Damage Control Orthopaedics: Fracture Care in Polytrauma

1
Damage Control Orthopaedics Fracture Care in
Polytrauma

• Peter J. Nowotarski, M.D.
• Associate Professor
• University of Tennessee
• College of Medicine
• Department of Orthopaedic Surgery

2
Blunt Multiple Trauma
Physiologic Hits of trauma and treatment

• First Hit
• Hypoxia
• Hypotension
• Soft tissue and organ injury
• Fractures
• Second Hit
• Reperfusion injury
• Compartment Syndrome
• Infection
• Surgery

Keel, Trentz, Injury, 2005
3
Orthopaedic Trauma Patient

• Four types
• Stable patient
• Borderline patient
• Unstable patient
• Patient in extremis

Damage Control Orthopaedic Trauma
Pape, J Trauma 2002
4
Damage Control Orthopaedics

• Definition
• Early, temporary external fixation followed by
  secondary definitive fixation of major fractures
  in patients at high risk for developing systemic
  complications

5
Damage Control Orthopaedics

• Outcomes Pape, J Trauma, 2002
• 81-89 E.T.C. 96 reamed femur IMN, 16 1º Ex
  Fix
• 90-92 Intermediate 76 reamed IMN, 24 1º Ex
  Fix
• 93-01 D.C.O. 14 reamed IMN,
• 36 1º Ex Fix

6
Damage Control Orthopaedics

• Outcomes Pape, J Trauma, 2002
• No difference in local complications (infection,
  nonunion)
• Reduced multiple organ failure DCO lt ETC
• ARDS greater in IMN vs. 1º Ex Fix in DCO group

7
Damage Control Orthopaedics

• Outcomes Pape et al, Ann Surg, 2007
• - Prospective RCT Damage control vs IMN
• - Less Acute Lung Injury in Borderline patients
  with DCO
• Less ventilator days in stable patients with
  primary IMN
• No difference in ICU stay, ARDS, SIRS, MOF,
  pneumonia

8
Negative Physiologic Parameters

• Lung Injury PaO/FiO lt 250
• Hypothermia - lt 32 c
• Coagulopathy / Thrombocytopenia PLTs lt 90 k
• Shock decreased urine output, BP lt80mmhg
• Acidosis delayed Lactate clearance, Lactate gt
  2.4 mmol/l

9
Favorable Patient Profile

• Adequate resuscitation
• Good oxygenation
• Hemodynamic stability
• Acidosis corrected
• No hypothermia or coagulopathy
• Medical comorbidities optimized
• Age

10
Age - Geriatric Trauma

• Increased morbidity/mortality with aging
• A small lick in an older patient is the same as
  a big lick in a younger patient
• LD50 for ISS score by age
• Age 15 - 44 ISS 40
• Age 45 - 64 ISS 29
• Age over 65 ISS 20
• Greenspan, J Trauma 1985

11
Injury Assessment - Clinical

• High versus Low Energy Injury
• Neurovascular Integrity
• Incipient Compartment Syndrome
• Skin Integrity

12
Fracture Surgery Timing

• Primary Determinants in Isolated Fracture
• Patient
• physiologic
• condition
• Soft tissue
• injury recovery

NOT DETERMINED BY FRACTURE!
13
Fracture Surgery Timing

• Emergency - Resuscitative
• Surgical stabilization of exsanguinating pelvic
  fracture
• Completion amputations for hemorrhage control
• Urgent - Within 12 Hours
• Open fracture debridement/stabilization
• Compartment syndrome fasciotomies
• Multiple long bone fractures
• Elective - After 24 Hours
• Upper extremity fractures
• Complex intraarticular fractures

14
Emergency Fracture Surgery
15
Urgent Fracture Surgery
16
Elective Surgery
17
Mission Statement

• Axioms of Orthopaedic Trauma Care
• Appropriate timing and treatment of
  musculoskeletal injuries in polytraumatized
  patients - Know when to say when!
• Expert Fracture Surgery - Anatomic joint
  reduction, stable fixation, does make a
  difference for functional outcome in complex
  fractures!

