Trauma/Gunshot - Smith

Question 1

Open fracture principles…

Answer 1

1. convert to clean wound
2. restore function
3. obtain cosmetic if possible

Question 2

Internal fixation principles…

Answer 2

1. atraumatic technique
2. anatomic reduction
3. rigid internal compression
4. early mobilization
   * ** promotes best stabilization and healing

Question 3

Gun shot wound treatment…

Answer 3

1. debride and irrigate the wound(this is a surgical emergency)
2. remove bullet fragments that are easily visible, esp those near neurovascular structures/joints
3. stabilize any fractures
   * ** important to track down the bullet.

Question 4

when is a wound considered contaminated?

Answer 4

when there is a bone sticking out…. always considered contaminated. our goal is to convert this situation into it being a clean wound.

Question 5

when is a wound considered infected?

Answer 5

after being open for 6 hours or more.
Open fractures are not always infected, however they are always considered contaminated.
*** we see infections consisting of inflammation, drainage, dirt, debris. our goal is still to convert this wound to being a clean one.

Question 6

Details on restoring function…

Answer 6

this is an aspect of open fractures
*best way to do this is to get the wound clean and to heal and well as the fracture can. this will make it functional again.

Question 7

importance of obtaining cosmetic healing/appearance?

Answer 7

sometimes this is not obtainable. however, if you usually do a good job things come together. cosmetic is not a high priority, however it is important esp to the patient. we are working to salvage a limb more than we are to beautify it.

Question 8

How do we get a wound clean?

Answer 8

sometimes requires 2 surgeries. one for irrigation and debridement. another for the actual procedure fixing the bones.
ancillary incisions = clean incisions intentionally made in a clean environment that can be sutured at a later date.
** there is a clssification system regarding when to close a wound. puncture wounds we close right away. Smith is hesitant to close.

Question 9

what is the golden time frame for taking care of open fractures?

Answer 9

before we hit the 6 hour mark!
at 6 hours we are considered infected. open fractures are considered medical emergencies and we try to get them in the OR right away.

Question 10

tell me more about using atraumatic techniques

Answer 10

make sure you dont cut important structures

avoid hurting nerves or tendons

Question 11

tell me about anatomic reduction?

Answer 11

make sure to know your anatomy!!! you will need to know this extremely well in order to put things back together once they have been dismantled.

Question 12

tell me about rigid internal fixation..

Answer 12

*compression is important in order to achieve primary bone healing ( cortical), not cancellous (? whatever is secondary)

Question 13

why do we care about primary bone healing?

Answer 13

we do not have very great outcomes without it

this is what allows us to get back to mobilization earliest.

Question 14

tell me more about early mobilization…

Answer 14

get the patient moving, get them to PT
increase ROM and decrease swelling
we dont want muscles to waste away

Question 15

calcaneal fractures…

Answer 15

fractures most commonly due to falls
severity determined by presence of lateral wall blowout
bruising on foot esp in the arch… this is an indicator.
calcaenus is like a hard boiled egg. spongy bone inside is smooshed with force causing blow out.
* able to see more detail on CT, also that joint is not uniform which could cause arthritis in the future.

Question 16

are gunshot wounds considered open fractures?

Answer 16

oftentimes yes! and will most oftentimes require surgery.

Question 17

do we need to remove all the shrapnel?

Answer 17

no! oftentimes searching for all the pieces can cause more damage and is impossible. due to atraumatic is #1.. we need to preserve structures. there is physics behind bullets and the shock wave that results.