbe runs from su;rnor to infenor. exendrng
fronr the aprx of Grsstne'scrucial angle to tlre planur asprt of tle calcanealbodi'. The sccondan'lnaure irne is
detenlrled bt tlre direcrjotr of force - r'enical drreqed force createslongue n';r ard arltenor dtreoed force creates.ioint
depressionfraqures. Funirer evaluatjonof anjnrlar drsru;xronthrough CT scan rn2]'k necessan

TrE A: ToneuenTr
- talus ames tlte force into t}le
subnalar1ornt
- sharp spur of talu-s ts dnt'en
infenorlv into rhe cn-rcial
angle. sPlimng tl aJong
l}re lateral coner
- secondan' fi-acn-re hne exen& .'.eeortia:f' Ftacturt Lrnr
lo posenot border of the ,,f't*
ruberostn

Prrnrary Fracture Liru./

Trr B: Joint DspressionTrrr

- priman tsagrnal Plane) fracture
dtvides calcueu< lnlo medial and
lateral fragnrents
the medjal bagnrent includes the
susenuorlum tall and medial
ponion of pnserior facet of STJ
the larcral fra-ernent includes tlre
lareral poruon of posenor fucet and
remaining bodv of calcaneus
tlre lateral tda-r process aos like a l A/ il
u,erige causing sryrarion ard Xt_-/
l'n'n ry lractut'e Lrtr€
depressiorr of 0arcral Ponion)
pcrsenor facet rnto bodt'of calcareu-<
iateral sall fracnrre occtlJs u'itb
lareral comcaj extension or sith disal
errension ilto calcaneo<uboidjoint

349
 Irratrucnl;
= calqlteal foacure ueaullenl variesaccordrlrgto t)rc ]ocatronof rire{racnue
arrdarucdar surface ur'ol'errre'1

tuberosn' friroures usuallv thts rrp" of calancal fraaure is mrrumalh,displaced

and respondsto cas rmmobi'zaron
ft635is1rrlh'- crosedard possibh'operrreducrionis rrecessan

sustcntaculum franures: tlrese frasures hroh,e ponlon-sof fle anrenor

and,/ormjddle facets lf nondisplaced_as
trluttobilizatiolt attd rtolt-*'eiglttbcarulg sulus is regu:red- Displaced
fracru-resrequue closed or ope' reducuorr
rechruques.

anterior prcress fizctures: dresefractures are usuailr'causedb| an

i-nvenronrnehanjsrn about tlre ankle.
'---' This
- '€ "'ru''
iniun
res;roltdsqell to cas tttutrobihzauon.If cluonic par:r result5.tlre
1,-agrrrent
nu., be excised

rnslcrior tqrk f;actures:should the Achilles lendon irusenjonrun *rrou;*r

or ahnvetle fracrure1ne. planurflexon.
Ff,i\\;erndll be cottrpronrised Open reducuonrvjdr cancellou-<
lag screq or rerxjon u"rral*rl"" ;o11o..f,};
l
c:.srng Lsindrcared \

err:z-anicular tndT fracures: usuall'r'linle or no joint depression'rr.ill 7

occw and &e in-ru4,u,ill respond *.il.l to non-
s,eighrbearurg cas ir:rnrobi.hzation
I
tnrra-arucula'r tnd'fraoures: ahrars in'slr,p-16r;tttdepressionlo some
ciegree. Se'erai me$ods oJ reducrionhe'e been
sugeesed in the lirerarure-
)
I immobilizarjon u,jr} earh,u,eighrbranng
? skeleuJ bacdon or BohJerclamp redualon
:. pnnur\' zuhalar joinr or triple anluodesis
I o;-rn reducrron $ilh internal fi-ratjon via the rnedial approachas
descnbedb' McRe\noldq

6. exenral f,radon (ig-Ilir^rov teclurique)

l
\

?
\

F
\
350

t
 Svndes
-can rangefrom mrnorstratns1o complelerupture raslasts thesvndesmottc
liganrents

Araromt'
- a n r e n o ri n f e r i o rt i b i o f i b u l a lri s a m e n t( A I T F )
- po$ erior inferior tibiofibuIar li g amentCPITF)
-posleriorinferiorlransverseIigament
-int erosseous ligamenl
-interosseous membrane

of injury
Ir4echanism
-forcedexernalrolalionof the foot u'ith simul'taneous
internalroralionof the lep
-hl,perdorsiflexion
u'ithforcefulexernalrotation

C l a s s i fci a ti o n o f S v n d e s m o t iDc i a s t a s i s
-latentdjastasis.anklesthat appearnorrnalon routineradio,eraphs but experienceankle
montseu'ideningu,ith stressex-rernal rotalionradiographs
- f r a n kd i a s t a s i s s: y n d e s m o l isce p a r a t i ovni s i b l eo n p l a i nr a d i o g r a p h s
* d c l t o i dl i g a n r c n tn r o s ll i k c l v c o r t c o r t t i r r a n lrl ul ' p t u r e du ' i t h a n k . l ed i a s t a s i s

Svmptoms
-marked,generalizededema
-pain our of proponionfor isolatediateralankle sprain
-ecchvmosis
-tenderness over the AITF/PITF thal nrav exend proximallvover lhe interosseous
membrane
- l i m i r e da n k l eR O M
-inabilitvro performloe raise
- 1 o et o h e e la m b u l a t i o n

SpecialTests
-anteriordrawer/talar tilt to r/o ATF/CFL involvemenr
- p a l p a r i o no f t h e s v n d e s m o t ilci g a m e n t s
-passivedorsiflexionof the foot (this wedgesthe wider anteriortalus in the anklemonise
causinaseparationof the tibia and fibula)
-exernal rolalion of the foot on a neulralankle u,ith the kneeheld at 90 degrees
-"squeezeresl" (manualcompressionof the tibia and fibula abovethe level of the calf.l
* l h e s el e s l a r e c o n s i d e r e dp o s i l i v ei f t h e y r c s u l l i n p a i n u ' i t h i n t h e s v n d e s m o s i s '

Adjunctivelmaging
-plain radio-eraphs
(needlo r/o fracture)
-slressexrernalrotalionradioeraphs(look for anklemoniservideningy'increase
in medial
clearspace)
-arthrographv
-MRl

351
a

-J
realment.
C o n s e n ' a l i v e :t h e s ep a l i e n t sl a k e a l o n p e rt i m e t o r e h a b i l i r a rteh e n m e d i a l / l a r e r aaln k l e
sprains
-immobilization w i t h s r a d u a pl r o g r e s s i orno p r o r e c r ew d eiphtbearinp
phvsicaltherapvto includeRo)4 propnoreceprive rraining-srrensrhenina

"'d"']:";;-
*,.'.ffi:,,:-:*":J::::J-;::r:,..
-transsvdesmolic
screrr/fixation

P o s s i b l eS e q u e l a e
-continuedpainlinstabil itr'
-heterotopicalcification ( u s u a l l vc a u s e sn o l o n g r e r mf u n c r i o n adl i s a b i l i r y t

352
AAKLE FRACTTIRES

The nrechanjsm br' rlhich an anlle fragure occurs mu.slbe fullt' undemood rn order to te$ore analomic airEmmentof the
iornt. Ralnsev found tiut exTrrimentrll'r' I nrm lateral t:lar drsplacementuidun dte ankJe moruse decreas€dubiolalat
conucl bv a-sluuclr a-<12oA )'ablon fourrdtlut dirisrort of tlre lateralIga:ttenLsandior lateral lrrrlleolusIeadsto €reater
ankie ln.qabihn' than secdomng of mediai srruclures He. tJrerefore.conclrrdedtiut anatomic reductron of the lareral
malleolus is the kq' lo rcsoratron of ankle sabi}n' in bimdleolar fracrures. The u'ork of Oresernvesig:tors as uell as tlrar
of tlre AO fonn the basrs of otu curetll rutdersartdutg of a:*Je {racrures

Eponl'ms d*nbrng ankle fiaoures

Pon's (Du nnrren's) fra oure : binull eolar fracrure
Collon's fracl ure: mmal leolar fiacrute
Bosu'ofl]r's fracture: lateral malleolar fraoure s'it} ankle drsplacement
lr4aisonrtetn'efra crure. proxttral f bul ar fuacturc
VolLrnann's fracture: posenor maUeolar(dbia) fraaure
Tillau; fnoure (tubercleof Chaput): arulsronfraoure of t}e arterior lateralobia
\\'agqafle fianure: avulsion fraaure of ilte atrtenor nrcdial fibula

Cla.ssificationof Anklc Fracturcs

Laulrt-F arrsr:nClassificatirln
Tlus cla-ssifisrrlonsvscm de-.€rtbes95/o of ail ankle frasures and allou's one to predro the depreeand ssvenn'of
llganrenrous injun' based upon tlre qpe of osseou-q iniul'. Each t.rpeof fi'aaure is describedb.r-nvo terms. The fi.rs
the
descrihres fnsitron of the lcnt at the dme of irlun' and t}e seconddescribesthe direcuon tlre talus uas driven bv the
inlunng force

Surrination-Adduoron
Suge I: trarlsversearukion fracnrre of the lrterai melleolus or lateral Lrgamentrupture
Suge I): r,emcal fracnrre of tlre medial nralleolu

Pronadon-AMuaion
Sragel: tr?rlsvers€arrrlsion fracn-ueof nredial nralleolusor deltoid li€anrent ruprur€
Suge Il: rup{we of AITF and/or PITF ligamenu
Suge Itr: short. obbque fracnrre of the lateral rnalleolu<

Surlinarion-Eversion
Suge I- ruFure of AITF litrament
Suge Il: giral fracrure of the fibular nulleolus
SrageITI: rupture of PITF ligament or Volkrnann's fracmrr
Suge A/: ruFure of deltoid ligament or arulsion fracrure of medial mrllsolu,s

honation-Eversion
Suge l: ruprure of dehoid Igament or arulsion franure of dbial malleolus
Suge Il: rup{ure of the AITF liganent or arr:lsion fracnue (Tillaux or Wagsufle)
Snge III: high fibular fncnue (Maisonneuve)
Suge r\/: ruprure of r]re PITF ligament or Vol]'znann's fraqure

honadon-Dorsiflerion
Suge l: r'enicai fraoure of o'bial malleolu-'
Suge I: fracn:re of tre anrcnor u'bial bp
SrageIII: srpramalleolar fihrJar fracnrre
Suge r\/: trarsvers€fi-acmreof posterior o-bia ln'el u'ith
prorimal aspectof tbe anterior ubial t'acnue

