Orthopaedic Trauma Jeremy Hall St. Michael’s Hospital September 29, 2009 Outline Compartment Syndrome Open Fractures Pelvic Fractures.
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Orthopaedic Trauma Jeremy Hall St. Michael’s Hospital September 29, 2009 Outline Compartment Syndrome Open Fractures Pelvic Fractures Compartment Syndrome Definition 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) 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 < 20 - 30 mm Hg within diastolic pressure – Whitesides McQueen, et al 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 Compartment Syndrome… Etiology Fractures-closed and open Exertional states Blunt trauma GSW Temp vascular occlusion IV/A-lines Cast/dressing Hemophiliac/coagulopathy Closure of fascial defects Intraosseous IV(infant) Burns/electrical Snake bite Arterial injury Compartment Syndrome… Diagnosis Pain out of proportion to injury Pain with passive stretch Palpably tense compartment Paresthesia/hypoesthesia Paralysis Pulselessness/pallor 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 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) 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 > 6 hours of total limb ischemia Injury at high risk of compartment syndrome CONTRAINDICATION – Missed CS (>24-48 hrs) Leg Fasciotomies 2 Generous skin incisions (Mubarak 1977) medial lateral Release completely all 4 fascial compartments Beware of neurovascular structures to prevent iatrogenic injury Compartment Syndrome… Other Areas Can occur anywhere in the body Hand Arm Buttock/thigh BEWARE arterial injury….consider angiogram Abdominal With you general surgeons! 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 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 Introduction Energy Transfer Fall from curb 100 ft-lbs Skiing 300-500 ft-lbs High-Velocity GSW 2000 ft-lbs Automobile Bumper @ 20 MPH 100,000 ft-lbs Skin Lesions Blisters Clear Sanguineous Abrasions Degloving Morel-Lavalle Open Fracture Definition A break in the skin and soft tissues communicating with a fracture or its hematoma. Gustilo-Anderson Grade I Gustilo-Anderson Grade II Gustilo-Anderson Grade IIIA Gustilo-Anderson Grade IIIA IIIA Includes severe comminution despite size of skin wound. Gustilo-Anderson Grade IIIB Gustilo-Anderson Grade IIIC Assessment History Mechanism High or low energy? Time since injury Pre-morbid conditions Other injuries Assessment Physical Exam One look soft tissue exam Neurological status Vascular status Compartments Assessment X-rays Standard two 90° views Joint above and below fracture Emergent Treatment One Look Exam Sterile Dressing No ER Cultures Poor indicator of probability of infection and organism expensive Realign and Splint Tetanus Toxoid Tetanus Toxoid 2.5 cc to all poly-trauma patients, otherwise: IMMUNIZATION HISTORY NON-TETANUS PRONE TETANUS PRONE* UNKNOWN YES YES >3 IMMUNIZATIONS (<5 YEARS) NO NO *Tetanus Prone: >6 hours old, complex soft tissue injury, wound >1 cm deep, missile, crush, burn, frostbite, devitalized tissues, soil contaminants, denervated, ischemic, early infection. Tetanus Immune Globulin 250-500 units IM: IMMUNIZATION HISTORY NON-TETANUS PRONE TETANUS PRONE* UNKNOWN NO YES >3 IMMUNIZATIONS (<5 YEARS) NO NO 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 Recommended Antibiotic Treatment 1 Gen Ceph Grade I Grade II Grade III Farm/War Wounds Gent PCN +/- +/- (Gustilo, et al; JBJS 72A 1990) Duration of Antibiotic Treatment Initial 72 hours 48 hours after each subsequent procedure Treatment Principles Limb Salvage? Vascular Injury? Principles of I&D Longitudinal incisions- extensile exposures Excise non viable tissue Systematic and detailed approach Irrigation Stabilize fracture I&D Systematic Skin Fascia and fat Muscle: 4 C’s of muscle viability Contractility Capacity to bleed Consistency Color Stable Fixation Reduces infection Options: External fixation +/- delayed internal fixation IM Nail ORIF Wound Closure Primary Closure? Delayed closure/coverage STSG Flaps VAC Pelvic Ring Injuries 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%) 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 17:691, 1994. Pohlemann T et al: Pelvic fractures: epidemiology, therapy and long term outcome. Overview of the multicenter studey of the pelvis study group, Unfallchirurg 99:160, 1996. 