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August 2012 ASOPA/NAOTOrthopaedic Technologists Symposium Conference and

Workshop

Complications in Orthopaedic Trauma

Michael S. Bongiovanni, M.D.

Scripps Mercy Hospital

San Diego, California

August 4, 2012

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Disclosures-none

Thanks=AONA archives and Jeff Smith, MD

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Objectives

1. Recognize goal in Orthopaedic Trauma decision making is prompt diagnosis and treatment of musculoskeletal injuries

2. Post-operative mobilization3. Discharge planning needs4. Describe different weight bearing types5. Case examples-discussion6. Concept changes7. Ortho technologist importance

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Orthopaedic Emergencies

1. Open fractures/joints

2. Unstable pelvis injuries

3. Compartment syndrome

4. Injuries with neurovascular compromise

5. Certain infections

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But I have a full office!

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Patient Evaluation

ATLS approach

ABCDE

Systematic

Team approach

Other injuries

JMS Orthopaedic trauma diagnosis

1. History

2. Physical exam

3. Studies-xrays, CT scans, and/or MRI

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Patient Factors

Age

Mech of injury

Assoc. injuries

comorbidities

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Mechanism of Injury

Patient hx

Paramedic hx

Scene description

Witnesses

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Physical Examination

Begins with ATLS primary survey

AirwayBreathingCirculationDisability (neurological)Exposure(undress)

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Open Fractures

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New concepts

-timing to Or?

-antibiotic length

-negative pressure wound therapy

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Type I

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Type II

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Type III

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Open Fracture: Type IIIA

Significant soft tissue injuryMuscle coverage of bone

unnecessarySTSG over muscle7% Infection Rate

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Open Fracture: Type IIIB

Significant soft tissue loss

–Requires Soft Tissue Coverage

–10–50 % Infection Rate

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Open Fracture: Type IIIC

Associated vascular injury that requires repair for limb salvage

25-50% Infection Rate ?

50 % Amputation Rate ?

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Identify Associated Injuries

What other interventions does the patient need?

What degree of extremity intervention will the patient tolerate?

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First aid: pre-hospital care

Emergency room care-ortho tech

Operating room: definitive care-ortho tech

Rehabilitation-ortho tech

Management Stages

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Control bleeding/ open woundDirect pressureCover wound with sterile

dressingtourniquets

Realign and splint decreases further soft tissue

damage and neurovascular compromise

comfort

First Aid

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First aid if not already given

Remove gross debris/ irrigate/dress/image/ splint

Tetanus prophylaxis - if necessary

Antibiotics!!!!!!!!!!!!!!

Emergency

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Open Fracture Management

Open fractures go to the OR

For a formal debridement

Followed by stabilization of the fracture

Continuation of IV antibiotics for treatment not prophylaxis

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Debridement

Layer by layer

Remove all devitalized and contaminated tissue (including bone)

JMS Fracture Stabilization: Why?

Limb:Prevents further soft tissue injuryAllows mobilization of the involved limb for

dressing changes/ wound checks on the floor

Patient:Reduces painLong bone stabilization decreases

activation of the immune system/ inflammatory cascade

Allows mobilization of the patient

JMS Temporizing or Definitive: VAC

-125 mm Hg pressure applied to an open cell sponge

Stimulates cell division and blood vessel in-growth

Sealed system placed in OR

Can be used to shrink wound size

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Wound Closure/CoverageOptimally by 3-7 days

Principles1 Durable coverage2 Well vascularized

soft tissue envelope

for bone3 Fill dead space

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Amputation vs Limb Salvage

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Factors Favoring Amputation

Warm ischemia time > 8 hrs

Severe crush

Chronic debilitating disease

Severe polytrauma (life before limb)

Mass casualty Complexity of reconstruction

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New Concepts

-seeing more GSW

-similar principles

-rapid rehab

JMS The ProblemDeaths from Firearms increased

60% since 1968.

For every death there are 3 Non-Fatal Injuries.

80% of the cost is paid by the Taxpayers.

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Antibiotics and Tetanus Prophylaxis

same as Open Fractures

JMS Internal vs External Fixation

Low / High / ShotgunClose Range.Pts. General Condition.Soft Tissue Injury.Fracture Pattern.

JMS Fxs. With Vasc. Injury

Shunt the Artery.

Irrigation and Debridment.

Definitive Fracture Fixation.

Final Vascular Repair.

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Unstable Pelvis Fractures

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In trauma center, 13-18% of pelvic injury patients present with unstable, high energy injuries

Associated injuries Mortality High rate of early and late morbidity

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Open Pelvic Fracture

Aggressive debridement of open wounds

Colostomy / urinary diversion nearly always

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-less traction

-early mobilization

-minimally invasive surgical techniques

-binders/pelvis sheets

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Pelvis binder

JMS Pelvic Binder

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Binder

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High Energy Injury Assessment

Beware of Associated Injuries

More extensive exam in polytrauma

Thorough distal neurovascular exam

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Associated Injuries

Massive energy input required to cause unstable pelvic injuries

Energy causes injuries to other organsHeadChestAbdomen

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Associated Injuries

Major vascular, neurological, gastrointestinal, and genitourinary structures pass through pelvis

Frequently involved with pelvic injuries

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Physical

Musculoskeletal Pelvic Exam

Inspection

Palpation

Function (Stability)

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Radiographic Evaluation

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Reduction and stabilization of pelvic ring

Emergent external fixation

• Decreases intrapelvic volume

• Minimizes motion at fracture site

• AP pelvis to determine if injury amenable to external fixation

Emergent Management

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Emergent Management

Open Surgery

Primarily reserved for failure to respond to ex fix or angiography

Occasionally coincident with emergent ex lap

Open packing usually preferred over ligation

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Early Management

Temporizing measures

External fixation

Binders/sheets

Longitudinal traction distal femur

• Very important with vertical shear injury

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External Fixation

-resusitation

-temporary

-definitive

-”damage control”

