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

13. INLET

14. Inlet View
anterior to posterior translation
rotation
SI Joint
sacrum

15. OUTLET

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

64. Timing - SUMMARY THE GOLD STANDARD:
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