Post on 05-May-2018
Orthopaedic Trauma Tips
Bryon Hobby, MD Billings Clinic Department of Orthopedics and Sports Medicine
Health Care, Education and Research
Disclosures
None
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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
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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
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Work up of pelvic ring injury
• Follow a protocol – ALTS • AP pelvis • CT scan of chest, abdomen and pelvis • Serial Hct’s, Lactate
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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
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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
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Who needs a binder?
• Unstable pelvic ring injuries • Increased pelvic volume • Hemodynamic instability
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Where does the binder/sheet go?
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Where does the binder/sheet go?
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Where does the binder/sheet go?
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Where does the binder/sheet go?
Routt et al JOT 2002
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Who doesn’t need a binder?
• Stable pelvic ring injuries • Hemodynamically stable patients • Those with decreased pelvic volume
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Binders have complications
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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
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Pathophysiology
• Elevation of pressure in fibro-osseus space resulting in decreased perfusion
Parasam et al JAAOS 2011
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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
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Who should you monitor?
• First of all remember that compartment syndrome is a clinical diagnosis
• Who? – Obtunded patients – Younger patients – Equivocal findings
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Where to measure?
Olsen et al. JAAOS 2005
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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
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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
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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.
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Why do we care?
• Increased rates of: – Infection – Malunion – Nonunion
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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
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Evaluation
• ALTS – don’t forget that other stuff • Note vascular status • Size, shape of wound • Contamination +/- ? • Have a high index of suspicion for
compartment syndrome
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Evaluation
• ALTS – don’t forget that other stuff • Note vascular status • Size, shape of wound • Contamination +/- ? • Have a high index of suspicion for
compartment syndrome
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Classification
Halawi et al Orthopaedics 2015
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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
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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
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Timing of antibiotics
Lack et al JOT 2015
7% 18% 28%
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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
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Antibiotics – what should I give?
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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
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TAKE HOME
• Pelvic ring injury – – Binder/sheet
• Unstable patients • Increased pelvic volume
– Binder is placed on Greater Trochanters
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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
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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 BHobby@billingsclinic.org