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BOOM!!!!

Orthopaedic Trauma

Douglas W. Lundy, MD, MBA, FACS31 July 2014

Orthopaedic Trauma SurgeryResurgens Orthopaedics

Atlanta, Georgia

Conflict

Consultant for

Synthes

Orthopaedics.

Board of Directors of

the OTA, GOS, ABOS

and Resurgens

Orthopaedics.

AAOSCommunications

Cabinet Liaison to the

Council on Advocacy.


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Outcomes

Comparative study

concerning outcomesafter major fracture.

Surgeons more

satisfied with

outcomes than the

patients were. Harris IA, Dao AT, Young JM,

Solomon MJ, Jalaludin BB:Predictors of patient and surgeon

satisfaction after orthopaedic

trauma. Injury40:377-384, 2009.

SF-36

Multi-purpose, short

health survey.

36 questions.

Made available in

standard form in1990.

Cited in 4000

publications.

Scales:

Physical Functioning

Role-Physical

Bodily Pain

General Health

Vitality

Social Functioning

Role-Emotional Mental Health


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Trauma patients with fractures

SF-36 scores: Bodily pain, Physical function,

Role-physical, Mental health,Role-emotional, Social function(p < 0.05).

Patients withorthopaedic injuries haverelatively worsefunctional recovery thantrauma patients without

orthopaedic injuries, andthis worsens with time. Michaels AJ, Madey SM, Krieg JC, Long WB:

Traditional injury scoring underestimates therelative consequences of orthopedic injury. JTrauma. 2001 Mar;50(3):389-395.

Psychological effects

Psychological distress isstrongly associated withpatient outcome--includingfunctional outcome--following trauma.

Psychological distress aftertrauma, with its large impacton trauma outcomes,

remains a substantialproblem that is usuallyignored and untreated. Starr AJ: Fracture repair: successful advances, persistent

problems, and the psychological burden of t rauma. J BoneJoint Surg Am. 2008 Feb;90 Suppl 1:132-7


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The Big Bad Five

Tibial plafond

Talar neck

Calcaneus

Unstable pelvis

Femoral neck

in young people

High mechanism injuries Falls

MVC


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Tibial Plafond Fractures

Plafond = roof.

Difficult surgery.

Prolonged recovery.

Nonunion and pain is

common.

Takes up to two years

to see what the

outcome will be.

Tibial plafond outcomes Tibial plafond

fractures are difficultto manage and mayhave seriouscomplications.

Loss of function andprogression to post-traumatic arthritis are

common after tibialplafond fractures. Harris AM, Patterson BM, Sontich JK, Vallier

HA: Results and outcomes after operativetreatment of high-energy tibial plafondfractures. Foot Ankle Int. 2006 Apr;27(4):256-265.


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Talar neck fractures

Difficult surgery.

Prolongedhealing.

Nonunion andavascularnecrosis is ahuge problem.

May need

pantalar fusion inthe future.

Talar fracture outcome

Osteonecrosis 49%: Collapse of the dome in 31%.

54% had posttraumatic arthritis comminuted fractures (p < 0.07)

open fractures (p = 0.09).

Fractures of the talar neck are associated withhigh rates of morbidity and complications.

Vallier HA, Nork SE, Barei DP, Benirschke SK, Sangeorzan BJ: Talar neck fractures:results and outcomes. J Bone Joint Surg Am. 2004 Aug;86-A(8):1616-1624.


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Calcaneal fractures

People

who fall:

Roofers

Dry

wallers

Framers

Painters

Calcaneal fractures

Most painful fracture

that there is!

Pain and difficulty

walking on uneven

ground.

Wound issues after

surgery.

May need a subtalar

fusion.


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Cost of injury Calcaneal fractures

have beenrecognized as havingrelatively poor clinicaloutcomes and amajor socioeconomicimpact with regard totime lost from work

and recreation. Brauer CA, Manns BJ, Ko M, Donaldson C,Buckley R: An economic evaluation ofoperative compared with nonoperativemanagement of displaced intra-articularcalcaneal fractures. J Bone Joint Surg Am.2005 Dec;87(12):2741-2749.

Wound Complications Smoking, diabetes,

and open fracturesall increase the riskof woundcomplication aftersurgicalstabilization ofcalcaneus

fractures. Folk JW, Starr AJ, Early JS: Earlywound complications of operativetreatment of calcaneus fractures:analysis of 190 fractures. J OrthopTrauma.1999 Jun-Jul;13(5):369-372.


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Fracture Blisters All blisters were unroofed, and

antibiotic cream (Silvadene)

was applied twice daily until theblister bed had re-epithelialized.

