Orthopaedic Trauma

1
Orthopaedic Trauma

• Jeremy Hall
• St. Michaels Hospital
• September 29, 2009

2
Outline

• Compartment Syndrome
• Open Fractures
• Pelvic Fractures

3
Compartment SyndromeDefinition

• Elevated tissue pressure within a closed fascial
  space
• Reduces tissue perfusion
• Results in cell death
• Pathogenesis
• Too much inflow (edema, hemorrhage)
• Decreased outflow (venous obstruction, tight
  dressing/cast)

4
Compartment Syndrome Pathophysiology

• Normal tissue pressure
• 0-4 mm Hg
• 8-10 with exertion
• Absolute pressure threshold
• 30 mm Hg - Mubarak
• 45 mm Hg - Matsen
• Pressure gradient threshold
• lt 20 - 30 mm Hg within diastolic pressure
  Whitesides
• McQueen, et al

5
Compartment Syndrome Tissue Survival

• Muscle
• 3-4 hours - reversible changes
• 6 hours - variable damage
• 8 hours - irreversible changes
• Nerve
• 2 hours - decreased nerve conduction
• 4 hours - neuropraxia
• 8 hours - irreversible changes

6
Compartment Syndrome Etiology

• Fractures-closed and open
• Blunt trauma
• Temp vascular occlusion
• Cast/dressing
• Closure of fascial defects
• Burns/electrical

• Exertional states
• GSW
• IV/A-lines
• Hemophiliac/coagulopathy
• Intraosseous IV(infant)
• Snake bite
• Arterial injury

7
Compartment Syndrome Diagnosis

• Pain out of proportion to injury
• Pain with passive stretch
• Palpably tense compartment
• Paresthesia/hypoesthesia
• Paralysis
• Pulselessness/pallor

8
Compartment Syndrome Emergent Treatment

• Remove cast or dressing
• Place limb at level of heart
• (DO NOT ELEVATE to optimize perfusion)
• Alert OR and Anesthesia
• Bedside procedure
• Medical treatment
• Consider coexistent crush
• ? Renal prophylaxis
• Maximize cardiac output

9
Compartment Syndrome Surgical Treatment

• Fasciotomy
• prophylactic release of pressure before permanent
  damage occurs.
• Will not reverse injury from trauma.
• GOAL RESTORE PERFUSION
• Fracture care
• Rigid stabilization
• Ex-fix
• IM Nail (locking optional)

10
Compartment Syndrome Indications for Fasciotomy

• Unequivocal clinical findings
• Pressure within 15-20 (30) mm hg of DBP
• Rising tissue pressure
• Significant tissue injury or high risk pt
• gt 6 hours of total limb ischemia
• Injury at high risk of compartment syndrome
• CONTRAINDICATION
• Missed CS (gt24-48 hrs)

11
Leg Fasciotomies

• 2 Generous skin incisions (Mubarak 1977)
• medial
• lateral
• Release completely all 4 fascial compartments
• Beware of neurovascular structures to prevent
  iatrogenic injury

12
Compartment Syndrome Other Areas

• Can occur anywhere in the body
• Hand
• Arm
• Buttock/thigh
• BEWARE arterial injury.consider angiogram
• Abdominal
• With you general surgeons!

13
Outcomes

• Heemskerk et al, World J Surg, 2003
• 40 successive cases
• 6 cases ACS from Gen Surg procedures in
  lithotomy position
• Majority trauma/vascular cases
• 15 MORTALITY
• 12 amputation
• Dysfunctional limb 27
• Functional 45
• AGE most significant factor
• Finkelstein et al
• Fasciotomy for missed compartment syndrome
• 50 incidence death, sepsis, deep infection

14
Open Fractures

• All fractures have some degree of soft tissue
  injury
• Prognosis determined by
• Amount of energy
• transferred to the soft
• tissue and bone
• Degree of contamination
• and type of bacteria
• Patient factors

15
Introduction

• Energy Transfer
• Fall from curb
• 100 ft-lbs
• Skiing
• 300-500 ft-lbs
• High-Velocity GSW
• 2000 ft-lbs
• Automobile Bumper _at_ 20 MPH
• 100,000 ft-lbs

16
Skin Lesions

• Blisters
• Clear
• Sanguineous
• Abrasions
• Degloving
• Morel-Lavalle

17
Open Fracture

• Definition
• A break in the skin and soft tissues
  communicating with a fracture or its hematoma.

