Complications in orthopaedic trauma
Download
1 / 95

Complications in Orthopaedic Trauma - PowerPoint PPT Presentation


  • 102 Views
  • Uploaded on

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.

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about ' Complications in Orthopaedic Trauma' - zulema


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
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



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)



New concepts
New concepts

  • -timing to Or?

  • -antibiotic length

  • -negative pressure wound therapy





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?


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 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



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



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.




Open pelvic fracture

Aggressive debridement of open wounds with unstable, high energy injuries

Colostomy / urinary diversion nearly always

Open Pelvic Fracture


New concepts2
New Concepts with unstable, high energy injuries

  • -less traction

  • -early mobilization

  • -minimally invasive surgical techniques

  • -binders/pelvis sheets


Pelvis binder
Pelvis binder with unstable, high energy injuries


Pelvic binder
Pelvic Binder with unstable, high energy injuries


Binder with unstable, high energy injuries


High energy injury assessment
High Energy Injury Assessment with unstable, high energy injuries

  • Beware of Associated Injuries

  • More extensive exam in polytrauma

  • Thorough distal neurovascular exam


Associated injuries
Associated Injuries with unstable, high energy injuries

  • Massive energy input required to cause unstable pelvic injuries

  • Energy causes injuries to other organs

    • Head

    • Chest

    • Abdomen


Associated injuries1
Associated Injuries with unstable, high energy injuries

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

  • Frequently involved with pelvic injuries


Physical
Physical with unstable, high energy injuries

  • Musculoskeletal Pelvic Exam

    • Inspection

    • Palpation

    • Function (Stability)


Radiographic evaluation
Radiographic Evaluation with unstable, high energy injuries


Emergent management
Emergent Management with unstable, high energy injuries

  • 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 with unstable, high energy injuries

  • 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 with unstable, high energy injuries

  • Temporizing measures

    • External fixation

    • Binders/sheets

    • Longitudinal traction distal femur

      • Very important with vertical shear injury


External fixation
External Fixation with unstable, high energy injuries

  • -resusitation

  • -temporary

  • -definitive

  • -”damage control”


O r i f
O R I F with unstable, high energy injuries

  • Symphysis


ORIF with unstable, high energy injuries

  • Iliac Fracture


Compartment syndrome
Compartment Syndrome with unstable, high energy injuries

  • Elevated compartment pressure

  • Painful!!

  • Early diagnosis

  • Early treatment

  • Examples


Compartment syndrome1
Compartment syndrome with unstable, high energy injuries

  • Neurovascular exam

  • Possible pressure measurements

  • Surgical decompression


Neurovascular exam
Neurovascular exam with unstable, high energy injuries

  • 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 with unstable, high energy injuries

  • Pain out of proportion

  • Pain with passive stretch

  • Paresthesias,(sensory changes)

  • Paralysis,(weakness)

  • Pulse(usually present, absent late finding)


Compartment syndrome3
Compartment Syndrome with unstable, high energy injuries

  • Loosen dressing, splints, wraps

  • Bivalve cast down to skin

  • Elevation controversial

  • Emergency notify surgeon


Deep venous thrombosis prevention
Deep Venous Thrombosis-prevention with unstable, high energy injuries

  • 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 with unstable, high energy injuries

  • 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 with unstable, high energy injuries

  • Medical-heparin infusion-coumadin

  • Mobilization

  • Further surveys


Orthopaedic trauma treatment
Orthopaedic trauma-treatment with unstable, high energy injuries

  • Age

  • Other injuries

  • Injury pattern

  • Soft tissue injury

  • Osteopenia

  • Comorbidities

  • Activities of daily living


Orthopaedic trauma treatment1
Orthopaedic trauma-treatment with unstable, high energy injuries

  • Closed,(cast,splint,brace)

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

  • Therapy-mainstay for recovery


Casting
Casting with unstable, high energy injuries

  • -fiberglas/plaster

  • -short/long/muenster/PTB

  • -molding

  • -Neurovasc check

  • -xray check

  • -listen to your patient


Skin traction
Skin Traction with unstable, high energy injuries

  • Example Buck’s traction

  • Comfort

  • Minimize further injury

  • Hip and knee dislocation

  • Hip fractures

  • 5-10 lbs.

  • Helpful?


Skeletal traction
Skeletal Traction with unstable, high energy injuries

  • Weight directly thru bone

  • Pelvis fractures, dislocations

  • Acetabular fractures

  • Femur fractures

  • External fixation

  • Temporary versus definitive


Pre op planning
Pre-op Planning with unstable, high energy injuries

  • Minimize OR time

  • Minimize blood loss

  • Proper equipment

  • Minimize exposure


Pre op planning1
Pre-op Planning with unstable, high energy injuries

  • Table/position

  • C-arm

  • Equipment

  • Implants


The tools
The Tools with unstable, high energy injuries

  • 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 with unstable, high energy injuries

  • Indications

    • Presence of significant associated injuries (Polytrauma)


ORIF with unstable, high energy injuries

  • Complications

    • Infection (4%)

    • Loss of reduction / fixation (5%)

    • DVT / PE (4%)

    • Nerve palsy (3%)

Matta, Tornetta 1982 -1991


Post op management
Post-Op Management with unstable, high energy injuries

  • Stable fixation

    • Early mobilization

    • Weightbearing as tolerated unaffected side

    • Non or partial weightbearing affected side 8 - 12 weeks


Post op management1
Post-Op Management with unstable, high energy injuries

  • 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 with unstable, high energy injuries

  • 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 with unstable, high energy injuries

  • 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 with unstable, high energy injuries

  • Full, partial, or non-weight bearing

  • Platform crutches/walker

  • Casting

  • Splints

  • Bracing


A team approach
A Team Approach with unstable, high energy injuries


RK with unstable, high energy injuries

  • 43 yo male

  • Fell 40 feet from tree

  • ETOH

  • Combative,confused

  • Bone sticking out of thigh


RK with unstable, high energy injuries

  • Moving all four extremities

  • Rapid sequence intubation(airway control)

  • Hemodynamic stable

  • Past history negative-possible psych issues


Closed head injury
Closed Head Injury with unstable, high energy injuries

  • Small Subdural Hematoma


Distal femur sc ic fracture open
Distal Femur SC/IC fracture open with unstable, high energy injuries

  • 5 cm lateral wound


Distal femur fracture
Distal Femur Fracture with unstable, high energy injuries


Distal femur fracture1
Distal Femur Fracture with unstable, high energy injuries


Distal radius fracture closed
Distal Radius Fracture, closed with unstable, high energy injuries


Treatment
Treatment with unstable, high energy injuries

  • 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 with unstable, high energy injuries


Intraop
Intraop with unstable, high energy injuries


Images
Images with unstable, high energy injuries


Post op
Post-op with unstable, high energy injuries

  • 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 with unstable, high energy injuriesOrthopaedicinformation

  • Npo status

  • Pain scale

  • Vital signs

  • Surgical drainage amount

  • Neurovascular exam

  • Labs –most recent


Discharge planning
Discharge planning with unstable, high energy injuries

  • Begins immediately

  • Home, SNF, Rehab, Hospice

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

  • Resources/managed care


Questions
QUESTIONS? with unstable, high energy injuries


THANK YOU with unstable, high energy injuries


ad