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JMS August 2012 ASOPA/NAOTOrthopaedic Technologists Symposium Conference and Workshop Complications in Orthopaedic Trauma Michael S. Bongiovanni, M.D.

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Presentation on theme: "JMS August 2012 ASOPA/NAOTOrthopaedic Technologists Symposium Conference and Workshop Complications in Orthopaedic Trauma Michael S. Bongiovanni, M.D."— Presentation transcript:

1 JMS August 2012 ASOPA/NAOTOrthopaedic Technologists Symposium Conference and Workshop Complications in Orthopaedic Trauma Michael S. Bongiovanni, M.D. Scripps Mercy Hospital San Diego, California August 4, 2012

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

3 JMS Objectives 1.Recognize goal in Orthopaedic Trauma decision making is prompt diagnosis and treatment of musculoskeletal injuries 2.Post-operative mobilization 3.Discharge planning needs 4.Describe different weight bearing types 5.Case examples-discussion 6.Concept changes 7.Ortho technologist importance

4 JMS Orthopaedic Emergencies 1.Open fractures/joints 2.Unstable pelvis injuries 3.Compartment syndrome 4.Injuries with neurovascular compromise 5.Certain infections

5 JMS But I have a full office!

6 JMS Patient Evaluation ATLS approach ABCDESystematic Team approach Other injuries

7 JMS Orthopaedic trauma diagnosis 1.History 2.Physical exam 3.Studies-xrays, CT scans, and/or MRI

8 JMS Patient Factors Age Mech of injury Assoc. injuries comorbidities

9 JMS Mechanism of Injury Patient hx Paramedic hx Scene description Witnesses

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

11 JMS Open Fractures

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

13 JMS Type I

14 JMS Type II

15 JMS Type III

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

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

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

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

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

21 JMS Control bleeding/ open wound Direct pressure Direct pressure Cover wound with sterile dressing Cover wound with sterile dressing tourniquets tourniquets Realign and splint decreases further soft tissue damage and neurovascular compromise decreases further soft tissue damage and neurovascular compromise comfort comfort First Aid

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

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

25 JMS Fracture Stabilization: Why? Limb: Prevents further soft tissue injury Prevents further soft tissue injury Allows mobilization of the involved limb for dressing changes/ wound checks on the floor Allows mobilization of the involved limb for dressing changes/ wound checks on the floorPatient: Reduces pain Reduces pain Long bone stabilization decreases activation of the immune system/ inflammatory cascade Long bone stabilization decreases activation of the immune system/ inflammatory cascade Allows mobilization of the patient Allows mobilization of the patient

26 JMS 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 JMS Wound Closure/Coverage Optimally by 3-7 days Principles 1Durable coverage 2Well vascularized soft tissue envelope for bone 3Fill dead space

28 JMS Amputation vs Limb Salvage

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

30 JMS

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

32 JMS The Problem Deaths from Firearms increased 60% since For every death there are 3 Non- Fatal Injuries. 80% of the cost is paid by the Taxpayers.

33 JMS Antibiotics and Tetanus Prophylaxis same as Open Fractures

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

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

36 JMS

37

38 Unstable Pelvis Fractures

39 JMS In trauma center, % of pelvic injury patients present with unstable, high energy injuries Associated injuries Associated injuries Mortality Mortality High rate of early and late morbidity High rate of early and late morbidity

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

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

42 JMS Pelvis binder

43 JMS Pelvic Binder

44 JMS Binder

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

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

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

48 JMS Physical Musculoskeletal Pelvic Exam Inspection Inspection Palpation Palpation Function (Stability) Function (Stability)

49 JMS Radiographic Evaluation

50 JMS Reduction and stabilization of pelvic ring Emergent external fixation Emergent external fixation Decreases intrapelvic volumeDecreases intrapelvic volume Minimizes motion at fracture siteMinimizes motion at fracture site AP pelvis to determine if injury amenable to external fixationAP pelvis to determine if injury amenable to external fixation Emergent Management