353
#$ #d$\
( --.rl' (',- ,!
Stager
(1.--,,''
('..-.-,;''
StaseII

Suprnaton-Eversr
or,

Pronanon-Abciucdorr

i ilt,., 1
1 5 .| t / t \
,Wffi)
) t)(
(, t__)
\#
@
354
 I
I

i , -Pronebori-.bversrorr
r
/ \\
A+\
(-.t'.- A,)
\:L-t
) \
Aiaee I,l
\_;'
I

( ' )
\--'

I
r---'
@
Sragtll SrageIIi SrageI\r
I
l t

Pronauon-Dorsile>ion

Stagei
Stage
III StageI\i

Danivn'ebcrclassificarion
a surgicalclassifcaoouba-sed
This s'stem repres€nts upon the la'el of the fitular fraaure and its relatiorship to tlre
sndesmoss

Ttpg:! fihrlar fi-acnrebeelts at or belou'Orcsndesmosis

conespondsto supiruoon-addt cdon classifcadon
Trr B: fibtrlarfracrurebeFnsat 0res-\'nd€smctsts
mrrespondsto supination<r'ersion andpronation-abdtmion
in-iunx
Tra C: fihrlar fracrurebegutsabovetlte s'ndestttosis
corresponds lo pronanon€\'ersion ir-iun

355
Tn:atnrcnl of Anklc Fracturcs

The A{ group sti&pest.(tiut exaq anatomic recon-qructjonof t}re ankie mon:se is necessan'for pcrfea guidance of the
talus. Eleganl retrosp€uve sudjes ;rrlormed b-r'Bauerindrcatesuprnadon-evenronsr.ageI fracn:resuith lessthan 2
nrnr ciispiacenlenlare stableand do not lead lo posl-tnurnaucarthrosrsu'iren reated consenzuvelr-rather*nn surgicalh
reduced

Ankle ioint inteerin'derrnds umn:

I ) Coneailg lengtir of tJrefhrla in rs posiuon u'ithi:t the fibuiar trorclr
2) integriq'of t-heobiofibular li1:anrenL.

The surgical clrrecdon of ankJefraoures requltes $e use of AO screrls. plares and/or rension band principles. Djsra;
fibular fractures rtul be repairedu'itlr lateral buuess platesor posenor ald-gdide plate recluuque. Weber C fraqures of
the fibula require fixadon of the fibula ro the tibia. rrhich
facilrutes rersu of the interosseousmembrane.

T]R]AL PLAFO]\D FRACTURES (PILON FRACTI]RES)

A pi)on fraoure is tiie resrlt of direg unpaq of dre ular uochlea agrnst the djsul ttbial anjmlar surface. The sofi
canccllous mcuphvsis of the duqal ubia is compaoed craedng a large void'rrlren lenprrhis resored

.AllgrrrrerClassification - besedupon tJreaJ'noru'lt of conurrinuuou

Jrrr l. fissure fraoure uitlrout siprrificant drsplacemenr
Trrr II: fissure fracrure n'ith signifcant arocular rncongruin
Trrr III: contpressionf-ractureu'itlr sipnilicant displacenrentof the u,eitrhrbearingca:rcellousseErienu of tlre
meuphrsis
1
.- r lt

t ' /v\
l. l.
r?:- * ,
rii'--
-
E
a:i

3s6
Trcalmcnl of Pilon Fracturcs

nrethod for a@uarc $upcai reducuon-

-Step ): recoL$rucnon of the fibula
-Srep 2: recorsu-ucrjon of the obial animiar surface
-Srep 3: knne graft the meuphrseal &fiot
-Srp 4: bunress plate the obra

I'H)'SEAI FRACTURES

Phvscal fractures are iniunes lnvolring tle phvsis or cpiphvscalgrour} platc These iniuries are often incorrecdr. referred
1sa-<epiphy'sealfracrures.u'hich descntrefracruresof the epiphvsis of t}le Lnne

Anatomr. and Phlsiologr

Each lon-eLnne nrav be dit'ided into epiphvss.nrenphvsrsand diaphvsis The epiphvsealcomplexrefen ro epiphr5i5sn6
the phrsis

The phvsis is t}e radioluccnt caniJapnous plate rrith a charaoeri.sucarmngenrenlof cells that progressfrom res:ag
clrondrocrresto ossifiedborre

Tirree zones of tlre nhvsis

I Grou'ilr zone
=' mos imponant zone of t}e phvsis
= reladvelv suoDg area a{iacent ro rhe epiphvss
=' cotlslsts of predonuuuttJr rntercellularnratrir u'irh germinal cells or diridug chorrdroo'res
: Zone of Canilage Cell Deeenerauon(zoneof nraturaDon)
: b1'penrophvof chondrocrresfollou'ed bv calcificauon and degenerarion
:3 tveakes alea of tJrephrusis becar.r-se
of tlre loss of intercelJuJarnutrix and rntracrllular subsnnce
I Zone of hrman'Bone Formadon (zone of rran-dormanon)
:= rz-scr-rlaringrourh occun follou'ed b-r'ossifcation and remodehng
:= ad.iacentto the meuphvsi:

Z,oneof Ranrier:
- cotuist-sof fibrou-stissue and oss€orxring of l-acroi:x {osseousR.rngof lacroix rs an exeruion of tlre
meuphrseal conex)
: prot'ides sruaural suppon ro the ph.r,sisand appositional prouth

Bloodlumb
Epiphvsis: epiphl'sealanenes form a rz-scularplexrx and exend ro suppll' the germirnJ cel.lsof the phvsrs
Meuohvsis: nteuphrseal anerjes via tlre nurienl aneries of tJrediaphrsis
Perjchondrium: perichondral ves-sels
Phrsis: supplied bv epiphvseal metaphrseal and pericbondral vessels

The result of inremrpron of tlre blcrxi suppli'to the ph1'sisrvil djfer accordrnglo lhe vesseldama-ped
<piphrseal vessel damage leads lo penrurnenl gronth disurbsnce
-nteuphuseal vesseldrsrugron resuJrcin gansient slon.ing of gronth
-perichondral vesseldamagehas no adverr efleos on longirudinal gronrh

3s7
 Diffcrcnccs lrcnvtu Child and Adult Iniuricr

=) The phvsis is the rYmkes area.rclative to bonesand lrganrcntsrn chilciren This resrlts rn fraoure
panernsthar difler
{rom thos rn adults
Lilurrrents are relauvelvsuolrser tJlanbortesrn children TJrerefore.liganrentousrn_iuries in cSildre' are rxrco'nlon
Cenair phvseal rn-iunesrrill ause prout} drsturtrrnce if ilre genrrina.lcells of the prouth zone ardrol
the epiphrseal
blood supplv are Crmaged

Rqarding anklc joint in.iuries-

I -bcfort 8 r'can of age tlle phvsis representsa relarjvelv rveal
$ruclure tlut is less resrsumlto telxi.le forces.
cornpared lo bolle and Irganrent
- *pat?ltron of the phrsis IS nlorc likel-t' srnce t}e liganrentsuith hjplr rerrsilesrrengrh rnsen
bclou, tle ph-rsrs
of tlre ankie-iornt
- bganrenlousor osseousin_iunesare rarer'seen in this agegroup
2' -at l(f lcan ol age the unton belu'eenthe epiphvsisand nremph'r'sis strengtlrens Separauol of tle ph'sis usualJr
rnvoh'es a fi:rqun
3. -:tfier l5 rqtrs ol agc tJrefracturerrellern resenrblestlroseoccurrureir adulL.

Classificationslst:ms

Epiohrseal Fracrures
(traaure of t}e epipln'sr-<uithoul invoh'enrenl of the phlsis)
l. Ar-ulsional li€anrentaruclurenl
2. Compression fraoure of epiphrsrs
3. Oseochondral fraanyr

Phrseal lniuries
The lt'o rrlx of phvscal rnluries are sefnrauon and fizcrur

Separaton ofphrsrs
- lr4os frequend\' occurs along t}le nteuphrseal tnrder of the ph.rsisin the region of $e
zone of priman. bone
fonlarion ard tlre degeneratingcarrilage cells
:= occurs al r]rer*eales area of $e phrsis and rs a resrjt of shear force:
-- There is no dmage ro the epiphl'sis- irs blood suppl'r'or lo tle grourh
zone of the phvsrs ard- thus.
progrrosisrs good
Fraqure ofphvsis
::> lnvo)r'es a fraaure at Oreanjcular epiph'rseal surfaceOul conDrues through
rhe physis
:= Injun'resJts fronr axial conrpressionand bend.hg forces
:> Danuge occutr lo rhe epiphYsis-tlre grort'th zone of phYsrsa:rd possiblv
rjre eipphr,sealblood zup\.. Thrs.
prcgDoslsls $'ors€

C<lmpliuti onsof Ph-r's:cai lnju ries

Commonconrplicaoonsj nclu&
l. Angujardeformin dueto premarurepanial phrsealclosure
2. Limblengrb drscrcrn-oo'due ro premarurecomplerepbi'sealclosure
3. Joint in congruiq' uitl secondan'post-rraurnatic oseoarthritis

The mos coruron rcasonfor groslb disrurbance is bon1,bridging

Tlils calhx bridge formauonbenleenilre epiph'r'sisand rtreupln,sisis tlre $rol€res sr1rngiqs
lo prerlur.,.eclosureof a
grourh plare

358
'Iroe
A: pcxd nrognosis &a
CJ
: NO rn-ru-r'togrorrth z-oneof phrsr
- NO rnju4'to epiphvsealvessels
=. good proprrosrsu'ith adequate
reducuon

Twe B: doubdtl progrrosts

- Inyur.r'togroulh zone
=. Potential in-iun'to epiphr'-sedvessels
:= Us.rah'serious sequellaeil trc.rted
inmrrect]t'
ffi
cat ion of n h vscal i n iu rier
Salt cr-h arris cla.^sifi
T11x l:
=, separarionof phrsrs uithout danrageto the germinal cells or epiphrseal
blood supplr
- resulu from a shsrnng force
:= dragrrosisQl clinical suspicronof ]ocalued edemaand pninr renderness
along dre phvsu

Treamrenl usualll possibleto ohain adeguateresuJuuith closed reducuon

Tlpc tr:
=, panial s€parauonof pln'srsu'iilr a nreuphvscal fraplnent
, Thurston-Holland sgn=nreuphvsed fragment prcduced b.r'a lareral drsplacenrentforcr

Treamrenl usualh'closed redunion u'ill give adeguarealigrrmenr

, rf drsplacenrenlrs unacceptable.ORtr m4r,be needed
ie-4.0 qancellou-(screrl Frallel to the pblsis; paralJelsmall smcnt} k-qrres approrimarelr' 9tr ro ph.rss
short leg cast ).i\\ts -1-6u'eela

HA
l r \
]l Al l
i \J-

359
 Tlpc III:
= fraqure of epiphvsis tyitir panial pln'seal sepafilrlor)rnua-anicuiar fracrure

Trcarrrrcnt:I or 2 screls (4.0 or 3.5 mm) panllel to phrsrs

slron leg cast hIWB.1-6 u,eela

fn]-nL]X fneCnnf tu-ans:gaml fraelulef

= represens
a Salrcr-Harris
III of tle drsaltrbia
most commonh'ocrus at a€tei3-11
phrsiologic closure of the disul ribra ph'rsis be-er-n-s
ar its mj@inr and progrersesmediallr.. tlre 1areral
lnlf of the pl^sis closesappro\-'tulel.r.I8 rnondx larerar age l.l-l g
e'vernaj routon'force nra\' aruse AIIF Igament to arulse t}e anteroiareralguadrant
of tjbia trith rhe
o;rn larerajphvss goal is an'rromicreductjonro resore_ioinrcon-sruencl
preltEnue closureof pirlsis is trol a concenl becauseilrere is li:rutedglonth potendal
on.ll caseu,hen a scre\l,nur\.bc placed across an opcn phvsir
follon'ORIF n'itb shon leg as N\lts 4{ s,ee}s

l
\\ t i { l
I
, €/ \
./ \ / \// 'i

T11rc A7:
:= fracnrre of epiph'sis. panial plr*seal s€parauonand facture of rneuph.r,sis

Tre:unenl: conrmonlv unsrableand uill requrre oRIF to ohain arceF-ablereducuon smoothjoint

surfaceand
adeguatereducrion lo prevenl born'bridging and prouth dimubance
shon leg cas NWB 4{ rvee}<s

N
@: combinatjonof Salrer-ltarrisII and Salrer-Flarris
III
=r fracrurelinesrun in threeplanesa:rd requiremuldplex-ral rieus to clarifi'fracnrrepanern
:- cr scan''ill helperaiuareesenr of in-1u4'and fragmentaipanems(2 or 3;
Treamrenr:sameasfor Sa]ter-llarrisr\/ i-uiun

360
 1'.r1rc\;:
- cnrshin-iun'oftlre phvsrs
nu]'be midiapnosed as a Salter-Harris l
proeylosrsjs rvorse bccau-* bonl briQ:rrg nuv leed to
panial or cornpleteprenulrue pln'seal closurea:rd
grorvt} drmubance

T1';rcW: RangModrficahorr
i \
- a'rulsion of penchondral nng a/ \

tmodification b\ Rang) /{\ ",

Vfr'-.j,
( , t
Trlr \/ll:
=3 an:ision fraoure of epipln'sisuithout invoh.enrenlof --/
phrsis
( nrodif cation \' Ogdcn)

Grrideto tre:rtmcnt of nhlsc.rl iniuricr

l. Bilareral filnu for oonrparircn ro help recog:nzephl'seal separauon
2. Mulriple riens in different planesto avoid missin-edifflcuJrfraqure linesu'hich ma.\'beobncuredbr or.erlappinghnnes
3. X-rat't}e.ioint abore and tbe loint trlotv if clinir-ellvindrcaredlo m]e ouraddjuonalfraqures.
4 OLnainpos-redrcLioD x:rzrvSlo assessanatonricposirronafier reductjonand to clarifr.fraoure panerns
Otlain CT scan-clo a-ss€ss anicular congrueno'and tlre exenr of injun-.
5. Trearrnent is derermined tn':
-qpe of iniu4'
degtee of damagero phrsrs. epiphvsrsand is blood supplr.
-skeleul age of pauenr
-potential prourh of bone remaimng
dcgree of inra-anjcular damage
quabn' of closedreducuon
6 The ket ro successfirJ ueamlenl of phvseal i:riuries is dependenron REMoDELING
Iing"'
Remode
*"th remaimng
;;TJ:HikT;::
, deformrn'int}e planeofjoinr modon
Remodelings'ilJ nothelp

, r;,#;j3;:Hxf;l#Tgtr'll
'
;i:5i*ilffi11;"J:r""
drsplacedfracarurecrossingpblsis al righl angJe
7. Genemlll'all phrxealiniuriesshouldbc follosvedfor 6 mont}s ro J I'earfor porenrialcompbcadorsof gour;
dr-snubance.
8. Effectsof conrpressionon dreph1'sis
-lrcrs[e in pressure aionganaxisparaUello diJecdonof grour]rmn'inhr'bitor;ur6l longirudirnJgrouth
-scre\\sor threadedpi-rsplacedacrosslhe phlsis sill causecornpression ard leadro prernanueph.rseal
closure

36i
 of pou{r drsnrba:rct

Summa:r of Ciassificauon
ofPhvsealInrurre-.

Sajter & Hams

196:.
(:)
ti
4
/,1,
r l
/,' \
Lrtker, I
I 9J6 r:--=41

L-^-'' 5e
I
j 1 t
f l
\
/Ar1
.l|L'

(4r
L,)U

Il.ang
19 6 9
A
PolanC
r B9t:
# u#nA
OPEI\ FRACTTIRES

Gusillo cl a-rsificarion
Tlpe l: u'ound lessrhan I cm long
ljttie sofl trrsue damage: no sip of cnshing m.lun
srmple- Dans\/erscor shon obbgue fi-acnrreu'jr} little commi:lutjon
Tlpe II: rvound grearcr than I cm long
no eslensit'e sofl ussue damage: slig-hror moderarccmshing injun.
modcraclv comminured fraaure: moderarc contanrirurion
Tlpe III: exensive sofi tjs,suedemage: high degreeof conunrinarion severeh'comminuredfraqure
assocrated uitb higlr velocil'Eaurn l
npc IIIA - sofi tissuecoverageof boneis adequare (dcspireflaps.laceradons. sofl rissuedesrrucoon)
se\/erei)'comminuredfranure from high energi'traturul
r}?e rnR - e$ensi'r'ein-iu4'to or lossof soff tissuerequiring local or fiee flap for csverageafier a@uare debrjdemenr
assmtatedsith penosealso'ippingand erqrosure of bone.masdreuound conraminadon and fracn-ue
commi-nution I
Dpe mC - aJn'openfncrure a-rscriaed*irh a:r anerialinju4'r-harmw be repatred
I

O;rcn btcorrs Kw)cblr{ $ith anrria! injur;e* Oat nrust tr rrpind lrrr e an spurcion rat-eof 2390o/o.
I

I
362
t
l

I
 Absolute i ndi catjons for pnman. anlpuultror.l
>l)pe lllC ilrun'accorrrprrued
br drsru@
tTlpe IIIC iryun'r*ith lossof soft tissue.ntassivecontanrjnarionse'ereh,commrnured
seglnentalfi-acrureor
nlassl\t loss of bone t)ut u'ilJ likelv resrlr ur significant inpairnrenr of funcuon
Relauveirrdrcattonfor anpuuuorr
>Tlpe iDC Lyun'riur is unrrearedfor g hours or more

Antibioric tlempr
Trpe I: singJedoseof 2.0 grn cephalosporilon adnrjssionand 1.0
€31eyen,6-Eho'rs for.tE-72 houn
Tlp Il & III: singledoseof 2.0 gm cephalosponnand an anrinogJ'r'coside (i.5 mgA-s bodl rveiglrr)on adrnission
conunue lhis reEntcn of cephalosporinand anurogJvcoside(3-5 nrgng Uoa' utjfor q-S-Z:
irn
add 10 nri.llionuriu penicillin if fann irliun
Accordrng lo lhe liler.rlure.infeoions are largelYdue to gram nes,qrir,ebacreria. preyious
snrdreshad implicared g:znr
;nsiove org:anisrrx

TrealmentProtocol
I . lnitjal e\alu.ltion in Ernergeno'DeFrrurrenr
-hisor-r'& plrvsical.u'outtd uxpccuon and cultures.
leunus prophvlaxs. lenlpora^,sabi;zauon
2. Debridcnrenru'ith copious irrigarron rn OR
a) rcpcat debridcnrentin 48-22 hours
b) debriderrrentrlutv lreed to be repeate'drvith rvpes IIIB or C ro achjevecleal- suble u,ound
3. Stabiltzarionof fraourc
4. Antibioric Therap'
5. Coverageand closure of u,ou:td
delaved pnnun,closure 5-7 da1,salier iryul,rrirh q,pcsI & lJ

ryPE RATE OF INFECNON RATE OF AMPI]TAT]ON

l 0-2otrt
II 2-79;
IIIA 7o/o U/,'
IIIB I0-50ozi, l6y"
MC 25-5V/" 4201,

363
 7

vascttla

Definirion
tnleruplrons or a single
Deat} of bone nuuro\\'and rrabecularelenrentssecondan'torepreated
rntermptionof the bloocisuppll to the bonc
nrassJ\,e
F
Etiolog5
,
Araumauc:
- aicoholisnr - hvperlipidemra \
- h1'perconicalrsm - hemoglobinopathies
- obesin - hlperuncem:a
- infection - oancreatius ;
- preelanc\'
Traumatic
- fractures/dislocalrons
- iauogenic I
S i g n sE S 1 ' m p t o m r )
a hoplessn'e \
a Acute loint paur
!,
Occasional spasm r
a Aggravated bn' u'eightLraring: relieved b1' rest
)
a Limiuuon of nrotron
a Conrrnuousjolnt pain
a Joint desrruction
)
Radir-rgraphic
o Not for arll'diagrrosis
o Focal subchondral denuneralizauon
o Radiolucensv surroundedb1' radiodensrq
o Subchondral collapse/suessfracture
o Total-ioinldesrucllon
?
\
Trcatmcnl
o Earl.r' Suges
GOAL :- prevenl subchondralcoliap'se )
Total N\ts
Elecrrcal bone stimuladon
NSAID's )
r Lale Srages
@AL - aUevtatepatn
Consen'auve -- pateliar tendon rveightbeari-ng brace- NSAID's b
Surgrcal -- art}trodesrsprocedures. bone grafrug procedures