18
Gustilo-AndersonGrade I
19
Gustilo-AndersonGrade II
20
Gustilo-AndersonGrade IIIA
21
Gustilo-AndersonGrade IIIA
IIIA Includes severe comminution despite size of
skin wound.
22
Gustilo-AndersonGrade IIIB
23
Gustilo-AndersonGrade IIIC
24
Assessment

• History
• Mechanism
• High or low energy?
• Time since injury
• Pre-morbid conditions
• Other injuries

25
Assessment

• Physical Exam
• One look soft tissue exam
• Neurological status
• Vascular status
• Compartments

26
Assessment

• X-rays
• Standard two 90 views
• Joint above and below fracture

27
Emergent Treatment

• One Look Exam
• Sterile Dressing
• No ER Cultures
• Poor indicator of probability of infection and
  organism
• expensive
• Realign and Splint

28
Tetanus Toxoid
Tetanus Toxoid 2.5 cc to all poly-trauma
patients, otherwise
IMMUNIZATION HISTORY NON-TETANUS PRONE TETANUS PRONE
UNKNOWN YES YES
gt3 IMMUNIZATIONS (lt5 YEARS) NO NO
Tetanus Prone gt6 hours old, complex soft tissue
injury, wound gt1 cm deep, missile, crush, burn,
frostbite, devitalized tissues, soil
contaminants, denervated, ischemic, early
infection.
29
Tetanus Immune Globulin
250-500 units IM
IMMUNIZATION HISTORY NON-TETANUS PRONE TETANUS PRONE
UNKNOWN NO YES
gt3 IMMUNIZATIONS (lt5 YEARS) NO NO
30
Bacteriology of Open Fractures
Blunt Trauma, Low Energy GSW Staph, Strept
Farm Wounds Clostridia
Fresh Water Pseudomonas, Aeromonas
Sea Water Aeromonas, Vibrios
War Wounds, High Energy GSW Gram Negative
31
Recommended Antibiotic Treatment
1 Gen Ceph Gent PCN
Grade I ?
Grade II ? /-
Grade III ? ? /-
Farm/War Wounds ? ? ?
(Gustilo, et al JBJS 72A 1990)
32
Duration of Antibiotic Treatment

• Initial 72 hours
• 48 hours after each subsequent procedure

33
Treatment

• Principles
• Limb Salvage?
• Vascular Injury?

34
Principles of ID

• Longitudinal incisions-extensile exposures
• Excise non viable tissue
• Systematic and detailed approach
• Irrigation
• Stabilize fracture

35
ID

• Systematic
• Skin
• Fascia and fat
• Muscle 4 Cs of muscle viability
• Contractility
• Capacity to bleed
• Consistency
• Color

36
Stable Fixation

• Reduces infection
• Options
• External fixation
• /- delayed internal fixation
• IM Nail
• ORIF

37
Wound Closure

• Primary Closure?
• Delayed closure/coverage
• STSG
• Flaps
• VAC

38
Pelvic Ring Injuries
39
Epidemiology

• Pelvic fractures account 1-3 of all fxs
• 60 Male
• Mechanism
• MVC (57-71)
• Collision w/ pedestrian (13-18)
• Motorcycle accident (5-9)
• Falls (4-9)
• Crush injury (4-5)

40
Epidemiology

• Overall reported mortality figures for pelvic
  injuries range from 8-13
• Higher energy injuries greater mortality
• Peds vs car (23)

Poole GV, Ward EF Causes of mortality in
patients with pelvic fractures, Orthop 17691,
1994. Pohlemann T et al Pelvic fractures
epidemiology, therapy and long term outcome.
Overview of the multicenter studey of the pelvis
study group, Unfallchirurg 99160, 1996.
41
Key Point

