1 M & M Rounds for UAH September 12, 2001 Dr. Abdulaziz Al-Ahaideb.
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Transcript of 1 M & M Rounds for UAH September 12, 2001 Dr. Abdulaziz Al-Ahaideb.
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M & M M & M Rounds for Rounds for UAHUAH
September 12, 2001Dr. Abdulaziz Al-Ahaideb
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M & M Rounds for UAHM & M Rounds for UAH
September 12, 2001
Dr. Abdulaziz Al-Ahaideb
University of Alberta
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MORTALITYMORTALITY
6 mortalities
Four “expected”
Two “unexpected”
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MORTALITY - MORTALITY - “Unexpected”“Unexpected”
Mr. C. G. is a 69 y. o.PMHx: DM, CRF, HTNAdmitted July 11/03 for pain controlMVA Iliac wing # R, # ribs , C-spine ? Soft
tissue swelling
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MORTALITY - MORTALITY - “Unexpected”“Unexpected”
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MORTALITY - MORTALITY - “Unexpected”“Unexpected”
In hospital: – Dec. LOC CT head X3 age-related
changes– C spine cleared C&R– Ileus– Arrhythemia cardiology involved– Dec. Hb urgent endoscopy N– Required dialysis
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MORTALITY - MORTALITY - “Unexpected”“Unexpected”
Code status D/W family DNRPronounced deceased on Aug 3/03Autopsy: ischemic gut
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MORTALITY - MORTALITY - “Unexpected”“Unexpected”
Mr. L .D is a 76 y. o.PMHx: L THA 1989July 4 uncomplicated revision of
acetabular cup and linerPOD 7 July 11 abdominal distention and
hematemesisHb 85 down from 106
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MORTALITY - MORTALITY - “Unexpected”“Unexpected”Central line inserted by the senior
residentUrgent GI consultWhile awaiting to reverse
anticoagulation pt codedResuscitated .. 20 min of down timeIntubated and transferred to CCU
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MORTALITY - MORTALITY - “Unexpected”“Unexpected” Blood products given , urgent CT
abdomen: no ruptured vesicus July 12 gastroscopy done, multiple
gastric ulcers,, no active bleeding No neurological response + hemodynamic
instability Family conference compassionate care Pronounced deceased July 12
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MORBIDITYMORBIDITY
Not necessarilyOurs !!
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CASE 1CASE 1
Mrs. A. N is a 67 y.oSustained L proximal tibial # Uneventful open reduction and
internal fixation was done
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CASE 1CASE 1
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CASE 1CASE 1
POD 7 fell and complained of pain at the thoracic spine
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CASE 1CASE 1
She sustained T10 compression fracture, treated conservatively
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CASE 2CASE 2
Mrs. S. P is a 75 y. o.PMHx: COPD, CAD, R THASustained L subcapital #Aug 11 L Modular Moore
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CASE 2CASE 2
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CASE 2CASE 2
Postop resp failure and NSTEMI ,, required ICU
Transferred to Fort McMurray in good Aug 25 started to drain from the wound,
then the wound dehisced Aug 27 back to UAH Aug 30 debridement and insertion of
gentamicin beads
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CASE 2CASE 2
Sep 1 culture grows enterococcus Sep 2 2nd debridement Sep 5 was supposed to go for 3rd
debridement and possible removal of prosthesis but developed new problems :– CHF– Dec urine output– Incr troponin
Hematology has seen here recently ? Lupus factor
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CASE 2CASE 2
Sep 8/03 Troponin 4.1 N ECGMedicine and hematology are
following
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CASE 3CASE 3
Mrs. M. C is a 60 y. o.Nov 02 elective lumbar discectomy
and instrumentationJan 03 deep infection
debridement and removal of hardware
Had been reasonably well till Aug 03, developed fever and malaise
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CASE 3CASE 3
Ultimately developed staph aureus septicemia and draining from the wound
Admitted to ICUUrgent MRI
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CASE 3CASE 3
•Aug 9 Urgent to ORDebridement and irrigation•Aug 11 repeat debridement and closure with retention sutures•Cardiology: MIBI and TEE•Sep 5 taken to the OR as the wound started to drain
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CASE 4CASE 4
Mr. C.L is a 40 y. o. PMHx: – R ACL reconstruction 20 yrs ago in
Ottawa– Taek-wan-do injury , found to have R
knee in varus– Feb 03 HTO (+? tubercle
osteotomy+allograft) was done by the same surgeon in Ottawa
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CASE 4CASE 4
Was able to walk without aidsR leg looked crooked Clinically R leg in varus and lack of
full extension
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CASE 4CASE 4
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CASE 4CASE 4
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CASE 4CASE 4
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CASE 4CASE 4
Sep 4/03 to the OR spinalRemoval of the hardwareNew fixation with 2 platesBone grafting from R iliac crest
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CASE 4CASE 4
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CASE 4CASE 4
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CASE 5CASE 5
Mrs. J. M is a 54 y. o.Involved in MVAGCS 5/15 on scene, intubated in
Prince George ERSent to Grande Prairie
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CASE 5CASE 5
Injuries:– Basal skull #– Small subarachnoid bleed– Bilat. Hemopneumothoraces– R sup/ inf pubic rami #– R midshaft tibia – ex fixed – L distal radius/ulna ORIF– L calcaneus #– R Lisfranc # dislocation
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CASE 5CASE 5
Injuries dealt with @ UAH on admission Aug 7– Ex-fix for R wrist – I & D L knee laceration
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CASE 5CASE 5
– Cannulated screws for L hip # (Aug 5)
– Satisfactory fixation
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CASE 5CASE 5
Repeat x-rays after discharge from ICU
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CASE 5CASE 5
Aug 29 to ORRemoval of the cannulated screws
and bipolar hemiarthroplasty
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CASE 5CASE 5
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CASE 6CASE 6
Mrs. S. F 44 y. o. chronic alcoholicJuly 4/03 seen @ Invuik hospital with
C/O neck , shoulder and arm pain bilaterally after falling 10 steps ( ? Abuse)
“C-spine x-rays were unchanged” , also CT spine done N
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CASE 6CASE 6
Admitted there for bowel obstructionGot worse neurologically: weakness
& numbness to the level of nipplesIntubated due to dec. O2 satTo Stanton QUADREPLEGIC
working Dx Gullian Barre synd.
