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PRINCIPLES OF
FRACTURES
Dr.David Samaroo
MBBS,MS
Department of Orthopedic Surgery
Georgetown Public Hospital Corporation,
University of Guyana School of Medicine.
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Mechanism of Injury
Types of Trauma
Mechanism of Injury
Types of Force
GENERAL CONSIDERATIONS IN MUSCULOSKELETAL
TRAUMA
 Assessment & treatment,principles of splinting
 Signs of a Fracture……dislocations,sprains/strains
 Classification of fractures
 Imaging
 Nonunion
 Malunion
 Complications of fractures
COST OF MUSCULOSKELETAL
TRAUMA
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Trauma is the “neglected disease”
Leading cause of death for people aged 1 to 44
yrs of all races & social levels
More than 100,000 persons in USA die from
accidents; 500,000 are permanently disabled
Cost over $40 billion per year
Generates over 3.5 million admissions to
acute-care hospitals per year
Local figures unavailable,you are the ones to
make them available
Mechanism of Injury
Types of Trauma
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Penetrating Trauma
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Compression (Blunt) Trauma
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Bending Trauma
Hyperflexion
Hyperextension
Mechanism of Injury
Types of Trauma
 Penetrating
Trauma
 Compression (Blunt) Trauma
 Bending Trauma
Hyperflexion
Hyperextension
Severe Contusion of Foot
Mechanism of Injury
Types of Trauma
 Penetrating
Trauma
 Compression (Blunt) Trauma
 Bending Trauma
Hyperflexion
Hyperextension
Cervical
(C5-C6)
Fracture
Dislocation
Mechanism of Injury
Types of Trauma
 Penetrating
Trauma
 Compression (Blunt) Trauma
 Bending Trauma
Hyperflexion
Hyperextension
Dorsal
Dislocation,
Long Finger
Middle Joint
(PIP Joint)
Mechanism of Injury
Types of Trauma
 Rotational
Trauma
 Distraction Trauma
 Crush Trauma
 Deceleration Trauma
 Acceleration Trauma
Normal
Tibia
Left
Spiral
Fracture
Tibia
Right
Mechanism of Injury
Types of Trauma
 Rotational
Trauma
 Distraction Trauma
 Crush Trauma
 Deceleration Trauma
 Acceleration Trauma
Brachial plexus injury/Dislocation of Right
Shoulder
Mechanism of Injury
Types of Trauma
 Rotational
Trauma
 Distraction Trauma
 Crush Trauma
 Deceleration Trauma
 Acceleration Trauma
Crush Injury, Leg
Mechanism of Injury
Types of Trauma
 Rotational
Trauma
 Distraction Trauma
 Crush Trauma
 Deceleration Trauma
 Acceleration Trauma
Mechanism of Injury
Types of Trauma
 Rotational
Trauma
 Distraction Trauma
 Crush Trauma
 Deceleration Trauma
 Acceleration Trauma
Car struck from behind “accelerates” passengers,
producing an extension injury
to the neck!