We urge caution when

planning to make a surgical

incision around fractureblisters in diabetic patients

because the zone of injury

might extend beyond theborders of the fracture blister. Strauss EJ, Petrucelli G, Bong M, Koval KJ, Egol

JA: Blisters associated with lower-extremity

fracture: results of a prospective treatmentprotocol. J Orthop Trauma. 2006 Oct;20(9):

618-622.

Open Tibial Fractures


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Definitions

Fracture: a soft tissueinjuryoverlying abroken bone.

Soft tissue trauma is the more important

injury. Norris BL and Kellam JF: Soft-tissue injuries associated with

high-energy extremity trauma: Principles of management. J.Am. Acad. Orthop. Surg.5:37-46, 1997.

Open fracture: any fracture associated

with a laceration or puncture wound on thesame limb segment.

Gustilo and Anderson ClassificationType Description Infection Antibiotics

I Clean, 1 cm, minimal

soft tissue injury

2% to 7% Ancef and

Gentamycin

III Extensive injury,

segmental fx,

GSW, farm injury,

etc.

10% to 25% Above + PCN

Gustilo RB, Anderson JT: Prevention of infection in the treatment of one thousand and twenty-five open fractures oflong bones: retrospective and prospective analyses. J. Bone Joint Surg.58-A:453-458, 1976.


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Gustilo Classification

Gustilo RB, Mendoza RM, Williams DN: Problems in the management of type III (severe) open

fractures: a new classification of type III open fractures. J. Trauma24:742-746, 1984.

Type I


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Definitely IIIC

Type II or IIIA?


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Type II or IIIA?

Antibiotics

A prospective double-blind randomized clinicaltrial comparing ciprofloxacin and cefamandole/gentamicin. No difference in Type I or II open fracture wounds. High failure rate for the ciprofloxacin Type III open

fracture group, with patients being 5.33 times morelikely to become infected than those in thecombination therapy group.

Single-agent antibiotic therapy with ciprofloxacinis effective in treatment of Type I and Type II

open fracture wounds. Patzakis MJ, Bains RS, Lee J, Shepherd L, Singer G, Ressler R, Harvey F, Holtom P.: Prospective,randomized, double-blind study comparing single-agent antibiotic therapy, ciprofloxacin, to combinationantibiotic therapy in open fracture wounds. J Orthop Trauma. 2000 Nov;14(8):529-533.


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LEAP!

LEAP Study 527 patients in this multi-centered study.

Bone loss was least significant variabledetermining limb salvage.

Soft tissue injury severity has the greatestimpact on decision making regarding limbsalvage versus amputation. MacKenzie EJ, Bosse MJ, Kellam JF, Burgess AR, Webb LX, Swiontkowski MF,

Sanders R, Jones AL, McAndrew MP, Patterson B, McCarthy ML, Rohde CA,LEAP Study Group: Factors influencing the decision to amputate or reconstruct

after high-energy lower extremity trauma. J Trauma. 2002 Apr;52(4):641-649.


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LEAP at seven years

397 - amputation orreconstruction.

Physical andpsychosocialfunctioningdeteriorated between24 to 84 months afterthe injury. MacKenzie EJ, Bosse MJ, Pollak AN, Webb

LX, Swiontkowski MF, Kellam JF, Smith DG,Sanders RW, Jones AL, Starr AJ, McAndrewMP, Patterson BM, Burgess AR, Castillo RC:Long-term persistence of disability following

severe lower-limb trauma. Results of a seven-year follow-up. J Bone Joint Surg Am. 2005Aug;87(8):1801-1809.

Poor outcome:

older age

female gender

lower education level

living in a poor household

current or previoussmoking

low self-efficacy

poor self-reported healthstatus before the injury

involvement with the legalsystem in an effort toobtain disability payments.

LEAP at seven years reconstruction for the

treatment of injuries belowthe distal part of the femurtypically results in functionaloutcomes equivalent tothose of amputation.

Regardless of the treatmentoption, however, long-term

functional outcomes arepoor. MacKenzie EJ, Bosse MJ, Pollak AN, Webb LX, Swiontkowski MF,

Kellam JF, Smith DG, Sanders RW, Jones AL, Starr AJ, McAndrewMP, Patterson BM, Burgess AR, Castillo RC: Long-term persistenceof disability following severe lower-limb trauma. Results of a seven-year follow-up. J Bone Joint Surg Am. 2005 Aug;87(8):1801-1809.


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Poor outcomes in severe trauma

LEAP showed that at twoyears, most patients had pooroutcomes, with only half of thepatients returning to work.

By seven years, half of thepatients continued to reportappreciable disability.

more than half of thepatients who were managed

with the current standard ofcare had treatment failure.

