orthopaedics iii basic fracture management · 2 the fracture patient causes management...

U N I V E R S I T Y O F C O P E N H A G E N U N I V E R S I T Y H O S P I T A L F O R C O M P A N I O N A N I M A L S

Faculty of Health and Medical Sciences

Orthopaedics IIIBasic Fracture Management

James MilesUniversity Hospital for Companion Animals

1.12.15Slide 1/110

Outline

1 Aims2 The fracture patient

CausesManagementImmobilisation

3 Specific fracture problemsPolytraumaOpen fractures

Pelvic fractures4 Fracture management

principlesFracture scoringAims of fracture repairFractures and healingFixation techniques

5 Fracture knowledgeapplied

/110 — James Miles — Orthopaedics III: Basic Fracture Management — 1.12.15

Intended Learning Outcomes

• Make a plan for initial management of the fracturepatient

• Differentiate between fractures that require specialistattention and those that can be managed in generalpractice

• Explain the role of different fracture treatment options(surgical and non-surgical)

• Understand the concept of fracture scoring and how itcan guide the treatment plan

What causes a fracture?

Fracturecauses

Extrinsic(outside the patient)

Intrinsic(inside the patient)

Directtrauma

Indirecttrauma

Musclerepetitive loading

Pathologicweakness

Triage

Identify conditions which:

• Will kill in minutes

• Will kill in hours

• Will kill in days

• Are a bit annoying

◦ Bladder rupture

◦ Arterial bleeding

◦ Diaphragmrupture

◦ Rib fracture

◦ Skin lacerations

◦ Liver bleeding

◦ Pneumothorax

◦ Tibial fracture

Priorities

FAST scan

Supportivecare

Clinicalassessment

ImmobilisationTraumaseries

Orthoexam

Fractureseries

Neuroexam Cardio

Respexam

Bleeding

Initial steps in clinical assessment

1 Alert colleagues

2 Obtain short, relevant history

3 Move patient to suitable treatment area

4 Assess ABCD

5 Assess other clinical parameters

6 Collect minimum database

Fracture first-aid

• Supportive treatment

• Clinical assessment

• Immobilisation• Radiography

• Trauma series• Fracture site

A B C DAirway Patency

Oxygen supplementation (avoid stress)

Breathing Symmetry of ventilationBilateral lung soundsPalpate for emphysema, fractured ribsPulse oximetry

Circulation Mental statusMM/CRTPulse character and rateECG

Disabilities Neurological statusCranial and peripheral reflexes

Minimum database

• Haematocrit (PCV)

• Total protein

• Blood glucose

• Activated clotting time

• Urine specific gravity

There is no specific test for trauma!Initial profiles rarely influence management

Fluid support in trauma

Volumes (ml/kg) Dogs Cats

Total body water 700 600Red blood cells 40 20Plasma 50 40Total blood 90 60

• Rates equivalent to plasma volume per hour areprobably sufficient

• Only 20% of infused crystalloids remains intravascularafter 1 hour

• Hypertonic saline may produce the same effect withless risk of oedema

Colloid support in trauma

• Colloids remain intravascular*

• Small volumes are effective in increasing circulatingvolume

• No survival advantage in human studies

• Human meta-study suggests crystalloids better withpulmonary contusions

*if there is capillary damage, colloids will leak out

Fluid rescuscitation

• Use at least one large bore IV catheter• Cephalic• Saphenous (lateral - dog, medial - cat)

• Monitoring• Maintain Hct >20%• Mainain TP >50% of initial value• Urine output (place catheter)• Peripheral pulse• Skin perfusion• Lactate

Why immobilise?

• Analgesia• Prevent further damage

• Fracture fragments• Surrounding soft tissues

Immobilisation

Green: reasonable expectationBlue: possible, with specialised splintsRed: not usually possible with bandages

• Simple to apply

• Resists bendingand rotation

• Useful fortemporarystabilisation

• Does not resistaxial forces

• Complicationsmay limit longerterm use

• Stable, rapidlyhealing fracturesonly

Fracture healing times

3 6 12 12+

Patient age (months)

ESF or IM pin

bone plate

Casts have similar healing properties as ESF/IM pin butrely more on inherent fracture stability

Cast and splint principles

• Immobilise the joint above and below the fracture

• Use appropriate amounts and type of padding

• Pay attention to bony prominences or high pressureareas

• Place the limb in a neutral position

• Avoid tension and wrinkling of materials

• Avoid excessive moulding and indentations

Casts provide more support than splintsToo loose is almost as bad as too tight!

Cast complications

• Bandage or cast slipping

• Pressure sores

• Ischaemia

• Dermatitis

• Joint stiffness (possibly permanent)

• Patient interference (chewing, poor tolerance)

• Owner compliance

Incidence can be reduced by proper bandaging technique.However, with prolonged use (>6-8 weeks), some level ofcomplications is almost inevitable.

Swaim, Renberg and Shike: Small animal bandaging, casting and splinting techniques. Wiley-Blackwell 2011

Why take a trauma series?Dogs with limb fractures:

• % with thoracic trauma

• % with overt signs

Polytrauma

What is polytrauma?

• Significant injuries to >1 major bodysystem, eg:

• Respiratory• Cardiovascular• Nervous (central, peripheral)• Excretory (biliary, renal)• Integumentary• Musculoskeletal

• Our patients typically havepolytrauma

• Maintain a high index of suspicion

Why worry about polytrauma?

• Multiple problems increase management complexity

• Increased risk of complications

• Increased financial costs

• Implications for surgical intervention

Human perspective - polytrauma

Early Total Care

• Popularised in the 1980s• Fracture fixation in <24hrs reduced

• Pneumonia• Respiratory distress syndrome• ICU and hospitalisation times

• Controversies• Increased mortality in severely injured patients?

