TIMING OF FRACTURE FIXATION INTIMING OF FRACTURE FIXATION INPOLYTRAUMA PATIENTSPOLYTRAUMA PATIENTS

ANAESTHESIOLOGIST’S PERSPECTIVESANAESTHESIOLOGIST’S PERSPECTIVES

Dr.R.SelvakumarDr.R.Selvakumar

POLYTRAUMA-NIGHTMARE FOR THE PATIENTPOLYTRAUMA-NIGHTMARE FOR THE PATIENT & AS WELL AS FOR THE ANAESTHESIOLOGIST& AS WELL AS FOR THE ANAESTHESIOLOGIST

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SURGEON & SURGEON & ANAESTHETISTANAESTHETIST

Opposite Views

having

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Why anaesthetist wants to avoid?

- prolonged hours of surgery

- Unexpected response

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Polytrauma:Polytrauma:

• HypovolemiaHypovolemia• Multiple system involvementMultiple system involvement• less time for evaluationless time for evaluation• missed injuries (head & abdomen)missed injuries (head & abdomen)• prolonged surgeryprolonged surgery• massive blood transfusionmassive blood transfusion• difficulty in monitoringdifficulty in monitoring• surgical difficultiessurgical difficulties

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Unique problemUnique problem

• increased incidence of increased incidence of respiratory failurerespiratory failure

• ARDSARDS

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Why there is an increased incidence of Why there is an increased incidence of respiratory failure?respiratory failure?

ARDS → fat embolism

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Fat embolism in polytraumaFat embolism in polytrauma

PathophysiologyPathophysiology• ↑ ↑ in intra medullary pressure →fat in intra medullary pressure →fat

droplets → get filtered in the pulmonary droplets → get filtered in the pulmonary circulationcirculation

• minute droplets go through pulmonary minute droplets go through pulmonary circulation & get trapped in cerebral circulation & get trapped in cerebral circulationcirculation

• alveolar lipase → hydrolysis of fat →alveolar lipase → hydrolysis of fat →

release of fatty acids (palmitic, stearic, release of fatty acids (palmitic, stearic, oleic)oleic)

• Neutralisation by albuminNeutralisation by albumin

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Pathophysiology of Fat Embolism - contd

• failure of neutralistion by albuminfailure of neutralistion by albumin• fatty acids + calcium fatty acids + calcium →intercellular →intercellular

septa rupture septa rupture → → diffuse areas of diffuse areas of haemorrhage & oedema in haemorrhage & oedema in

pulmonary pulmonary interstitium & alveolar interstitium & alveolar spacespace

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• Integrins CD11b & CD18 cause Integrins CD11b & CD18 cause adherence of neutrophils & endotheliumadherence of neutrophils & endothelium

• Injured pnumocytes stop surfactant Injured pnumocytes stop surfactant production→ collapse of alveoliproduction→ collapse of alveoli

• ↑ ↑ shunt and dead spaceshunt and dead space

Pathophysiology of Fat Embolism - contd

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Just to relax……Just to relax……

Secondary injury:Secondary injury:

• FE incidence in a polytrauma -30-90%FE incidence in a polytrauma -30-90%

• If surgery is performed following If surgery is performed following polytrauma, polytrauma,

will reaming further increase the incidence will reaming further increase the incidence of of

FE?FE?

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Will it produce a second hit ?

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Medullary reaming & CementationMedullary reaming & Cementation

• Normal I.M pressure - 30 – 50mm of Normal I.M pressure - 30 – 50mm of Hg.Hg.

• Violent force in the bone - Violent force in the bone - I.M I.M pressure ↑many fold.pressure ↑many fold.

• Reaming increases I.M.P ↑ up to 400-Reaming increases I.M.P ↑ up to 400-600 mm of Hg.600 mm of Hg.

• Cementation → 650-1500 of Hg.Cementation → 650-1500 of Hg.

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What they did….What they did….

In 1960s:• Ill development of pulmonary care

• Wait till FES resolves

• Kuntscher’s three recommendations

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Kuntscher’s recommendations:Kuntscher’s recommendations:

1. Don’t nail as long as symptoms of FE are

present 2. Take special precaution for patients with multiple fracture and extensive soft

tissue injuries 3. Don’t nail immediately, but wait a few

days

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Negative effects of delayed Negative effects of delayed fixationfixation

• prolonged immobilisation

• pneumonia, bedsore, renal failure, inadequate nutrition, vascular abnormalities

• poor results

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A word about hyponatraemia…

• old ageold age• ↓ ↓ appetiteappetite• depressiondepression• social conditionssocial conditions

restlessness,disorientation etcrestlessness,disorientation etc

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Drastic changes in the 1980sDrastic changes in the 1980s

• Early fixationEarly fixation

• better understanding of pathophysiology of better understanding of pathophysiology of traumatrauma

• improvement in critical careimprovement in critical care

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Changes in the 1980s…..