Starr AJ: Fracture repair: successful advances, persistent problems, and thepsychological burden of trauma. J Bone Joint Surg Am. 2008 Feb;90 Suppl1:132-7

The joys of call

Hey doc, sorry to call

you at 2:30 AM. I

have a really bad

open xxx fracture

here in the ER

xxx =

Tibial

Femoral

Pelvic


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So what is acceptable?

Is it standard of

care to operate

this fracture at

2:30 AM or

should (can) I

wait until

morning?

Timing of debridement

LEAP found that time

from injury to surgicaldebridement was not

contributory factor ofinfection.

Timing from injury to

the definitive

treatment center wasindicative of infection.


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Timing of debridement

Findings should not

be interpreted as anargument that

operativedebridement of open

fractures should not

be accomplishedurgently. Pollak AN, Jones AL, Castillo RC, Bosse MJ,

MacKenzie RJ, LEAP study group: Therelationship between time and surgical

debridement and incidence of infection afteropen high-energy lower extremity trauma. J

Bone Joint Surg92-A:7-15, 2010.

Ex-fix vs. nail? External fixator had

more surgicalprocedures, took longerto achieve full weight-bearing status, and hadmore readmissions thandid those treated with anintramedullary nail. Webb LX, Bosse MJ, Castillo RC,

MacKenzie EJ, LEAP Study Group: Analysisof surgeon-controlled variables in thetreatment of limb-threatening type-III opentibial diaphyseal fractures. J Bone Joint Surg

Am. 2007 May;89(5):923-928.


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Smoking

Patients with unilateralopen tibia fractures weredivided into 3 baselinesmoking categories:never smoked, previoussmoker and currentsmoker.

Smokers 37% less likelyto heal.

Previous smokers were32% less likely to heal. Castillo RC, Bosse MJ, MacKenzie EJ,

Patterson BM, LEAP Study Group: Impact ofsmoking on fracture healing and risk ofcomplications in limb-threatening open tibiafractures. J Orthop Trauma. 2005 Mar;19(3):151-157.

Smoking Current smokers twice as

likely to develop an infection(P = 0.05) and 3.7 times aslikely to developosteomyelitis (P = 0.01).

Smoking places the patientat risk for increased time tounion and complications.Previous smoking historyalso appears to increase therisk of osteomyelitis andincreased time to union. Castillo RC, Bosse MJ, MacKenzie EJ,

Patterson BM, LEAP Study Group: Impact ofsmoking on fracture healing and risk ofcomplications in limb-threatening open tibiafractures. J Orthop Trauma. 2005 Mar;19(3):151-157.


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Return to work

37 type III high-energy open

tibial shaft fractures.

(76%) returned to work.

64% returned to work at asimilar level of manual labor.

Average delay between injuryand return to work was 11

months (range, 3-18 months).

89% reported one or more

subjective complaints. Arangio GA, Lehr S, Reed JF 3rd: Reemployment of patients with

surgical salvage of open, high-energy tibial fractures: an outcomestudy. J Trauma. 1997 May;42(5):942-945.

There are no emergencies in

orthopaedic trauma

Femoral neck fractures

Talar neck fractures

Open fractures

Open book pelvic

fractures

Unreduced dislocations

Compartmentsyndrome


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Rule #1 - Timing is everything

Compartment syndrome (CS) isan emergency/

urgency to save limb and possibly life.

#2 - Compartment syndrome is rare

Incidence is

3.1/100,000 persons

Incidence for men: 7.3

per 100,000.

Incidence for women:0.7 per 100,000.

McQueen MM, Gaston P, Court-BrownCM: Acute compartment syndrome:

Who is at risk?. J Bone Joint Surg 82-B, 200-203, 2000.


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Incidence

1.5% McQueen MM, Christie J, Court-Brown CM.: Compartment pressures after intramedullary

nailing of the tibia. J Bone Joint Surg Br. 1990 May;72(3):395-397.

7% Kutty S, Farooq M, Murphy D, Kelliher C, Condon F, McElwain JP.: Tibial shaft fractures

treated with the AO unreamed tibial nail. Ir J Med Sci.2003 Jul-Sep;172(3):141-142.

14.5% Barei DP, Nork SE, Mills WJ, Henley MB, Benirschke SK.: Complications associated with

internal fixation of high-energy bicondylar tibial plateau fractures utilizing a two-incisiontechnique. J Orthop Trauma. 2004 Nov-Dec;18(10):649-657.

29% Ovre S, Hvaal K, Holm I, Stromsoe K, Nordsletten L, Skjeldal S.: Compartment pressure innailed tibial fractures. A threshold of 30 mmHg for decompression gives 29% fasciotomies.Arch Orthop Trauma Surg. 1998;118(1-2):29-31.