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O R I F

Symphysis

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ORIF

Iliac Fracture

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Compartment Syndrome

1. Elevated compartment pressure

2. Painful!!

3. Early diagnosis

4. Early treatment

5. Examples

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Compartment syndrome

1. Neurovascular exam

2. Possible pressure measurements

3. Surgical decompression

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Neurovascular exam

1. circulation-motor-sensory

2. Pulses-palpation or doppler

3. Capillary refill-nl less than 2 seconds

4. Sensation-present, diminished, absent

5. Motor-specific movement-present, diminished, or absent

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Compartment syndrome

1. Pain out of proportion

2. Pain with passive stretch

3. Paresthesias,(sensory changes)

4. Paralysis,(weakness)

5. Pulse(usually present, absent late finding)

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Compartment Syndrome

1. Loosen dressing, splints, wraps

2. Bivalve cast down to skin

3. Elevation controversial

4. Emergency notify surgeon

JMS Deep Venous Thrombosis-prevention

1. ambulation-out of bed

2. Pharmacology-heparins/coumadin

3. Mechanical devices( SCD’s/Foot pumps)

4. IVC filter can help prevent PE in high risk patient

JMS Deep Venous Thrombosis-diagnosis

1. leg and/or chest pain2. Fever3. Tachycardia4. Leg swelling(unilateral)5. Doppler ultrasound6. Chest CT scan7. Pulmonary angiogram

JMS Deep Venous Thrombosis-treatment

1. Medical-heparin infusion-coumadin

2. Mobilization

3. Further surveys

JMS Orthopaedic trauma-treatment

1. Age2. Other injuries3. Injury pattern4. Soft tissue injury5. Osteopenia6. Comorbidities7. Activities of daily living

JMS Orthopaedic trauma-treatment

1. Closed,(cast,splint,brace)

2. Open,(plates/screws, external fixation, intramedullary implants, joint prosthesis, and/or pins)

3. Therapy-mainstay for recovery

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Casting

-fiberglas/plaster

-short/long/muenster/PTB

-molding

-Neurovasc check

-xray check

-listen to your patient

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Skin Traction

1. Example Buck’s traction

2. Comfort

3. Minimize further injury

4. Hip and knee dislocation

5. Hip fractures

6. 5-10 lbs.

7. Helpful?

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Skeletal Traction

1. Weight directly thru bone

2. Pelvis fractures, dislocations

3. Acetabular fractures

4. Femur fractures

5. External fixation

6. Temporary versus definitive

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Pre-op Planning

Minimize OR time

Minimize blood loss

Proper equipment

Minimize exposure

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Pre-op Planning

Table/position

C-arm

Equipment

Implants

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The Tools

Radiolucent table

C-arm

Pelvic reduction clamps

Pelvic instruments

Oscillating drill

• 3.5 mm / 4.5 mm pelvic reconstruction plates

• Large and small fragment screws

• 7.3 mm fully and partially threaded cannulated screws

• Large external fixator

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ORIF

Indications

Presence of significant associated injuries (Polytrauma)

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ORIF

Complications

Infection (4%)

Loss of reduction / fixation (5%)

DVT / PE (4%)

Nerve palsy (3%)

Matta, Tornetta 1982 -1991

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Post-Op Management

Stable fixation

Early mobilization

Weightbearing as tolerated unaffected side

Non or partial weightbearing affected side 8 - 12 weeks

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Post-Op Management

Unstable or incomplete fixation

Bedrest

Longitudinal traction on unstable side

Duration individualized, but caution to avoid deformity

Non-weightbearing 3 months

JMS Weight bearing-lower extremities

NWB-non weight bearing

TDWB-touch down weight bearing

PWB-partial weight bearing(% or lbs.)

FWB-full weight bearing

WBAT-weight bear as tolerated

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Weight bear examples

Joint fractures-TDWB

Hip hemiarthroplasty-WBAT

Femur/Tibial shaft IM nails-TDWB-WBAT

Joint dislocations-TDWB-WBAT

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Full, partial, or non-weight bearing

Platform crutches/walker

Casting

Splints

Bracing

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A Team Approach

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RK

43 yo male

Fell 40 feet from tree

ETOH

Combative,confused

Bone sticking out of thigh

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RK

Moving all four extremities

Rapid sequence intubation(airway control)

Hemodynamic stable

Past history negative-possible psych issues

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Closed Head Injury

Small Subdural Hematoma

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5 cm lateral wound

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Distal Femur Fracture

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Distal Femur Fracture

JMS Distal Radius Fracture, closed

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Treatment

Femur sterile dressings, hare traction splintAntibiotics(Cephalosporin, aminoglycoside)Tetanus toxoidRapid completion CT scansImmediate Neurosurgery consultationTo operating room, emergently for DCONS-’rapid ortho procedure so early repeat head ct

scan done’

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Debridement

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Intraop

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Post-op

IV ABS, dressing changes, resuscitation

Head CT stabilized

Definitive treatment at 96 hours-

Wound re-debride, distal femur LISS, wound closure over drain

Wrist external fixation and pinning

JMS Helpful Orthopaedic information

1. Npo status

2. Pain scale

3. Vital signs

4. Surgical drainage amount

5. Neurovascular exam

6. Labs –most recent

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Discharge planning

1. Begins immediately

2. Home, SNF, Rehab, Hospice

3. Team approach,(Nursing, orthopaedist, ortho tech, therapist, case manager, patient/family)

4. Resources/managed care

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QUESTIONS?

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