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Recent literature in a variety of disci- tral components that function to sense and control motion purchase cefdinir 300 mg free shipping virus yahoo search. These signals are carried along the vestibulo- cochlear nerve (cranial nerve eight) to the brain stem discount cefdinir 300 mg on-line 801 antibiotic. Studies performed since is readily evaluated clinically through optokinetics and 351 352 Textbook of Traumatic Brain Injury nystagmus order 300mg cefdinir with visa treatment for frequent uti. In addition purchase 300 mg cefdinir fast delivery antibiotic keflex 500mg, peripheral vestibular signals in- movement away leads to the opposite: a decrease or inhi- teract with both cervical and lower spinal motor neurons bition of resting discharge rate. A variety of neurotransmit- to generate the vestibulocolic and vestibulospinal re- ters exist throughout the peripheral and central vestibular flexes. These function to maintain and modulate posture, system with glutamate and related amino acids dominat- gait, and head position. The cerebellum also plays a criti- ing the afferent vestibular synapses (Highstein and Hol- cal role in coordination and the ability to adapt to vestib- stein 2006). Finally, while their exact function remains a near the utricle, thus utriculo- or ampullopedal flow subject of ongoing investigation, both cortical and auto- causes an increase in firing, while flow in the opposite nomic pathways are believed to play a role in various vis- direction (ampullo- or utriculofugal) is inhibitory. Con- ceral responses to vertigo, such as nausea, as well as the versely, the opposite is true in the posterior and superior conscious sense of motion. Here the kinocilium is located near the canal side, and deflection of the cupula away from the utricle leads to an excitatory response, whereas deflection toward (utric- The Peripheral Vestibular System ulo- or ampullopedal) is inhibitory. As most head move- The peripheral vestibular system is composed of three ment exists in multiple planes, typically all three canals semicircular canals-the horizontal (or lateral), the poste- are stimulated simultaneously. Using the bilateral planar- rior (or inferior), and the anterior (or superior)-and two paired canals mentioned previously, complex integration otolithic organs-the utricle and saccule (Figure 22–1). Each acceleration are detected by the otolithic organs, the utri- canal is paired with the canal in the opposite ear that lies cle and saccule. In each, the neuroepithe- within each fluid-filled bony framework is the membra- lium is found in a specialized region called the macula, nous labyrinth or the vestibular end-organ. Overlying the mac- fluid of bony labyrinth, has an electrolyte composition ulae is the otoconial membrane, a gel-like matrix similar to similar to extracellular fluid with a greater ratio of sodium the cupula, into which the kino- and stereocilia of the hair to potassium. Embedded in the otoconial membrane are rate from the perilymph and enclosed within the mem- deposits of calcium carbonate called otoliths. Gravita- branous labyrinth, contains a greater concentration of tional and linear acceleration cause movement of these potassium relative to sodium. Ultimately, the vestibular crystals, leading to deflection of the hair cell stereocilia. As in the ampullae of the semicircular canals, Each semicircular canal contains an eccentric dilated movement of the kinocilium with respect to the stereocilia or ampullated end, in which the vestibular sensory recep- allows modulation of neural firing. These ampullae are sepa- polarization in the macula is complex and centered rated from the rest of the canal by a perpendicular septum, around an irregular line called the striola. As in the semi- the cristae ampularis, containing neuroepithelium, blood circular canals, the integration of inhibitory and excitatory vessels, and connective tissue. Vestibular hair cells sit signals in neural firing allows translation of gravitational within the crista, and their cilia protrude into the endo- or linear movement into mechanical stimuli and, ulti- lymphic space topped by a gelatinous mass called the cu- mately, electrical impulses. This leads to release of neurotransmitters and of cranial nerve eight, the vestibulocochlear nerve. Specif- depolarization of the afferent nerve fibers that innervate ically, impulses from the neuroepithelium of the lateral the hair cells. Each hair cell has approximately 70 short and anterior canals, as well as the macula of the utricle and stereocilia and one longer kinocilium that project into the part of the saccule, are carried along the superior vestibu- gelatinous cupula. It is the laterally located kinocilium lar nerve, while information from posterior canal and re- that is the primary determinant of the direction of polar- maining saccular macula are transmitted by the inferior ization. At rest, there is a high baseline firing rate for the ves- Inferior and superior nerve fibers transmit afferent vestib- tibular nerve in each canal. Head movement, leading to ular input from the periphery to four vestibular