jms august 2012 asopa/naotorthopaedic technologists symposium conference and workshop complications...
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JMS
August 2012 ASOPA/NAOTOrthopaedic Technologists Symposium Conference and
Workshop
Complications in Orthopaedic Trauma
Michael S. Bongiovanni, M.D.
Scripps Mercy Hospital
San Diego, California
August 4, 2012
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Disclosures-none
Thanks=AONA archives and Jeff Smith, MD
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Objectives
1. Recognize goal in Orthopaedic Trauma decision making is prompt diagnosis and treatment of musculoskeletal injuries
2. Post-operative mobilization3. Discharge planning needs4. Describe different weight bearing types5. Case examples-discussion6. Concept changes7. Ortho technologist importance
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Orthopaedic Emergencies
1. Open fractures/joints
2. Unstable pelvis injuries
3. Compartment syndrome
4. Injuries with neurovascular compromise
5. Certain infections
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But I have a full office!
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Patient Evaluation
ATLS approach
ABCDE
Systematic
Team approach
Other injuries
JMS Orthopaedic trauma diagnosis
1. History
2. Physical exam
3. Studies-xrays, CT scans, and/or MRI
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Patient Factors
Age
Mech of injury
Assoc. injuries
comorbidities
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Mechanism of Injury
Patient hx
Paramedic hx
Scene description
Witnesses
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Physical Examination
Begins with ATLS primary survey
AirwayBreathingCirculationDisability (neurological)Exposure(undress)
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Open Fractures
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New concepts
-timing to Or?
-antibiotic length
-negative pressure wound therapy
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Type I
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Type II
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Type III
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Open Fracture: Type IIIA
Significant soft tissue injuryMuscle coverage of bone
unnecessarySTSG over muscle7% Infection Rate
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Open Fracture: Type IIIB
Significant soft tissue loss
–Requires Soft Tissue Coverage
–10–50 % Infection Rate
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Open Fracture: Type IIIC
Associated vascular injury that requires repair for limb salvage
25-50% Infection Rate ?
50 % Amputation Rate ?
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Identify Associated Injuries
What other interventions does the patient need?
What degree of extremity intervention will the patient tolerate?
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First aid: pre-hospital care
Emergency room care-ortho tech
Operating room: definitive care-ortho tech
Rehabilitation-ortho tech
Management Stages
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Control bleeding/ open woundDirect pressureCover wound with sterile
dressingtourniquets
Realign and splint decreases further soft tissue
damage and neurovascular compromise
comfort
First Aid
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First aid if not already given
Remove gross debris/ irrigate/dress/image/ splint
Tetanus prophylaxis - if necessary
Antibiotics!!!!!!!!!!!!!!
Emergency
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Open Fracture Management
Open fractures go to the OR
For a formal debridement
Followed by stabilization of the fracture
Continuation of IV antibiotics for treatment not prophylaxis
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Debridement
Layer by layer
Remove all devitalized and contaminated tissue (including bone)
JMS Fracture Stabilization: Why?
Limb:Prevents further soft tissue injuryAllows mobilization of the involved limb for
dressing changes/ wound checks on the floor
Patient:Reduces painLong bone stabilization decreases
activation of the immune system/ inflammatory cascade
Allows mobilization of the patient
JMS Temporizing or Definitive: VAC
-125 mm Hg pressure applied to an open cell sponge
Stimulates cell division and blood vessel in-growth
Sealed system placed in OR
Can be used to shrink wound size
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Wound Closure/CoverageOptimally by 3-7 days
Principles1 Durable coverage2 Well vascularized
soft tissue envelope
for bone3 Fill dead space
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Amputation vs Limb Salvage
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Factors Favoring Amputation
Warm ischemia time > 8 hrs
Severe crush
Chronic debilitating disease
Severe polytrauma (life before limb)
Mass casualty Complexity of reconstruction
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New Concepts
-seeing more GSW
-similar principles
-rapid rehab
JMS The ProblemDeaths from Firearms increased
60% since 1968.
For every death there are 3 Non-Fatal Injuries.
80% of the cost is paid by the Taxpayers.
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Antibiotics and Tetanus Prophylaxis
same as Open Fractures
JMS Internal vs External Fixation
Low / High / ShotgunClose Range.Pts. General Condition.Soft Tissue Injury.Fracture Pattern.
JMS Fxs. With Vasc. Injury
Shunt the Artery.
Irrigation and Debridment.
Definitive Fracture Fixation.
Final Vascular Repair.
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Unstable Pelvis Fractures
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In trauma center, 13-18% of pelvic injury patients present with unstable, high energy injuries
Associated injuries Mortality High rate of early and late morbidity
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Open Pelvic Fracture
Aggressive debridement of open wounds
Colostomy / urinary diversion nearly always
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-less traction
-early mobilization
-minimally invasive surgical techniques
-binders/pelvis sheets
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Pelvis binder
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Binder
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High Energy Injury Assessment
Beware of Associated Injuries
More extensive exam in polytrauma
Thorough distal neurovascular exam
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Associated Injuries
Massive energy input required to cause unstable pelvic injuries
Energy causes injuries to other organsHeadChestAbdomen
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Associated Injuries
Major vascular, neurological, gastrointestinal, and genitourinary structures pass through pelvis
Frequently involved with pelvic injuries
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Physical
Musculoskeletal Pelvic Exam
Inspection
Palpation
Function (Stability)
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Radiographic Evaluation
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Reduction and stabilization of pelvic ring
Emergent external fixation
• Decreases intrapelvic volume
• Minimizes motion at fracture site
• AP pelvis to determine if injury amenable to external fixation
Emergent Management
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Emergent Management
Open Surgery
Primarily reserved for failure to respond to ex fix or angiography
Occasionally coincident with emergent ex lap
Open packing usually preferred over ligation
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Early Management
Temporizing measures
External fixation
Binders/sheets
Longitudinal traction distal femur
• Very important with vertical shear injury
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External Fixation
-resusitation
-temporary
-definitive
-”damage control”
