1. Provisional Stability & Damage Control In Orthopaedic Surgery
Michael T. Archdeacon, M.D., M.S.E.
Director, Division of Musculoskeletal Trauma
Professor & Vice Chairman Department of Orthopaedic Surgery University of Cincinnati Medical Center

2. Assessing Injury Resuscitation Injury Surveys Emergent Intervention
Surgical Intervention
Definitive Intervention

3. Dynamic / Integrated Process
Resuscitation
Injury Surveys
Damage Control Orthopaedics
Emergent Intervention
Definitive Intervention
Surgical Intervention

4. Primary Orthopaedic Survey
Hemodynamic Instability
Obvious Deformity Or Open Wounds
Vascular Compromise To Limb
Neurologic Deficit

5. Orthopaedic Management – Survey Of Injury
Secondary Survey
Make A Limb Look Like A Limb
Re-assess Neurovascular Status
Provisionally Stabilize Long Bones & Pelvis
Tertiary Survey
Re-evaluate All Tenderness, Crepitus, Ecchymosis
Radiograph Any Suspected Injury
11-18% Fractures Missed On Initial Surveys

6. Initial Treatment Bring The Limb Out To Length Restore Gross Alignment
Obtain Adequate Images
Plain Films
Contralateral Side
CT Scans

7. Orthopaedic Priorities
Provisional Pelvic Stability
Correct Ischemia
Reduction & Splinting
Emergent Intervention
Surgical Intervention
Definitive Intervention
Pelvic Ex Fix
Wound Debridement
Provisional Stability
ORIF & IM Nails
Wound Coverage / Closure

8. Damage Control Orthopaedics
Rapid Long Bone & Pelvic Temporary Stabilization
Aggressive
Resuscitation
Emergent Intervention
Staged, Definitive, Reconstructive Surgical Intervention

9. Definitive Care
Windows Of Opportunity Will Occur Which Allow For Definitive Treatment
Repeat Wound Debridements
Conversion Ex Fix To Definitive Fixation
Articular Reconstructions
Wound Closure / Coverage

10. What Will Kill You? Problem Defined Assessment Strategy
Treatment Outlined
What Will Kill You?

11. Kill You Pelvic Fractures Multiple Long Bone Fractures
Spinal Cord Injury

12. Pelvic Fx High Energy to Significantly Fracture Pelvis
Potentially Life-Threatening Injury
Aggressive Evaluation & Management
Team / Multiple Disciplinary Approach
ATLS Protocols

13. ASSOCIATED INJURIES Pelvic Fx’s Shock – 25 - 67% Neurologic – 27 - 60%
ARDS – %
Thoracic – 19 – 43%
Urologic – %
Mortality – %

14. Managing the Hemodynamically Unstable Pelvic Fx
Identify Patient At Risk
Hypotension
Pelvic Exam
Radiographic Evaluation
ATLS Resuscitation
Determine Orthopaedic Intervention (If Any)
Pelvic Immobilization
Reduction Of Hip Dx
External Fixation
Angiography

15. Emergent Pelvic Immobilization
Goals
Decrease Pelvic Volume
Provisional Stabilization
Prevent Further Hemorrhage

16. Pelvic Binder

17. Pelvic Clamp

18. Sheet Wrap

19. Multiple Long Bone Fractures

20. Multiple Long Bone Fx’s
Aggressive Resuscitation
Temp Immobilization
Urgent or Emergent Stabilization
Early Mobility / Ambulation
NA Goal: Fixation w/in 24 hours

21. Spinal Cord Injury

22. Spinal Cord Injury Aggressive Resuscitation Temp Immobilization
+/- High-Dose Steroids
Temp Immobilization
Cranial Tong Tx
Halo Vest
Urgent or Emergent Decompression / Stabilization
Early Mobility / Ambulation

23. Hurt You Really Bad Amputations Dysvascular Limb Crush Injuries
Compartment Syndrome

24. Amputations

25. Amputations Primary Closure of Traumatic Amputation
Can Be Life Threatening
Control Hemorrhage
Direct Pressure
Rare – Tourniquet Or BP Cuff
Reduce Infection Risk
Sterile Wound Dressing
Prophylactic ATB
Tetanus Update
Surgical Debridement
Primary Closure of Traumatic Amputation

26. Dysvascular Limb

27. Dysvascular Limb Limb Threatening 6 Hour Warm Ischemia Time
Must Recognize The Injury
Don’t Forget To Assess The Hypotensive Pt’s Limbs During / After Resuscitation
Reduction Fx / Dx’s
Involve Vascular Sx
+ / - Angiogram
6 Hour Warm Ischemia Time

28. Crush Injury

29. Crush Injury Limb Threatening Must Eval For Compartment Syndrome
Debridement Of Devitalized Tissue
Bony Stabilization
Follow For Rhabodomyolysis

30. Compartment Syndrome

31. Compartment Syndrome Emergent Decompression A Clinical Diagnosis
Your Patient Will Tell You They Have It
Pain Out Of Proportion
Pain With Passive Stretch
Paresthesias
Pallor
Pulselessness
Measuring Pressures
Obtunded Patients
Confirms Clinical Suspicion
Δ P
Difference Between Diastolic Pressure And Tissue Compartment

32. INAdequate Decompression
17 cm Incisions

33. Orthopaedic Trauma -Summary
Team Approach
Few (True) Life Threatening Orthopaedic Injuries
Protocols
Primary
Secondary
Tertiary