nuclei in deflection of the kinocilium, causes modulation of this the pontomedullary junction. Deflection of the kinocilium toward that the initial integration and distribution sensory affer- the stereocilia causes an increase in neurotransmitter re- ent input occurs. Focused view of the dilated, or ampullated, end of a semicircular canal showing the cristae ampullaris, neuroepithelium (including the hair cells), and the cupula. Fluid motion, generated by head rotation, generates forces across the cupula that bend the stereocilia of the hair cells, resulting in release of neurotransmitter into the vestibular synapse. Each hair cell has approximately 70 short stereocilia and one longer kinocil- ium that project into the gelatinous cupula. It is the laterally located kinocilium that is the primary determinant of the direction of po- larization. Each hair cell is innervated by vestibular afferent neurons that allow transmission of positional information to the brain. Connections between the vestibular nuclei and ocu- complished by activation of left lateral and right medial lomotor nuclei allow maintenance of clear vision during rectus muscles and inhibition of left medial and right lat- head movement (see Figure 22–2). The neural circuitry included in this reflex starts ical states such as trauma, nystagmus can yield informa- with the vestibular nuclei and ultimately involves both tion on the location of the vestibulopathy. Inte- stem, projections from vestibular nuclei synapse on the oc- gration of these signals takes place directly in the medial ulomotor, trochlear, and abducens nuclei (cranial nerves longitudinal fasciculus and indirectly in the pontine retic- three, four, and six, respectively). Smooth hibitory peripheral signals depending on the direction of pursuit is responsible for maintaining a moving target on motion. Simply put, these signals ultimately translate to the fovea, while saccadic movements allow quick redirec- synchronized contraction and relaxation of the extraocu- tion of gaze from one target to another. Connections among the vestibular, abducens, and oculomotor nuclei allow maintenance of vision during head movement. Rotational head movement yields both excitatory and inhibitory peripheral signals depending on the direction of motion. In this example, main- tenance of an image on the retina during head rotation to the right requires conjugate leftward gaze. This is accomplished by stimulation of the right lateral semicircular canal and subsequent activation of the vestibular, abducens, and oculomotor nuclei. Ultimately, this neural circuitry culminates in activation of the left lateral and right medial rectus muscles and inhibition of left medial and right lateral recti. Integration of these signals takes place directly in the medial longitudinal fasciculus and indirectly in the pontine reticular for- mation (not shown). Comprehensive neurologic exam as well as op- Vertigo, from the Latin vertere meaning “to spin,” re- tokinetic testing can assist with localization of pathology fers to a hallucination of rotary movement, either of the pa- or injury. These reflexes result from multifaceted thology related to the semicircular canals. A sensation of interactions between peripheral afferent stimuli from the falling forward or linear motion can suggest problems with semicircular canals and otolithic organs and the somatic the otolithic organs. These complex tionary objects are moving during head motion, is indica- pathways allow maintenance of gait, posture, and balance. The meaning of the term light-headedness directly, from the superior vestibular nuclei, and indi- is extremely variable; it can represent vestibular, cerebral, rectly, to the cerebellum. More specifically, ance, the cerebellum is critical to adaptation after vestibu- it is often representative of presyncopal sensations and lar injury. Unsteadi- ness, imbalance, lack of coordination, and disequilibrium and Physical Examination are terms used to describe inability to confidently navigate in one’s environment.
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Teir size can range from pregnancy – fbroids may increase in size or degenerate a few millimetres to several centimetres discount cefdinir 300mg on line antibiotics for acne amoxicillin, and they are (red degeneration) resulting in pain; they can also cause usually present in the main body of the uterus buy discount cefdinir 300mg line infection types, occa- premature labour cheap cefdinir 300 mg with amex virus 1999 torrent, malpresentation buy 300 mg cefdinir free shipping antibiotics for uti and bv, obstructive labour, sionally occurring in the cervix or the broad ligament. Confrmation of diagnosis is generally straightforward Leiomyomas can be divided into four categories with physical examination and pelvic ultrasonography. Intramural leiomyomas are the most common and, when large, may distort the uterine outline, resulting in a large, irregular mass. This type of myoma can give rise to men- strual problems and to complications of pregnancy. Submucosal leiomyomas are found beneath the muco- sal surface of the uterus and can cause bleeding, even