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

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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


  • Thanks=AONA archives and Jeff Smith, MD



  • 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


  • 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


First aid if not already given

Remove gross debris/ irrigate/dress/image/ splint

Tetanus prophylaxis - if necessary


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



  • 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


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


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



  • 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


  • Symphysis

Complications in orthopaedic trauma


  • 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



  • -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


  • Indications

    • Presence of significant associated injuries (Polytrauma)

Complications in orthopaedic trauma


  • 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


  • 43 yo male

  • Fell 40 feet from tree

  • ETOH

  • Combative,confused

  • Bone sticking out of thigh

Complications in orthopaedic trauma


  • 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



  • 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’







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



Complications in orthopaedic trauma


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