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! Pelvic Anatomy Inominate bones (2) ilium, ischium & pubis Sacrum Coccyx Pelvic Anatomy Pelvis contains 5 joints Lumbosacral Sacroiliac Sacrococcygeal Symphysis pubis Acetabulum *movement* Pelvic Amatomy Ring structure is basis for stability Stability via ligaments Iliolumbar Sacroiliac Sacrotuberous Sacrospinous 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 Pelvic Anatomy Nerve supply from lumbar & sacral plexi Proximity to posterior arch of pelvic ring 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 AP Pelvis Adequacy: Both iliac crests Proximal femurs Lower lumbar spine No rotation Pubic symphysis aligns midline with sacral spinous processes 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 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. 1997;35:559-590. 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) Tile Classification Tile Type A Stable Tile Type B Rotationally Unstable Vertically Stable Tile Type C Rotationally Unstable Vertically Unstable Young & Burgess Classification Mechanism 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%) Young & Burgess Classification Lateral Compression AP Compression Vertical Shear Lateral Compression: LC-III Windswept Pelvis Contralateral sacral fx & SI joint diastasis Ipsilateral SI disruption Iliac wing fracture Pubic rami fractures AP Compression: APC-III Wide SI Joint Wide Pubic Symphysis 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 Vertical Shear Left hemipelvis displaced cephaloposteriorly Associated sacroiliac joint diastasis Pubic rami fracture Ipsilateral (usually) Vertically oriented Vertical Shear Complete disruption of posterior elements Factors Increasing Mortality Type of pelvic ring injury Posterior disruption High ISS Tile, 1980 McMurty, 1980 Hemorrhagic shock on admission Gilliland, 1982 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 Extremely High Energy Injuries with a Large Number and Variety of Associated Injuries Instability Shock Etiology of Hypovolemic Shock Intra-thoracic bleeding Intra-peritoneal bleeding Ultrasound Peritoneal tap CT Retroperitoneal bleeding Burgess, J Trauma 1990 Mortality 8.6% 2/210 pelvic injury patients where pelvic injury was primary cause of death Contributed 10/210 Adams, JOT 2003 Up to 25% pelvic fractures in traffic fatalities Most commonly vertically unstable fractures Perhaps more common than originally thought Hemorrhage Control Average blood replacement (units) LC = 3.6 AP = 14.8 VS = 9.2 Mortality 3% hemodynamically stable patients 38% unstable patients Hemorrhage (cont.) Sheet/C-clamp Skeletal traction External fixation Mast suit Embolization Surgical stabilization +/- packing Hemorrhage (cont.) Contributes to 60% of deaths Retroperitoneal veins 20% arterial injury Coagulopathy Hypothermia Ca2 (blood citrate) Acidotic Prolonged Hypovolemia Aggravate pulmonary contusion Head and visceral injuries Increased sepsis Adult respiratory distress syndrome (ARDS) Multiple organ failure Instability Only patients with mechanical instability can have hemodynamic instability related to the pelvic injury 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) Indications for Angiography Unexplained blood loss after stabilization and aggressive resuscitation Pulselessness extremity Surgical Stabilization with internal fixation of pelvis Stabilization of hemodynamic instability with surgical packing of retroperitoneal space Associated Injuries Other MSK Long bone injuries Knee injuries Foot injuries Abdominal Urologic/Gyne Neurological Open Pelvic Injuries Colon, rectum, or perineum Early diverting colostomy Soft-tissue wounds aggressively debrided Early repair of vaginal lacerations minimize subsequent pelvic abscess Colostomy is Indicated for Any Open Injury Where the Fecal Stream Will Contact the Open Area Urologic Injuries 15% incidence Blood at meatus or high riding prostate Eventual swelling of scrotum and labia (occasional arterial bleeder requiring surgery) Urologic (cont.) Retrograde urethrogram indicated in pelvic injured patients but insure hemodynamic stability or embolization may be difficult due to dye extravasation Urologic (cont.) Intra & extra peritoneal bladder ruptures are repaired Foley preferred supra-pubic catheter tunneled to prevent ant. wound contamination That’s A lot of Info! Any Questions?? Thanks!