18
Polytrauma

• Definition - Multiply Injured Patient
• More than two body systems injured
• ISS gt 40
• Thoracic trauma and ISS gt 20
• Aortic, solid viscus injury
• Severe brain injury
• Hemodynamic unstable incomplete resuscitation
• Coagulopathy
• Hyper immune response (IL-6 gt 500)

19
Borderline Polytrauma

• ISS gt 40 w/o chest trauma
• Polytrauma, ISS gt 20 w/chest trauma
• Polytrauma, shock and abdominal injury
• Bilateral lung contusion
• pulmonary artery pressure w/IMN

Roberts, et al. JBJS-A, 2005
20
Orthopaedic Priorities in Polytrauma

• Rapid fixation unstable pelvis fracture bed
  sheet wrap, traction, Ex Fix, c-clamp,
  percutaneous SI screws
• Spine fracture immobilization
• Debridement/stabilization of open fractures
• Reduction of major dislocations
• Spanning Ex Fix joint fractures
• Early fixation of femur fractures
• Bone, JBJS 1989

21
Rationale for Early Orthopaedic Care

• Allow patient positioning for vertical chest
• Reduced ventilator days, ARDS, Pneumonia
  
  Johnson, J Trauma 85
• Allow patient mobility
• Reduced DVT/PE
• Decreased pain narcotic requirement
• Improved, easier nursing care
• Earlier joint rehabilitation

22
Immediate Orthopaedic Care in Polytrauma

• When to temporize definitive care Damage Control
  Orthopaedics
• Hemodynamic Instability
• Inadequate Resuscitation
• Elevated Base Deficit Lactate levels
• Hypothermia
• Coagulopathy
• Head Injury with Labile ICP
• Major Thoracic Trauma

23
Polytrauma Patient fracture
Borderline
Stable
Unstable
In extremis
Resuscitate
If in shock/or need chest decompression
hypoxia, urine output, and IL-6
Stable
Uncertain
OR for DCO
OR for ETC
Pape AJSurg 2002
24
Tools for Damage Control Orthopedics

• Skeletal traction
• Splints
• External fixation
• Pelvic binders
• Wound debridement

25
Pelvic Fx DCO

• Goals
• Hemorrhage Control
• Fracture stabilization
• Modalities
• Pelvic binders
• Ex fix
• Angiography

26
Long Bone DCO

• Goals
• Stabilize femur/tibia fx out to length
• Rapid, minimum physiologic insult
• Modality
• Temporary Ex Fix conversion to IMN

27
Conversion Ex Fix ? IM Nail Polytrauma

• Reduced surgical time
• Reduced initial blood loss
• Early reaming embolization eliminated
• Minimal invasive fracture stabilization
• Definitive reconstruction when patient stabilized

28
(No Transcript)
29
Resuscitate, provisionally stabilize, and reserve
this for later!
30
Polytrauma Long Bone Fracture Management

• Two stage conversion literature support
• Scalea et al. J Trauma 01
• Damage control orthopaedics
• 13 of all femur fractures - two-stage conversion
• Pape, et al. J Trauma 01
• 134 Borderline patients, temporary fracture
  stabilization, secondary definitive fixation
• Higher multiple organ fracture with early
  conversion lt4 days

31
Conversion Ex Fix ? IMN Femur

• Indications
• Multi-trauma patient with physiologic instability

Example ped struck male, subarachnoid
hemorrhage, liver laceration, femur and forearm
fx
CNS 5225Abdo 4216 I.S.S. 50 Ortho 329
32
Conversion Ex Fix ? IMN Femur

• Indications
• Contaminated GR 3 open femur fracture

33
Conversion Ex Fix ? IMN Femur

• Indications
• Associated vascular injury

34
Conversion Ex Fix ? IMN Femur

• Tips and pearls
• Stabilize femur out to length with Ex Fix
• Unilateral 5mm half pin double stacked Ex Fix
• Knee bridging frame for distal fractures
• One stage Ex Fix ? IMN conversion safe if
  duration of Ex Fix lt 2 weeks
• Protect vascular repair with traction table
  during conversion

