Knee Dislocations
Dislocations at the knee occur as a result of a violent
trauma. For example, a Posterior Dislocation—the dashboard injury, is the most
common mechanism of injury which includes exaggerated hyperextension of the
knee and dashboard (posteriorly directed force with the knee flexed at 90
degrees). Posterior dislocation is associated with a high incidence of popliteal
artery injury. With an established popliteal artery injury and resultant
ischemia, blood flow must be restored within 6 hours. Posterior tibialis and
dorsalis pedis pulses should be carefully evaluated in any patient with a knee
dislocation. Look for any evidence of ischemia, diminished blood flow, or
compartment syndrome. Incidence of nerve injury range from 14 percent to 35
percent. Be cautious of spontaneously reduced knee dislocations and its
associated pathology.
Urgent reduction of the knee dislocation is mandatory. Once
the reduction is complete, it is important to reevaluate circulation. If the
circulation is normal, serial follow-up up to 48 hours with clinical
examination and non-invasive studies (ABI). If the circulation is abnormal, an
arteriography should be performed. If no pulses are palpable, immediate
exploration will need to be initiated. The arterial injury is treated,
circulation restored, and prophylactic fasciotomy may be necessary.
Posterior Sternoclavicular Joint Dislocation
A Posterior Sternoclavicular Joint Dislocation typically results
from either a direct force applied to the front of the medial clavicle or an
indirect force applied to the posterolateral aspect of the shoulder. Posterior
dislocation of the sternoclavicular joint could be missed. It is imperative to look
for compression of the trachea, esophagus, or great vessels of the neck. A
posterior dislocation is difficult to diagnose by x-ray so a CT scan is the
preferred method for diagnosing the dislocation and any associated
complications. An urgent reduction is mandatory in order to assure that a
closed reduction is successful and stable. Open reduction may be performed if a
closed reduction is unsuccessful. If an open reduction is decided, during the
operation, a cardiac surgeon will be waiting standby.
Scapulothoracic Dissociation
Scapulothoracic Dissociation is a rare entity that consists
of disruption of the scapula-thoracic articulation. It is a closed avulsion of
the scapula with associated clavicular fracture or disruption of its
articulations and severe soft tissue injury. This injury has been described as
a closed, traumatic fore-quarter amputation. It is a traumatic lateral
displacement of the scapula with intact skin. It is associated with upper
extremity fractures such as fractures of the scapula, clavicle, and humerus.
Most often, there are varying degrees of injury to the brachial plexus and the
subclavian artery, resulting in a flail and pulseless upper extremity. An arteriogram
should be performed to diagnose a vascular injury. A chest x-ray shows
significant lateral displacement of the scapula; however, the injury can be
missed!
First method of treatment consists of advanced trauma life
support (airway breathing, circulation), followed by an arteriogram for
evaluation of the vascular injury and repair of the arterial injury, if possible.
Fat Embolism
Fat embolism syndrome is a clinical diagnosis with
non-specific or insensitive diagnostic tests. This occurs in trauma patients
with multiple long bone fractures or pelvic fractures. Suspect fat embolism
syndrome with the appropriate signs and underlying risk factors. The clinical
signs usually develop within 24-72 hours of the injury. A fat embolism will
develop earlier than a pulmonary embolism. Early stabilization of the fractures
decreases the rate of incidence of this complication.
Major signs of a fat embolism include: confusion, agitation,
petechial rash—axillae, conjunctivae, palate, and shortness of breath. Minor
signs are listed as: tachycardia, fever, anemia, thrombocytopenia, and fat in
the urine. For a diagnosis of a fat embolism, there must be one major sign and
four minor signs, as mentioned above. Treatment of the fat embolism consists of
diagnostic tests—however these are non-specific and insensitive, supportive
treatment—such as intubation and oxygenation, and prevention (stabilization of
long bone fractures).
Femoral Fracture in the Multiply Injured Patient
In a multiply injured patient, early skeletal stabilization
of a femoral fracture within 24 hours results in decreased incidence of
pulmonary complications and fat embolisms. The effect of reamed intramedullary
nailing for femoral fractures on the incidence of pulmonary complications in a
multiply injured patient or patients with concomitant chest injury is
controversial. Multiple studies have shown that reamed intramedullary nailing
for the acute stabilization of femoral fractures in the multiply injured
patient with a thoracic injury did not increase the occurrence of pulmonary
complications. External fixation is indicated for early stabilization of femoral
fractures in severely injured patients as a form of damage control in
orthopedics and as a temporary bridge to femoral nailing. External fixation is
also indicated in the presence of an associated vascular injury requiring
stabilization before repair and in the presence of severe soft tissue injuries
with extensive contamination.
Hip fractures in an elderly patient
Nonoperative treatment in elderly patients with hip
fractures results a high complication rate including pneumonia,
thromboembolism, urinary tract infection, and decubitus ulcers, resulting in a
high mortality rate.
The mortality rate is 25% in the first year following the
fracture. Early surgery within 48 hours of an injury has been shown to be
associated with a decreased one-year mortality rate.
