1. TIMING OF FRACTURE FIXATION IN
POLYTRAUMA PATIENTS
ANAESTHESIOLOGIST’S PERSPECTIVES
Dr.R.Selvakumar

3. POLYTRAUMA-NIGHTMARE FOR THE PATIENT
& AS WELL AS FOR THE ANAESTHESIOLOGIST
KANISACON-2010

4. SURGEON & ANAESTHETIST
having
Opposite Views
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5. Why anaesthetist wants to avoid?
- prolonged hours of surgery
- Unexpected response
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6. Polytrauma: Hypovolemia Multiple system involvement
less time for evaluation
missed injuries (head & abdomen)
prolonged surgery
massive blood transfusion
difficulty in monitoring
surgical difficulties
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7. Unique problem increased incidence of respiratory failure ARDS
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8. Why there is an increased incidence of respiratory failure?
ARDS → fat embolism
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9. Fat embolism in polytrauma
Pathophysiology
↑ in intra medullary pressure →fat droplets → get filtered in the pulmonary circulation
minute droplets go through pulmonary circulation & get trapped in cerebral circulation
alveolar lipase → hydrolysis of fat →
release of fatty acids (palmitic, stearic, oleic)
Neutralisation by albumin
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10. Pathophysiology of Fat Embolism - contd
failure of neutralistion by albumin
fatty acids + calcium →intercellular septa rupture → diffuse areas of haemorrhage & oedema in pulmonary interstitium & alveolar space
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11. Pathophysiology of Fat Embolism - contd
Integrins CD11b & CD18 cause adherence of neutrophils & endothelium
Injured pnumocytes stop surfactant production→ collapse of alveoli
↑ shunt and dead space
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12. Just to relax……

13. Secondary injury: FE incidence in a polytrauma -30-90%
If surgery is performed following polytrauma,
will reaming further increase the incidence of
FE?
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14. Will it produce a second hit ?
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15. Medullary reaming & Cementation
Normal I.M pressure - 30 – 50mm of Hg.
Violent force in the bone - I.M pressure ↑many fold.
Reaming increases I.M.P ↑ up to mm of Hg.
Cementation → of Hg.
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16. What they did…. In 1960s: Ill development of pulmonary care
Wait till FES resolves
Kuntscher’s three recommendations
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17. Kuntscher’s recommendations:
1. Don’t nail as long as symptoms of FE are
present
2. Take special precaution for patients with
multiple fracture and extensive soft tissue
injuries
3. Don’t nail immediately, but wait a few days
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18. Negative effects of delayed fixation
prolonged immobilisation
pneumonia, bedsore, renal failure, inadequate nutrition, vascular abnormalities
poor results
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19. A word about hyponatraemia…
old age
↓ appetite
depression
social conditions
restlessness,disorientation etc
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20. Drastic changes in the 1980s
Early fixation
better understanding of pathophysiology of trauma
improvement in critical care
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21. Changes in the 1980s…..
It led to aggressive management without improving the supportive care
Bad results
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22. Damage control orthopaedics:
Pack the major sources of haemorrhage
Resuscitation and stabilisation of the
general condition
Temporary immobilisation of bone
fractures
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23. Current recommendations
Classify the patients according to their physical status
1. stable grade I
2. borderline grade II
3. unstable grade II
4. In extremis grade IV
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24. Creteria used in the physical status classification
Shock – B.P, No of blood units,
lactate levels,B.D,ATLS
Coagulation status
Temperature
Soft tissue injuries
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25. Stable patients:
Do whatever you want….
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26. Borderline patients who respond to resuscitation……
proceed with definitive fixation
limit the surgical duration within 2 hours
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27. Remember… Grade II to IV easily….. A bad surgeon can shift the ASA
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28. Borderline patients: Continuous reassessment
Pao2/F102 should not drop below 200mm of Hg
Temperature should not drop below 32C
Requirement of fluids should not exceed 3L or 5units of blood
Absence of significant coagulopathy
If not → DCO
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29. Unstable and patients in extremis:
Life saving surgeries
External fixation
Resuscitation and stabilization simultaneously
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30. Strategy in patients with head injury:
Beware of the fact that cerebral auto regulation goes off following head injury
Extensive sympathetic block due to regional anaesthesia may hamper CBF
Severe head injury → only life saving procedures
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31. Strategy in patients with chest injury
Rib fracture or lung contusion
Monitoring with pulseoximeter or ABG
Incidence of ARDS
Severe chest injury →only life saving procedures
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32. What to do to prevent the incidence of FES?
Avoid increase in IM pressure
Medullary channel depletion
Venting the medullary channel
Uncemented prosthesis
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33. summary In polytrauma, immediate fixation may lead
to secondary complication
Classify the patients according to their
Physical status
Grade I and II – Immediate surgery
Grade III and IV – resuscitation,DCO,
Delayed fixation
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34. Conclusion: Pre-operative status of the patient
decides the timing of the fracture
fixation in the poly-trauma patients….
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35. THANK YOU Dr.R.SELVAKUMAR M.D.,D.A.DNB ASSOCIATE PROFESSOR
COIMBATORE MEDICAL COLLEGE
COIMBATORE