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

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

  • Thanks=AONA archives and Jeff Smith, MD


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

  • Open fractures/joints

  • Unstable pelvis injuries

  • Compartment syndrome

  • Injuries with neurovascular compromise

  • Certain infections


But I have a full office!


Patient Evaluation

  • ATLS approach

  • ABCDE

  • Systematic

  • Team approach

  • Other injuries


Orthopaedic trauma diagnosis

  • History

  • Physical exam

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


Patient Factors

  • Age

  • Mech of injury

  • Assoc. injuries

  • comorbidities


Mechanism of Injury

  • Patient hx

  • Paramedic hx

  • Scene description

  • Witnesses


Physical Examination

  • Begins with ATLS primary survey

  • Airway

  • Breathing

  • Circulation

  • Disability (neurological)

  • Exposure(undress)


Open Fractures


New concepts

  • -timing to Or?

  • -antibiotic length

  • -negative pressure wound therapy


Type I


Type II


Type III


Open Fracture: Type IIIA

  • Significant soft tissue injury

    • Muscle coverage of bone unnecessary

    • STSG over muscle

    • 7% Infection Rate


Open Fracture: Type IIIB

  • Significant soft tissue loss

    • Requires Soft Tissue Coverage

    • 10–50 % Infection Rate


Open Fracture: Type IIIC

  • Associated vascular injury that requires repair for limb salvage

  • 25-50% Infection Rate ?

  • 50 % Amputation Rate ?


Identify Associated Injuries

  • What other interventions does the patient need?

  • What degree of extremity intervention will the patient tolerate?


Management Stages

First aid: pre-hospital care

Emergency room care-ortho tech

Operating room: definitive care-ortho tech

Rehabilitation-ortho tech


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


Emergency

First aid if not already given

Remove gross debris/ irrigate/dress/image/ splint

Tetanus prophylaxis - if necessary

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


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

  • Layer by layer

  • Remove all devitalized and contaminated tissue (including bone)


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

  • -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

  • Optimally by 3-7 days

  • Principles

    • Durable coverage

    • Well vascularized

      soft tissue envelope

      for bone

    • Fill dead space


Amputation vs Limb Salvage


Factors Favoring Amputation

  • Warm ischemia time > 8 hrs

  • Severe crush

  • Chronic debilitating disease

  • Severe polytrauma (life before limb)

  • Mass casualty Complexity of reconstruction


GSW


New Concepts

-seeing more GSW

-similar principles

-rapid rehab


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


Internal vs External Fixation

  • Low / High / Shotgun

  • Close Range.

  • Pts. General Condition.

  • Soft Tissue Injury.

  • Fracture Pattern.


Fxs. With Vasc. Injury

  • Shunt the Artery.

  • Irrigation and Debridment.

  • Definitive Fracture Fixation.

  • Final Vascular Repair.


Unstable Pelvis Fractures


  • 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


Aggressive debridement of open wounds

Colostomy / urinary diversion nearly always

Open Pelvic Fracture


New Concepts

  • -less traction

  • -early mobilization

  • -minimally invasive surgical techniques

  • -binders/pelvis sheets


Pelvis binder


Pelvic Binder


Binder


High Energy Injury Assessment

  • Beware of Associated Injuries

  • More extensive exam in polytrauma

  • Thorough distal neurovascular exam


Associated Injuries

  • Massive energy input required to cause unstable pelvic injuries

  • Energy causes injuries to other organs

    • Head

    • Chest

    • Abdomen


Associated Injuries

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

  • Frequently involved with pelvic injuries


Physical

  • Musculoskeletal Pelvic Exam

    • Inspection

    • Palpation

    • Function (Stability)


Radiographic Evaluation


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 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

  • Temporizing measures

    • External fixation

    • Binders/sheets

    • Longitudinal traction distal femur

      • Very important with vertical shear injury


External Fixation

  • -resusitation

  • -temporary

  • -definitive

  • -”damage control”


O R I F

  • Symphysis


ORIF

  • Iliac Fracture


Compartment Syndrome

  • Elevated compartment pressure

  • Painful!!

