Complications in orthopaedic trauma
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Complications in Orthopaedic Trauma. Michael S. Bongiovanni , M.D. Scripps Mercy Hospital San Diego, California August 4, 2012. Disclosures-none. Thanks=AONA archives and Jeff Smith, MD. Objectives.

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Complications in orthopaedic trauma

Complications in Orthopaedic Trauma

Michael S. Bongiovanni, M.D.

Scripps Mercy Hospital

San Diego, California

August 4, 2012

August 2012 ASOPA/NAOTOrthopaedic Technologists Symposium Conference and Workshop


Disclosures none

Disclosures-none

  • Thanks=AONA archives and Jeff Smith, MD


Objectives

Objectives

  • Recognize goal in Orthopaedic Trauma decision making is prompt diagnosis and treatment of musculoskeletal injuries

  • Post-operative mobilization

  • Discharge planning needs

  • Describe different weight bearing types

  • Case examples-discussion

  • Concept changes

  • Ortho technologist importance


Orthopaedic emergencies

Orthopaedic Emergencies

  • Open fractures/joints

  • Unstable pelvis injuries

  • Compartment syndrome

  • Injuries with neurovascular compromise

  • Certain infections


But i have a full office

But I have a full office!


Patient evaluation

Patient Evaluation

  • ATLS approach

  • ABCDE

  • Systematic

  • Team approach

  • Other injuries


Orthopaedic trauma diagnosis

Orthopaedic trauma diagnosis

  • History

  • Physical exam

  • Studies-xrays, CT scans, and/or MRI


Patient factors

Patient Factors

  • Age

  • Mech of injury

  • Assoc. injuries

  • comorbidities


Mechanism of injury

Mechanism of Injury

  • Patient hx

  • Paramedic hx

  • Scene description

  • Witnesses


Physical examination

Physical Examination

  • Begins with ATLS primary survey

  • Airway

  • Breathing

  • Circulation

  • Disability (neurological)

  • Exposure(undress)


Open fractures

Open Fractures


New concepts

New concepts

  • -timing to Or?

  • -antibiotic length

  • -negative pressure wound therapy


Type i

Type I


Type ii

Type II


Type iii

Type III


Open fracture type iiia

Open Fracture: Type IIIA

  • Significant soft tissue injury

    • Muscle coverage of bone unnecessary

    • STSG over muscle

    • 7% Infection Rate


Open fracture type iiib

Open Fracture: Type IIIB

  • Significant soft tissue loss

    • Requires Soft Tissue Coverage

    • 10–50 % Infection Rate


Open fracture type iiic

Open Fracture: Type IIIC

  • Associated vascular injury that requires repair for limb salvage

  • 25-50% Infection Rate ?

  • 50 % Amputation Rate ?


Identify associated injuries

Identify Associated Injuries

  • What other interventions does the patient need?

  • What degree of extremity intervention will the patient tolerate?


Complications in orthopaedic trauma

Management Stages

First aid: pre-hospital care

Emergency room care-ortho tech

Operating room: definitive care-ortho tech

Rehabilitation-ortho tech


Complications in orthopaedic trauma

First Aid

  • Control bleeding/ open wound

    • Direct pressure

    • Cover wound with sterile dressing

    • tourniquets

  • Realign and splint

    • decreases further soft tissue damage and neurovascular compromise

    • comfort


Complications in orthopaedic trauma

Emergency

First aid if not already given

Remove gross debris/ irrigate/dress/image/ splint

Tetanus prophylaxis - if necessary

Antibiotics!!!!!!!!!!!!!!


Open fracture management

Open Fracture Management

  • Open fractures go to the OR

  • For a formal debridement

  • Followed by stabilization of the fracture

  • Continuation of IV antibiotics for treatment not prophylaxis


Debridement

Debridement

  • Layer by layer

  • Remove all devitalized and contaminated tissue (including bone)


Fracture stabilization why

Fracture Stabilization: Why?

  • Limb:

    • Prevents further soft tissue injury

    • Allows mobilization of the involved limb for dressing changes/ wound checks on the floor

  • Patient:

    • Reduces pain

    • Long bone stabilization decreases activation of the immune system/ inflammatory cascade

    • Allows mobilization of the patient


Temporizing or definitive vac

Temporizing or Definitive: VAC

  • -125 mm Hg pressure applied to an open cell sponge

  • Stimulates cell division and blood vessel in-growth

  • Sealed system placed in OR

  • Can be used to shrink wound size


Wound closure coverage

Wound Closure/Coverage

  • Optimally by 3-7 days

  • Principles

    • Durable coverage

    • Well vascularized

      soft tissue envelope

      for bone

    • Fill dead space


Amputation vs limb salvage

Amputation vs Limb Salvage


Factors favoring amputation

Factors Favoring Amputation

  • Warm ischemia time > 8 hrs

  • Severe crush

  • Chronic debilitating disease

  • Severe polytrauma (life before limb)

  • Mass casualty Complexity of reconstruction


Complications in orthopaedic trauma

GSW


New concepts1

New Concepts

-seeing more GSW

-similar principles

-rapid rehab


The problem

The Problem

  • Deaths from Firearms increased 60% since 1968.