when small, secondary to compression of the overlying endometrium and compromise of its vascular supply. As they become larger, they may bulge into the endome- trial cavity and increase the surface area of the endo- metrium. Rarely, this kind of myoma can become pedunculated and prolapse through the cervix. Subserosal leiomyomas develop beneath the peritoneum that covers the external surface of the uterus, and are either sessile or pedunculated. The latter may undergo torsion, infection, and even separation from the uterus itself. When separation occurs, attachment to another Figure 3 Hysterectomy specimen showing enlarged uterus due to fbroids. Pendunculated subserous Subserous displacing and Intramural obstructing fallopian tube Pendunculated subserous Subserous Submucous Cervical Pendunculated Vagina Figure 4 Transverse section across a fbroid showing a whorled appearance. In these cases, the distended uterus may adjacent organs, resulting in intestinal and urinary symp- present with pain and may be palpable on physical toms. Causes include cervical scarring secondary to trauma All types of myomas can undergo degenera- (lacerations following parturition or abortion), sur- tive change. Submucosal myomas are frequently gery (cone biopsy, cryotherapy, cervical cauterisa- ulcerated and haemorrhagic. Malignant with endometrial cancer present with postmenopau- change of fbroids is reported to occur in 0. Adenomyomas recommended initial investigation is a transvaginal (circumscribed nodular aggregates of smooth mus- ultrasound scan for measurement of endometrial cle, endometrial glands, and endometrial stroma thickness and identifcation of ovarian masses. The located within the myometrium) can mimic uterine most commonly used threshold for further inves- leiomyomas. Adenomyosis is a condition charac- tigation is an endometrial thickness of over 5 mm. The endometrium is the second most commonly infected site in the female genital tract, afer the Fallopian tubes. Infection develops by hae- matogenous spread from a primary focus in the lungs or gastrointestinal tract, and uterine infection is usu- ally by direct transmission from the Fallopian tubes. Tis is usually asymptomatic but may result in a distended uterine cavity on imaging. In this age group, the presence of a haematometra Figure 6 Benign asymptomatic polyp presenting as a pelvic mass. The overall 5-year survival The cornerstone of treatment is total hysterec- rate is high, refecting early presentation in most cases, tomy and bilateral salpingoophorectomy, and lap- but outcomes for advanced disease remain poor. Most aroscopic surgery is recommended as a means of arise in the endometrium, and the majority are diag- reducing morbidity. Systematic lymphadenectomy nosed in women aged over 50 years, although 20–25 in all cases is unjustifed. Adjuvant radiotherapy is per cent of women are premenopausal and approxi- given to selected patients at high risk of recurrence, mately 5 per cent are women below 40 years of age. Serous, clear cell, and squamous carcinomas, est sources of metastatic disease at this site include and uterine sarcomas, including leiomyosarcomas, direct extension from cervical malignancies and, less commonly, other genital tract cancer primaries. Haematogenous spread from the breast and involve- ment due to lymphoma are also high on the list. Pathological ● pre-pubertal; Figure 7 Hysterectomy specimen showing an endometrial cancer. Physiological discharge The normal discharge from the vagina is a mixture of secretions from the uterine body, the cervix, and the vaginal wall, the bulk of which originates from the columnar epithelial cells in the cervix. Tere are no mucous glands in the vagina and, as such, it is not mucosa but a skin (non-keratinised stratifed squa- mous epithelium). The secretions vary throughout the menstrual cycle, being abundant, clear, and almost free from leucocytes at the time of ovulation. At this time, the elasticity of the secretions is at its greatest (spin- nbarkeit), which allows easier penetration by the spermatozoa. At other times of the month, the cer- vical mucus is scanty, opaque, and tenacious. The Figure 8 Magnetic resonance image of the pelvis showing an endo- secretion from Bartholin’s gland, which is thin and metrial cancer infltrating the myometrium (arrow). Poor hygiene again is not uncommon and Normally, the amount of mixed vaginal discharge appropriate advice should be given to the mother. One needs to be cautious if sexual abuse is of an ectropion, where there is eversion of the colum- suspected, in which case the paediatric lead for child nar epithelium towards the vagina (Fig. Girls before puberty and women afer discharge or bleeding in young girls and would need menopause do not have the protection of an acid referral to a cancer centre for further management. In pregnancy, the physiological white discharge Reproductive age usually increases owing to the increased shedding Vaginal discharge in women of reproductive age of epithelial cells and an increased vascularity of the is most likely to be caused by infection. However, cervix, which in turn leads to an increase in secretion