provisional stability & damage control in orthopaedic surgery michael t. archdeacon, m.d.,...

Provisional Stability & Damage Control In

Orthopaedic Surgery

Provisional Stability & Damage Control In

Orthopaedic Surgery

Michael T. Archdeacon, M.D., M.S.E.

Director, Division of Musculoskeletal Trauma

Professor & Vice Chairman Department of Orthopaedic Surgery

University of Cincinnati Medical Center

Assessing Injury

• Resuscitation• Injury Surveys• Emergent

Intervention• Surgical Intervention• Definitive Intervention

Dynamic / Integrated Process

ResuscitationResuscitation

Injury Surveys

Emergent InterventionEmergent

Intervention

Surgical Intervention

Surgical Intervention

DefinitiveInterventionDefinitive

Intervention

Damage Control Orthopaedics

Primary Orthopaedic Survey

Hemodynamic Instability

Obvious Deformity Or Open Wounds

Vascular Compromise To Limb

Neurologic Deficit

Orthopaedic Management –

Survey Of Injury• Secondary SurveyMake A Limb Look Like A LimbRe-assess Neurovascular StatusProvisionally Stabilize Long

Bones & Pelvis• Tertiary Survey

Re-evaluate All Tenderness, Crepitus, Ecchymosis

Radiograph Any Suspected Injury• 11-18% Fractures Missed On Initial Surveys

Initial Treatment• Bring The Limb Out

To Length• Restore Gross

Alignment• Obtain Adequate

ImagesPlain FilmsContralateral SideCT Scans

Orthopaedic Priorities

• Emergent Intervention

• Surgical Intervention

• Definitive Intervention

Provisional Pelvic Stability

Correct IschemiaReduction &

Splinting

Pelvic Ex FixWound Debridement Provisional Stability

ORIF & IM NailsWound Coverage /

Closure

Damage Control

Orthopaedics

Aggressive ResuscitationAggressive

Resuscitation

Rapid Long Bone & Pelvic Temporary Stabilization

Emergent InterventionEmergent

Intervention Staged, Definitive, Reconstructive

Surgical Intervention

Staged, Definitive, Reconstructive

Surgical Intervention

Definitive Care

Windows Of Opportunity Will Occur Which Allow For Definitive Treatment

Repeat Wound Debridements

Conversion Ex Fix To Definitive Fixation

Articular Reconstructions

Wound Closure / Coverage

• Problem Defined• Assessment

Strategy• Treatment

Outlined

What Will Kill You?

Kill You• Pelvic

Fractures• Multiple

Long Bone Fractures

• Spinal Cord Injury

Pelvic Fx

• High Energy to Significantly Fracture Pelvis

• Potentially Life-Threatening Injury• Aggressive Evaluation &

ManagementTeam / Multiple Disciplinary ApproachATLS Protocols

ASSOCIATED INJURIES

• Pelvic Fx’sShock – 25 -

67%Neurologic – 27

- 60%ARDS – 6 - 19%Thoracic – 19 –

43%Urologic – 0 -

16%Mortality – 14 -

37%

Managing the Hemodynamically Unstable Pelvic Fx

• Identify Patient At RiskHypotensionPelvic ExamRadiographic

Evaluation• ATLS

Resuscitation

• Determine Orthopaedic Intervention (If Any)Pelvic

ImmobilizationReduction Of

Hip DxExternal

FixationAngiography

Emergent Pelvic Immobilization

• GoalsDecrease

Pelvic Volume

Provisional Stabilization

Prevent Further Hemorrhage

Pelvic Binder

Pelvic Clamp

Sheet Wrap

Multiple Long Bone Fractures

Multiple Long Bone Fx’s • Aggressive

Resuscitation• Temp Immobilization• Urgent or Emergent

Stabilization• Early Mobility /

Ambulation

NA Goal: Fixation w/in 24 hours

Spinal Cord Injury

Spinal Cord Injury

• Aggressive Resuscitation+/- High-Dose Steroids

• Temp ImmobilizationCranial Tong TxHalo Vest

• Urgent or Emergent Decompression / Stabilization

• Early Mobility / Ambulation

Hurt You Really Bad• Amputations• Dysvascular Limb• Crush Injuries• Compartment

Syndrome

Amputations

Amputations

• Can Be Life ThreateningControl

Hemorrhage• Direct Pressure• Rare – Tourniquet

Or BP CuffReduce Infection

Risk• Sterile Wound

Dressing• Prophylactic ATB• Tetanus Update

Surgical Debridement

Primary Closure of Traumatic Amputation

Dysvascular Limb

Dysvascular Limb

• Limb ThreateningMust Recognize

The Injury• Don’t Forget To

Assess The Hypotensive Pt’s Limbs During / After Resuscitation

Reduction Fx / Dx’s

Involve Vascular Sx• + / - Angiogram

• 6 Hour Warm Ischemia Time

Crush Injury

Crush Injury

• Limb ThreateningMust Eval For

Compartment Syndrome

Debridement Of Devitalized Tissue

Bony Stabilization

Follow For Rhabodomyolysis

Compartment Syndrome

Compartment Syndrome

• A Clinical DiagnosisYour Patient Will

Tell You They Have It• Pain Out Of

Proportion• Pain With Passive

Stretch• Paresthesias• Pallor• Pulselessness

• Measuring PressuresObtunded PatientsConfirms Clinical Suspicion

• Δ PDifference Between Diastolic Pressure

And Tissue Compartment

Emergent Decompression

INAdequate Decompression

17 cm Incisions

Orthopaedic Trauma -Summary

• Team Approach• Few (True) Life

Threatening Orthopaedic Injuries

• ProtocolsPrimary Secondary Tertiary