Acceleration Trauma
Mechanism of Injury
Types of Force
Mechanism of Injury
Types of Force
 Direct
Force
 Indirect Force
 Twisting Force
 High Energy Force
Direct
Mid-Shaft Fracture, Femur
Mechanism of Injury
Types of Force
 Direct
Force
 Indirect Force
 Twisting Force
 High Energy Force
Indirect
Posterior Dislocation, Elbow
Mechanism of Injury
Types of Force
 Direct
Force
 Indirect Force
 Twisting Force
 High Energy Force
Twisting
Subtalar Dislocation, Ankle
Mechanism of Injury
Types of Force
 Direct
Force
 Indirect Force
 Twisting Force
 High Energy Force
High Energy
Fractured Pelvis
GENERAL CONSIDERATIONS IN
MUSCULOSKELETAL TRAUMA
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Assessment & treatment priorities are
established according to type of injury,
stability of vital signs, & mechanism of injury
Assessment:1)Rapid primary evaluation
2)Restoration of vital function
3)Detailed secondary
evaluation
4)Definitive care
GENERAL CONSIDERATIONS IN
MUSCULOSKELETAL TRAUMA
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ABCs of Trauma Care:
Airway maintenance (with c spine control)
 Breathing and ventilation
 Circulation (with hemorrhage control)
 Disability (neurologic status)
 Exposure & environmental control (undress pt but
prevent hypothermia)
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GENERAL CONSIDERATIONS IN
MUSCULOSKELETAL TRAUMA
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Pre-Hospital Principles:
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Joints above & below fracture should be immobilized
Splints can be improvised with pillows, blankets, or
clothing
Immobilization doesn’t need to be absolutely rigid
Overt bleeding should be tamponaded with dressing & firm
pressure
Tourniquets should be avoided, unless it is obvious that pts
life is in danger
Injury Management
Splinting Immobilizes the Injury
 Reduces
Pain
 Prevents
further damage to blood
vessels, nerves and skin adjacent to
the injury
 Decreases Bleeding
 Facilitates
Transport
Principles of Splinting
Dress all wounds
 Immobilize the joints above and below a
suspected fracture
 With injuries at or near joints, immobilize
the bones above and below the injury
 Stabilize the injury site during splint
application
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Principles of Splinting
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Use gentle in-line manual traction to realign
displaced long bone fractures
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Expect to encounter increased pain and some
resistance when attempting to realign a
deformed limb
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Immobilize all suspected spinal injuries in a
neutral in-line position on a spineboard
Principles of Splinting
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If the patient demonstrates major signs of
shock, align the limb as close to its normal
anatomic alignment as possible on a
spineboard (immobilization of total body), and
provide rapid transport
Total Body Immobilization
When in doubt:
SPLINT!
Rigid Splints
Quick Splint
Cardboard Splint
Ladder Splint
SAM Splint
Soft Splints
Air Splint
Sling and Swathe
Vacuum Splint
Blanket Roll
Traction Splint
When standard splints
are unavailable,
improvisation
is better than doing nothing!
UPPER
EXTREMITY
All fractures can be
immobilized by
securing the
extremity to the
chest!
LOWER EXTREMITY
All fractures can be immobilized by
securing the injured extremity to the
opposite lower extremity!
GENERAL CONSIDERATIONS IN
MUSCULOSKELETAL TRAUMA
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ORTHOPEDIC EXAM
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Assess axial skeleton, pelvis, & extremities
Depends on overall central neurologic status
Assess for swelling, hematomas, open wounds
Palpate entire spine, pelvis, & each joint
Exam pelvis by compression of iliac wings in mediolateral
direction & pubis
Must document neurologic status to fullest extent possible,
motor & sensory, all major nerves & dermatomes inupper
& lower extremities
Must document all reflexes
Signs of a Fracture
 Tenderness
 Swelling
and Ecchymosis
 Deformity
 Crepitus
 Exposed Fragments
 False Motion
 Inability to Use the Limb
Seven Signs of Fracture
 Tenderness
 Swelling
and Ecchymosis
 Deformity
 Crepitus
 Exposed Fragments
 False Motion
 Inability to Use the Limb
Fractured Patella
Seven Signs of Fracture
 Tenderness
 Swelling
and Ecchymosis
 Deformity
 Crepitus
 Exposed Fragments
 False Motion
 Inability to Use the Limb
Angulated Fracture,
Radius and Ulna
Seven Signs of Fracture
 Tenderness
 Swelling
and Ecchymosis
 Deformity
 Crepitus
 Exposed Fragments
 False Motion
 Inability to Use the Limb
Crepitus
In a complete fracture, the sounds of bone
ends clicking or rubbing against each other;
denotes an unstable fracture!
Seven Signs of Fracture
 Tenderness
 Swelling
and Ecchymosis
 Deformity
 Crepitus
 Exposed Fragments
 False Motion
 Inability to Use the Limb
Open Ankle Fracture
Seven Signs of Fracture
 Tenderness
 Swelling
and Ecchymosis
 Deformity
 Crepitus
 Exposed Fragments
 False Motion
 Inability to Use the Limb
False Motion
The unusual visual sensation of
observing motion at a long bone fracture
site where
“there is no joint!”
Seven Signs of Fracture
 Tenderness
 Swelling
and Ecchymosis
 Deformity
 Crepitus
 Exposed Fragments
 False Motion
 Inability to Use the Limb
Fracture, Right Clavicle
Right Arm Protected
Seven Signs of Fracture
The presence of
any one
of the
seven fracture signs just listed
is sufficient to assess this injury!
Types of Injury Dislocation
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Disruption of a joint such that the bone
ends are no longer in contact
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Must have torn ligaments and joint
capsule
Signs of Dislocation
 Tenderness
 Deformity
(usually marked)
 Swelling and Ecchymosis
 Loss of normal joint motion
Common Dislocations
 Shoulder
 Finger
 Hip
 Elbow
Anterior Dislocation, Right Shoulder
Common Dislocations
 Shoulder
 Finger
 Hip
 Elbow
Dislocation, Middle Joint
(PIP Joint), Ring Finger
Common Dislocations
 Shoulder
 Finger
 Hip
 Elbow
Posterior Hip Dislocation
Common Dislocations
 Shoulder
 Finger
 Hip
 Elbow
Posterior Elbow Dislocation
Types of Injury
Fracture-Dislocation
A combined injury with joint
dislocation and an adjacent bone
fracture
Fracture–Dislocation, Ankle
Types of Injury
Sprain
 Partial
or complete
temporary joint dislocation
 Ligaments are torn
partially or completely
 May produce as much structural
damage as a dislocation
Sprain, Left Ankle
Types of Injury
Strain
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“Muscle Pull”
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Stretching or tearing of muscle,
or muscle fascia (covering)
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Occurs frequently in the lower
back secondary to poor posture
and poor abdominal muscle
control
Types of Injury
Fracture
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Any break in the continuity of a
bone
May vary from a simple crack to a
completely shattered bone
FRACTURE
CLASSIFICATION
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Location of bone
-Epiphyseal
-Metaphyseal
-Diaphseal
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Integrity of skin & soft tissue envelope
-Open vs. Closed
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Amount of displacement
Nondisplaced
Displaced
Incomplete/Complete
Angulated
Distracted
FRACTURE CLASSIFICATION
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Orientation/Extension of Fracture Line
-Transverse
-Torus
-Comminuted
-Greenstick
-Oblique
-Impaction
-Segmental
-Compression
-Spiral
-Depression
-Intra-articular
-Stress (Fatigue)
-Pathologic
-Linear
Closed Fracture,
Base of Thumb
Closed
Dorsally
Angulated
Forearm Fracture
Open Fracture, Tibia
Open Fracture, Forearm
Open Fractures Are More
Serious!
 Blood
 Potential
loss
contamination with
risk of infection
Fracture Classification
Closed/Open
Incomplete/Complete
Displaced/Displaced
Incomplete Fracture,
Distal Radius
Complete Fracture, Femur
Fracture Classification
Closed/Open
Incomplete/Complete
Non-Displaced/Displaced
Non-Displaced Fracture,
Distal Tibia and Fibula
Displaced/Angulated Forearm
Fractures
Types of Fracture
Comminuted – fractured into more
than two segments
Pathologic – fracture through
diseased bone
Epiphyseal – fracture passes through
the growth plate
Comminuted Femur Fracture
Types of Fracture
Comminuted – fractured into
more than two segments
Pathologic – fracture through
diseased bone
Epiphyseal – fracture passes through
the growth plate
Pathologic
Lytic lesion (darker = tumor) in
proximal phalanx of finger, with
associated transverse fracture
Other Types of Fracture
Comminuted – fractured into many
pieces
Pathologic – fracture through
diseased bone
Epiphyseal – fracture through the
growth plate
Epiphyseal (growth-line) Fracture,
Distal Femur
GENERAL CONSIDERATIONS IN
MUSCULOSKELETAL TRAUMA
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CONFIGURATION OF FRACTURES:
Intra-articular (fx line crosses articular cartilage &
involves joint)
 Displaced (expressed in mm or cm or % in
direction of displacement of distal fragment)
 Nondisplaced
 Angulated (expressed in degrees in direction of
apex)
 Comminuted (more than 1 piece at one fx location)
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GENERAL CONSIDERATIONS IN
MUSCULOSKELETAL TRAUMA
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IMAGING STUDIES:
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Polytrauma pts: c-spine, chest, pelvis
Long bone fx requires complete evaluation of joint
proximally & distally to fx
Long bone x-rays, minimum of 2 views AP & Lateral
CT scans visualize complex fx patterns esp with joint
involvement
MRI scans give soft tissue details
Bone scan: indicative of blood flow & therefore of bone
formation or destruction
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GENERAL CONSIDERATIONS IN
MUSCULOSKELETAL TRAUMA
“Clearing” the Cervical Spine:
X-ray: A-P views, Lateral views, Open mouth
odontoid view
Open mouth: lateral masses of C1 should line up
with body of C2
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Must see down to C7, if can’t then Swimmer’s
view, lateral cervical spine x-ray with arm
abducted & elevated
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May need flex/ext views to determine ligamentous
stability
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GENERAL CONSIDERATIONS IN
MUSCULOSKELETAL TRAUMA
“Clearing” the Cervical Spine:
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Amount of total overhang of C1 over C2 should be
less than 3 mm
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Lateral view, anterior border of bodies of cervical
segments should describe an arc
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No diastasis of spinous processes
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Joints & facet joints should all be visible
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Watch orientation from one cervical spine level to
another, r/o cervical fx, jumped facets, or dislocations
GENERAL CONSIDERATIONS IN
MUSCULOSKELETAL TRAUMA
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NONUNION:
Nonunion: fx that fails to show progressive healing ,there are
permanent radiologic signs the situation is permanent
CLASSIFICATION OF NONUNIONS:
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Hypertrophic: “elephant’s foot ”, “horse’s foot ”
flared out with viable bone ends,fracture visible ,fracture
filled with cartilage and fiberous tissue
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Atrophic: nonviable bone ends,rounded,osteoporotic
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If left untreated, may develop into pseudoarthrosis (false
joint)
Causes of non union
General
Specific
Diastasis of fx fragment
Compromise blood supply
Excessive motion
Infection
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GENERAL CONSIDERATIONS IN
MUSCULOSKELETAL TRAUMA
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CAUSES OF NONUNION:
1) General: age, nutrition, steroids, anticoagulants, radiation,
burns, immunosupression -predisposure to nonunion
2)Diastasis of fx fragment
a. Soft tissue interposition
b. Distraction from traction or internal fixation
c. Malposition
d. Loss of bone
GENERAL CONSIDERATIONS IN
MUSCULOSKELETAL TRAUMA
CAUSES OF NONUNION:
3)Compromised blood supply
a. Damage to nutrient vessels
b. Stripping or injury to periosteum & muscle
c. Free fragments; severe comminution
d. Avascularity due to internal fixation devices
GENERAL CONSIDERATIONS IN
MUSCULOSKELETAL TRAUMA
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CAUSES OF NONUNIONS:
4) Excessive motion: inadequate immobilization
5) Infection
a) Bone death (sequestrum)
b) Osteolysis (Gap)
c) Loosening of implants (motion)
GENERAL CONSIDERATIONS IN
MUSCULOSKELETAL TRAUMA
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NONUNION OF FRACTURES:
Delayed union: fx that has not gone on to full bony
healing after 6 months
 Areas prone to nonunion:
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Distal tibial diaphysis
 Proximal diaphysis of 5th metatarsal
 Segmental fx
 Transcervical hip fx,scaphoid,talus
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GENERAL CONSIDERATIONS IN
MUSCULOSKELETAL TRAUMA
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TREATMENT OF NONUNIONS:
Correction of cause, if possible
 Stabilization of bone ends
 Eradication of infection
 Restoration of blood supply
 Surgical excision of interposing tissues
 Bone graft of fracture gaps at time of internal
fixation
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GENERAL CONSIDERATIONS IN
MUSCULOSKELETAL TRAUMA
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MALUNION OF FRACTURE:
Fx that has healed with unacceptable amt of
angulation, rotation,or overriding
 Shortening is better tolerated in upper ext than
lower ext
 Angular deformity better tolerated in humerus than
femur or tibia
 Shortening more than 1 inch is poorly tolerated in
lower extremity
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GENERAL CONSIDERATIONS IN
MUSCULOSKELETAL TRAUMA
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COMPLICATIONS:
Compartment Syndrome
 Acute Respiratory Distress Syndrome (Fat
Embolism Syndrome)
 Thromboembolic Disease
 Atelectasis
 Ectopic (Heterotopic) Bone Formation
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GENERAL CONSIDERATIONS IN
MUSCULOSKELETAL TRAUMA
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COMPARTMENT SYNDROME:
Pathologic developments in a closed space in body
caused by buildup of pressure
 Pressure rises from edema or bleeding within
compartment, compromising circulation to
compartment, can result in necrosis of muscle &
nerve damage
 Causes: Fracture, soft-tissue injury, arterial injury,
burn, abnl external compression from
immobilization
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GENERAL CONSIDERATIONS IN
MUSCULOSKELETAL TRAUMA
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COMPARTMENT SYNDROME:
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Characteristics: Pain
Pulselessness
Pallor
Paresthesias
Paralysis
-Pulses generally remain intact until late
-Paresthesias occur only when significantly advanced
-Paresis, if present, is an unreliable finding
-Pain with passive stretching is subjective
GENERAL CONSIDERATIONS IN
MUSCULOSKELETAL TRAUMA
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COMPARTMENT SYNDROME
Pressure is key component
 Palpation of soft compartment doesn’t rule out
compartment syndrome
 Intracompartmental pressure readings greater than
30-40 mmHg are indications for fasciotomy
 Late fasciotomy may result in muscle damage or
possible necrosis with resulting infection
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GENERAL CONSIDERATIONS IN
MUSCULOSKELETAL TRAUMA
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COMPARTMENT SYNDROME:
Forearm: Extensile volar incision to permit
complete release, including carpal tunnel distally
& lacertus fibrosis proximally; Dorsally, a
longitudinal incision is used
 Calf: Two incisions are used to release the four
compartments of leg
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Longitudinal incision over anterior intermuscular
septum for anterior & lateral compartments
 Posteromedially, second incision for superficial & deep
posterior compartments
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GENERAL CONSIDERATIONS IN
MUSCULOSKELETAL TRAUMA
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Fat Embolism Syndrome:
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Special ortho manifestation of ARDS
Caused by release of marrow content into circulation e.g.
s/p fracture
Lungs show fat droplets, usually diffusely distributed
throughout pulmonary vasculature
Can occur when medullary canal of a long bone is
pressurized during IM alignment jigs of TKA
Dx: Decrease in arterial Po2, Increase systemic Pco2,
infiltrates on chest X-ray, presence of petechiae, & mental
confusion
Rx: Minimize hypoxemia with ventilatory support
GENERAL CONSIDERATIONS IN
MUSCULOSKELETAL TRAUMA
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HETEROTOPIC BONE FORMATION
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Occurs in 10% of trauma cases
May cause pain or joint motion restriction or ankylosis
Without head trauma can be seen on x-ray 1-2 months after
trauma
Much more common in head injury pts, release of humeral
modulators
Resection may be indicated by 6 months if NL alkaline
phosphatase & mature x-ray appearance
May benefit from low dose radiation (7Gy) &
indomethacin for 3-6 weeks