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Orthopaedic Trauma The first 15 min……..

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Presentation on theme: "Orthopaedic Trauma The first 15 min…….."— Presentation transcript:

1 Orthopaedic Trauma The first 15 min……..


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

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

5 Outline Femoral neck fractures

6 The Pelvic Fracture

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

8 Pelvic Stability

9 Intrapelvic Contents bladder urethra vagina rectum

10 Instability: Implications

11 High vs. Low Energy Injuries

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


14 Inlet View anterior to posterior translation rotation SI Joint sacrum



17 APC

18 APC

19 LC

20 LC-3

21 VS

22 Approach Stabilize Pelvis Work up urethral/bladder injuries
Sheet Beanbag +/- traction Work up urethral/bladder injuries Retrograde urethrogram, cystogram 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 IR rotation injuries or fractures into the sciatic notch – consider angiography

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

25 Acute Dysvascular limb
Signs and symptoms Colour or pulse asymmetry Rapid pulsatile blood loss Any difference in pulses needs to be explained (not all 5 Ps present) Early consult 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 Acute amputation morbidity rate approach 0% Salvage 5 - 20% mortality Multiple surgeries, drug addiction, divorce 80% left with significant disabilities

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

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

29 Compartment Syndrome Diagnosis Index of suspicion 5 Ps Pressures
Crush injury (forearm, leg) Vascular injury 5 Ps Pain out of proportion, pulseless, palor, parathesias, paralysis Pressures art line 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 Less than 3 mm subluxation 4 lines

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

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

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

36 Hip dislocations Usually high energy

37 Hip Dislocations



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



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

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

45 Femoral Neck Fractures

46 Vascular Anatomy

47 Femoral Neck Fractures
Displaced Undisplaced

48 Hip fractures

49 Case




53 The Open Fracture Ensure DNVS
Consider degree of contamination and soft tissue involvement Gustilo and Anderson: Grade 1: < 1cm (Ancef) Grade 2: >1cm – 10cm (Ancef/Gent) Grade 3: (a) high energy, gross contamination (add penicillin) Grade 3: (b) soft tissue loss requiring graft/flap 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 Cover with wet gauze and splint Book for OR (within 8) Definitive I&D ORIF +/- repeat I&D at 48 hrs 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 Reduces pain and swelling May restore blood flow to region Reduces skin complications Temporizes

56 Treatment Timing ETC vs DCO Early Total care Goals Problems
Minimize blood loss Minimize mediator release Improve pulmonary function Decrease sepsis and pain Shorten LOS and expense Problems 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 Goals Problems
Fast hemodynamic and orthopaedic stabilization Avoid pulmonary complications and SIRS Problems Prolongs treatment period ‘miss your opportunity’

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

59 How to Identify The “Borderline Patient”
Coagulopathy platelets < 90K >25 U RBC Cold: Temp. < 32 Inadequate resuscitation pH < 7.2, Base excess > 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 Correlates with ISS Rise with Trauma and 2nd ORIF Hit

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

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

62 Initial Rapid External Fixation
DAMAGE CONTROL ORTHOPAEDICS Initial Rapid External Fixation

63 Staged Intramedullary Nailing
After Physiologic Stabilization

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


67 The Quiz

68 The Quiz

69 The Quiz

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