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CASE 6CASE 6
July 19 transferred to UAH to R/O spinal injury
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CASE 6CASE 6
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CASE 6CASE 6
Diagnosed to have bilateral jump facet C7 on T1
What should be done ?
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CASE 6CASE 6
With 20 Ibs With 72 Ibs
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CASE 6CASE 6
Traction unsuccessful (even with 72 Ibs)
35 Ibs left on overnightCT C-spine done
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CASE 6CASE 6
CT shows partialreduction
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CASE 6CASE 6
July 11 to OR: posterior instrumentation and fusion C6 to T2
Was not stable enough
Halo vs ant. plating
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CASE 6CASE 6
July 15 C7-T1 anterior discectomy, partial corpectomy, tricortical bone grafting and anterior plating
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CASE 7CASE 7
Mr. W. H 48 y. o.PMHx:– Obesity– DM– Peripheral neuropathy– NSTEMI – Chronic renal impairment
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CASE 7CASE 7
Apr 03 sustained L ankle #Seen @ RAH – treated in a cast then a walking cast – # displaced pressure ulcer laterally
infected with soft tissue defect and exposed bone
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CASE 7CASE 7
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CASE 7CASE 7
Pt wants to keep his legAdmitted to UAH ICU with another
NSTEMIRequired hemodialysisNot a candidate for CABGStill wants to keep his leg
What should be done ?
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CASE 7CASE 7
Irrigation & debridementResection of articular surfacesEx-Fix with an attempt to fuseWound closed primarily
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CASE 8CASE 8
Mrs. N. J is a 69 yo PMHx: HTN L hip OA
June 19
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CASE 8CASE 8
June 23/03 uncomplicated L THA
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CASE 8CASE 8
Fell at homeCouldn’t wt bearNo hx of constitutional symptoms
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CASE 8CASE 8
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CASE 8CASE 8
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CASE 8CASE 8
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CASE 8CASE 8
Work up for infection – negativeOR July 31/03– Removal of the cup– ORIF posterior wall– Allograft– Recon ring & cemented liner
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CASE 8CASE 8
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CASE 9CASE 9
Mrs. M.K is a healthy 44 y.o. womanSustained L distal radius #Outside filmsAug 1/03 closed reduction and perc.
pinning
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CASE 9CASE 9
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CASE 9CASE 9
2 weeks post-op
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CASE 9CASE 9
Aug 25 Revised with a volar plate
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CASE 9CASE 9
At night , developed paresthesia and numbness ( carpal tunnel like )
Wound was opened in the ward partial relief
Aug 27 irrigation and debridement
Wound wasn’t closableAug 30 2nd debridement & closure..
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CASE 10CASE 10
Mr. L. N is an 83 yo malePMHx: CHF, A.fibPSHx:– 5 revisions L hip – 2 revisions R hip– L TKA
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CASE 10CASE 10
July 17 fell at home and C/O of L hip pain
No Hx of fever, chills or night sweats
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CASE 10CASE 10
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CASE 10CASE 10
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CASE 10CASE 10
Infection work up negativeJuly 29 to OR– Revision of the stem to a longer one– Strut allograft– Dall-Miles cables
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CASE 10CASE 10
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CASE 10CASE 10
2 weeks post-op: ill, fever, erythema, Left leg swelling
Aug 17 L hip irrigation & debridement + genta beads + removal of the cables
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CASE 10CASE 10
Aug 20 2nd debridement L hip and excision of necrotic skin L leg
Stable componentsSep 7 debridement + removal of
beads + closure of wound, good hemostasis + debridement of L leg by plastics
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CASE 10CASE 10
@ 2240 the resident called Re: low BP soaking dressing Hb 59
Medicine consulted to R/O DICLost > 10 units total but eventually
bleeding is less
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CASE 11CASE 11
Mr. L. B is a 23 y.o. male MVA 3 Aug 03 Multiple injuries, arrived intubated Ortho injuries:– L midshaft femur– L open midshaft tibia– L tibial plateau– L open humerus– L ulna
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CASE 11CASE 11
L humerus #
L ulna #
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CASE 11CASE 11
OR Aug 4 – I&D + plating L humerus– Plating L ulna– IM nail L femur
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CASE 11CASE 11
L femur L humerus
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CASE 11CASE 11
Aug 20 from ICU to the wardL wrist dropPain L kneeRepeat x-rays
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CASE 11CASE 11
L humerus
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CASE 11CASE 11
L ulna L knee
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CASE 11CASE 11
Aug 24 to OR– Exchange locking screw L distal femur– Revision ORIF L ulna– Revision ORIF L humerus and
exploration of radial nerve
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CASE 11CASE 11
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Interesting techniqueInteresting technique
Ms S.E is a 29 y.oHad internal tortion of the femur with
zero external rotationPLAN: derotational femoral
osteotomy
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Interesting techniqueInteresting technique
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Interesting techniqueInteresting technique
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Interesting techniqueInteresting technique
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Thank You