35
Conversion Ex Fix ? IMN Femur

• Results
• 59/1507 (4) femur IMN treated with early Ex Fix
  ? IMN conversion in physiologic unstable (46) or
  vascular injury (8)
• 55/59 one stage conversion (6.6 days)
• 1/59 (1.7) infection, 97 union
• 11 unplanned reoperation
• Nowotarski, et al, JBJS 2000

36
Conversion Ex Fix ? IMN Tibia

• Indications
• Primary limb injury considerations
• Contaminated open tibia fractures
• Staged reconstruction in multiple ipsilateral
  limb fracture
• Staged treatment of complex metaphyseal fracture
• Multi trauma patient with physiological
  instability

37
Conversion Ex Fix ? IMN Tibia

• Tips and Pearls
• Attempt spanning Ex Fix with pin sites out of IM
  nail path
• Early soft tissue coverage essential (2 - 5 days)
• One stage conversion must be early (lt2 weeks)
• Employ safe interval
• (7 - 14 days) and two
• stage conversion when
• Ex Fix on gt 2-3 weeks
• Dont nail with history
• of pin track infection!!

38
Conversion Ex Fix ? IMN Tibia

• Results Poor
• McGraw, L. JBJS 88 - 16 cases
• 44 infection, 50 nonunion
• Maurer et al. JBJS 89 - 24 cases
• 25 infection
• 5 of 7 with pintract infection developed IM
  infection
• Long duration of Ex Fix and history of
• pintrack infection hazardous!

39
Conversion Ex Fix ? IMN Tibia

• Results Good
• Blachut et al. JBJS, 90 - 41 cases
• 5 infection
• Short duration Ex Fix (Average 26 days) and
  safety interval!
• Siebenrock et al. C.O.R.R. 93 - 24 cases
• 4 infection and nonunion
• 50 one stage conversion

40
Conversion of External Fixation to IM Nailing

• Two stage orthopaedic treatment of lower
  extremity long bone fractures enhances
• Patient survival in critical polytrauma patients
• Functional limb survival in complex tibial and
  femur fractures with soft tissue injury

41
Conversion of External Fixation to IM Nailing

• One stage conversion within 1 to 2 weeks if
  possible. Otherwise, consider Ex Fix removal,
  safety interval, and second stage nailing

42
Controversies in Polytrauma Fracture Care

• Early femur IMN in Head Injured
• Worse CNS outcomes
• Jaicks, J Trauma 97
• No effect on CNS outcomes
• Better CNS outcomes early vs delayed IMN
• Brundage, J Trauma 02

McKee, J Trauma 97 Scalea, J Trauma 99
43
Controversies in Polytrauma Fracture Care

• Early reamed femur IMN w/ Chest trauma
• Increased ARDS, pulmonary complications
• Pape, J Trauma 93
• Decreased ARDS, pulmonary complications
• Bone, JBJS 89
• Charash, J Trauma 94
• Reamed femoral IMN does not effect pulmonary
  morbidity
• Bosse, JBJS 97

44
Controversies in Polytrauma Fracture Care

• Timing of Definitive Fracture Care
• Within 4 days - increased ARDS, MOSF
• Delayed 5 to 8 days - reduced ARDS, MOSF
• Femur IMN within 24 hours - reduced ARDS,
  pneumonia, ICU stay highest GCS in head injury
• Femur IMN between 2 and 5 days - highest ARDS,
  pneumonia in chest injured patients
• Brundage, J Trauma 02

Pape, J Trauma 01
45
Timing of Fracture Surgery

• Conclusions
• Use Damage Control Orthopaedics for
• Polytrauma borderline, unstable, extremis
• Head Injury hemorrhage, elevated ICP
• Severe thoracic trauma
• Hypothermia/Coagulopathy
• Avoid Second Hit of extensive definitive
  fracture surgery in Borderline trauma patients
  between day 2 and 5!
• Delay complex periarticular fracture repairs
  until soft tissues recover

46
Thank You