1. Saving Lives By Strengthening Our Region’s Trauma Care System December 5, 2013 JASON SANSONE, MD CASE STUDIES IN ORTHOPEDIC INJURY

2. CASE 1 History 51 y/o female Fell from bicycle onto L knee Abrasions left arm No LOC PMH: alcoholism

3. CASE 1: RADIOGRAPHS

4. CASE 1: CONSIDERATIONS With these radiographs, what complication needs to at least be considered, and monitored for?

5. CASE 1: CONSIDERATIONS With these radiographs, what complication needs to at least be considered, and monitored for? COMPARTMENT SYNDROME

6. CASE 1: COMPARTMENT SYNDROME Most common cause: Tibial shaft fracture Other common causes to be aware of: Any fracture Crush injury without fracture (esp. in patient on anticoagulation) High energy open fractures Tight-fitting casts or compressive wraps Reperfusion following prolonged ischemia Burns (especially circumferential) Penetrating trauma (GSW)

7. CASE 1: COMPARTMENT SYNDROME

9. Diagnosis—5 P’s Pain with passive flexion/extension and out of proportion with examination Paresthesias Paralysis Pallor/pulselessness (late) Poikilothermia (late) Clinical diagnosis, but…

10. CASE 1: COMPARTMENT SYNDROME Can measure compartment pressures Known to be unreliable and inconsistent

11. CASE 1: COMPARTMENT SYNDROME Mechanism Swelling due to fracture and/or bleeding increases pressure in non-compliant fascial compartments

12. CASE 1: COMPARTMENT SYNDROME Mechanism Swelling due to fracture and/or bleeding increases pressure in non-compliant fascial compartments

13. CASE 1: COMPARTMENT SYNDROME Mechanism As tissue pressure increases, veins become compressed and venous pressure increases This decreases arterial inflow FINAL COMMON PATHWAY: ISCHEMIA AND CELLULAR DEATH

14. CASE 1: COMPARTMENT SYNDROME Heckman, et al., JOT, 1993 Ischemic threshold of muscle= 8 hours Of nerve: 1-2 hours? Pressure threshold to induce ischemia: Within 30 mm Hg of MAP Within 20 mm Hg of diastolic pressure

15. CASE 1: COMPARTMENT SYNDROME Ischemic injury results in… Muscle and nerve necrosis Contractures and dysfunctional limb Foot drop Loss of plantar sensation Toe/ankle contracture* * Can also occur in the arm, forearm, hand, gluteals, thigh, foot

16. CASE 1: COMPARTMENT SYNDROME

17. Treatment Release circumferential dressings/casts Emergent/urgent fasciotomy Obtain immediate orthopedic consultation If unavailable, transfer emergently

18. CASE 1: COMPARTMENT SYNDROME

19. Hospital Course Prolonged stay Multiple I&D Delayed closure Skin grafting Recommended length of incision= 16 +/- 4 cm

20. CASE 1: COMPARTMENT SYNDROME

21. Expected Outcomes (if diagnosed correctly) Delayed healing (vascular insult) Stiffness Cosmesis Sheridan, et al., JBJS, 1976 If treated <12 hours: 68% “normal function” at final f/u If treated >12 hours: 8% “normal function” at final f/u Finkelstein, et al., J Trauma, 1996 5 pts., >36 hours from dx: 1 death, 4 amputations

22. CASE 1

23. CASE 2 History 38 y/o male Fell from roof onto L arm No other injuries No LOC PMH: Negative Reports needing to apply belt to arm in the field to stop bleeding

24. CASE 2: RADIOGRAPHS

25. CASE 2: CONSIDERATIONS What is the optimal management of an open fracture? Antibiotics/tetanus ppx Surgical debridement Fracture fixation Definitive soft tissue coverage

26. CASE 2: OPEN FRACTURES Gustilo and Anderson Classification Grade I: <1 cm, minimal contamination/muscle damage, minimal periosteal stripping Grade II: >1 cm, moderate contamination Grade IIIA: >10 cm, severe contamination, fracture comminution Grade IIIB: requires flap coverage Grade IIIC: vascular injury

27. CASE 2: OPEN FRACTURES Gustilo and Anderson Classification Grade I: <1 cm, minimal contamination/muscle damage, minimal periosteal stripping Grade II: >1 cm, moderate contamination Grade IIIA: >10 cm, severe contamination, fracture comminution Grade IIIB: requires flap coverage Grade IIIC: vascular injury

28. CASE 2: GRADE I/II

29. CASE 2: GRADE IIIB/C

30. CASE 2: OPEN FRACTURES (ABX) Needs coverage of both Gram positive and Gram negative organisms Cefazolin (Gram +) Gentamicin (Gram -) Tobramycin 3 rd generation cephalosporin Add PCN if… Concern for anaerobic infection (farm, vascular injury)

31. CASE 2: OPEN FRACTURES (I&D) “Six hour rule”… Dogma 1898 Sir Paul Leopold Friedrich Inoculates guinea pigs with mold and stair dust Finds that after 6 hours, debridement is unsuccessful at preventing infection 1976 Gustilo and Anderson: “There is universal agreement that open fractures require emergency treatment including adequate debridement and irrigation of the wound” No citation

32. CASE 2: OPEN FRACTURES (I&D) Since then, many studies have demonstrated no difference in infection rate between patients undergoing I&D at <6 hours versus 6-24 hours Primary factors that do relate to infection risk Grade of injury (Grade I: 0-2%; Grade III: 10-50%) Time to administration of IV abx (<12 hours?) Fracture location (tibia)

33. CASE 2: OPEN FRACTURES (FIXATION) Stabilization of fractures Enhances host response to bacteria Improves soft tissue health Limits pain Simplifies nursing care Allows for serial examination of the injured limb Allows for early mobilization of adjacent joints

34. CASE 2: OPEN FRACTURES (FIXATION) Stabilization of fractures IM nail ORIF External fixation Ring fixation

35. CASE 2: OPEN FRACTURES (FIXATION)

38. CASE 2: OPEN FRACTURES (COVERAGE) It is acceptable to close an open fracture wound immediately Some wounds cannot be closed with local tissue and require either pedicle flaps (gastrocnemius, soleus) or free flaps (latissimus, serratus, etc.)

39. CASE 2: OPEN FRACTURES (COVERAGE)

40. When flap coverage is necessary, VAC dressings are often placed temporarily

41. CASE 2: OPEN FRACTURES (COVERAGE) BUT… VAC dressings do not extend the time allowed for definitive wound coverage Recommendation: Within 3-7 days Godina, Plast Recon Surg, 1986 <72 hours: flap failure <1%, infection 1.5% >72 hours: flap failure 12%, infection 18%

42. TAKE HOME POINTS 1.Compartment syndrome is a true orthopedic emergency 2.Requires awareness, vigilant/serial examination, and timely treatment or transfer 3.Open fractures need IV abx and tetanus ppx 4.Consider need for surgical intervention urgent, but not necessarily emergent