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Complications in Orthopaedic Trauma

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Presentation on theme: "Complications in Orthopaedic Trauma"— Presentation transcript:

1 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

2 Disclosures-none Thanks=AONA archives and Jeff Smith, MD

3 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

4 Orthopaedic Emergencies
Open fractures/joints Unstable pelvis injuries Compartment syndrome Injuries with neurovascular compromise Certain infections

5 But I have a full office!

6 Patient Evaluation ATLS approach ABCDE Systematic Team approach
Other injuries

7 Orthopaedic trauma diagnosis
History Physical exam Studies-xrays, CT scans, and/or MRI

8 Patient Factors Age Mech of injury Assoc. injuries comorbidities

9 Mechanism of Injury Patient hx Paramedic hx Scene description

10 Physical Examination Begins with ATLS primary survey Airway Breathing
Circulation Disability (neurological) Exposure(undress)

11 Open Fractures

12 New concepts -timing to Or? -antibiotic length -negative pressure wound therapy

13 Type I

14 Type II

15 Type III

16 Open Fracture: Type IIIA
Significant soft tissue injury Muscle coverage of bone unnecessary STSG over muscle 7% Infection Rate

17 Open Fracture: Type IIIB
Significant soft tissue loss Requires Soft Tissue Coverage 10–50 % Infection Rate

18 Open Fracture: Type IIIC
Associated vascular injury that requires repair for limb salvage 25-50% Infection Rate ? 50 % Amputation Rate ?

19 Identify Associated Injuries
What other interventions does the patient need? What degree of extremity intervention will the patient tolerate?

20 Management Stages First aid: pre-hospital care
Emergency room care-ortho tech Operating room: definitive care-ortho tech Rehabilitation-ortho tech

21 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

22 Emergency First aid if not already given
Remove gross debris/ irrigate/dress/image/ splint Tetanus prophylaxis - if necessary Antibiotics!!!!!!!!!!!!!!

23 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

24 Debridement Layer by layer
Remove all devitalized and contaminated tissue (including bone)

25 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

26 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

27 Wound Closure/Coverage
Optimally by 3-7 days Principles Durable coverage Well vascularized soft tissue envelope for bone Fill dead space

28 Amputation vs Limb Salvage

29 Factors Favoring Amputation
Warm ischemia time > 8 hrs Severe crush Chronic debilitating disease Severe polytrauma (life before limb) Mass casualty Complexity of reconstruction

30 GSW

31 -seeing more GSW -similar principles -rapid rehab
New Concepts -seeing more GSW -similar principles -rapid rehab

32 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.

33 Antibiotics and Tetanus Prophylaxis same as Open Fractures

34 Internal vs External Fixation
Low / High / Shotgun Close Range. Pts. General Condition. Soft Tissue Injury. Fracture Pattern.

35 Fxs. With Vasc. Injury Shunt the Artery. Irrigation and Debridment.
Definitive Fracture Fixation. Final Vascular Repair.



38 Unstable Pelvis Fractures

39 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

40 Open Pelvic Fracture Aggressive debridement of open wounds
Colostomy / urinary diversion nearly always

41 New Concepts -less traction -early mobilization -minimally invasive surgical techniques -binders/pelvis sheets

42 Pelvis binder

43 Pelvic Binder

44 Binder

45 High Energy Injury Assessment
Beware of Associated Injuries More extensive exam in polytrauma Thorough distal neurovascular exam

46 Associated Injuries Massive energy input required to cause unstable pelvic injuries Energy causes injuries to other organs Head Chest Abdomen

47 Associated Injuries Major vascular, neurological, gastrointestinal, and genitourinary structures pass through pelvis Frequently involved with pelvic injuries

48 Physical Musculoskeletal Pelvic Exam Inspection Palpation
Function (Stability) Feel and Move -Rectal and Vaginal Exam -Feel for fracture fragments -Look for blood -Very important not to miss an occult open fracture -Complete neurologic exam -L5, S1 and lumbosacral trunk -Pudendal nerve -Bladder/sexual function

49 Radiographic Evaluation

50 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 Must stabilize unstable pelvis fractures acutely -Reduce pelvic volume to increase tamponade -Stabilize cancellous surgaces and veins to allow hemostasis -Easier nursing care -Increased mobility, get patients out of bed