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O R I F
Symphysis
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ORIF
Iliac Fracture
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Compartment Syndrome
1. Elevated compartment pressure
2. Painful!!
3. Early diagnosis
4. Early treatment
5. Examples
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Compartment syndrome
1. Neurovascular exam
2. Possible pressure measurements
3. Surgical decompression
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Neurovascular exam
1. circulation-motor-sensory
2. Pulses-palpation or doppler
3. Capillary refill-nl less than 2 seconds
4. Sensation-present, diminished, absent
5. Motor-specific movement-present, diminished, or absent
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Compartment syndrome
1. Pain out of proportion
2. Pain with passive stretch
3. Paresthesias,(sensory changes)
4. Paralysis,(weakness)
5. Pulse(usually present, absent late finding)
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Compartment Syndrome
1. Loosen dressing, splints, wraps
2. Bivalve cast down to skin
3. Elevation controversial
4. Emergency notify surgeon
JMS Deep Venous Thrombosis-prevention
1. ambulation-out of bed
2. Pharmacology-heparins/coumadin
3. Mechanical devices( SCD’s/Foot pumps)
4. IVC filter can help prevent PE in high risk patient
JMS Deep Venous Thrombosis-diagnosis
1. leg and/or chest pain2. Fever3. Tachycardia4. Leg swelling(unilateral)5. Doppler ultrasound6. Chest CT scan7. Pulmonary angiogram
JMS Deep Venous Thrombosis-treatment
1. Medical-heparin infusion-coumadin
2. Mobilization
3. Further surveys
JMS Orthopaedic trauma-treatment
1. Age2. Other injuries3. Injury pattern4. Soft tissue injury5. Osteopenia6. Comorbidities7. Activities of daily living
JMS Orthopaedic trauma-treatment
1. Closed,(cast,splint,brace)
2. Open,(plates/screws, external fixation, intramedullary implants, joint prosthesis, and/or pins)
3. Therapy-mainstay for recovery
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Casting
-fiberglas/plaster
-short/long/muenster/PTB
-molding
-Neurovasc check
-xray check
-listen to your patient
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Skin Traction
1. Example Buck’s traction
2. Comfort
3. Minimize further injury
4. Hip and knee dislocation
5. Hip fractures
6. 5-10 lbs.
7. Helpful?
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Skeletal Traction
1. Weight directly thru bone
2. Pelvis fractures, dislocations
3. Acetabular fractures
4. Femur fractures
5. External fixation
6. Temporary versus definitive
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Pre-op Planning
Minimize OR time
Minimize blood loss
Proper equipment
Minimize exposure
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Pre-op Planning
Table/position
C-arm
Equipment
Implants
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The Tools
Radiolucent table
C-arm
Pelvic reduction clamps
Pelvic instruments
Oscillating drill
• 3.5 mm / 4.5 mm pelvic reconstruction plates
• Large and small fragment screws
• 7.3 mm fully and partially threaded cannulated screws
• Large external fixator
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ORIF
Indications
Presence of significant associated injuries (Polytrauma)
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ORIF
Complications
Infection (4%)
Loss of reduction / fixation (5%)
DVT / PE (4%)
Nerve palsy (3%)
Matta, Tornetta 1982 -1991
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Post-Op Management
Stable fixation
Early mobilization
Weightbearing as tolerated unaffected side
Non or partial weightbearing affected side 8 - 12 weeks
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Post-Op Management
Unstable or incomplete fixation
Bedrest
Longitudinal traction on unstable side
Duration individualized, but caution to avoid deformity
Non-weightbearing 3 months
JMS Weight bearing-lower extremities
NWB-non weight bearing
TDWB-touch down weight bearing
PWB-partial weight bearing(% or lbs.)
FWB-full weight bearing
WBAT-weight bear as tolerated
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Weight bear examples
Joint fractures-TDWB
Hip hemiarthroplasty-WBAT
Femur/Tibial shaft IM nails-TDWB-WBAT
Joint dislocations-TDWB-WBAT
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Full, partial, or non-weight bearing
Platform crutches/walker
Casting
Splints
Bracing
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A Team Approach
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RK
43 yo male
Fell 40 feet from tree
ETOH
Combative,confused
Bone sticking out of thigh
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RK
Moving all four extremities
Rapid sequence intubation(airway control)
Hemodynamic stable
Past history negative-possible psych issues
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Closed Head Injury
Small Subdural Hematoma
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5 cm lateral wound
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Distal Femur Fracture
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Distal Femur Fracture
JMS Distal Radius Fracture, closed
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Treatment
Femur sterile dressings, hare traction splintAntibiotics(Cephalosporin, aminoglycoside)Tetanus toxoidRapid completion CT scansImmediate Neurosurgery consultationTo operating room, emergently for DCONS-’rapid ortho procedure so early repeat head ct
scan done’
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Debridement
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Intraop
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Post-op
IV ABS, dressing changes, resuscitation
Head CT stabilized
Definitive treatment at 96 hours-
Wound re-debride, distal femur LISS, wound closure over drain
Wrist external fixation and pinning
JMS Helpful Orthopaedic information
1. Npo status
2. Pain scale
3. Vital signs
4. Surgical drainage amount
5. Neurovascular exam
6. Labs –most recent
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Discharge planning
1. Begins immediately
2. Home, SNF, Rehab, Hospice
3. Team approach,(Nursing, orthopaedist, ortho tech, therapist, case manager, patient/family)
4. Resources/managed care
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QUESTIONS?
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