51 JMS Emergent Management Open Surgery Primarily reserved for failure to respond to ex fix or angiography Primarily reserved for failure to respond to ex fix or angiography Occasionally coincident with emergent ex lap Occasionally coincident with emergent ex lap Open packing usually preferred over ligation Open packing usually preferred over ligation

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

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

54 JMS O R I F Symphysis

55 JMS ORIF Iliac Fracture

56 JMS Compartment Syndrome 1.Elevated compartment pressure 2.Painful!! 3.Early diagnosis 4.Early treatment 5.Examples

57 JMS Compartment syndrome 1.Neurovascular exam 2.Possible pressure measurements 3.Surgical decompression

58 JMS Neurovascular exam 1.circulation-motor-sensory 2.Pulses-palpation or doppler 3.Capillary refill-nl less than 2 seconds 4.Sensation-present, diminished, absent 5.Motor-specific movement-present, diminished, or absent

59 JMS Compartment syndrome 1.Pain out of proportion 2.Pain with passive stretch 3.Paresthesias,(sensory changes) 4.Paralysis,(weakness) 5.Pulse(usually present, absent late finding)

60 JMS Compartment Syndrome 1.Loosen dressing, splints, wraps 2.Bivalve cast down to skin 3.Elevation controversial 4.Emergency notify surgeon

61 JMS Deep Venous Thrombosis- prevention 1.ambulation-out of bed 2.Pharmacology-heparins/coumadin 3.Mechanical devices( SCDs/Foot pumps) 4.IVC filter can help prevent PE in high risk patient

62 JMS Deep Venous Thrombosis- diagnosis 1.leg and/or chest pain 2.Fever 3.Tachycardia 4.Leg swelling(unilateral) 5.Doppler ultrasound 6.Chest CT scan 7.Pulmonary angiogram

63 JMS Deep Venous Thrombosis- treatment 1.Medical-heparin infusion-coumadin 2.Mobilization 3.Further surveys

64 JMS Orthopaedic trauma- treatment 1.Age 2.Other injuries 3.Injury pattern 4.Soft tissue injury 5.Osteopenia 6.Comorbidities 7.Activities of daily living

65 JMS Orthopaedic trauma- treatment 1.Closed,(cast,splint,brace) 2.Open,(plates/screws, external fixation, intramedullary implants, joint prosthesis, and/or pins) 3.Therapy-mainstay for recovery

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

67 JMS Skin Traction 1.Example Bucks traction 2.Comfort 3.Minimize further injury 4.Hip and knee dislocation 5.Hip fractures lbs. 7.Helpful?

68 JMS Skeletal Traction 1.Weight directly thru bone 2.Pelvis fractures, dislocations 3.Acetabular fractures 4.Femur fractures 5.External fixation 6.Temporary versus definitive

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

70 JMS Pre-op Planning Table/positionC-armEquipmentImplants

71 JMS 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 JMS ORIF Indications Presence of significant associated injuries (Polytrauma) Presence of significant associated injuries (Polytrauma)

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

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

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

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

78 JMS Weight bearing upper extremity Full, partial, or non-weight bearing Platform crutches/walker CastingSplintsBracing

79 JMS A Team Approach

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

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

82 JMS Closed Head Injury Small Subdural Hematoma

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

84 JMS Distal Femur Fracture

85 JMS Distal Femur Fracture

86 JMS Distal Radius Fracture, closed

87 JMS 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 JMS 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 JMS Helpful Orthopaedic information 1.Npo status 2.Pain scale 3.Vital signs 4.Surgical drainage amount 5.Neurovascular exam 6.Labs –most recent

93 JMS Discharge planning 1.Begins immediately 2.Home, SNF, Rehab, Hospice 3.Team approach,(Nursing, orthopaedist, ortho tech, therapist, case manager, patient/family) 4.Resources/managed care

94 JMS QUESTIONS?

95


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