7
!

i
I'
?
\
364
>
CO]\IPARThl]'N T S'I'NDR O ]\If

1*' 800/oof qlses occur in the lolver exuemln

Etiologies
a) fizcnrres
b) cnxh rn_iunes
c) muscuJoskeleuJsurge4
d) hematoma
e) anerial emtrob trare)
0 infecuon

Pathogcncsis
a) incrca-sedttssuepressure:incrcasern net force per unit ar€zron tlre'r'esselrrails
b) increased vetlolts pressure
c) decreasedanenoveltousgradrent
d) decrcasedlocal blood florr and o\'8enaDon

Diagnosis
a) the six Ps
l. nu: the nrcv tntpona,Tls5z. The Fun rs usuall out of proporuon lo u'hat one s'ould eryect for thc
c l i n i c a l s r r u a d o nT.h i s r s o f t e n o n e o f t J r e f i r s t s i p r u s i n c e n e n ' e s a r e l h e n r o s t s e n s i t j v e u s s u e l o
ischenua. The parn is exacerbatedb1 purung ilre nrusles in tJreconrfrarurenl al passivesretch
2. paresdresras: follou'ed bl hlgreslresra and anesOresia: t}ese are reliableindrcaton
3. paralvss: a late findrng
1. pressure:tcrlsenessof t}e comfxnment envelopc.
kconri nost ,ntportoil.trlz: can be nrqrsuredria a t'ick catheter. An intracomfrrnnrental
pressureof lreater fian 3() mmHg is consideredto be dragnosncof conrpannrenl srrdrome.
irol'ever- some beljeve Otat rrreversibledamagedoesnl occur until 45 mmHg
-i pink: rouunelr' luve good capillan' relill. e.rcep ln casesof major anerial drseasc.
6. pulses: routinelt pres€nl exccpt in ca-sesof pre<xisung malor anerial drsease.

b) rimrng of sgrs, s\fnp{olrrs and ussuedamage:Orediseaseprogressesrapidll'. t}us paucnts should bc

monitored ever-r'30 minutes
. 30 minurespare$hestas
. 2-4houn fimcuonal nruscle changes
. 3 houn pos-ischemlc su'elliag
. 4-12 houn rrrsversible muscle detenoradonbeg:n
. o\rer 12 hours conuacrure formadon
. 24 hour onset of mvogJobinuna

Trcatrnenl
a) remove all cass and dressrng<
b) keep limb al hcan lo'el: do not ele'rzte. Ele'rztjon crealesmore ischemraand interferess'ith venous
drairuge
c) h1'dration(prevens deleterious efleos of m1'opobinuria)
d) surgcai decompressionvia fasciotomr': iadjridual companmen6 can be decompressedil not all
comp3nmenrsare in,oh'ed Often all four comF:nmenr and decompressed The u'ound is not closed
but pcked open
l. singje inosion: through an incision at the peroneal companmenl all four companmenE can be
decompressed
n. dS&]_qrncistop: througDan anterolarcralincision t-heanteriorand lateral conrpanmentscan be
deconrpressedThrough a poneromedial incision both deepcompannlenr can be decompressed

365
 IIl. Four comFxtrtmenL(
-=-r-f
anrefiitr:A@
commonlv tnvolved in contDanntenlsrnd-rome
b) latcral
c) de.cpposcrior: along rritlr the anlenor conr;rrnnlenl are the nvo con4llruncnts mosl
contmonlv rnvolved rn compannlenlsrndrome
d) supcrficial ;toscrior

Scquela
a) Vollsrunn's conradure of mrucle
- ntuscleischenua nrusclenecrosis mu-scleconrafiure
b) renal failure: secondan' to nt1'ogJobinuria

Orrr:ochondritider

Dcfinition:
A group of related djsorders.s'hich are tlrougdrtto tr due to a drsturbanceto the ossification cenler
of the bone. lt nu1' affect both the prinrar-r'a:rd secondal' ossification cenlers dLrringthe unre of
developnrenuJactit"itr.

Clinical Findings
pam
srrelling
s\mploms increaseu'ith acnun

Radiographtt tt ot"i,l".n..,
I
fraSmenulton
collapse of anicular surface

N :rnrcs of Specific Ostttchondrit idcs:

Theiman - Phalanges
Freiberg - Metaursal heads
lslen - -str'meuursal base
Buschke - Cuneilorms
Kohler - Naricular
Lance - Cuboid
Sever - Calcaneus
Osgood-Schjaner - Tibial ruberosin'
Blount - Tibial epiphl'sis lproximal)
KoNer - Patella

366
GUNSBOT\\'OUNDS
Krnetic Enercl G(E) -rt-c-
r,E
Thcor.r'of \\'ounding Capacitl ,.,,,=,'.,rs, .
I
t-r,eloctn

-r,elocilv is more tmponant than trrass

rnergi'inpaned on rntpocl determtnesexent of in-1u4'

lireh velocin'= >2000 fusec

-- -requiresemerptenlradical u'ound debridemenl
:= -miliun' banleAruntrngaccidents
- -caviurion eflect
r cn€rg},of bullet exceedsexpansile capacll: of tissue
r a vacuum ts createdpulhng debns into $e rvound
Los velocin'= <2000 fusec tmalonn'of pedal gunshotu'ouncis)
= -consisrsof bullersseigtung 100-300grans
=. -enul'rnn sontelintesnol enoupfrenergl for ext
= -occur al shon ranges
- -no caritarron.exTxnsible€pacln'of tjssueexceedsenergl of bullet

N ta n a g c n r e n t
-AB.C'Vsubilze yxrtent
detailed foot and ankle esam
-r'ascularsutus
-neurological satus
-muscleleslrn!
-entn'/er.ll u'ou nds. lacerati on slon slou gf,
-ROM- paur. crepllus. deformrn
-presenceof foreign bodies
-radrographrc stud-res
-t'?"'!r11il:l:ft."Jff:i"Hil[.'*ril""i
irnoprerious
o,- orroxoid
inrmunizatron

Fracturc
-anl fractwe assocrateduith erternal enrironment is consideredopen
-buller not hear serihzed / u,ound consideredcontaminated/ potendalJv infeqed
-adhereto pnnciples oulhned b-r'Gustillo for open fracrures
-if > 8 fu consideredrnleaed
-mo$ L\/ are qpe )
-antibiorrc recomrnended{cephalosporin)for 3 davs or until inJect. subsides
-open reduction
-fracrureslhar requrreintraanicu.larreconsuuctjor/riS:idfixation to stabilize

Surycn'
debridement
-8vossconunr:ratiorvnecrosts
-inu'aaniculav
-neurovascujar destucDon
{ompsffneDt qldrome
-prophvl acti c ann-bioti cs
-nol essentizlfor $'ounds not grossll'conraminated
determined b-r'cbnical appear-anc€of eacb irdividual t'ound
-mofl L\/ irjunes nol causedn'itahzed dssueat dinance from u'ou-ndract

367
 -e\'rremedebridement mal nol bc necessan
-cle2nsmgoi rvound
-3 L salrne or l0 on povidtne iocirne
-exctseexposed muscle and fascla
-avoid probrng of missile racr i
-forerpn bodles renro'ed onl' iJ excessi'e dissection
not re4urred
t
-buJler nol excrsedunlesssuperficialand palpable
-conrplrcatedexplorari on a'oided unlessr"iul su-ucrure 7
tluearened
-closure
-de;-rnds on degree of surg:rcal inren,endon
I
-small rvounds lefi open allos' to pranuJate
-su-rgicaldebridemenr Gustiilo 1&lr <ghr
can close primarir'
-anl quesllon leat'e o;rn unriJ no sign of infecdon (3_7
davil

SOFT TISSUE TRA ul\lA (Gcncrat)

t
Gcrreraj guidclincsfor e'alrrarion of lon,cr crtrcmin. soll tissuelr.ruma-
l. hinr:rn,sun,e.r': assessainval.- brearhingand crrcularjon
2. Secondan'sun'er': checkfor ljfe threaterungin-iuriesand assocjared iniunes (ie-spinalfiasrures.erc)
r
3. Orair a hrson
PM}L Meds: Allcrgres:PSH: F:rnilr'lusory: Social ]lson
Female - las mensruai penod
t
teumus sutllr.(
time food/drink las rngesed (rn c:rseof enrergencv surgen,)
mechanism of in-iur.r'andunre oI occurrence
esrimaredblood loss
l
injrial pj3nt.,.nt
4. Phvsical Eraminadon
rirals: remperarure.puJse.respiratjon blood pressure
I
rascuiar: pulses: capillary'fillng trme: slen temp: edema
if prl-scsnonpaipoble - Doppler. anenoglzlm
neurolog:c.senson':motor: deep tendon rellexes
musculoskeletai.
t
e.rzluatefor nruscle or lendon damaee
ROM: palpation
muscle srenglr resting
t
x-rars if fraoure or foreign bodl sspeoed
u'ound elaluauon: dtntensioru (u,jd.h- deph- lengh)
sigru of infecuon (ie-edenul enlhema cajor. p:s. etc)
ryoundclassi_ficauon:
t
clean = Iess dran 6 hours pos rraurul
conramjruted = grcate Oun 6 houn pos traurrra
dcbris and necrotic tissue present
enen-sivesofi rjssuedamage or loss ircreases the possibiln' of rnfecrjon
r
infeoed = clinical sprs of inlecdon
signrf canr gross conumiruri on t
\\;ound care guidelines for sofi ri-ssueraurna
l. Teunus immuniz.arion flanrs
2. Cleansesurroundrng slia u,itb beudine or Hibiclens soluron
I
3. Explorarion:
. inqpeq for foreign bodv and debris I
r inspect fot deepussue damage (ie-tendon laceration joi-nt in'olvernent)
. urspeq for rzscuJar danuge

