Orthopaedic Trauma Tips - Frances Mahon … Trauma Tips.pdfOrthopaedic Trauma Tips Bryon Hobby, MD Billings Clinic Department of Orthopedics and Sports Medicine Health Care, Education

Orthopaedic Trauma Tips

Bryon Hobby, MD Billings Clinic Department of Orthopedics and Sports Medicine

Health Care, Education and Research

Disclosures

None


Objectives

•  Describe a stable vs unstable pelvic ring injury •  List acute treatment options for pelvic ring injury •  Recognize signs and symptoms of compartment

syndrome •  Recognize indications for monitoring compartment

pressures •  Describe soft tissue injury associated with open

fractures •  List initial therapies for open fractures





Pelvic Ring Injuries

•  Do come in many forms •  Mechanism of injury

– Low energy -- falls – High energy – MVC, Fall from height, Horse,

etc. •  Early appropriate treatment can be life

saving •  Patients have other injuries – vascular,

visceral or orthopaedic


Work up of pelvic ring injury

•  Follow a protocol – ALTS •  AP pelvis •  CT scan of chest, abdomen and pelvis •  Serial Hct’s, Lactate


AP Pelvis vs CT scan

•  An AP pelvis is still necessary !! •  Gibson et al JOT 2016 showed a 6.6mm

reduction of PS in CT scans


Classification of Pelvic Ring Injuries

Figure 2 The Young‐Burgess classification of pelvic fracture. A, Anteroposterior compression (APC) type I. B, APC type II. C, APC type III. D, Lateral compression (LC) type I. E, LC type II. F, LC type III. G, Vertical shear. The arrow in each panel indicates the direction of force producing the fracture pattern. (Copyright Jesse B. Jupiter, MD, and Bruce D. Browner, MD.)

Copyright © 2016 AAOS. Published by Lippincott Williams & Wilkins. 10

Langford et al. JAAOS 2013

Health Care, Education and Research Copyright © 2016 AAOS. Published by Lippincott Williams & Wilkins. 11

Langford et al. JAAOS 2013


Who needs a binder?

•  Unstable pelvic ring injuries •  Increased pelvic volume •  Hemodynamic instability



Where does the binder/sheet go?







Routt et al JOT 2002


Who doesn’t need a binder?

•  Stable pelvic ring injuries •  Hemodynamically stable patients •  Those with decreased pelvic volume



Binders have complications












Compartment Syndrome Who gets it?

•  Orthopaedic causes – Most Common –  High energy fractures –  Low energy fractures – 15-20%

•  Vascular Causes •  Iatrogenic

–  Injections/extravasation –  Anticoagulation

•  Soft tissue –  Crush injuries –  Found down – Drugs/ETOH –  Snake bite


Pathophysiology

•  Elevation of pressure in fibro-osseus space resulting in decreased perfusion

Parasam et al JAAOS 2011


How do you diagnose compartment syndrome?

•  High index of suspicion •  5 P’s of Compartment Syndrome

– Pain, Parathesia, Pallor, Paralysis, Pulselessness – PAIN, PAIN, PAIN, PAIN, PAIN

•  Physical exam – Swollen tense compartments – Pain w/ passive stretch

•  Diagnostic testing


Who should you monitor?

•  First of all remember that compartment syndrome is a clinical diagnosis

•  Who? – Obtunded patients – Younger patients – Equivocal findings


Where to measure?

Olsen et al. JAAOS 2005


What do the measurements mean?

•  Absolute pressure – many values – 30 mmHg – 45 mmHg – 50 mmHg

•  Critical pressure – – Delta pressure – DBP – ICP – Positive result < or = 30 mmHg


Initial Treatment

•  Reduce and splint the fracture •  Elevate the affected extremity •  Loosen bandages and splints •  Phone a friend

– Definitive treatment is prompt fasciotomy •  Monitor patients with potential to develop

compartment syndrome





Open Fractures

Open fracture is defined as one with an associated break in the skin that is capable of communicating with the fracture and or its

hematoma.


Why do we care?

•  Increased rates of: –  Infection – Malunion – Nonunion


Open Fractures

•  Mechanism – often high energy, but also can be low energy

•  Crush, falls, road traffic accidents •  Most commonly males •  Most common is of hand, tibia, distal

radius


Evaluation

•  ALTS – don’t forget that other stuff •  Note vascular status •  Size, shape of wound •  Contamination +/- ? •  Have a high index of suspicion for



Evaluation

•  ALTS – don’t forget that other stuff •  Note vascular status •  Size, shape of wound •  Contamination +/- ? •  Have a high index of suspicion for



Classification

Halawi et al Orthopaedics 2015


Initial Management

•  GIVE ANTIBIOTICS EARLY!!! •  Bedside debridement

–  if contaminated •  Tetanus

–  If unsure or < 5 years •  Reduce and splint

–  Make it straight –  Get the bone back in the skin

•  Phone a friend -- make an early referral


Antibiotics – when should I give them?

•  Patzakis et al -- Administration < 3hours from injury –  4.7% vs 7.4%

•  Gosselin et al – As soon as possible •  88% of OTA members believe < 60min from

time of injury •  Many studies have shown that only timely

administration of antibiotics decreases infection risk


Timing of antibiotics

Lack et al JOT 2015

7% 18% 28%


Antibiotics – what should I give?

•  Surgical infection Society guideline 2006 – 1st generation cephalosporin – No evidence to support aminoglycoside/PCN

•  Newer trends (Rodriguez et al 2014) – Grade I/II – cefazolin (clinda) – Grade III – ceftriaxone (clinda, aztreonam)

•  Consider adding vancomycin for MRSA colonized – Saveli et al JOT 2013


Antibiotics – what should I give?


How do we improve?

•  Education – All ED staff •  Protocol •  Early recognition •  Have the antibiotics stocked in ED

– Cefazolin 2 gm •  Early help from an orthopaedic surgeon

Collinge et al JOT 2014


TAKE HOME

•  Pelvic ring injury – – Binder/sheet

•  Unstable patients •  Increased pelvic volume

– Binder is placed on Greater Trochanters


TAKE HOME

•  Compartment syndrome – Many causes – High index of suspicion – Clinical diagnosis

•  Remember the 5 P’s •  Pain w/ passive stretch

– Only Stryker those who are unable to cooperate


Take Home

•  Open Fractures – Early Antibiotics – w/in 60 min of injury

•  Grade I/II – Cefazolin 2 grams •  Grade III – Ceftriaxone

– Remove contamination – Tetanus if <5 years – Reduce, splint, and refer early

Thank you for your attention Bryon D Hobby, MD Orthopaedic Trauma Surgeon Department of Orthopedics and Sports Medicine [email protected]

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Orthopaedic Trauma Tips - Frances Mahon … Trauma Tips.pdfOrthopaedic Trauma Tips Bryon Hobby, MD Billings Clinic Department of Orthopedics and Sports Medicine Health Care, Education