cervical polyps and malignancy may present with production. The Pathological discharge causes of vaginal discharge in this age group can be Pre-pubertal classifed as: The causes of vaginal discharge in this age group can Non-infective be classifed as: Cervical ectopy. In all cases, a relevant history should be obtained, followed by any appropriate physical examination plus a vaginal speculum examination in order to take Figure 1 Cervical ectropion. It gives rise to charac- present with vaginal discharge which is homogenous, teristic white patches of thrush on the vagina walls grey/white, thin, watery, copious, and with an ofen- and cervix (Fig. Unless associated with another ness, external dysuria, and superfcial dyspareunia. Examination show non-malodorous discharge, mild infammation shows discharge coating the vagina and the vestibule of the vagina or vulva with fssuring, redness, and and the absence of vaginal infammation. It teria can be used for diagnosis, the presence of 3 out can occur as a complication of diabetes, immunosup- of 4 criteria confrming the diagnosis: 1) vagina pH pression, during pregnancy, following the use of anti- is >4. A swab may be taken for recogni- microscopy; 4) release of fshy odour on adding alkali tion of the mycelium and spores of Candida albicans (10% potassium hydroxide) to drop of discharge on in stained smears and for culture. It can arise and that are extremely irritating to the external genita- resolve spontaneously in sexually active and inactive lia (Fig. The motile protozoon can be identifed branes, preterm birth, postpartum endometritis, and on wet mount microscopy. Systemic treatment is recommended with metronidazole 400 mg twice daily orally for 5–7 days, or metronidazole 2 g stat oral dose (avoid during pregnancy and breast- feeding) and should also include treatment for the partner. It usually infects the per cent of sexually active women under the age of mucous membranes of the endocervix, urethra, rec- 24 have chlamydia) and the highest incidence is seen tum, pharynx, and conjunctiva. It is caused by an intracellular abnormal vaginal discharge (the incubation period obligate pathogen which usually afects the mucous is 3–5 days) but is asymptomatic in 50 per cent of membranes of the endocervix, urethra, rectum, women.
The Ninth Plan targets that personnel and community health level workers in the gaps will be completely filled by 2002 buy cefdinir 300 mg without prescription infection mrsa pictures and symptoms. Population served: 30 purchase 300mg cefdinir visa antibiotic xtreme,000 (20 purchase cefdinir 300 mg fast delivery antibiotic resistance oxford,000 in tribal cheap cefdinir 300 mg amex antibiotics for sinus infection dose, hilly and backward • Implementing the National Health Programs. Total 3 Records of all cases should be maintained and diseases 535 Population served: 6,000 (3,000 in tribal, hilly and backward areas). The efforts in this direction include education, guidance He also has to attend to school health program, check and help to the community as regards the following: the records and performance of the Health Assistant • Provision of safe and wholesome water supply by or Sanitary Inspector, and visit villages for specific construction of new sanitary wells and tanks, repair tasks. The Medical Officer has a vehicle to move in the of the old ones, maintenance of hand-pumps and area and to shift maternity and other cases to the periodical disinfection of water by the use of referral hospital. Handflush water-seal various duties which include, in addition to the above, latrine is considered to be the best but aqua privy, taking care of the indoor patients, which may be either septic tank and trench latrines may also be indicated maternity cases or general emergency cases. Antenatal and natal services were traditionally provided Unfortunately, various states have not accepted the by untrained dais. Both are of crucial importance for Communicable diseases still form the most important the health and welfare of the family. Details about school health service are given in tuberculosis, diphtheria, whooping cough, tetanus and Chapter 32. The sanitary inspector, health He supervises and guides the work of other members inspectors and health assistants should check the village of the staff. He visits subcenters and other villages for registers and find omissions of births by comparing them this purpose. They should help He coordinates and cooperates with other health the village registrars (e. Sarpanch, Panchayat Secretary, agencies and voluntary organizations working in the Village Munsif, Police Patel, etc. He enlists cooperation of other departments such tration, keeping of records and making reports. Registers as revenue, agriculture, education and Public Health on epidemic disease should be checked and properly Engineering for promotion of health and prevention of maintained. A large number of national programs have been • All matters relating to management of personnel. The more • Reporting the progress of activities under all pro- important among these are the Family Welfare Program, grams to the Chief Medical Officer. This