• Presence of a pelvic fracture indicates the
  profound magnitude of disruptive energy at the
  time of injury
• Alerts to likelihood of major injury to other
  body systems

Pelvic fractures bad, associated injuries very
bad!
42
Pelvic Anatomy

• Inominate bones (2)
• ilium, ischium pubis
• Sacrum
• Coccyx

43
Pelvic Anatomy

• Pelvis contains 5 joints
• Lumbosacral
• Sacroiliac
• Sacrococcygeal
• Symphysis pubis
• Acetabulum movement

44
Pelvic Amatomy

• Ring structure is basis for stability
• Stability via ligaments
• Iliolumbar
• Sacroiliac
• Sacrotuberous
• Sacrospinous

45
Pelvic Anatomy

• Pelvis is extremely vascular
• Majority of blood from hypogastrics (internal
  iliac)
• Proximity to pelvic arch
• Superior gluteal largest branch, commonly
  injured in posterior fxs
• Obturator internal pudendal often injured in
  fxs involving pubic rami

46
Pelvic Anatomy

• Nerve supply from lumbar sacral plexi
• Proximity to posterior arch of pelvic ring

47
Pelvic Radiography

• Unique skeletal evaluation in trauma setting
• Only one view is obtained
• AP Pelvis
• Most injuries can be identified
• More commonly missed
• Acetabulum, sacroiliac joints, sacrum
• May not define the extent of the injury

48
AP Pelvis

• Adequacy
• Both iliac crests
• Proximal femurs
• Lower lumbar spine
• No rotation
• Pubic symphysis aligns midline with sacral
  spinous processes

49
Pelvic CT

• CT has replaced supplementary plain-films
• Greater anatomic detail
• The best study for acetabular sacral fxs
• Assesses extent of instability
• Evaluates retroperitoneal hematoma

50
Pelvic CT

• Specific indications for pelvic CT
• Acetabular fractures
• Dislocations of the hip
• All potential or recognized sacral fractures
• All potential or recognized SI injuries
• Question of instability
• Patient must be hemodynamically stable

Hunter JC, Brandser EA, Tran KA. Pelvic and
acetabular trauma. Radiol Clin North Am.
199735559-590.
51
Angiography

• Method of diagnosing controlling
  life-threatening arterial hemorrhage in pelvic
  fractures
• Indicated in hemodynamic instability when
• Thoracic source r/o
• External source r/o
• Negative DPL
• Presence of pelvic fx
• Use in conjunction with mechanical fracture
  stabilization (Ex-Fix)

52
Tile Classification
Tile Type B Rotationally Unstable Vertically
Stable
Tile Type C Rotationally Unstable Vertically
Unstable
Tile Type A Stable
53
Young Burgess ClassificationMechanism of
Injury Direction of Force

• Three patterns
• Lateral compression (50)
• Pedestrian struck on side by car
• MVC in which car is broadsided
• AP compression/open book (25)
• Head-on MVC
• Pedestrian struck anteriorly by car
• Vertical Shear (5)
• Fall or jump from height
• Combination (20)

54
Young Burgess Classification
Vertical Shear
AP Compression
Lateral Compression
55
Lateral Compression LC-IIIWindswept Pelvis
Contralateral sacral fx SI joint diastasis
Ipsilateral SI disruption Iliac wing fracture
Pubic rami fractures
56
AP Compression APC-III
Wide SI Joint
Wide Pubic Symphysis
57
Vertical Shear

• Least common
• Vertical force
• Fall from height, landing on LE
• Pelvis disrupted in vertical plane
• Cephaloposterior displacement
• Malgaigne fracture
• Grossly unstable!
• High incidence of neurovascular injury

58
Vertical Shear

• Left hemipelvis displaced cephalo-posteriorly
• Associated sacroiliac joint diastasis
• Pubic rami fracture
• Ipsilateral (usually)
• Vertically oriented