51 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 PASG/MAST pants -Excellent for short term stabilization and transport -Can cause compartment syndromes -Decreases vital capacity -NOT indicated with diaphragmatic rupture or pulmonary edema

52 Early Management Temporizing measures External fixation Binders/sheets
Longitudinal traction distal femur Very important with vertical shear injury

53 External Fixation -resusitation -temporary -definitive
-”damage control”

54 O R I F Symphysis

55 ORIF Iliac Fracture

56 Compartment Syndrome Elevated compartment pressure Painful!!
Early diagnosis Early treatment Examples Mortality 42% if hypotensive on admission, 3.4% if not

57 Compartment syndrome Neurovascular exam Possible pressure measurements
Surgical decompression

58 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

59 Compartment syndrome Pain out of proportion Pain with passive stretch
Paresthesias,(sensory changes) Paralysis,(weakness) Pulse(usually present, absent late finding)

60 Compartment Syndrome Loosen dressing, splints, wraps
Bivalve cast down to skin Elevation controversial Emergency notify surgeon

61 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

62 Deep Venous Thrombosis-diagnosis
leg and/or chest pain Fever Tachycardia Leg swelling(unilateral) Doppler ultrasound Chest CT scan Pulmonary angiogram

63 Deep Venous Thrombosis-treatment
Medical-heparin infusion-coumadin Mobilization Further surveys

64 Orthopaedic trauma-treatment
Age Other injuries Injury pattern Soft tissue injury Osteopenia Comorbidities Activities of daily living

65 Orthopaedic trauma-treatment
Closed,(cast,splint,brace) Open,(plates/screws, external fixation, intramedullary implants, joint prosthesis, and/or pins) Therapy-mainstay for recovery

66 Casting -fiberglas/plaster -short/long/muenster/PTB -molding -Neurovasc check -xray check -listen to your patient

67 Skin Traction Example Buck’s traction Comfort Minimize further injury
Hip and knee dislocation Hip fractures 5-10 lbs. Helpful?

68 Skeletal Traction Weight directly thru bone
Pelvis fractures, dislocations Acetabular fractures Femur fractures External fixation Temporary versus definitive

69 Pre-op Planning Minimize OR time Minimize blood loss Proper equipment
Minimize exposure

70 Pre-op Planning Table/position C-arm Equipment Implants

71 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

72 ORIF Indications Presence of significant associated injuries (Polytrauma)

73 ORIF Complications Infection (4%) Loss of reduction / fixation (5%)
DVT / PE (4%) Nerve palsy (3%) Matta, Tornetta

74 Post-Op Management Stable fixation Early mobilization
Weightbearing as tolerated unaffected side Non or partial weightbearing affected side weeks

75 Post-Op Management Unstable or incomplete fixation Bedrest
Longitudinal traction on unstable side Duration individualized, but caution to avoid deformity Non-weightbearing 3 months

76 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

77 Weight bear examples Joint fractures-TDWB Hip hemiarthroplasty-WBAT
Femur/Tibial shaft IM nails-TDWB-WBAT Joint dislocations-TDWB-WBAT

78 Weight bearing upper extremity
Full, partial, or non-weight bearing Platform crutches/walker Casting Splints Bracing

79 A Team Approach

80 RK 43 yo male Fell 40 feet from tree ETOH Combative,confused
Bone sticking out of thigh

81 RK Moving all four extremities
Rapid sequence intubation(airway control) Hemodynamic stable Past history negative-possible psych issues

82 Closed Head Injury Small Subdural Hematoma

83 Distal Femur SC/IC fracture open
5 cm lateral wound

84 Distal Femur Fracture

85 Distal Femur Fracture

86 Distal Radius Fracture, closed

87 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’

88 Debridement

89 Intraop

90 Images

91 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

92 Helpful Orthopaedic information
Npo status Pain scale Vital signs Surgical drainage amount Neurovascular exam Labs –most recent

93 Discharge planning Begins immediately Home, SNF, Rehab, Hospice
Team approach,(Nursing, orthopaedist, ortho tech, therapist, case manager, patient/family) Resources/managed care



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