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Orthopaedic Trauma The first 15 min……... The Basics 10% of blunt trauma have a missed injury Difficult environment Difficult environment Difficult to.

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Presentation on theme: "Orthopaedic Trauma The first 15 min……... The Basics 10% of blunt trauma have a missed injury Difficult environment Difficult environment Difficult to."— Presentation transcript:

1 Orthopaedic Trauma The first 15 min……..

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3 The Basics 10% of blunt trauma have a missed injury Difficult environment Difficult environment Difficult to assess Difficult to assess To avoid Systemic head-to-toe examination Systemic head-to-toe examination Assess pelvis and palpate all long bones Assess pelvis and palpate all long bones Active or Passive ROM all joints Active or Passive ROM all joints Careful Neurovascular exam of each limb Careful Neurovascular exam of each limb If it is swollen – image it If it is swollen – image it

4 The Basics Appropriate resuscitation Pelvis - > 2 L Pelvis - > 2 L Femur fracture – 1 - 1.5 L Femur fracture – 1 - 1.5 L Tibia – 400 - 700 cc Tibia – 400 - 700 cc Humerus – 200 - 500 mL Humerus – 200 - 500 mL Method of Maull for estimating blood loss

5 Outline Femoral neck fractures Femoral neck fractures

6 The Pelvic Fracture

7 High energy, consider associated injuries Assess History for mechanism History for mechanism Pelvic stability (once) Pelvic stability (once) ?urethral bleeding, rectal blood, vaginal bleeding, high riding prostate ?urethral bleeding, rectal blood, vaginal bleeding, high riding prostate DNVS + DNVS + Radiography Radiography

8 Pelvic Stability

9 Intrapelvic Contents bladderurethravaginarectum

10 Instability: Implications

11 High vs. Low Energy Injuries

12 Radiographs: AP most information Sufficient to determine stability for resusc Sufficient to determine stability for resusc Other imaging useful for determining method of definitive fixation Other imaging useful for determining method of definitive fixation

13 INLET

14 Inlet View anterior to posterior translation rotation SI Joint sacrum

15 OUTLET

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17 APC

18 APC

19 LC

20 LC-3

21 VS

22 Approach Stabilize Pelvis Stabilize PelvisSheetBeanbag +/- traction Work up urethral/bladder injuries Work up urethral/bladder injuries Retrograde urethrogram, cystogram If blood in the rectum/vagina, treat as open If blood in the rectum/vagina, treat as open

23 Look for blush on CT scan If remains unstable ER rotation injuries to the OR ER rotation injuries to the OR IR rotation injuries or fractures into the sciatic notch – consider angiography IR rotation injuries or fractures into the sciatic notch – consider angiography

24 Pelvic fracture Definitive management If stable If stable Ex-fix or definitive management If unstable If unstable Ex-fix, laparotomy prn, angiography, packing prn If open If open I&D, stabilize, diverting colostomy, urethral/vaginal management, soft tissue closures

25 Acute Dysvascular limb Signs and symptoms Colour or pulse asymmetry Colour or pulse asymmetry Rapid pulsatile blood loss Rapid pulsatile blood loss Any difference in pulses needs to be explained (not all 5 Ps present) Any difference in pulses needs to be explained (not all 5 Ps present) Early consult Early consult Angiogram rarely required (unless potential for 2 level injury) Angiogram rarely required (unless potential for 2 level injury) Delays treatment 2-3 hrs If required, on the table angiogram

26 Acute Dysvascular limb Realistic approach Attempts to salvage are not without risk Attempts to salvage are not without risk Acute amputation morbidity rate approach 0% morbidity rate approach 0%Salvage 5 - 20% mortality 5 - 20% mortality Multiple surgeries, drug addiction, divorce Multiple surgeries, drug addiction, divorce 80% left with significant disabilities 80% left with significant disabilities

27 Acute Dysvascular limb Approach Correct Deformity and reassess DNVS Correct Deformity and reassess DNVS Perform ABI – ankle brachial index Perform ABI – ankle brachial index >0.9 – monitor with repeated exams < 0.9 - vascular consult, angiogram If bleeding If bleeding Direct pressure Tourniquet Clamp (snap) Treat like an open fracture – I&D, antibiotics, tetanus

28 Acute Dysvascular limb Consider ? period of ischemia ? period of ischemia if > 6-8 hr then fasciotomies if > 6-8 hr then fasciotomies ? risk of compartment syndrome ? risk of compartment syndrome Definitive management approach Urgent OR Urgent OR Bone stabilization – ex-fix, nail Bone stabilization – ex-fix, nail Vascular repair/bypass Vascular repair/bypass Fascitomies if > 6-8 hrs Fascitomies if > 6-8 hrs Definitive Bone fixation Definitive Bone fixation

29 Compartment Syndrome Diagnosis Index of suspicion Index of suspicion Crush injury (forearm, leg) Vascular injury 5 Ps 5 Ps Pain out of proportion, pulseless, palor, parathesias, paralysis Pressures Pressures art line art line Controversial, but if within 20 mm Hg of diastolic BP it requires release Controversial, but if within 20 mm Hg of diastolic BP it requires release

30 Treatment Urgent release within 6 hrs of injury Long incisions, complete release

31 Compartment Syndrome

32 Spine Injuries ADI < 4mm Soft tissue swelling 5 mm, 21 mm 5 mm, 21 mm Less than 3 mm subluxation 4 lines

33 Spine injuries Define level Asia scale to define motor and sensory level Asia scale to define motor and sensory level !! Document and reassess !!! !! Document and reassess !!!