• It led to aggressive management It led to aggressive management without improving the supportive carewithout improving the supportive care

• Bad resultsBad results

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Damage control orthopaedics:Damage control orthopaedics:

• Pack the major sources of haemorrhagePack the major sources of haemorrhage

• Resuscitation and stabilisation of the Resuscitation and stabilisation of the

general conditiongeneral condition

• Temporary immobilisation of bone Temporary immobilisation of bone

fracturesfractures

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Current recommendationsCurrent recommendations

Classify the patients according to their physical status

1. stable grade I 2. borderline grade II 3. unstable grade II 4. In extremis grade IV

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Creteria used in the physical status Creteria used in the physical status classificationclassification

Shock – B.P, No of blood units,Shock – B.P, No of blood units, lactate levels,B.D,ATLSlactate levels,B.D,ATLS

Coagulation statusCoagulation statusTemperatureTemperatureSoft tissue injuriesSoft tissue injuries

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Stable patientsStable patients:

• Do whatever you want….Do whatever you want….

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Borderline patients who respond Borderline patients who respond to resuscitation……to resuscitation……

proceed with definitive fixationproceed with definitive fixation

limit the surgical duration within 2 hourslimit the surgical duration within 2 hours

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Remember…Remember…

A bad surgeon can shift the A bad surgeon can shift the ASA ASA

Grade II to IV easily…..Grade II to IV easily…..

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Borderline patients:Borderline patients:

Continuous reassessmentContinuous reassessment Pao2/F102 should not drop below 200mm Pao2/F102 should not drop below 200mm

of Hgof Hg Temperature should not drop below 32CTemperature should not drop below 32C Requirement of fluids should not exceed 3L Requirement of fluids should not exceed 3L

or or 5units of blood5units of blood Absence of significant coagulopathyAbsence of significant coagulopathy If not If not → DCO→ DCO

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Unstable and patients in extremis:Unstable and patients in extremis:

Life saving surgeriesLife saving surgeries

External fixationExternal fixation

Resuscitation and stabilization Resuscitation and stabilization simultaneouslysimultaneously

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Strategy in patients with head Strategy in patients with head injury:injury:

Beware of the fact that cerebral auto Beware of the fact that cerebral auto regulation goes off following head injuryregulation goes off following head injury

Extensive sympathetic block due to regional Extensive sympathetic block due to regional anaesthesia may hamper CBFanaesthesia may hamper CBF

Severe head injury Severe head injury → only life saving → only life saving proceduresprocedures

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Strategy in patients with chest Strategy in patients with chest injuryinjury

Rib fracture or lung contusionRib fracture or lung contusion Monitoring with pulseoximeter or ABGMonitoring with pulseoximeter or ABG Incidence of ARDSIncidence of ARDS Severe chest injury Severe chest injury →only life saving →only life saving

proceduresprocedures

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What to do to prevent the incidence of FES?

Avoid increase in IM pressureAvoid increase in IM pressure Medullary channel depletionMedullary channel depletion Venting the medullary channelVenting the medullary channel Uncemented prosthesisUncemented prosthesis

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summarysummary

In polytrauma, immediate fixation may lead In polytrauma, immediate fixation may lead to secondary complicationto secondary complication

Classify the patients according to their Classify the patients according to their Physical statusPhysical status

Grade I and II – Immediate surgeryGrade I and II – Immediate surgery

Grade III and IV – resuscitation,DCO,Grade III and IV – resuscitation,DCO,Delayed fixationDelayed fixation

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Conclusion:

Pre-operative status of the patientPre-operative status of the patientdecides the timing of the fracture decides the timing of the fracture fixation in the poly-trauma patients….fixation in the poly-trauma patients….

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Dr.R.SELVAKUMAR M.D.,D.A.DNBDr.R.SELVAKUMAR M.D.,D.A.DNBASSOCIATE PROFESSORASSOCIATE PROFESSORCOIMBATORE MEDICAL COLLEGECOIMBATORE MEDICAL COLLEGECOIMBATORECOIMBATORE