  • Early diagnosis

  • Early treatment

  • Examples


Compartment syndrome

  • Neurovascular exam

  • Possible pressure measurements

  • Surgical decompression


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 syndrome

  • Pain out of proportion

  • Pain with passive stretch

  • Paresthesias,(sensory changes)

  • Paralysis,(weakness)

  • Pulse(usually present, absent late finding)


Compartment Syndrome

  • Loosen dressing, splints, wraps

  • Bivalve cast down to skin

  • Elevation controversial

  • Emergency notify surgeon


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

  • leg and/or chest pain

  • Fever

  • Tachycardia

  • Leg swelling(unilateral)

  • Doppler ultrasound

  • Chest CT scan

  • Pulmonary angiogram


Deep Venous Thrombosis-treatment

  • Medical-heparin infusion-coumadin

  • Mobilization

  • Further surveys


Orthopaedic trauma-treatment

  • Age

  • Other injuries

  • Injury pattern

  • Soft tissue injury

  • Osteopenia

  • Comorbidities

  • Activities of daily living


Orthopaedic trauma-treatment

  • Closed,(cast,splint,brace)

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

  • Therapy-mainstay for recovery


Casting

  • -fiberglas/plaster

  • -short/long/muenster/PTB

  • -molding

  • -Neurovasc check

  • -xray check

  • -listen to your patient


Skin Traction

  • Example Buck’s traction

  • Comfort

  • Minimize further injury

  • Hip and knee dislocation

  • Hip fractures

  • 5-10 lbs.

  • Helpful?


Skeletal Traction

  • Weight directly thru bone

  • Pelvis fractures, dislocations

  • Acetabular fractures

  • Femur fractures

  • External fixation

  • Temporary versus definitive


Pre-op Planning

  • Minimize OR time

  • Minimize blood loss

  • Proper equipment

  • Minimize exposure


Pre-op Planning

  • Table/position

  • C-arm

  • Equipment

  • Implants


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


ORIF

  • Indications

    • Presence of significant associated injuries (Polytrauma)


ORIF

  • Complications

    • Infection (4%)

    • Loss of reduction / fixation (5%)

    • DVT / PE (4%)

    • Nerve palsy (3%)

Matta, Tornetta 1982 -1991


Post-Op Management

  • Stable fixation

    • Early mobilization

    • Weightbearing as tolerated unaffected side

    • Non or partial weightbearing affected side 8 - 12 weeks


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

  • 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

  • Joint fractures-TDWB

  • Hip hemiarthroplasty-WBAT

  • Femur/Tibial shaft IM nails-TDWB-WBAT

  • Joint dislocations-TDWB-WBAT


Weight bearing upper extremity

  • Full, partial, or non-weight bearing

  • Platform crutches/walker

  • Casting

  • Splints

  • Bracing


A Team Approach


RK

  • 43 yo male

  • Fell 40 feet from tree

  • ETOH

  • Combative,confused

  • Bone sticking out of thigh


RK

  • Moving all four extremities

  • Rapid sequence intubation(airway control)

  • Hemodynamic stable

  • Past history negative-possible psych issues


Closed Head Injury

  • Small Subdural Hematoma


Distal Femur SC/IC fracture open

  • 5 cm lateral wound


Distal Femur Fracture


Distal Femur Fracture


Distal Radius Fracture, closed


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’


Debridement


Intraop


Images


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 Orthopaedicinformation

  • Npo status

  • Pain scale

  • Vital signs

  • Surgical drainage amount

  • Neurovascular exam

  • Labs –most recent


Discharge planning

  • Begins immediately

  • Home, SNF, Rehab, Hospice

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

  • Resources/managed care


QUESTIONS?


THANK YOU


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