59
Vertical Shear
Complete disruption of posterior elements
60
Factors Increasing Mortality

• Type of pelvic ring injury
• Posterior disruption
• High ISS
• Tile, 1980
• McMurty, 1980
• Hemorrhagic shock on admission
• Gilliland, 1982

61
Factors Increasing Mortality

• Requirement for large quantities of blood
• 24 u vs. 7 u, McMurty, 1980
• Perineal lacerations, open fractures
• Hanson, 1991
• Associated injuries
• Head abdominal, 50 mortality
• Age
• Looser, 1976

62
Extremely High Energy Injuries with a Large
Number and Variety of Associated Injuries
63
Instability
64
Shock
65
Etiology of Hypovolemic Shock

• Intra-thoracic bleeding
• Intra-peritoneal bleeding
• Ultrasound
• Peritoneal tap
• CT
• Retroperitoneal bleeding

66
Burgess, J Trauma 1990

• Mortality 8.6
• 2/210 pelvic injury patients where pelvic injury
  was primary cause of death
• Contributed 10/210

67
Adams, JOT 2003

• Up to 25 pelvic fractures in traffic fatalities
• Most commonly vertically unstable fractures
• Perhaps more common than originally thought

68
Hemorrhage Control

• Average blood replacement (units)
• LC 3.6
• AP 14.8
• VS 9.2
• Mortality
• 3 hemodynamically stable patients
• 38 unstable patients

69
Hemorrhage (cont.)

• Sheet/C-clamp
• Skeletal traction
• External fixation
• Mast suit
• Embolization
• Surgical stabilization /- packing

70
Hemorrhage (cont.)

• Contributes to 60 of deaths
• Retroperitoneal veins
• 20 arterial injury

71
Coagulopathy

• Hypothermia
• ? Ca2 (blood citrate)
• Acidotic

72
Prolonged Hypovolemia

• Aggravate pulmonary contusion
• Head and visceral injuries
• Increased sepsis
• Adult respiratory distress syndrome (ARDS)
• Multiple organ failure

73
Instability

• Only patients with mechanical instability can
  have hemodynamic instability related to the
  pelvic injury

74
(No Transcript)
75
(No Transcript)
76
Radiographic Signs of Instability

• Sacroiliac displacement of 5 mm in any plane
• Posterior fracture gap (rather than impaction)
• Avulsion of fifth lumbar transverse process,
  lateral border of sacrum (sacrotuberous
  ligament), or ischial spine (sacrospinous
  ligament)

77
(No Transcript)
78
Indications for Angiography

• Unexplained blood loss after stabilization and
  aggressive resuscitation
• Pulselessness extremity

79
(No Transcript)
80
(No Transcript)
81
Surgical

• Stabilization with internal fixation of pelvis
• Stabilization of hemodynamic instability with
  surgical packing of retroperitoneal space

82
Associated Injuries

• Other MSK
• Long bone injuries
• Knee injuries
• Foot injuries
• Abdominal
• Urologic/Gyne
• Neurological

83
Open Pelvic Injuries

• Colon, rectum, or perineum ? Early diverting
  colostomy
• Soft-tissue wounds ? aggressively debrided
• Early repair of vaginal lacerations minimize
  subsequent pelvic abscess

84
(No Transcript)
85
Colostomy is Indicated for Any Open Injury Where
the Fecal Stream Will Contact the Open Area
86
Urologic Injuries

• 15 incidence
• Blood at meatus or high riding prostate
• Eventual swelling of scrotum and labia
  (occasional arterial bleeder requiring surgery)

87
(No Transcript)
88
Urologic (cont.)

• Retrograde urethrogram indicated in pelvic
  injured patients but insure hemodynamic stability
  or embolization may be difficult due to dye
  extravasation

89
(No Transcript)
90
Urologic (cont.)

• Intra extra peritoneal bladder ruptures are
  repaired
• Foley preferred supra-pubic catheter tunneled to
  prevent ant. wound contamination

91
Thats A lot of Info!Any Questions??
92
Thanks!