staff is stationed mostly health program at the headquarter while some members are posted at • Training to untrained dais. At the end of the training, the health guides are given a certificate, a manual and The Rural Health Scheme emerged out of the recom- a kit. The manual tells them in simple words what to mendations of the Shrivastav Committee and was intro- do and what not to do in the situations they might face. It is based on a 4-tier system of services The kit contains common medicines (modern as well provided at the level of the village, the subcenter, the as indigenous) needed in the community. As The health guide is to be selected by the Gram per the provisional totals of the 2001 census, the literacy 10 Panchayat. In these ones, which are referred to the concerned Medical conditions, it is not surprising that health facilities are Officer. It is not possible for a physician population (500 in case of tribal, hilly or remote areas). One of these should be a envisaged to enlist local people in the health service set- woman, and one should be from a Scheduled Caste/ up. The health guide cannot administer injections and cannot prescribe Village Health Guides outside the list of drugs provided to him. He should not On October 2, 1977 the Community Health Workers treat any case for more than 2 days if there is no Scheme was launched in India to provide health services improvement. This scheme is in homes, unattended by a doctor or a properly trained operation in all states and Union Territories except in health functionary. The high maternal mortality rate and four states where alternative rural health schemes are in progress. These states and their schemes are as neonatal tetanus mortality rates are largely due to lack follows: Jammu and Kashmir (Rehbar-e-Sehat), of proper antenatal, natal and postnatal care. This is the idea behind the within the community who provides primary health care dai training scheme. During the one month • He or she should have had formal education up to training, the dai has to conduct at least 2 deliveries under at least sixth standard. The Dai is free month and is taught basic health concepts including to charge the community for her services. All “Assured Services” as envisaged in the subcenters In the public sector, a Subcenter (Subhealth Center) is should be available, which includes routine, the most peripheral and first contact point between the preventive, promotive, few curative and referral primary health care system and the community. As per services in addition to all the national health the population norms, one subcenter is established for programs as applicable. All the support services to fulfill the above objectives 3000 population in hilly/tribal/desert areas. There are 146036 Subcenters functioning subcenter which have been classified as Essential in the country as per Rural Health Statistics Bulletin (Minimum Assured Services) or Desirable (that all States/ published in July, 2009. Maternal and child health: services such as immunization, antenatal, natal and postnatal care, prevention of malnutrition and common Maternal Health childhood diseases, family planning services and i. Besides these, several national health and pregnancy for registration, she should be registered family welfare programs are delivered through these and care given to her according to gestational age. For this, the 3rd visit: Between 28 and 34 weeks unipurpose workers were to undergo a training for 6 4th visit: Between 36 weeks and term to 8 weeks (6 weeks for females and 8 weeks for males). Family planning and contraception: Essential • Managing labor using Partograph • Identification and management of danger signs • Education, Motivation and counseling to adopt during labor. House-to-house surveys • Immediate reporting of any cluster/outbreak based These surveys would be done once annually, preferably on syndromic surveillance. Some of the diseases would require special • High level of alertness for any unusual health event, surveys- but at all times not more than one survey per reporting and appropriate action. National Health Programs: under 5 children as per immunization schedule (A) Communicable Disease Program • Assessment, treatment, counseling, referral as per a. Where filaria is available treatment for hearing impairment/ endemic, identification of cases of lymphedema/ deafness. Oral Health: Desirable Essential • Health education on oral health and hygiene • Detection of cases of impaired vision in house to especially to antenatal and lactating mothers, house surveys. The cases with decreased vision school and adolescent children will be noted in the blindness register. Disability Prevention: Desirable treatment and health care facilities for referral of • Health education on Prevention of Disability such cases. Physical infrastructure: A Subcenter should have its • Education of community, especially the parents own building. If that is not possible immediately, the 542 of young children regarding importance of right premises with adequate space should be rented in a feeding practices, early detection of deafness in central location with easy access to population. Location of the center: For all new upcoming for malaria cases, Register for records pertaining to subcenters, following may be ensured.
