Orthopaedic Trauma
The first 15 min……..
The Basics
10% of blunt trauma have a missed injury
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Difficult environment
Difficult to assess
To avoid
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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
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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
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Femoral neck fractures
The Pelvic Fracture
The Pelvic Fracture
High energy, consider associated injuries
Assess
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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
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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
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Stabilize Pelvis
Sheet
Beanbag
+/- traction
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Work up urethral/bladder
injuries
Retrograde urethrogram,
cystogram
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If blood in the
rectum/vagina, treat as
open
Look for blush on CT scan
If remains unstable
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ER rotation injuries to the
OR
IR rotation injuries or
fractures into the sciatic
notch – consider
angiography
Pelvic fracture
Definitive management
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If stable
Ex-fix or definitive management
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If unstable
Ex-fix, laparotomy prn, angiography, packing prn
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If open
I&D, stabilize, diverting colostomy, urethral/vaginal
management, soft tissue closures
Acute Dysvascular limb
Signs and symptoms
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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
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Attempts to salvage are not without risk
Acute amputation
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morbidity rate approach 0%
Salvage
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5 - 20% mortality
Multiple surgeries, drug addiction, divorce
80% left with significant disabilities
Acute Dysvascular limb
Approach
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Correct Deformity and reassess DNVS
Perform ABI – ankle brachial index
>0.9 – monitor with repeated exams
< 0.9 - vascular consult, angiogram
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If bleeding
Direct pressure
Tourniquet
Clamp (snap)
Treat like an open fracture – I&D,
antibiotics, tetanus
Acute Dysvascular limb
Consider
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? period of ischemia
if > 6-8 hr then fasciotomies
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? risk of compartment syndrome
Definitive management approach
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Urgent OR
Bone stabilization – ex-fix, nail
Vascular repair/bypass
Fascitomies if > 6-8 hrs
Definitive Bone fixation
Compartment Syndrome
Diagnosis
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Index of suspicion
Crush injury (forearm, leg)
Vascular injury
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5 Ps
Pain out of proportion, pulseless, palor,
parathesias, paralysis
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Pressures
art line
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Controversial, but if within 20 mm Hg of diastolic BP it
requires release
Treatment
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Urgent release within 6 hrs of injury
Long incisions, complete release
Compartment Syndrome
Spine Injuries
ADI < 4mm
Soft tissue swelling
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5 mm, 21 mm
Less than 3 mm
subluxation
4 lines
Spine injuries
Define level
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Asia scale to define
motor and sensory
level
!! Document and
reassess !!!
Spine Injuries
Shock
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Hemorrhagic
Low BP, tachycardia, narrow pulse pressure
Tx – fluid resusc
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Neurogenic
Low BP, lack of tachycardia, widened pulse pressure
Initial fluid resusc
Spinal shock
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Bulbocavernosus reflex 1st to return
Pull foley, pinch glans/clitoris
Spine Injuries
Treatment
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Stabilize
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Role of solumedrol
Controversial
3m mg/Kg then 5.4 mg/kg/hr x 48 hrs
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Timing of reduction
If complete – stabilize patient completely
If incomplete
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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
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95% of presentations
Flexion, adduction, IR, shortening
Reduce
Appropriate sedation
++ flexion, traction, IR/ER
Anterior Hip dislocations
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Rare
ER, extension
Reduce
Appropriate sedation
In-line traction, lateral traction, IR
Traumatic hip fracture
Sciatic nerve injury in 20% of posterior
dislocations
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Document!!!
With reduction 40% resolution, 25-35% partial
resolution
Head
Neck
Trochanteric
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:
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Grade 1:
Grade 2:
Grade 3:
Grade 3:
Grade 3:
< 1cm (Ancef)
>1cm – 10cm (Ancef/Gent)
(a) high energy, gross contamination (add penicillin)
(b) soft tissue loss requiring graft/flap
(c) vascular injury
Ensure Tetanus up to date
The Open fracture
Gentle I&D at time of reduction
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Don’t worry about risk of contamination with reduction
Cover with wet gauze and splint
Book for OR (within 8)
Definitive
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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
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Reduction and splinting
Reduces pain and swelling
May restore blood flow to region
Reduces skin complications
Temporizes
Treatment Timing
ETC vs DCO
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Early Total care
Goals
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Minimize blood loss
Minimize mediator release
Improve pulmonary function
Decrease sepsis and pain
Shorten LOS and expense
Problems
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High ISS = High risk of ARDS
Especially if severe chest injuries, severe shock or
coagulopathy (Pape 1993)
Treatment Timing
ETC vs DCO
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Damage control Orthopaedics
Goals
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Fast hemodynamic and orthopaedic stabilization
Avoid pulmonary complications and SIRS
Problems
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Prolongs treatment period ‘miss your opportunity’
Controversy Continued:
Early skeletal fixation is appropriate but
what are the limits in patients with :
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Hemodynamic instability ?
Coagulopathy ?
Hypothermia ?
Severe head or chest injury ?
= SHOCK
How to Identify The “Borderline
Patient”
Coagulopathy
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platelets < 90K
>25 U RBC
Cold: Temp. < 32
Inadequate resuscitation
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pH < 7.2, Base excess > 10,
Bilateral Lung contusions
Probable OR time >6 hrs
Multiple Long bones plus truncal AIS >2
High Inflammatory Markers
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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)
DAMAGE CONTROL ORTHOPAEDICS
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