  • For every death there are 3 Non-Fatal Injuries.

  • 80% of the cost is paid by the Taxpayers.


Antibiotics and tetanus prophylaxis same as open fractures

Antibiotics and Tetanus Prophylaxis same as Open Fractures


Internal vs external fixation

Internal vs External Fixation

  • Low / High / Shotgun

  • Close Range.

  • Pts. General Condition.

  • Soft Tissue Injury.

  • Fracture Pattern.


Fxs with vasc injury

Fxs. With Vasc. Injury

  • Shunt the Artery.

  • Irrigation and Debridment.

  • Definitive Fracture Fixation.

  • Final Vascular Repair.


Unstable pelvis fractures

Unstable Pelvis Fractures


Complications in orthopaedic trauma

  • In trauma center, 13-18% of pelvic injury patients present with unstable, high energy injuries

  • Associated injuries

  • Mortality

  • High rate of early and late morbidity


Open pelvic fracture

Aggressive debridement of open wounds

Colostomy / urinary diversion nearly always

Open Pelvic Fracture


New concepts2

New Concepts

  • -less traction

  • -early mobilization

  • -minimally invasive surgical techniques

  • -binders/pelvis sheets


Pelvis binder

Pelvis binder


Pelvic binder

Pelvic Binder


Complications in orthopaedic trauma

Binder


High energy injury assessment

High Energy Injury Assessment

  • Beware of Associated Injuries

  • More extensive exam in polytrauma

  • Thorough distal neurovascular exam


Associated injuries

Associated Injuries

  • Massive energy input required to cause unstable pelvic injuries

  • Energy causes injuries to other organs

    • Head

    • Chest

    • Abdomen


Associated injuries1

Associated Injuries

  • Major vascular, neurological, gastrointestinal, and genitourinary structures pass through pelvis

  • Frequently involved with pelvic injuries


Physical

Physical

  • Musculoskeletal Pelvic Exam

    • Inspection

    • Palpation

    • Function (Stability)


Radiographic evaluation

Radiographic Evaluation


Emergent management

Emergent Management

  • Reduction and stabilization of pelvic ring

    • Emergent external fixation

      • Decreases intrapelvic volume

      • Minimizes motion at fracture site

      • AP pelvis to determine if injury amenable to external fixation


Emergent management1

Emergent Management

  • Open Surgery

    • Primarily reserved for failure to respond to ex fix or angiography

    • Occasionally coincident with emergent ex lap

    • Open packing usually preferred over ligation


Early management

Early Management

  • Temporizing measures

    • External fixation

    • Binders/sheets

    • Longitudinal traction distal femur

      • Very important with vertical shear injury


External fixation

External Fixation

  • -resusitation

  • -temporary

  • -definitive

  • -”damage control”


O r i f

O R I F

  • Symphysis


Complications in orthopaedic trauma

ORIF

  • Iliac Fracture


Compartment syndrome

Compartment Syndrome

  • Elevated compartment pressure

  • Painful!!

  • Early diagnosis

  • Early treatment

  • Examples


Compartment syndrome1

Compartment syndrome

  • Neurovascular exam

  • Possible pressure measurements

  • Surgical decompression


Neurovascular exam

Neurovascular exam

  • circulation-motor-sensory

  • Pulses-palpation or doppler

  • Capillary refill-nl less than 2 seconds

  • Sensation-present, diminished, absent

  • Motor-specific movement-present, diminished, or absent


Compartment syndrome2

Compartment syndrome

  • Pain out of proportion

  • Pain with passive stretch

  • Paresthesias,(sensory changes)

  • Paralysis,(weakness)

  • Pulse(usually present, absent late finding)


Compartment syndrome3

Compartment Syndrome

  • Loosen dressing, splints, wraps

  • Bivalve cast down to skin

  • Elevation controversial

  • Emergency notify surgeon


Deep venous thrombosis prevention

Deep Venous Thrombosis-prevention

  • ambulation-out of bed

  • Pharmacology-heparins/coumadin

  • Mechanical devices( SCD’s/Foot pumps)

  • IVC filter can help prevent PE in high risk patient


Deep venous thrombosis diagnosis

Deep Venous Thrombosis-diagnosis

  • leg and/or chest pain

  • Fever

  • Tachycardia

  • Leg swelling(unilateral)

  • Doppler ultrasound

  • Chest CT scan

  • Pulmonary angiogram


Deep venous thrombosis treatment

Deep Venous Thrombosis-treatment

  • Medical-heparin infusion-coumadin

  • Mobilization

  • Further surveys


Orthopaedic trauma treatment

Orthopaedic trauma-treatment

  • Age

  • Other injuries

  • Injury pattern

  • Soft tissue injury

  • Osteopenia

  • Comorbidities

  • Activities of daily living


Orthopaedic trauma treatment1

Orthopaedic trauma-treatment

  • Closed,(cast,splint,brace)

  • Open,(plates/screws, external fixation, intramedullary implants, joint prosthesis, and/or pins)

  • Therapy-mainstay for recovery


Casting

Casting

  • -fiberglas/plaster

  • -short/long/muenster/PTB

  • -molding

  • -Neurovasc check

  • -xray check

  • -listen to your patient


Skin traction

Skin Traction

  • Example Buck’s traction

  • Comfort

  • Minimize further injury

  • Hip and knee dislocation

  • Hip fractures

  • 5-10 lbs.