34 Spine Injuries Shock Hemorrhagic Hemorrhagic Low BP, tachycardia, narrow pulse pressure Tx – fluid resusc Neurogenic Neurogenic Low BP, lack of tachycardia, widened pulse pressure Initial fluid resusc Spinal shock Bulbocavernosus reflex 1 st to return Bulbocavernosus reflex 1 st to return Pull foley, pinch glans/clitoris

35 Spine Injuries Treatment Stabilize Stabilize Role of solumedrol Role of solumedrolControversial 3m mg/Kg then 5.4 mg/kg/hr x 48 hrs Timing of reduction Timing of reduction If complete – stabilize patient completely If incomplete Ensure no disc if C spine disclocation Ensure no disc if C spine disclocation Early reduction and decompression to avoid secondary injury Early reduction and decompression to avoid secondary injury

36 Hip dislocations Usually high energy

37 Hip Dislocations

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40 Posterior Hip Dislocation 95% of presentations 95% of presentations Flexion, adduction, IR, shortening Flexion, adduction, IR, shortening Reduce Reduce Appropriate sedation ++ flexion, traction, IR/ER Anterior Hip dislocations Rare Rare ER, extension ER, extension Reduce Reduce Appropriate sedation In-line traction, lateral traction, IR

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43 Traumatic hip fracture Sciatic nerve injury in 20% of posterior dislocations Document!!! Document!!! With reduction 40% resolution, 25-35% partial resolution With reduction 40% resolution, 25-35% partial resolution

44 Inter’ & Sub’ Proximal Femoral Anatomy Head Head Neck Neck Trochanteric

45 Femoral Neck Fractures

46 Vascular Anatomy

47 Femoral Neck Fractures Displaced Undisplaced

48 Hip fractures

49 Case

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53 The Open Fracture Ensure DNVS Consider degree of contamination and soft tissue involvement Gustilo and Anderson: Grade 1: < 1cm (Ancef) Grade 1: < 1cm (Ancef) Grade 2: >1cm – 10cm (Ancef/Gent) Grade 2: >1cm – 10cm (Ancef/Gent) Grade 3: (a) high energy, gross contamination (add penicillin) Grade 3: (a) high energy, gross contamination (add penicillin) Grade 3: (b) soft tissue loss requiring graft/flap Grade 3: (b) soft tissue loss requiring graft/flap Grade 3: (c) vascular injury Grade 3: (c) vascular injury Ensure Tetanus up to date

54 The Open fracture Gentle I&D at time of reduction Don’t worry about risk of contamination with reduction Don’t worry about risk of contamination with reduction Cover with wet gauze and splint Book for OR (within 8) Definitive I&D I&D ORIF +/- repeat I&D at 48 hrs ORIF +/- repeat I&D at 48 hrs If gross contam – I&D + ex-fix, repeat I&D until ready for fixation definitive If gross contam – I&D + ex-fix, repeat I&D until ready for fixation definitive

55 The Closed Fracture/Dislocation Preferable to have an injury film Exam joint above and below DNVS – Document!!! Prepare to reduce Reduction and splinting Reduction and splinting Reduces pain and swelling May restore blood flow to region Reduces skin complications Temporizes

56 Treatment Timing ETC vs DCO Early Total care Early Total careGoals Minimize blood loss Minimize blood loss Minimize mediator release Minimize mediator release Improve pulmonary function Improve pulmonary function Decrease sepsis and pain Decrease sepsis and pain Shorten LOS and expense Shorten LOS and expenseProblems High ISS = High risk of ARDS High ISS = High risk of ARDS Especially if severe chest injuries, severe shock or coagulopathy (Pape 1993)

57 Treatment Timing ETC vs DCO Damage control Orthopaedics Damage control OrthopaedicsGoals Fast hemodynamic and orthopaedic stabilization Fast hemodynamic and orthopaedic stabilization Avoid pulmonary complications and SIRS Avoid pulmonary complications and SIRSProblems Prolongs treatment period ‘miss your opportunity’ Prolongs treatment period ‘miss your opportunity’

58 Controversy Continued: Early skeletal fixation is appropriate but what are the limits in patients with : Hemodynamic instability ? Hemodynamic instability ? Coagulopathy ? Coagulopathy ? Hypothermia ? Hypothermia ? Severe head or chest injury ? Severe head or chest injury ? = SHOCK

59 How to Identify The “Borderline Patient” Coagulopathy platelets < 90K platelets < 90K >25 U RBC >25 U RBC Cold: Temp. < 32 Cold: Temp. < 32 Inadequate resuscitation pH 10, pH 10, Bilateral Lung contusions Probable OR time >6 hrs Multiple Long bones plus truncal AIS >2 High Inflammatory Markers IL-6, IL-1β, TNF- α IL-6, IL-1β, TNF- α Correlates with ISS Correlates with ISS Rise with Trauma and 2 nd ORIF Hit Rise with Trauma and 2 nd ORIF Hit

60 Damage Control Mode Provisional stabilization with Rapid External Fixation Once the Patient at Risk is Identified...

61 Patient in Shock Multiply injured patient Physiologically unstable Severe chest injury (pulmonary insufficiency) Severe TBI (Hemorrhage or elevated ICP)

62 DAMAGE CONTROL ORTHOPAEDICS Initial Rapid External Fixation

63 Staged Intramedullary Nailing After Physiologic Stabilization

64 Timing - SUMMARY Timing - SUMMARY THE GOLD STANDARD: Early stabilization (<24 hrs) of long bone fractures in multiply injured patients. Early stabilization (<24 hrs) of long bone fractures in multiply injured patients. For most patients who are physiologically stable, reamed IM nailing is the procedure of choice.

65 Timing - SUMMARY In “borderline” patients, who are physiologically unstable because of severe chest or head injury OR inadequate resuscitation, temporizing external fixation - “damage control orthopaedics” may be advantageous. Definition of “Borderline” patients continues to evolve

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67 The Quiz

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