Peggers’ Super Summary of External Fixation & DCO Indications: PATIENT FACTORS Organ Injury Thoracic trauma Polytrauma HI or raised ICP Hamodynamic instability Systolic Bp <100mmhg Use of catecholamines Anuria Transfusion > 25 units of blood Terrible Traid Acidosis Hypothermia Coagulopathy Bloods IL 6 > 800pg/dl Lactate levels >2.5 All Increase MOD/MOF FRACTURE FACTORS Limb deformity not reduced by non operative techniques out of hours Limb shortening or skin compromise due to tenting Soft tissue damage or skin blisters Complicated Comminuted intra-articular fracture Deciding ETC vs DCO: Stable - ETC Boarderline - ?? Factors aiding choice include o ISS > 40 o ISS > 20 + thoracic trauma o pH < 7.24 o Temperature <350 o Transfusion > 10 RBC o Coagulopathy o IL-6 Unstable - DCO Extremis - DCO Biomechanics Monolateral fixation and 60-70% of load is supported by near cortex Bending rigidity is ∞ pin diameter 4 2 screws per segment (adding a 3rd makes no difference) Decrease ‘working length’ of the screws i.e. bone to bar distance Near to fracture site screws far away from each other i.e. shorten working length of bar Add more bars increases stability Increase planes increases stability Preoperative planning Pin diameter should not exceed 20% of bone diameter Safe corridors Spanning or non-spanning of joints Anatomy Safe Corridors: NB Avoid 2-3 cm around joints to avoid synovium thus intraarticular joint penetration PELVIS ASIS horizontal stab incisions down to bone o Lateral cutaneous femoral nerve o Hip joint Supra-acetabular pin placement o Risk of injuring femoral vessels o Lateral femoral cutaneous nerve o Sciatic notch o Hip joint FEMUR Anterior to 900 laterally TIBIA Subcutaneous boarder anteromedially to the tibial spine running perpendicularly to subcutaneous boarder of the tibia. The more distally placed schanz pin needs to be more medially in a 900 arc FOOT 2.5cm proximal and anterior to calcaneum through and through Medial and in the centre of great toe (1st) MT via open placement HUMERUS Proximal 1/2 blind pin placement into lateral humerus Distal ½ Open placement laterally to avoid radial nerve FOREARM Proximal half subcutaneous ulnar posteriorly Distal 1/2 Into Radius via open placement between ECRL/B interval o To Avoid superficial radial nerve Dorsal hand pins are inserted either side of listers tubercle or EPL (4rd compartment) via open placement HAND Index Metacarpal 450 to the long axis dorsal radial angle via open placement distal to the interosseous muscle in proximal 2/3rds of the MC bone - Avoid radial artery and superficial radial nerve aim in the middle to avoid extensor hood or joint External fixation principles: Near-far technique Open placement in ‘danger’ areas Single pin clamps Avoid pins in peri-articular regions Avoid robs over # site; obscure reduction on x ray REDUCE FRACTURE DISPLACEMENT Pelvic Fractures: INDIACATIONS OF PELVIC FRACTURE Seeing bruising to thighs, flanks or blood at meatus Movement on pelvic springing CLASSIFICATION – 1) Burgess & Young AP Compression – partially stable o Pubic Diastasis gap >1cm o >2.5cm = SIJ thus posterior injury Lateral Compression – partially stable Vertical Shear - unstable Combination Page 1 of 2 Peggers’ Super Summary of External Fixation & DCO 2) J Orthopaedic Sugery (Am) 1996 Type A – stable Type B – Partially stable Type C – Unstable (LC III, APC III, VS) Algorithm for pelvic Fracture: MANAGEMENT 75% have massive haemorrhage 25% have urological injuries 20% have abdominal injuries HAEMORHAGE SOURCE: Arterial o Gluteal o Lateral sacral o Obturator o pudendal Venous o Posterior venous plexus # cancellous bone NB indications for EX-FIX is uncontrolled haemorrhage and unstable pelvis ATLS Closed Pelvis – if in shock consider another cause Apply sheet or external fixator Arterial bleeding is only present in 10% of cases thus arteriography is not indicated in UNSTABLE PATIENTS Katish et al J Trauma 1973 Unstable Stable Unstable Unstable Treatment No treatment Probably not pelvic – look for other source No Urgent pelvic treatment needed URGENT pelvic stabilisation AND look for other bleeding sources Equipment: Instrument and dissection set External fixators set o AO o Orthofix o Smith & Nephew Schanz pins II + Radiolucent operating table If unstable pelvis need vascular and general surgeons DPL / FAST scan negative DPL / FAST scan POSITIVE Angiography if available quickly External fixator and laparotomy with packing Burgess & Young Detailed: Indication for angiography persisting haemodynamic instability after pelvic stabilisation without evidence of abdominal or thoracic haemorrhage Pelvic Fracture summary: Mechanical Haemodynamic Stable Stable Stable Unstable Open pelvis LC Blood loss in 24hrs* APC Blood loss in 24hrs* VS Blood loss in 24hrs* Pubic rami and sacral # 2.4 Associated iliac # 2.8 Contralateral open book 5.7 Anterior diastasis ligaments intact Isolated anterior ligament injury Anterior and posterior ligament injury 6.4 20.5 Disruption of anterior & posterior elements 7.8 *Burgess et al J Trauma 1990 Page 2 of 2