Orthopaedic Trauma The first 15 min……..

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

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

Outline Femoral neck fractures

The Pelvic Fracture

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

Pelvic Stability

Intrapelvic Contents bladder urethra vagina rectum

Instability: Implications

High vs. Low Energy Injuries

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

INLET

Inlet View anterior to posterior translation rotation SI Joint sacrum

OUTLET

APC

APC

LC

LC-3

VS

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

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

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

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

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

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

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

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

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

Compartment Syndrome

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

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

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

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

Hip dislocations Usually high energy

Hip Dislocations

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

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

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

Femoral Neck Fractures

Vascular Anatomy

Femoral Neck Fractures Displaced Undisplaced

Hip fractures

Case

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

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

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

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)

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’

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

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

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

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

Initial Rapid External Fixation DAMAGE CONTROL ORTHOPAEDICS Initial Rapid External Fixation

Staged Intramedullary Nailing After Physiologic Stabilization

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.

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

The Quiz

The Quiz

The Quiz