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By: Steve Yentis, Consultant Anaesthetist, Chelsea and Westminster Hospital; Honorary Reader, Imperial College, London, UK
Gustilo classification category to ‘increase’ with The dressings are removed before the skin is time as the patient receives treatment discount 20 mg vardenafil mastercard doctor for erectile dysfunction in gurgaon. The wound should be irri- Typ e I Open fractures with a small generic vardenafil 20mg fast delivery impotence at 43, 1 cm buy vardenafil 20mg without a prescription impotence 24-year-old, clean gated with normal saline order antabuse 250 mg overnight delivery. A minimum of 6L of wound with minimal injury to the musculature fluid is usually needed purchase discount lasix on-line, depending on the size of the and no significant stripping of the periosteum wound. Careful assessment associated extensive injury to the muscle, peri- and the excision of unhealthy tissue may involve osteum and bone which is often associated with extending the wound in the knowledge that subse- significant contamination of the wound. Such injuries can be better to have a zone of clean healthy tissue around subdivided into: the fracture. This is called a degloving bone and neurovascular structures with- injury and is most commonly seen inassociation out muscle transfer. Contraction The category of Gustilo injury generally reflects the Circulation velocity of the trauma sustained by the patient: remembered as the four Cs. They usually take well but the cosmetic do so may result in increasing pressure within the result is often poor. All these full thickness grafts are less reliable and The management of devascularized bone frag- leave a significant scar at the donor site, but when ments is controversial. If the Primary closure of the wound can be per- fracture is not stabilized further soft tissue damage formed after the removal of all the dead tissue and may occur, which increases the risk of developing washout provided there is negligible skin loss, the infection. This consists of a tissues, neurovascular structures and any adjacent polyurethane sponge with transparent self-adhesive joint. The vacuum draws fluid from the zone of injury blood loss and promotes wound healing. Complications of fractures 155 The immediate complications of fractures are: the femoral artery in a supracondylar fracture of the femur bleeding (haemorrhage) the internal iliac and superior gluteal arteries in vascular injury association with pelvic fractures. In pelvic fractures the haemorrhage is often from injured veins and retroperitoneal blood Bleeding vessels. An artery may appear normal externally, but fol- Although a fracture may be associated with an injury lowing a blunt injury may contain an intimal tear or to a major blood vessel, the local soft tissue trauma flap which restricts blood flow causing intravascu- and, indeed, bleeding from the bone itself can lead to lar thrombus formation leading to distal embolism significant blood loss. The degree of blood loss varies with the bones Arterial injuries are suspected on clinical exami- involved: nation and are confirmed by measuring doppler pressures. Treatment is dependent on the nature of the vascu- The significance of such fractures must never be lar injury. If an angiography shows the vessels are underestimated, especially if there are other injuries. Thrombosed vessels can It is crucial to anticipate these requirements and be cleared by a balloon catheter. When an arterial repair is performed the frac- ture must be stabilized simultaneously to prevent Vascular injuries further injury to the blood vessel. Arteries and veins may be damaged by sharp or Nerve injuries blunt trauma (see Chapter 6 and 11). An artery may be cut, torn, contused, compressed or simply go The effects of a nerve injury are seen in the ana- into spasm, in association with a fracture.
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