  • Helpful?


Skeletal traction

Skeletal Traction

  • Weight directly thru bone

  • Pelvis fractures, dislocations

  • Acetabular fractures

  • Femur fractures

  • External fixation

  • Temporary versus definitive


Pre op planning

Pre-op Planning

  • Minimize OR time

  • Minimize blood loss

  • Proper equipment

  • Minimize exposure


Pre op planning1

Pre-op Planning

  • Table/position

  • C-arm

  • Equipment

  • Implants


The tools

The Tools

  • Radiolucent table

  • C-arm

  • Pelvic reduction clamps

  • Pelvic instruments

  • Oscillating drill

  • 3.5 mm / 4.5 mm pelvic reconstruction plates

  • Large and small fragment screws

  • 7.3 mm fully and partially threaded cannulated screws

  • Large external fixator


Complications in orthopaedic trauma

ORIF

  • Indications

    • Presence of significant associated injuries (Polytrauma)


Complications in orthopaedic trauma

ORIF

  • Complications

    • Infection (4%)

    • Loss of reduction / fixation (5%)

    • DVT / PE (4%)

    • Nerve palsy (3%)

Matta, Tornetta 1982 -1991


Post op management

Post-Op Management

  • Stable fixation

    • Early mobilization

    • Weightbearing as tolerated unaffected side

    • Non or partial weightbearing affected side 8 - 12 weeks


Post op management1

Post-Op Management

  • Unstable or incomplete fixation

    • Bedrest

    • Longitudinal traction on unstable side

    • Duration individualized, but caution to avoid deformity

    • Non-weightbearing 3 months


Weight bearing lower extremities

Weight bearing-lower extremities

  • NWB-non weight bearing

  • TDWB-touch down weight bearing

  • PWB-partial weight bearing(% or lbs.)

  • FWB-full weight bearing

  • WBAT-weight bear as tolerated


Weight bear examples

Weight bear examples

  • Joint fractures-TDWB

  • Hip hemiarthroplasty-WBAT

  • Femur/Tibial shaft IM nails-TDWB-WBAT

  • Joint dislocations-TDWB-WBAT


Weight bearing upper extremity

Weight bearing upper extremity

  • Full, partial, or non-weight bearing

  • Platform crutches/walker

  • Casting

  • Splints

  • Bracing


A team approach

A Team Approach


Complications in orthopaedic trauma

RK

  • 43 yo male

  • Fell 40 feet from tree

  • ETOH

  • Combative,confused

  • Bone sticking out of thigh


Complications in orthopaedic trauma

RK

  • Moving all four extremities

  • Rapid sequence intubation(airway control)

  • Hemodynamic stable

  • Past history negative-possible psych issues


Closed head injury

Closed Head Injury

  • Small Subdural Hematoma


Distal femur sc ic fracture open

Distal Femur SC/IC fracture open

  • 5 cm lateral wound


Distal femur fracture

Distal Femur Fracture


Distal femur fracture1

Distal Femur Fracture


Distal radius fracture closed

Distal Radius Fracture, closed


Treatment

Treatment

  • Femur sterile dressings, hare traction splint

  • Antibiotics(Cephalosporin, aminoglycoside)

  • Tetanus toxoid

  • Rapid completion CT scans

  • Immediate Neurosurgery consultation

  • To operating room, emergently for DCO

  • NS-’rapid ortho procedure so early repeat head ct scan done’


Debridement1

Debridement


Intraop

Intraop


Images

Images


Post op

Post-op

  • IV ABS, dressing changes, resuscitation

  • Head CT stabilized

  • Definitive treatment at 96 hours-

  • Wound re-debride, distal femur LISS, wound closure over drain

  • Wrist external fixation and pinning


Helpful orthopaedic information

Helpful Orthopaedicinformation

  • Npo status

  • Pain scale

  • Vital signs

  • Surgical drainage amount

  • Neurovascular exam

  • Labs –most recent


Discharge planning

Discharge planning

  • Begins immediately

  • Home, SNF, Rehab, Hospice

  • Team approach,(Nursing, orthopaedist, ortho tech, therapist, case manager, patient/family)

  • Resources/managed care


Questions

QUESTIONS?


Complications in orthopaedic trauma

THANK YOU


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