368
I
I
 4. control small vesselbleedrngbl the follourng-
------z--TFpl son
lgendernmdcompres
r elerztionof theltmb
. elecuocospnlarion u'ith bovre
. hand oe or sulwe iiganm
. t]rrombir lprotein substanceOut clots fibrutogen of blood)
' Sur€dcel@(a serile abcorbableknrned fabric of cellulose: aier srturated tt'ith blood the Surpcel
su'ellsrnlo a gelarinousmassu'hich acceleratesclontng)
' Gelfoam@(absorbable serile gclaun sponge:absorbsntanl Dmes rrs tleiS:htin blood uithrn its nresh
and funcuors as a hemostaDc agcnl)
5. Take deep culrures (aerobic. aruerobic); Smnr sarn
6 Dcbridement and lmgaoon
. dilule begdln€. Hibiclers soluuon sa)tneor lacuted Ringer'ssoluuon
. use q\nnge and blunt lteedle or fV catheterlo crealepuls"tin8 la'r'age
7. Decision nlannine for $'ound closureis suided br'
a) conranrinatedu'ound versus infected s'ound
J srlrrs of infecuon lclinical inlenron = >10 -10 orgJg nssueor one sulure+10or898 ussue]
? lrours pos inyut-t
-.. mechanismof rnyu4'and rnncnrlum
4 (ie-rusr_r'.
&m nail punauring throupfr a snc-ekervs clean kitchen I':dfe I's. ammd or human bite)
5. degreeofussue danuge or loss
b) rurural defense mecha-nisrn-<
- hos resisurncedeprnd<on nredicalhrson'(ie-drabetes.long term seroid tlrerapr'.etc)
- inrnruneresponse(ie-AIDS. leukenua etc)
c) generallv prinra4'closure can be;rrformed on
- clcan u'oundq
- conunruratedu,oundsconvcncd to clcan uounds bv coprousirnganon and debndement(if
quesdonable.pack uound open)
dt rnfeced u'ounds reguuc
- culture and gram statn
- local u'ound care s'itlr pocktng
- empiric anubiotic therapl'until culture resulu -evaluareu'ound in 2-3 dars for progress
- delavedclosureu'hen indrcatedor secondan'inrentionhealtng
7. Bonhr'lacpc rs Therdrf,utic Anb'biotic Therdpr
pophrlacuc anribioucs shouJdtr Even 's'ithin the fm 3 hours of conamiruuon for eflectiveness
-clean and conunrinated u'ounds regulre adeguatedebridement and imgaoon not prophvlaalc annbioucs
one excepdon is human bites. nfiich have a high risk of infection
therapeuucann-bioticsare irdjcarcd for esublished clinical u'ound i-nfectioru
8. Tetanus proohr'lari.is
teranusprone u'ound: €rearertran 6 hours post ln-iut\
- grcarcr tlnn I cm deP-h
- hrrn frostbite. cnxh or rnissiJeilju4
- scliate u'ound abrasion or aurlsion of s}'rn
- jsq'irnlized ischemictjssue
- contamirnnrs (iedin feces.safilz)

Teunus Proph'r'laxis
immune s:ru-. last teu..nu-s
booser
rvound uncenain<5 1rs 6-10 rrs
leunus prone Td + TIG Td Td
non-leunus prone Td no Td

'Td = lelanus and diphtlreria toxoid adsorbed dose:0.5 cc IM

*TIG = leunus rmmune g:lobr:.linfhuman) dose: 250 U IM

369
 C I ] R O N ) C R E G ] O N A I - J ' AI \ S ) ' N D R O A 1 E( R E F I - I - X S ' l ' I t t J , -TAl ] E l - l C D ) , S T R O l , t J ) , r

\1isrrontcl
P.SD:rnd Srrdeck's arropitr;trc noi nlerciuilsq.lble Sudeclts arropirrts nnLjiogrrolrronlc lor lirc seconcjsu0c ol
]{$l). rllrich inclucjcssr**cijrcose olr.sr:
f,tiqlogr
. usuallvtngaenn! laqol rs lr.iunt:1
' s\cnlI oJ trzunr.a ir:asjtnie correlettonlo se\jcnl\.01 sr.trtltrorn:
' anklc spr:jxl's. ;-csralgo pialrus.IrcutonlairrlecIrolrs. lounror]ets.;-n)ronrr,ellus. rnJecuol,
j]jra.rs:
l-A coldrvasocon.qtncuve pira-sct ?<r rr cCs r
decrL:rsedlentper:trurco1lllecrcd lcpi
Inlxrale cstaprescnl
si::n norrled b.\.rxlcheso1pllior on a prnkish_biue hrckcirop
I B : i l r e c i a s s r c a l hd c s c n t r r Ji n i r r a Jp i u r s c .s \ \ c a l \ . - \ . a q o d i l a r po lnu s e, ' ( l { l p o r r d r s ,
rncrqr.<eduarnrth lo looi
hrpnl gesrasrill prcrenr
Joot color clurlrges lo red color:lrolr
)
.!lsllcsl ljkeljhoodoJ rrrnrssronrn duspirav
Il . h:rllnrarl of Srrdcck's arroplrr('$corx)ros)s t
risible radroer:rplrrcalir
oseollsrs ls ln a 'sfxln\'' Flteni
Srrdcck'sauophr <ireto hr';r:rclttra.rncru.r\cdlrtr:irnedulianprcssurc- ::ndcjmrczsed pH. liot ouc lo cjrsusc,
skur ts urul :urdglossruitlr a bl:tulr color:tLron ,
txror likcli)roodoJ rcrcnurr sr-ncirolnr
lll cjcadplu-re(6-J2 ntonlhst
Jool rs ;nlc and uan-lir.'t
rrr"rrkcd.iornrs-illnes:
lrulrk cri crstcoporosrs
-14:rrr1rcl11.
. locai ar)esthet)c blo:l:-srllo trur-( o1;-rrrn(rn&t2erpllnt.-<)
. TENSunru
. surlui-?lsvnr;railrecr olrrr ,
. suprFru\'(
. I
phvsrcaltJrerapr.anal.gcsrcs. anlr-rnllanuraroncs
. cilctlonrnlhenm

I
@ot-oG)
\cn,e Anaromr l
cndont'urium surrouncjsa srnglelren.efil-rel
pcrincurium sum-runclq
a bundleoJ ncn.e fiben (fasciclet
cPirrt,uriumsunound-s
a l:r.lgcrien.etlnulLiplefzr-scicul) )

.kdd94 -Cl4qsrficeuql Atlene I n r_u1

Nr'uropnxla : leaslser,erc
nen'econtusion/conlpr esslor I
conducuondeficrruithout aronaldenrage
.Aronounesis:\\ralienandcacncrdlron (ciepcnerauon of irron disralro ullun.)
:rron d3rn!se uilhour encioncurialrube drrnapc
F
re\,ersible.nru<cler\asLutpnu\ occut
\eurouness: nros seven
;rmid or compieteSe\s13v1g.' ol lren'e uit} contpieredrsrupuonof endoneurialrubcr
rrrn,ersib]e unle-sssu-rgrcajir I emi reci

F
i

:
370 a
{
F-
 'lt
Featurc euroDraxt a .4xonontrcs: Neurotnrcg:
Pathologrc
Anslomic condnuin hesen,ed hesen'ed Mav be losr
Essentialdlmage M v e l r n s h c a t hd r s t o n r o n \\tallenanciegenerauon Completedisorgrnrzatron
$rtlr endoneurialtube
presen'auon

Clinical
Motor paralvsrs Conrplete Complete Complete
Muscleauophr Ven'linlc Propresslve hogressrve
Selrson'parah'sls Usualll'spared Complete Conrpletc
Autonolnicparall'sis Usuallv s;xred Complete Complete

Recoven'
Ch,ralrn Perfect Perfecr lnrprrfect
R^ate
of recovery' Rapid: davs to u'eeli-. I -2 rnm/dar I -2 mnridar' (if surgicaUr
reparred)
Irlarchof recoven No ordel Accordrngto order of Accordmg ro order of
lnner\'alron innen'ation

Treatment
Sursrcalreoau Nol necessan Usuallv nol necessan Essenrial

Scddon vs Sundcrland Cla-ssificarionr

STINDERLAND
TypelDegree Second I Third

SEDDOn* Neurooraxia
Axonotmesis
Neurotmesis

SunderlandClassif cation
Firs degree- eqturalent lo Neuropranra
Seconddegree- correspondsu'iti anontmess sit} aron drsruprionbul nor endoneurial rube disru;lion
Third degree- form of aronrnresis or neurotmess ard incorpontes aron and endonuiral rube drsrup:on u'it}l
muo peri-neunum.
Founh degree- encompassesph-r'sicaldisrupt"ronof fascicles and pcrinewium ui0r inuo epineurium
Fifi-h degye€- true neurotmesis.complete drsruption of Orenerve runli-

Nen'e sureen'
' neuroll'sis:l1'sisof adhesions
. exemal neurolvsis (deuch adhesors outside of nerve)
. i-nremalneuroll'sis t enter epineuriurn to deuch adhesrors)
' neurorrhapb\':resecdon sith end-teend anasomosis
' neureqomv: nen,e resecdon
. nen,e grdfung

3'ti
 Sg!g,g.l_g_q,1U!entgltr:rrrr1,3.U!_,.r19_rr{!ry:__
\otc. Nunrerous procecuresancj cierrcesirave ii€n O:irsco to prcr'entsunip lteuronla (ute lnosl conlnlor,
cotrrpircluon rritlr ltcurt';toutr') Tire foliorlrng rs Lrsrl:lll lrs oJ ui'ut ha-sbccn altcirrDreC ,r.\olrelrave breel,
consrscnilr'rchablc

-lnhibit
i o n o f A r o n a l JIii rtt rorrl h r SrltiretrcConl:ru'rrlclrl
Pirvsrc-aI Conurrunent Siitcr'nec-rps
'l
e Clrenrrcal rq:tntcnt Rub'rrl
Alcohol Pitsuc
PirenoJ i-uote
Fornrrldehvdc Pclr-etlrvJcnc
Nttrogcn rnusurd Collodum
Pe;xin Ccllophane
H l d r o c h l o r r ca c i o \4cnihc forl
lod-rnc l:urulunr
Crent:anviolct Gl::-s:
Steroidr \en.e glue
r C:uler] o J)trrsiologrcconLlrnllrenl
Elaucrccx.culalron F n,ner rrnn)r':nlrt
'I
a-sel \en'e grafiu!
P-adiolrecrrenc\ surrenr
'l
Cn'osurgen rantlucatir)a n \ \ a \ ' l r r r m J ) a i n l u lS t i l r r r r l i
r Ligletrort Ercrsronand rcu:rctron
lnrp:anuuonlrlo lnu.scic
Jrnpllinutronrntotnnt
En bloc translocauon

