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

Assessing Injury Resuscitation Injury Surveys Emergent Intervention Surgical Intervention Definitive Intervention

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

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

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

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

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

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

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

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

Kill You Pelvic Fractures Multiple Long Bone Fractures Spinal Cord Injury

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

ASSOCIATED INJURIES Pelvic Fx’s Shock – 25 - 67% Neurologic – 27 - 60% ARDS – 6 - 19% Thoracic – 19 – 43% Urologic – 0 - 16% Mortality – 14 - 37%

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

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

Pelvic Binder

Pelvic Clamp

Sheet Wrap

Multiple Long Bone Fractures

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

Spinal Cord Injury

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

Hurt You Really Bad Amputations Dysvascular Limb Crush Injuries Compartment Syndrome

Amputations

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

Dysvascular Limb

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

Crush Injury

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

Compartment Syndrome

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

INAdequate Decompression 17 cm Incisions

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