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
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)
New concepts • -timing to Or? • -antibiotic length • -negative pressure wound therapy
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
Factors Favoring Amputation • Warm ischemia time > 8 hrs • Severe crush • Chronic debilitating disease • Severe polytrauma (life before limb) • Mass casualty Complexity of reconstruction
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.
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.
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
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)
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