1 'r';rurof Ncn'c ln.iun' Il:rv'd on ErioluR'r l.-

Cou.se of lnJun .t,turopr ax,c 4.\())10Ltie-9S "|aro!!!st:_

Cuu and laceralroltl
l ractures : l,
lr4issiler
I ractron
Conrprcssion + (nrontenla ') . lprolongedr T
Thermal :
I schemta
' - . f r e q u e n l :-
o c c a s r o n a l-.- r n l l e o u e n t

;^

372
7'
I

F
 Q u a n t i t a l i v eS e n s o r )T' e s t i n g( O S T )

C o n c e i v e db 1 ,n e u r o l o g i s ri sn orderlo pro\/idea non-painfurmethodlo measureperipherar

nerve function
M e a s u r e sc u t a n e o u ps r e s s u r e perceplionu'ith the useof a pressure-speciryin-q
sensorydevrce
rPSSD)

' Designed10measurethe thresholdforperceptionof pressuresrimuijon the surface

of the
h u m a nb o d v
' Providesa thresholdmeasurenrent throughouta conlinuousranpeof appliedpressures
' Consislsof 2 metal prongsu'ith hemispherical
rips that measurethe distanc.t.to,..n the tips
of the prongsas well as lhe amounlof cutaneouspressurerecuiredforperceprionof the rifs
' Able lo measureone-pointmovinq.one-poinlsraljc.wo-point moving. and rwo-pojnt
sraiic
over a particularpieceof skin
o Pressurethresholdmeasuredin grmm2
r Patientrecordingscomparedlo normalivedata

I nd i c a l i o n s

. Diabeticneuropathv
o Tarsaltunxel syndrome
. H e e lp a i n
. Cubital tunnel syndrome
o Monon's neuroma
r Sural nerye entrapmenl
r Carpal runnel syndrome

) IJ
 l

n cHil-r-rs rax lloN HDI,Tti

ni
plagnost:
' s:rhbrrrglllr Fxn ol poserrolankle4el'
' rcrrcjcnre-sand palpeble&1eq rn thc AchilieslcncionuiricJrilrcruss urllr cjonillcxron
. decruisd acuvcpiartulrflcrrorr artcirr grkrrcssof planurflcrron of tirc ankle.lolnra!.lilnslreslsanc{
, "Lrali-like''
apropulslveglrl rrrt} a colrt-runed qall rrrusclc
' Tirontpron'slcsl- rriilr tirep3lrentir:nr rn a pr()lreffJsltrolt.the !:r.<troc-soieuscornp)crts squeez,edtr
:r\css pl;rlrtarficrronof tlrcanlie iornr
.
= to no plantarficrrorr
;rcsrtrvetcst cjc;rqrscrJ of tJrcurllic.iorntrclauvcto drc corrtrll:rtcrallcrlr
fllsc rregtuve= thc lottt frcrors.tibialrsprqcnor :urdl.l:rolrcus)olrgu-s proricicnrollon at 0rc ankle.iornr

D{1_crql ti aj Dr a srt951: h r r r r r r l r ( ' l r s . i l i c : r r r o r or l . A c l r i l l r s ' lr . r r r l o t l){ r r n r u r r

, achillcstelrdonitis4rursius 'l
' l\nr I I'anral car Les: I lran i0,,,
F-lnja.lruplure 01rl-sucrnclrrrur lrnc I ( ( ) n t n l c t ( I c a r \ \ ' r t h i _ r s sI h a n a r c n t l ) c t r c :
, anrlsion it.rrure of the celcrrrer:. 'i
rpr lJ Lontnretc I car \\'ith a j-o cnt l)ctcc;
, lnrlnalic hernatorna of t-)relou er ler lrpc I\
'l
( ontptctr rar \\ rth a l)cl(cl (rrcalrr
l'l)an O cr)

Pa!]rogelre.srs
' RuPiurc cottttttonh(facurs2<.-r cltt p;crlttaj lo )ts urscnronal alt arezof ciecrc:.:sed
r':tqcullrnlr'(I;rectlrel
& Llrrdholmr
. lactors collagenvascularcjrsgrsesoe-r'ouL RA)
Preci:s;-x-.srn.g
. lorr-elenlt s\slcnlc scrojd tirc;:rpr
. local seroid urlecuon

l:crfUtfelt
C o l r w ' r ra l i v c :
' lndrsted 1ot ;rntal tqrn. socjclrun olcicrprtrenL<and lron-sulerqrlqrndidlrc:
. higlrcrrncrcicncr o1rc-rupurc cont;rtrcdto surrricallrulullcnl
r gr:lvll\ cgulnu-(c3-sunt
'
7
lonc lep crs uitlr kret f iered at ltr or SLC. anlllc.iorntplaccdrn !rd\'rr\ eclrnus for ('-Ss'ecis \
. foliou'cdbl SLC rlcight-h:rnns uith recjrrccxj :lnrounl<oi egurnuslo cr.cntuellrc:ellrfi rn sirocpcar

Suryical:
a) pnnun'reg;rruit}suturey'mplanr ;
L N4aand Gnffrtlr. percuutteoussulurc rcpiur uit} lronab'sortrable sutureon a $r.r-iehtlrccdlc
2. Elrci-tc'Endattaqontosts uiilr nonei>orhrsble surun
3 lnrplalr- taLxoriublcpo)rrrer cartnn fiLrcrcortrprsrte- Parson-c et al )
-1.Pull<rut$rrc teclrnrque:
-i Fasial rcrnlorcenrcnt
a Bugg arrdBovd. nrodrfiedEu;rncll prll<rut \\rre sulure rn conrbrneuonrljtlr tJrre l:rscialau snp I
b Lrnn. rcinlorcelnentof cnd-tr.-clrd an:solrrosrsuith tlc pianuns lerrdon:planransis dcuclred
ltonr rL<lr)\cruon and falurecioul to Jonn a nrelnbralc
i Silr enh-roldcentraislp o1.giqrocricnrusa;-xrrrcurcxis rs flap;-rd dqallr or er Lhedefecr r
C Lrndholm t\\o outet snp of gasll(>:nenlru-( af)oneuroslsare flapped cirs:rljr ro reinJorcedrr
tencicnrefr::r
t
6. I endurou-< rernJorccnrenl
a Bosu onh. a srip of g.a.srcrr,e nirustendon rs freed proxmalJr'. flapped drs-alh and passed
tJuougfr$e prouma.land d:sd tencionsrunrfx to.ioin the rupruredrencion
'l
b, eufier:fr:roneu-(brelrs is ds":chedfrom lt.suLscniorLplacedilrrough a dnll hole rr the calcineal
ruh:lcstn and gt-r<edprosmailv alons ,re rupturedlencjonfol rernlorcenrent: lL<rs alsosuturei
to rL<elJto proCucea d.rlenrrc ioop

I
--.; A
) t? a

F
 MA .T GRJFF]TH
BLIGG.&FOYT,

UNDHOLM

LI G A,Iv ENTO US ANXIE IN'JTI RJES

Diagnosis
a) lusory'
l. s'hat happned? hou'long ago?
2. rr'lreredoes it hurt? t pornt n'ith one finger)
3. rlhat uslrnrenl have vou done? can 1'ouuall on it"
4. mechanism of rnyut-r
5. pas medical lusory'. social luso4
6. current modicatiors. il anr'
7. allergies
b) phvsical exam
l. r'ascular slarusQrdal puJses:cft)
2. senson'/neurolopc satus
3. edema eryrJ'remaecchrrnosis. calor. dolor
a. palporion
lateral foot
dorsolateral foot
lareral ankle - anrcnor ulofibular iigament
calcaneofibular iigament
pos enor talofi hrlar I gament
nredial ankle - deltoid Usamenu
posenor aakle
lateraj malleolu-<
high fihla (Maisonneure fracrure)
medial malleolu-<
5. radiographic exam
DP and obligue of De foot
lateral ofthe foot and ankle
AP. monise. and obligue of the ankle
6. sress irn'erson
normal depcndson u'hich stri{'mus compate to oppositelimb
posirive usuallr' erezler tlnn l0 for double LigamentinJuf\'(ATF and CF)

375
 /. :rnlenoton)\\'e;
srcitter liran { ntnr ts r}f stttveJor ATi- tcit'
scvcral\\?\'s to nle.:l-(urc anlcnorcirau'c'
b. 1^.-rolrca I I cr)o-gntnr I
rnlrluatedve rnro;rrolrcel rcncjonslrc:Lh I
CF bg in Inunlar colrl:tcluith l:ttcralanklc.iorlrtapsulc and ciccp:rsrrciof pcronealrenoonsircatit
nloru.scand latera.lankle r-rar':
nonnai sudr'= dle surs u'itiurrrencionslrq:t-ir
Flsrtrvestudvfor CF bsrrrrentru]rurn = civeexravagaleslnlo thc alJ,le.lornr
. severalautlton ot-scribcI rronnll conlJllunrc3lton itrrrecn ryrorrer)tencjonslie:drarrdankle rotrl
tappros.20%)
9. ankle.rorntanhrographr
d r c r n t e o e dr n t ot h c a n k l e . r o r n r
I
;nsitlvc sudr'= dve ertravagtlcstnlo softussues
ci:agnosucJor .ATF ltglrrcnl ruplurc
lcssarcurureilrar rerrosramJor CF lrg rupruri
1 0 . \ 1 R l - a h l c t o e v a l u : t rsco f tu s s r r e(sr e - l r g r n r c n t s )

As.rri:tted f r:rctunr
a) f.lfi-]r nrcraursal ba-sc
b) :urtcrrolprcressof calqllrcu:
c) ciorsall:rrcralcalcureust€DE arlisron r
d) l:rtcral ui:l prcres:
e) Shcplurnd'sfractureUDoscnortalar prrrcss)
Jr osteocirondraj1raqureof dre urlar cionrc
g ) a r r r l s r o nl r a c t u r eo f l a t c r a ln n l l c . o i r rr-t<r s u e l l :rr s s o c r a r eudt t J rd i s l o ; u o n o { ; - r l o n e q lr e n c i o n s t
h) h jgh fibula fMarsoru]euve lncrure i
i t nrcdial rrurllcolu-.
-jt Salrcr-liams I jn clriidrcn