It can also be used for severely comminuted or unstable fractures where internal fixation may not be possible purchase 300mg cefdinir fast delivery antibiotics zosyn. The advantage of Resultant external fixation is that it allows access to the soft tissues cheap 300 mg cefdinir with mastercard antimicrobial vs antiseptic, allowing interventions such as skin or soft X tissue grafting buy cefdinir 300 mg visa bacteria at 8 degrees. Extramedullary fixation includes the use of X pins cefdinir 300 mg amex virus midwest, plates, screws and wires (Fig 7. The objective of this type of fixation aims to achieve anatomical reduction of the fracture fragments and hold them in position. Effort should be made to preserve the bone fragments and the soft tissue by means of an ‘atraumatic’ surgical traction or skeletal traction, which is counteracted technique. This should be followed by early active by the patient’s body weight, usually by raising the pain-free mobilization of the muscles and joints end of the bed. Pulleys can be used to ensure the adjacent to the fracture to prevent the development correct line of pull. Fixed traction uses the same principle, but the Internal fixation is indicated lower limb is placed in a Thomas splint so the trac- tion, which is applied to the distal part of the limb when long-lasting immobilization of the soft and connected to the end of the splint, is counter- tissues, especially around joints, may result in acted by the proximal ring of the splint pressing pain and stiffness; against the pelvis. Precise reconstruction of these surfaces is important, as any incongruity of Surgical interventions the articulating surfaces will give rise to areas Surgical intervention may be required to reduce of high stress and the risk of developing post- the fracture to a satisfactory position and hold the traumatic arthritis; fracture in an acceptable position by external or when recovery of function of long bones internal fixation and intramedullary or extramed- is dependent on early exact and stable ullary techniques. The nail may to have a hemiarthroplasty (replacement of the either be solid or flexible. Solid nails are secured femoral or humeral head) or a total joint replace- with locking screws at each end. Flexible An open or compound fracture is an orthopaedic nails are sometimes used in childhood fractures. Some wounds are known to be On arrival in the Accident and Emergency tetanus-prone, e. The fracture will have been temporarily splinted Those patients with an unknown tetanus status and any wound covered at the scene of the incident or those who have not had recent immunization (see Chapter 6). Intravenous flucloxacillin The neurovascular status of the limb should be and amoxicillin or cefuroxime are currently ascertained and recorded. Flucloxacillin and penicillin applied over the wound and should not be can be used in combination or a second-generation removed once an accurate description of the cephalosporin, such as cefuroxime. If heavily contaminated, metronidazole may be added possible, this should be supplemented with a to prevent infection by Gram-negative and anaero- photograph. The Gustilo classification of open wounds (see Once the patient has been anaesthetized, atten- below) can be used to record and assess the degree tion can be directed towards the wound, the frac- of soft tissue damage. Gustilo classification category to ‘increase’ with The dressings are removed before the skin is time as the patient receives treatment. The wound should be irri- Typ e I Open fractures with a small, 1 cm, clean gated with normal saline. A minimum of 6L of wound with minimal injury to the musculature fluid is usually needed, 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. This may tomical distribution of the nerve, and may include result in haemorrhage, thrombosis or both. Arterial Sensory, Motor, Autonomic, Reflex and Trophic bleeding is generally pulsatile and can be torrential. The axons, their containing sheaths and the Both may be contained and concealed within a myelin may be injured in three ways. Neuropraxia This is considered to be a bruising of The arteries most often injured in association the nerve with transient loss of function and early with specific fractures are: recovery. It is the least severe injury because the the axillary artery in proximal humeral fractures continuity of the nerve is preserved. It is character- the brachial artery in supracondylar fractures of ized by a conduction block. Wallerian degeneration the humerus in children of the myelin sheath does not occur and there is the popliteal artery in fractures and dislocations no axonal loss. Unless there Wallerian degeneration occurs, with Schwann cells is clear evidence that a nerve has been transected ingesting the fragmented myelin to restore the (neurotmesis) a period of observation is indicated. Recovery is good but may take significant motor functional loss, to provide joint weeks to months.
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