Causes

Increase the contents

of the compartment.

Decrease the fascial

volume of the

compartment.

Metabolic insults that

disrupt the

microvasculature.


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#3 - Young people get CS more often

Is a patient younger

than 35 with a tibialfracture more likely to

have a CS than apatient over 35 years

of age?

3 times!

#4 - He cant have a CS he can

still move his toes!

The six dreaded Ps:

Paralysis

Pallor

Pulselessness

Pressure

Paresthesia

Pain out of proportion

What exactly is painout of proportion?


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Pain out of proportion

Pain is highly

subjective.

To know what pain is

proportional, one would

have to know how

much pain a certain

injury produces.

As a CS progresses,

pain may actually

decrease masking theCS.

#5 Pressure measurements are

the best way to diagnose CS

Whitesides method.

STIC monitors.

Arterial pressure

monitor.

Accurately measures

pressure in thecompartment.


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Continuous monitoring

One group with continuous monitoringcompared with control clinical group.

In monitored group, 18% had !p< 30 mm Hg,but none developed compartment syndrome.

Overall compartment syndrome incidence was2.5%.

Continuous monitoring is not indicated in alert

patients. Harris IA, Kadir A, Donald G: Continuous compartment pressure monitoring for tibiafractures: Does it influence outcome? J. Trauma60:1330-1335, 2006.

Traumatic measurements

84% had at least one measurement within 30mm !p, and 58% had at least onemeasurement within 20 mm !p.

None of the patients ever manifested acompartment syndrome.

Quantitative measurements may not accuratelydiagnose compartment syndrome.

Prayson MJ, Chen JL, Hampers D, Vogt M, Fenwick J, Meredick R: Baseline compartmentpressure measurements in isolated lower extremity fractures without clinical compartmentsyndrome. J. Trauma60:1037-1040, 2006.


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Pressure measurements are the best way to

diagnose CS

Clinical exam is key!

Clinical assessment

is still the diagnostic

cornerstone of ACS

(acute compartment

syndrome). Shadgan B, et al: Diagnostic

techniques in acute compartment

syndrome of leg J Orthop Trauma

22:581-587, 2008.

Meta-analysis The positive predictivevalue of the clinicalfindings was 11% to 15%,and the specificity andnegative predictive valuewere each 97% to 98%.

The clinical features ofcompartment syndromeare more useful by theirabsence in excluding the

diagnosisthan they arewhen present in confirmingthe diagnosis. Ulmer T.: The clinical diagnosis of

compartment syndrome of the lower leg:are clinical findings predictive of thedisorder? J Orthop Trauma. 2002 Sep;

16(8):572-577.


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What about the asensate or

head injured patients?

Close monitoring of

clinical exam:

Firmness

High clinical suspicion

Pulses

Release the

compartments if in

doubt.

#6 - To calculate !p, use the intra-

operative DBP

Mean DBP in surgery

was 18mm Hg less

than pre-operative

DBP.

Intra-operative DBP

may be spuriously low

when for deciding to

do a fasciotomy. Kakar S, Firoozabadi R, McKean J,

Tornetta P: Diastolic blood pressure inpatients with tibia fractures under

anaesthesia: implications for the

diagnosis of compartment syndrome. J.

Orthop. Trauma21: 99-103, 2007.


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#7 - Open fractures cant have

compartment syndrome

The tears in the fascia release the compartment

pressure

CS in open fractures

The incidence of

compartment syndrome

was found to be directly

proportional to the degree

of injury to soft tissue and

bone; this complication

occurred most often in

association with a

comminuted, type-IIIopen injury to a

pedestrian. Blick SS, Brumback RJ, Poka A, Burgess

AR, Ebraheim NA.: Compartment

syndrome in open tibial fractures. J Bone

Joint Surg Am. 1986 Dec;68(9):1348-1353.


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#8 - I can tell by the firmness

Well orthopaedic

residents cant!

Positive predictive

value was 70%

Negative predictive

value was 63%. Shuler FD, Dietz MJ: Physicians'

ability to manually detect isolated

elevations in leg intracompartmental

pressure J Bone Joint Surg 92-A;

361-367, 2010.

One incision or two?


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Single incision fasciotomy

Centered over fibula.

Superficial dissection can access anterior, lateral

and superficial posterior compartments.

Dissect posterior to fibula and release deep

compartment.

Post-fasciotomy care

NPWT for several days to a week.

Often dictated by fracture care.

Often require STSG.


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#9 - I missed it Im in trouble!

Liability Increasing time from theonset of symptoms to the

fasciotomy was associatedwith an increased

indemnity payment (p

thurs 1 lundy

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