C l a . s i f r c : rito r r so f L a t c r a j A n k l c L i ; t an r r . nor u s l n . i un c r
a) l-c.tclr
firs &g.rec: ;-nnial or conrplcrev*tr o{.ATF ijearrrcnr
s<x'onddcgree.prrual or c<-rnrplere rul of ATF and CF
third ci":gree : ;-xnial or conrplererc:r of AlT. CF and PTF Lgr.
b) O'Donoelruc
firs ciegree:Llanrcnt srretchuitlt rrrjnunaldrsruprion
ssolrd degrec.parualLtalrenl drsrupuonu'jtlr.ioinrrlisubilIrr
tlt rl d cieere€.complete b lunr ent cirsrupr-r on
c) Dra-.
g.rudel: fxinjal ruptureof CF L!:;.lrrcnr
qnrdc2:ATF bianrcnl rufxu(
gnde 3: ATF. CF andtorPTT l:r:rnrenl nifxurc
d)Henn
group l: lenderor.erATF ltg,: liegrtrveanrenordrarrer
ular tilt < .'
group 2: nrcxierateirtlun': tenoel o'rer ATF and CF Lgs.: lrcg:ur,€anlenor cjra$er. Ular tilt <
group 3: selere rn-iun':lateral ankle su eli.meand ;-rrrn.pnsiur,eanlenor cirJu'er.talar dt > I i
group 4; chrorucproblern:;rxiuve anrenorcirau'er.
tala-rtijt> l-< .f

3i6

t
 'l
n:;rtrrcnl
---- 'gl]len3_uYr
l. res- tcc.conrprcssrorl und eievtttror:
2. l-ltna frrot
3 Gibnel bxror
4. Jollescollpressrvccjrc:suruurdt , Fcsenor splrntAO splrnt
egcshellcrs
5. Arr ca-sl
tr desrecol uereht fr:rnns cic;-tnoron selenn' of uttun
bt,.qlgcal
l. pnrtun rc;rrtr o1t<lrnLuuncnrr
usualir rcscn'edlor a conrbrnedATF alrd CF Lc rcar
l. leteralanklesebjlrz-;rtron prcrerjure:

\ / A S C U L A RT R A U A I A

-crtqgqrgs
a blunt LruultLi anen rs cnrshc,i ol conrusedresrlunr ln hcrrrorriilgc. nta\.qluse colt.lfrjnntcnl srlcirornt
b' ;-tneuau:ig trdunra. rc-deep iaceratron gun-siiot\\ ounc
'l
ruilrrrelil
' slop aolve bleoing hr g'cntlc nt:iltual col)lpressron. elevuron of lrntb nral fun)ier collplorrlse tlrr
rsclrenriclcnr
' ass65 DP alrd Pf prlses. tf llrc lttltor vessel in tlte vrcrtrrll of llre u'orrnd rs nonpalJ-nble. r'ou lnus assur.n(
vasculzu m.lun unu.l prolcn otj'rcnrrsc
' il ;rulse-.non;nJ;nble. atr<cttll:tterrith tire Doppler. cjcrcnnrrrernil)e/orachial rnder
' e\cn rtith pu)sestlte cnrcttrtll sirouldlx- rrrolirtored1or corrrpan-rncnr srlcironrc
' il l'ascul:u slslu-(ls (orlrpr()lllrscdol oLrcstronable.get a vlsculil colrsull: anenogriint lnar.bc rcqurrg,3to
cvaluate ilre crrclrl of the urtun

N A I L R E D I N . I U R ] fS

Ail nxryrre x-r:tvsto R/O drnel plrel:rn,rlnourc

. Suhngual henutonrir
tnvolvrng<25'l,oolnajl Lrecj
dratnltelttatotrlz
usmp#)l scalpclblade. 1b sJugelreedie.roun'bsll bun or serilued n:rrr
cirp
tnvolvrng>25"toof luijl brc<j
skn ;rep. nail arujsronro fuO ruil bed laccrauorr

' Nail trcd laccrauon

a skrnprcp iind naii a'rr-rlson
b rr ounciclrc
( pnnun'repltr rtitlt ab<orbeble suturerritlrin 7 cirrs;-rcs inlun'to alojd sar lornrauon
oI rnil bd
d prelent neil h:d and prorrmal nail fold conucl rn order ro a'r'oidnajl dcJomirn-.usc
Acepuc \;asehneimpre_uured!L.rweor Xerolorm ro nrainu:n spiic(

'rf rnjl Led lacer.ltroltrroteriuidr underl'rrngphajan-eeal

franure. u€r ul.lun'as an op€n f:zcturc'

37't
 k osclrISi Cl:-r'sifr;rr i on of Di srd l ntLll
F o s e n t l a l C l a s s i f r ra r i o r ro f
Irtql of trssue_lq-<: Digjtal brju;ies
zorreI cjrqalto ir.rnrphalanr J -^1
zolreIl drsur)to lulrul:: nT,TT-
zolrc lIl: prorurralto cirs:rJend of lunuli' m\1=il,
\ n t r
t (! r, '
I

LL-
i_lenqqf rtf:!-e l!!:
ciorsrloblrquc Ple-rrtar OLUgur
tr.1lt.c\ cr.\( \ --*;:.='-:
pilrni:uobirouc --ia;>{-li- --
a r r a Jt u b i a i o r f i h u l a ro b L g u e ) h,r:eJ OLLieue -- .._-t-a:_-
)
ccrrual (-!.lou lrJlrgl ';_;---_-.
[t Ri'r
\tr*t
\)rrJ'
Adal

]rc:t;lerrt
zone .l
' cjrsaldiertalun;rutarionuirh ruil LLcj,arrrlsron
. uillirn ,,oneI u-iilroutcrlxscd ir.rrrc_ a]lon ro r:ranularern br scconci:n lnlenrlonhcahng
' llsstle lorq > I cnt - slart sreJtott iicule ot dclavedtusrs lre-full thicknexsskrn 3rafr clndiurtal up
revcrsccicrnralr:rafi ro filJ latr:c neil l-cciarllsron delect)

zone l,l
local (ad.r:rcent) pedicle fluJ> are urcjrurrcc'
t l c - A u - s o \ p l a n u r \ ; - ) ' a d r a l r c e r t r c r t t g r a f i . X u t l e r r - r ' 1 x\ ' - ) ' a c j v a l r c e r r r c l r l g r a f i 1 o r r < x
rmon.structlon)
nail bed ausrlentauon
eblate renurnme nail trd iJ rrn rrrrrchha-<hren los

z o n el l l
gelrcrdh lrol antenableto n:ul hed lccor)qlrucuon
pnrlu an)Ixrun)on ts usuiJlr ;rrlonncd urth atrenrfrto pn-s€ne drsuallP.l and cirsui rencion
Julrcuon

PU\Cl'trRE \\'OUNDS

Fo.gtg4_bqd. t_!_t qD_q

a.1p)anuu lt>otrrouncisttuv bc conulrrrn:led uith ci:n grass. sock or sltcrcnutenal
b; prnznecdle
ci.ralrrosrs. ru nd: rd r -ravs
rnroval bn't}e follouirg nrethod.
-rranguiauon rrrtlr ncediesplacoi :tt 90 ansle to rsolateOreforers, brrCr''sdcpr}l
-rrsualizauon underC-arm fl uorusopr
-ir:nd held elecuonuglctjc ntcul loeton elnrt a }lisher pirch sound \\'ijve ncar nreul ob.lecL.
<1rssecuon follous clinical sgru. of inllarnnrelrorLabscessor hentorrh:ee
c.)\r ood toothpicksrsplrnten
c.:arlnosrs: relorad:oeraphr'.sund:rrd r-ru\s. CT tnros rehablet
d.l giass
dr::srosrs.sanciud r-nn can pick up unrcxjor eiassconulning lcac

37E
--!-{-<4312ir_qltrorrc{l:Ir.i.t1t_clUrs jMnq.
a t ccllulitrs:Sunir !urcu-c>-iO'iool case:
Supir cpr.strcplococcus. E coi,
b) abscess
c l o s t c o n t l c l t u sP: s e t r o o n r o naaesr u t : u ) ( )Jspr p r o \ 9 ( , o l c a v ' ( u s u q l l lu o u n d s3 - 1 t r l s o l C
'l
-1. niltnlenl o;lrlrrrq1le rrqundr
a ) leuinll-(st:llu.
b) -r-rays
6 y u ound curc rrtilr rcrtto'r'alof /orerg.nbodr . Jr--rcA \r oulto ol-.r--r,
surgrcaldeirricicrrrent and )ar';rge if tt ;-r--rrcrrure< tlic.lornr
d ) a n t i i r r o t r ci fs i n l e c r e d , c c l l u i r ui fcd. c c pr r o r : r r dc r r c l r c j rso h : r n eo r r f ; r r r e t r . t r etsi r c r o r n r
e) tf rnlcsed purrculesound cioesnot rcs;nlrdto:rnlibrorrcs. rlrcrets prohebJra JorersnLrrdr prescni

I}ITE \\'OUN])S

l)tr;.1:rnd C:rt llire

. c o r l l n l o lpr r d r o l c r r -i.l.i s u r c l l a n r u l t i c i d r( l r r c u l u r t r r!c' n l n n c e r o d )
Surplr aurcus.alpha-irenrol'rrc sucprococcu.
lrcSutlenl
L tcunu-<prophli:irr:
l. R:tbresprophllau:
Doer(-:it )t1 altlnralis haelthl anciar:rilablcJol oixcn:lrorl no trci.]uncnl unlessaninul cier.ciopx
rabrc:
>r:rbidartrlrml.sug-rced or unl:lrourrsalu:
stvc ntbtesttrtltrulleelobulrnand J-lDC\;OrunlrndLploidccll vaccrnet
rf arrrnralrs negluve.sop prophvlaxr:
i \\;oulrcicrrc crploreto ro rendonlacrrarronlou.l cilnr;rlc
J, Antibiortct)rcrupl conuovcrsial
-sottteadvo:rte prophrlanrsLrec.iusc :nunal bltcsare high nsk and hrgN'rconlamrnlrrxj
-rtrorrrrrrclrd Aulnrcrrun(rf F{-\.^^ allclurc.crve Entllolltrgip I
<rtlrenonll uscantibrotics if clinrcallrrnlc.cred

l : l r r n r a nI J i r r r
. Conunorr;nilrovcns anaerobes tie-B:rcrcroicies
lrasilist
Eikcnella corrcricnslgrarn neg rodr
Suph aurcus.Suph cpicicrnridrs
I reurrcnl'
I. follou guidelrnesJoruound carc
2 if rrr.runX lroursold ;nck u ound o;xn and fol)ou -up rn 2-3 ciavs
3. Anubroucs
oraj: Augrrrcnun
;rrrcnteral:Una-srn I uucntrn
prophr'larrsadrrscdr^\'ctusehumanbrtes:rrehiqhh conralntnared uound<and at Jriqhrisk of infeqron

