Introduction  

This 24 year old woman was the belted driver of a car travelling at 100km/h on the highway.  She had her left arm outside the driver's door window when she lost control of her car.  With her arm still outside the car flipped onto its side and travelled 20-30 metres in this position.  Paramedics found this patient with her hand trapped between the car door and the asphalt.  She was evaluated according to ATLS protocols and this was found to be an isolated injury.

Pictures From the Trauma Room:

Trauma Room Radiographs:

How would you manage this patient now ?  

Tetanus status was unknown, but the patient recalled that she had her series of tetanus toxoid when she was a child.  She had no allergies, no history of renal dysfunction, and did not take any medication.  A detailed hand examination was carried out as part of the secondary survey.  Sensation was found to be intact in the Median, and Ulnar nerve distribution.  Motor function for all three nerves was intact.  There was no sensation to the radial side of the thumb which (see picture) had a hemi-degloving type injury.  Radial and Ulnar pulses were present, and there was no evidence of an acute Carpal Tunnel syndrome.  There were no injuries to the left upper extremity proximal to the forearm.    

What is the appropriate management now ?  

0.5cc of Tetanus Toxoid was given, and the patient was also given 1g of Ancef, 40mg of Gentamycin, and 1.5 milion units of Penicillin.  After informed consent was obtained, the operating room was booked for an urgent irrigation & debridement of this patient's hand.  Limb salvage was considered to be possible given the intact perfusion and neurological function.  A staged procedure was felt to be the best option

What would the best management be for the second stage ?  

There was extensive degloving of the distal thumb, with most of the distal phalanx missing (see trauma room pictures).  Clinical and radiographic examination revealed that almost 1/2 of the total depth of the carpus was missing (including articular cartilage) and that there was massive bone loss from  the distal ulna.  Finally, there was a large amount of soft tissue loss.   Therefore, the second stage procedure consisted of:  

Repeat Irrigation and debridement

What would the postoperative plan be ?  

Postoperatively, the arm was placed in a full-length splint.  Perfusion to the free flap was monitored for one week using continuous Laser Doppler Flow (LDF) readings.  The hand and elbow were immobilized for four weeks at which time sutures and the proximal radioulnar pin was removed.  The wrist remained splinted but active ROM was begun at the MCP, PIP and DIP joints of the fingers and at the elbow.

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Introduction  

This 40 year old man was the backseat passenger of a car involved in a head-on collision.  He was not wearing a seat belt and was thrown into the front of the car.  His left knee caught one of the seats and when he was found, his left leg was caught between the driver and passenger's seats, while the rest of his body was in the front of the car.  The driver and passenger were belted and were uninjured.  Aside from severe left knee pain and deformity he is stable in the trauma room.  There is no dorsalis pedis or posterior tibial pulse on the left side, either by palpation or Doppler.  

Knee Radiographs in Trauma Room:

What is your diagnosis ?  

How would you manage this patient in the trauma room ?  

After IV conscious sedation in the trauma room, a closed reduction of the left knee was carried out with return of the dorsalis pedis and posterior tibial pulses.  He was placed in a Waddell-Jones bandage post reduction and referred to one of the sports medicine surgeons for reconstruction.  

Post Reduction Views in Trauma Room:

What are the short term problems with this injury ?  

What are the indications for an angiogram ?  

What is your specific management plan ?

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Introduction

This 60 year old woman was in her bakery when she got her right hand caught in an automatic bread kneading machine.  She suffered a severe degloving injury from the shoulder distally with bone and tendon clearly visible through the degloved skin.  She is otherwise stable.  Examination of her upper extremity reveals that there are no radial or ulnar pulses, although the brachial pulse is diminished to palpation.  Her thumb, index, and long fingers on the right side are cold and blue.  When asked to actively move her fingers, her tendons are seen to move through the skin.  There is no sensation to any of her digits of the right hand.   She complains bitterly of pain from "the shoulder down", but has an insensate right hand.  She has a large mass over her anterior right thorax and her shoulder is squared-off.

Radiographs in Trauma Room:

What are your diagnoses ?

How would you manage this patient in the trauma room ?  

The patient was given Tetanus Toxoid and intravenous Ancef.  Fluid resuscitation was instituted and blood was sent for cross-and-type.  After IV conscious sedation in the trauma room, a closed reduction of the right shoulder was attempted.  

Post Reduction Views in Trauma Room:

Is the shoulder reduced ?

What may be the cause ?

What is your management plan ?

The patient was taken to the operating room for management of her injuries.  After a quick debridement of her wounds, an attempt was made at revascularization of the digits and forearm.  Although this was successful, there was a great degree of bone loss and the brachial artery thrombosed intraoperatively.   There was a large amount of soft tissue loss.  At this point it was felt that limb salvage was impossible, so we reverted to an upper extremity amputation with disarticulation of the right shoulder.

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Introduction

A 30 year old man was involved in a motor vehicle accident.  He was riding his motorcycle and was cut off by a car which ran across the front of his motorcycle.  As a result, he ended up hitting the passenger's side of the car head-on.  He was wearing a helmet and did not suffer any head trauma.   He is brought into the trauma room immobilized on a long spine board and with a C-collar on.  He complains of extreme bilateral hip, groin, and thigh pain.   Primary survey in the trauma room reveals that he is stable and has suffered bilateral hip injuries.  Luckily, he is neurovascularly intact.  His pelvic radiograph is shown below.

AP Pelvis Radiograph in Trauma Room:

 

What is your diagnosis ?

How would you manage this patient in the trauma room ?

After IV conscious sedation in the trauma room, a closed reduction of both hips is carried out.

Post Reduction Views in Trauma Room:

   

Are both hips adequately reduced ?

What investigations should you perform now ?

Management  

The right hip remained subluxed post reduction.  In order to identify any structures which may have been blocking the reduction, a CT scan was done.  

CT Pelvis (Fine Cuts):

The patient was taken to the operating room for an open reduction of the right hip.  The left hip was allowed to heal in-situ and an ORIF was not carried out.  Postoperative radiographs showed excellent reductions and the long-term result of the left femoral head fracture is excellent.  

Postoperative Radiographs of Pelvis and Hips: