EditorMS Dhillon MBBS MS FAMS
Professor and Head Department of Orthopedic Surgery Head Physical Medicine and Rehabilitation Incharge, Sports Medicine Clinic Postgraduate Institute of Medical Education and Research
Chandigarh, India
Formerly Dean Physiotherapy and Associated Sciences Baba Farid University of Health Sciences
Faridkot, Punjab, India
Associate EditorSarvdeep S Dhatt MBBS MS
Assistant Professor Department of Orthopedic Surgery Postgraduate Institute of Medical Education and Research
Chandigarh, India
ForewordPiet de Boer
7Contributors
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First Aid and Emergency Management in Orthopedic Injuries
First Edition: 2012
9789350256459
Printed at
5Dedicated to
The two most important women in my life.
My mother, Dr Satwant Ganda Singh, who nurtured a respect for the written word, and who taught me to be inquisitive about everything if I want to gain any kind of knowledge.
My wife, Rima, who has withstood my idiosyncrasies, and has allowed me the time and space to pursue my career and my aspirations to publish.
All positives I attribute to them; the mistakes and omissions, if any, are mine alone
— MS Dhillon
- Amit Rastogi ms (Ortho)
- Consultant
- Department of Orthopedics
- Banaras Hindu University
- Varanasi, Uttar Pradesh, India
- Anil Agarwal mbbs ms (Ortho)
- Consultant Orthopedics
- Department of Pediatric Orthopedics
- Chacha Nehru Bal Chikitsalaya
- Delhi, India
- Anil Arora ms (Ortho) dnb (Ortho) dip sirot
- Head
- Department of Orthopedics
- Max Superspecialty Hospital
- Delhi, India
- Banchong Mahaisavariya md
- Professor
- Department of Orthopedic Surgery
- Faculty of Medicine
- Siriraj Hospital, Mahidol University
- Bangkok, Thailand
- Ben Okafor frcs (Ortho)
- Consultant Orthopedics
- Whipps Cross University Hospital
- NHS Trust, Leytonstone, London, UK
- Edward G McFarland md
- Vice Chairman, Wayne H Lewis
- Professor of Shoulder and Orthopedic Surgery
- Division of Shoulder Surgery
- Department of Orthopedic Surgery
- The Johns Hopkins University
- Baltimore, Maryland, USA
- Harpal Singh Selhi mbbs ms
- Senior Consultant and Head
- Department of Orthopedics
- SPS Apollo Hospitals
- Ludhiana, Punjab, India
- Harpeet Gill ms
- Senior Consultant and Coordinator Orthopedics
- SPS Apollo Hospitals
- Ludhiana, Punjab, India
- Jaspal S Sandhu mbbs ms (Ortho) dsm fais fasm fiasmes fafsm
- Dean
- Faculty of Sports Medicine
- Guru Nanak Dev University
- Amritsar, Punjab, India
- Juan Garzon-Muvdi md
- Clinical Research Fellow
- Department of Orthopedic Surgery
- The Johns Hopkins University
- Lutherville, Maryland, USA
- K Vivek Pannikar ms dnbe frcs(Eng) mch (Ortho) frcs (Ortho)
- Consultant Orthopedic Surgeon
- Doncaster and Bassetlaw NHS Foundation
- Trustarmthorpe Road, Doncaster DN2 5LT
- S Yorkshire, UK
- Konkhet Riansuwan md
- Assistant Professor
- Department of Orthopedic Surgery
- Faculty of Medicine
- Siriraj Hospital, Mahidol University
- Bangkok, Thailand
- Mandeep Singh Virk mbbs ms (Ortho) md
- Orthopedic Resident
- The New England Musculoskeletal Institute
- University of Connecticut Health Center
- 263, Farmington Avenue, Farmington
- Connecticut 06030-5456 USA
- MS Dhillon mbbs ms fams
- Professor and Head
- Department of Orthopedic Surgery
- Head
- Physical Medicine and Rehabilitation
- Incharge, Sport Medicine Clinic
- Postgraduate Institute of Medical Education and Research
- Chandigarh, India
- Formerly Dean
- Physiotherapy and Associated Sciences
- Baba Farid University of Health Sciences
- Faridkot, Punjab, India
- Nandkishore Shamrao Laud ms (Ortho) frcs (Eng) dsc (Hon)
- Chairman
- Shushrusha Citizen's Co-operative Hospital Ltd
- Dadar (W), Mumbai, Maharashtra, India
- Consultant
- Laud Clinic
- Hindu Colony, Dadar (E)
- Mumbai, Maharashtra, India
- Raj Bahadur ms (Ortho) frcs (Glasg) fams fimsa fica fpasc
- Professor of Orthopedics
- Postgraduate Institute of Medical Education and Research
- Chandigarh, India
- Director-Principal
- Government Medical College and Hospital
- Chandigarh, India
- Ramesh K Sen mbbs ms dnb
- Professor
- Department of Orthopedic Surgery
- Postgraduate Institute of Medical Education and Research
- Chandigarh, India
- Ravi Gupta mbbs ms dnb
- Associate Professor
- Department of Orthopedics
- Government Medical College and Hospital
- Chandigarh, India
- Rohit Rambani mbbs ms (Ortho) mrcs (Eng) fimsa
- Specialist Registrar
- Leeds General Infirmary
- Leeds, UK
- Sameer Aggarwal mbbs ms
- Associate Professor
- Department of Orthopedic Surgery
- Postgraduate Institute of Medical Education and Research
- Chandigarh, India
- Sarvdeep S Dhatt mbbs ms
- Assistant Professor
- Department of Orthopedic Surgery
- Postgraduate Institute of Medical Education and Research
- Chandigarh, India
- SC Goel mbbs ms
- Professor and Head
- Department of Orthopedics
- Institute of Medical Sciences
- Banaras Hindu University
- Varanasi, Uttar Pradesh, India
- Shamal Das De mbbs frcs (Edin) frcs (Ortho) mch (Ortho) md
- Professor and Senior Consultant
- Department of Orthopedic Surgery
- University Orthopedic, Hand and Reconstructive Microsurgery Cluster
- National University Health System/Yong Loo Lin School of Medicine
- 5 Lower Kent Ridge Road, Singapore 119074
- Sharad Prabhakar mbbs ms (Ortho)
- Assistant Professor
- Department of Orthopedic Surgery
- Postgraduate Institute of Medical Education and Research
- Chandigarh, India
- Shivinder Sandhu ms
- Senior Consultant
- Bone and Joint Clinic
- Lawrence Road, Amritsar, Punjab, India
- Shweta Shenoy phd
- Reader
- Faculty of Sports Medicine and Physiotherapy
- Guru Nanak Dev University
- Amritsar, Punjab, India
- Soumen Das De mbbs (Hons) mrcs (Edin) mmed (Ortho) mph
- Registrar
- Department of Orthopedic Surgery
- University Orthopedic, Hand and Reconstructive Microsurgery Cluster
- National University Health System/Yong Loo Lin School of Medicine
- 5 Lower Kent Ridge Road, Singapore 119074
- Srinivas Samsani ms frcs (Edin) frcs (Glasg) msc (Trauma) frcs (Tr & Ortho-Edin)
- Consultant and Orthopedic Surgeon
- Medway NHS Foundation Trust
- Gillingham, Kent, ME7 5NY England
- Steve A Petersen md
- Associate Professor
- Co-Director, Division of Shoulder Surgery
- Department of Orthopedic Surgery
- The Johns Hopkins University School of Medicine
- Baltimore, Maryland, USA
- Steven J Lawrence md
- Associate Professor
- Department of Orthopedic Surgery
- Head of Foot and Ankle Surgery
- University of Kentucky
- Lexington, Kentucky 40536, USA
- Sudhir S Babhulkar ms (Ortho) d (Ortho) phd (Ortho) dsc (Ortho) fams
- Emeritus Professor
- Indira Gandhi Medical College
- Nagpur, Maharashtra, India
- Director
- Sushrut Hospital, Research Centre and Postgraduate Institute of Orthopedics
- Ramdaspeth, Nagpur, Maharashtra, India
- Sudhir Warrier ms (Ortho)
- Hand and Reconstructive Orthopedic Surgeon
- Lilavati and Jaslok Hospitals
- Mumbai, Maharashtra, India
- Sukhpal Kaur msc phd
- Lecturer
- National Institute of Nursing Education
- Postgraduate Institute of Medical Education and Research
- Chandigarh, India
- Uttam Chand Saini ms dnb mnams
- Senior Resident
- Department of Orthopedic Surgery
- Postgraduate Institute of Medical Education and Research
- Chandigarh, India
Martin Allgower, one of the pioneers of modern fracture treatment, described orthopedic trauma as being the “Cinderella of Orthopaedics” when he accepted his honorary fellowship from the Royal College of Surgeons of England in 1976. He meant that most surgeons did not regard trauma as being important. At that time, most practicing orthopedic surgeons felt that fracture management was relatively easy and results were good. Most fractures were treated nonoperatively, unsupervised trainees treated most fractures and many fractures such as intra-articular fractures of the distal humerus were deemed untreatable.
Since that time, there has been a very slow and gradual acceptance that correct fracture treatment is very important and that most injuries can be managed so as to allow full return of function.
Trauma is important. Trauma is the second most common cause of death in men under the age of 40s in nearly every western country. It is the most common cause of long-term disability in this group. Deaths and long-term morbidity from trauma are increasing rapidly throughout the developing world as high energy injuries increase in the context of a medical environment designed to treat the low velocity injuries of yesteryear. Trauma will continue to be a major health problem in the future as the decline in high energy deaths caused by improved treatment and road safety will be accompanied by a sharp rise in the number of people with osteoporosis and accompanying fractures.
Fracture healing has been present on earth for at least 350 million years. Indeed, it is impossible to image the survival of land animals with endoskeletons without a natural healing mechanism capable of mending fractures. A glance at any of the dinosaur skeletons that are present in many of our museums will usually show at least one healed fracture and a study of that fracture will reveal the characteristic form of callus. So, it is reasonable to propose that a surgeon's role is to support and promote that healing process.
Treatment of fractures and soft tissue injuries potentially begins immediately after the accident. Prompt evacuation of injured patients combined with simple primary treatment including wound coverage, splintage, analgesia, fluid replacement and antibiotics, as needed, does make a significant contribution to the long-term results of treatment. Harald Tscherne from Hannover has showed dramatic changes in the rate of infection in open fractures dependent on the speed of evacuation of patients to hospital. He was practicing at a level 1 trauma unit in Germany and much of his work is not applicable in rural India where the golden hour of ATLS may indeed turn out to be the golden week in reality. For this reason, two chapters on prehospital care are included in this book—one from the Western standpoint and one from the Indian one.
First aid treatment whether it is at the roadside or the casualty department of the hospital is another vital stage in the successful management of injured patients. Doctors in training assisted by nursing staff usually give this treatment. This book has several chapters on this vital first stage in treatment with sections focusing on specific injury categories. Of particular importance is the chapter on the nurse's viewpoint. Junior doctors need to understand the complimentary role of nurses in the emergency situation, where not infrequently, it is the nurse who has the experience. They also need to understand that successful treatment of an injured patient involves teamwork from many other disciplines including radiographers and the emergency services.12
One of the saddest features of the modern world is the increasing number of disasters both natural and man-made. Multiple road accidents, terrorist outrages and natural disasters have produced problems unique to the last twenty years. The logistic problem of communication, evacuation and triage are daunting and are well described in the chapter on disasters.
This book is designed for all doctors who have the responsibility of dealing with injured patients as an emergency. I hope that all who read it will gain knowledge attitudes and skills, which will allow them to administer better care. Better care in the emergency situation will be associated with better long-term functional results to the benefit of the patients and the society from which they come.
Piet de Boer ma frcs
Hon Senior Lecturer
University of Hull and York Medical School
United Kingdom
13Preface
In the modern era, Orthopedic Surgery has progressed much further than just setting bones, and Traumatology is fast evolving into a specialty in its own right. Nevertheless, the basics for any orthopedic surgeon still evolve from trauma management, and there are many new ideas and concepts which have taken root. The principal reason why this particular topic was chosen as the focus was the fact that despite many times in the established literature, the basic approach to emergency orthopedics is sometimes overlooked; we cannot expect our residents and young doctors to become good clinicians and primary care givers, if they are not well versed in the management scenarios in the emergency room. This book, thus, deals with the different aspects related to emergency management of injuries, with the principal aims in trying to highlight “what is”, with an attempt to show “what can be”.
We have tried to cover many topics, and the idea is to have a flow from the basics to the more specific art of first aid and ER management in specific situations. Prehospital management is a much neglected issue in many countries, and the two separate chapters, from the UK and India show the differences and what the overall scenario should be. The discerning reader shall notice that each topic is covered differently, but all have a certain degree of depth, as various levels of surgeons in training and orthopedists in the making are the potential readers. We hope this book benefits the orthopedic residents, especially in their day-to-day approach to patients presenting with acute trauma.
This book would not have been possible without the efforts and suggestions of many people, all of whom cannot be listed here. However, the editors would like to thank all the contributors for their kind cooperation as well as their patience in publishing this book, which has been due for a long time.
MS Dhillon
15Acknowledgments
The efforts of all those who contributed to this book cannot be mentioned individually. I would like to mention the special motivation of my friend, Dr Willy Sandhu, who is no longer with us, as he repeatedly cajoled me to finish this project; it is unfortunate that he did not live to see the culmination of the same.
Special mention has to be made of Dr Sarvdeep S Dhatt who came on as an Associate Editor when this book was languishing and brought on extra energy (which the youth always have) and has pushed this project to print.
I cannot thank enough the dedicated staff at M/s Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, India, whose professionalism and motivation are commendable.
— MS Dhillon