BURNS

Classifiqru<rn
Bv deF}i
' firs deg.ree= enlhenrz
' secondciegree= blrnerrng
' durd dcglree= cirsrucuonof epiciernls ciennrsand shr: api^*nda-ees:
anesleuc
. founi degre = cieqnrcuonof fat nru-qcJe end tolre

319
 -
o:--fnnjal-iltickress.frst
, or sccond'oegre.
. full tirickrrcss:dttrcior iottn.iro':urur

Br crrcrrl of l>trrn.ozilotajhodr sttrl:rc:c:rrc:l

(BSAr
ntte ol ,ll,le.' -
irc:ld9),' clrcst/ahiorrrcn l 6'.1,,
arm V)i heck lti'),,
rrroln ]uz, ieg J8'),,

I t-Lrtnrcnl
I . reluovcixrnu:tg aeent
I ABCs and trslt as.socr:ttcd llrrrrlc:
In tcuurussurtu-.
4. usscssr';rccularslatus
-rhsen,ejor vascuialconlpromr\crritir cucumfcrcnualbunx. erjclrulnd eschar
-crrculttjclcrrrial e.<chars In;l\ rL'ourrccschnrotorttr
-i rr orrndqlra
' rrrunedt:rtclr cool drc arc=lrl.)r u.rrcror srllr<
' blrsel qrn
' dcbnderupturcdbirstcn
. n l r : ) c l b l r s c n n r alr- r ) e l t u n c i r s u r l - ' c d f2oJl - 3 6l r o u r s t o P l o r i d c b i o l o s r c r r o u n d c o r c r . r g c a n d r c
Prc\;cnl ussLre nccrosl:
. roprcalagclrt.((for hunr-q>?o%' llSA r
srlvel ntu-.tlc
silver sulfadr:v,rne( Sih'acicnc.).
hscltracrn.
t)@mYcln
nrafe nidc :rc{lal i
)eroform orcssll-r'
' nja()l)srnrcuon for tlrirci or ltrtrnir ci'-'r:rccburn-qs'it} skrn grafu rs rndrqrtcd
o Antibiotrcs
. -prophllacLic antibrotrcs a^- not rc:cornlncndcd beczuse rt nral rcsult rn su;^*nnfecnon uit-ir
I\cudonrona-( or \ cssr
i conrDlon ;latlrogerrsof infccred irun}
Suphvlcrccrccu:
Srrefx crcoccus
Pscudorttona-.
Proteus

c'ot-D lN.turitES
.[l:r_enron lcrcr
lnlun' lo trssuedue lo a combrnauon01u et and cold

trqSlU-
inlun' ro ussuedue to fretz-rng
frosbrte classifrgluon
I inTrrenrra
2 bl:sen
3. lrecros-.
4. l)ecrosr-<ald ussueloss
Lrgttntenl
leBlltrs SL?IIL(
rel\'arm linrb r.lpidJlal rcnrflrrrrur-e
o1 11I-1-l{t8for l-i-2Onrllres: nral regurrcn3rcoucanalgcsrc:

380
 -I;]T€ST{'ITJ:
v I Defrnitron:
. A . I r o s r n i p . p l r l o r a n d n r r n r b r r r sosf t j r c r f l c c t e dl r s s u e sn. r i l c i c sl o n t t . r r ' : t r n r u tr. ces u l t si n f r e e c i o n t
lronr cprcicrntaior dcnltal clllLzjt:(
B C h i l h l a i r u p er r r i o c l u o n r cl r s c r r l r t r so f t i r ec i c r r r u tsh a t r s p r o ' r ' o k ebdr l c p a n t e cei r ; n s u r e t o c o l c
l c r ] ) p c r a l t r r casi r o l ei r e e z t l t ct n i u e h l l t t n t l d l t .
'l
C r t , n c h l r x r t o c c u r sr r ' l r c nl e e t: r r ec r l n s e d t o \ e t c o n d i l r o l La<n d l e r ) ) l { - r a l l r r ebsc l \ e e n 0 - 2 0 o e e r * - :
ceistur
D l r o s l l r i r r ( ) c c u r s ' l r e ns I : r n : u r ds u k u t : r l r e o u sl r s s l r c sc x ; x l s c dt o t i r c n n a js t t c s sl r c r c z ,uei l - i r
tcnlJf,-nllure < s2 d eg r c c sc c l s t u :

l l \ \ ' t r o r sa t r i s i : ' '

- l n a l e st r l u c e l t a g e s2 [ t - - i r t -elderir
- : r l r e r e dn r e n L asl t : t t u t -nralttounshei
'psrchnurc cjtsorcjen -mtltu4 pcrsotttte)
'alcoholehtrsr - o u t d c n ts f n n s c l t l l t t t s l a s l :
' i r c : l c lu t - 1 u n t s k r c r sr. l t l l t l c r sc. l t n l l r c r :
-lronrelcs: - l a b o l e r sl n c o l c ic t l v l r o l l l l l L ' l l l

I li Prccirs;nstn.c it iJclor:
- c D v i l o l r l r e n u rt cl r t l J } - - r a t u r c : - l i o s ll a c t o r :
'lou lcrrr;tr:tture: ' a l c o h o ll t i - r u s e / i t o t t t c l c : s
'Illolsltlr( ' p n l c h t l r t r i ci l l r l i - s r
'urnd chill tntalnltounsltltteltl
t d u r a l r o no 1c s J - r o s u r e rP\rDiat}closclerost:
-\lrsccllrureou: 'sttroktnt'
' l n ( ) l o r v e l r i c i ep r o b l e r r r : t c h r o n i cl n e v l c t r a ld : s c a s r
'uttpl oyr-rclot)rrnr' t Rar:taud-sdtscasr
'fauguc

I\t. l'atJrogencsr:
Dtrccl Jrctzt
-cxuaccllrrlrurcc cn'sul lonrr:rrronfol)oucd br rnulrccllul:urcc cn'stal lornr:itronuit-h cell nren-tbnilrr
cltnugc
-llrcrcase osnrotrp c r c s s u r eI n l l r c r s l r l l u n rc a u s u l g\ \ a l e t l o b e d r a u r ro u t o f c e l l s .r n u a c e l l u l a r
deh'r'drauttnalrd cell dcatlr
d c l i a l u n n p o f l t p i d D l o l c l nn t c r n b t : l t t t

I n c i r r e cIll t l u n ' ( \ ' s s c u l aar n d t n f i : t n t l t t : : I o n

cilanges)
- " H u ntrng Rcacrj on'': alt crnatrn! \':r\oc on slnctron and'r'a-sodi l atron
-lxrsrslcnl\'asocor)flriction lcadrng to h)'porra. acidosis.inclcascd blood rrscosttr
-capill:rrrcs. anerioles. and ve nulcs tllromtnsc
- r e i c a s eo f r n f i a n u n a t o nl n e c j r a t o r sp,r o s u s i a n d r nP G F 2 a n d t l u o m b o r a n eA l
-\.:iso(onsncr ron. platelct ir![] elau o[ and blood r-esse]tu ontbcsts

\ / C l i n r c a lP t c s c n m l t o n
Farorablefindurgs Predrctonof Poor Outconle
-senslllon ro prnpncl, -smallvcssiclessith darti blmd fluid
-skin tJut incjent-s uitt plcssurt -nonblanclulg nanosis
-normal skn colot -sicn tlut feels "uooden" to touch
-)a:geblrsrersfilled uith clcar fluic -sktn *rat doesnot rndentuilh pressur(
-rntecUon
{elal rn see}.rngmedicalanentlon

38r
 \l . Dragnosrs
- -=phrsr cai-exatnInJ u or:
ionventl onaI raciro-r.raph.
-i-nre sctnugrapltr
-argrographr
-di gital pledrvslrrographr
-ciopplerfl orr stucircs

\41.'l rc:uncnt
- U n n ' e r s r n o f C h l c a g oB o t o c o ;
- r u p i d r c s a r r l l l n gI n \ \ ' a n n \ \ ' a l c Ia l l ( 1 1 - l O fcJi c . r . r r cFe lso l l - i - l U r n r n u r e (sp 3 t r c n l sp r c s c n u r l g
24 irrrurs
posl m-lur.\arc not lcuanncdr
- u ' h t l eb l r s c r s a r e d c b r i d c dn i t J r a p p l r c a t r o o n 1r o p r c a a l lcr lera even.6 irrs
- i r c n r o n h a g i cb l r s l c r sa r c l c f t u t l u c lu i i l r l p p l r c l t r o n o 1 r o p r c a u l l c er c r a e v c n . 6 ] y :
- a f l e c t e dp a n r s c i e v a t e du r t h s p l r n u l c a s r n d r c a r e o
-anaigesraas incirc:rtcc
-.ASA/ibuprolen
-d.ailvhvdrollterupr
-pln'sicaldrcrapr

' d c f i n i t r v e a n t P l l l r l r o nl s d e i a r c x u
j n r j l c l e a rc j c r t r a r c : r r rooJns a n g r e n er e a r h ' d e b n c i e n r e on nl l r
i l r d r c a r eud i t l r u n c o r r u o l l e di n l e c r i o n )

\'l)l Sequclac
-cold rnscnstirrtr - r r s . s ul e
oss
-ht'yrrhvdrosrs -\ asosfJ(Jsllc arrack
- r n t r i n s r cn t u s c l ea u o p i r r -l^Trrcsthcsras
-color cira:tpesln tltlegunlcnt -r;r6nrc p:rn
-:rrthrius -prrrncalcalcjficauor,
-:lroulh platc abtronnaltuc: -scli.t:trllous cell c3rcrnonu

382