Nicola: Early total care versus damage control: current concepts in the orthopedic care of polytrauma patients. ISRNOrtho 2013;329452:1-9

Human perspective - polytrauma

Damage Control Orthopaedics

• Currently popular (from 2000)• Divides treatment into 4 phases

• Acute life-saving• Haemorrage control and fracture immobilisation• Monitoring• Definitive fracture fixation

• Controversies• Timing of definitive fixation• Days 2-4 seem ’bad’

Nicola: Early total care versus damage control: current concepts in the orthopedic care of polytrauma patients. ISRNOrtho 2013;329452:1-9

Human perspective - why the change inapproach?

• Severe trauma induces SIRS• Severe SIRS can produce organ failure

• SIRS is mediated by CARS• Mild SIRS + excessive CARS induces prolonged

immunosuppression• Mild SIRS = ’first hit’• Surgery =’second hit’• Surgery may worsen initial SIRS• Surgery during excessive CARS induces organ failure

Systemic Inflammatory Response SyndromeCounter-regulatory Anti-inflammatory Response Syndrome

Human perspective - timing

• Initial SIRS phase ≈ 24 hours• CARS phase ≈ 48-96 hours

• Stable or borderline patients→ ETC• Unstable or critical patients→ DCO

• How do these timings relate to dogs and cats?

• Could monitoring of eg IL-6 aid decision making?

Open fractures - decision making

Incidence

• Of all traumatic fracture patients:• 14% dogs• 29% cats

• Particular risk factors:• Young (<16 months)• Distal to tibiotarsal joint• Increasing body size• Comminution• Hit by car

Millard and Weng: Proportion of and risk factors for open fractures of the appendicular skeleton in dogs and cats.JAVMA 2014;245:663-668

Classification

Grade Wound Description Infection

1 <1cm Clean wound 0-12%

2 1-10cm No extensive skin loss or avulsion 2-12%

3A >10cm, orextensive damage,or loss of skin

Periosteal coverage of bone intact9-55%3B Periosteal stripping, bone damage, extensive contamination

3C Vascular compromise requiring surgery

Gustilo-Anderson open fracture classification, see J Bone Joint Surg Am 1976; 58:453-458

Assessment

• Can the limb be salvaged? (ie: 1-3B)

• Will limb function be acceptable?• Arthrodesis• Reconstructive surgery

• Financial and emotional cost

Treatment

• Prevent further contamination• Cover wound immediately• Standard sterile precautions whenever uncovered

• Decontaminate wound• Prepare surrounding skin• Irrigation• Debridement

• Antibiotic therapy• IV broad spectrum ASAP• Consider post-debridement culture and sensitivity

Preventing contamination

• A dirty wound is noexcuse for a dirtysurgeon

• Maintain normalsterile precautions

• Protect the woundfrom the hospital

• Take a swab!

• Give antibiotics early

Wound plan

Reduce contaminationLavage

• effectively reduces bacterialnumbers and removes debris

• is dependent on adequate pressure• 60ml syringe with 18g needle• specialised lavage equipment

• is dependent on adequate volume• at least 250ml• 50ml/cm2 wound?

• use isotonic fluids• LRS better than saline?• tap water acceptable?• not hydrogen peroxide or other

chemicals

Debridement• Carefully remove necrotic tissue• Sharp dissection best• Stage removal (don’t remove tissue unless you know

it is dead)• May need to repeat as extent of injury becomes

apparent

Culture and antibioticsSensitivity Specificity

Pre-debridement culture 88% 43%Post-debridememt culture 63% 50%

• Infecting organism found:• 8-29% pre-debridement cultures• 42-60% post-debridement cultures

• Negative culture has a good predictive value• Antibiotic choice

• IV 1st or 2nd gen. cephalosporin TID-QID 48-72hrs• Veterinary data lacking!

Kreder and Armstrong: The significance of perioperative cultures in open pediatric lower-extremity fractures. ClinOrthop Rel Res 1994;302:206-212, and Lee: Efficacy of cultures in the management of open fractures. Clin OrthopRel Res 1997;339:71-75

Fracture fixation

• Stabilise as soon as possible

• Infection does not stop bone healing• Options:

• Internal fixation• Titanium better than steel• Reserve for Grade 1?

• External fixation• Combine with open wound management• Consider conversion once infection controlled?• Use alone may be successful

Ness : Treatment of inherently unstable open or infected fractures by open wound management and external skeletalfixation. JSAP 2006;47:83-88

Case - initial presentation

Case - post-operative

Case - progress

• ESF removed at 6 weeks

• Open wound management at carpus continued• At check-up 20 weeks after injury

• Wound healed• Residual instability at the carpus• Arthrodesis recommended

Summary

• Evaluate fracture in terms of potential for recovery

• Consider amputation if:• Limb function likely to be poor• Patient will not tolerate intensive management• Financial constraints

• Start antibiotic therapy early

• Minimise infection risk• Prevent further contamination• Aggressive debridement and lavage• Early stabilisation

Pelvic fractures - decision making

Pelvic structure

• Box-like

• Extremely rigid

• Fracture=large force

• Multiple fractures

Pelvic fractures

• Common• ≈ 25% of fracture patients

• Frequently complicated• thoracic injuries (≈ 30%)• urinary tract injuries (≈ 40%)• neurological (lumbosacral, sacrococcygeal)• spinal fractures• vascular

Triage

• Full clinical examination

• Trauma series• Thorax and abdomen

• Ultrasonography• Thorax and abdomen• FAST scan

Abdominal and Thoracic Focused Assessment with Sonography in Trauma, Lisciandro (2011) J Vet Emerg Crit Care

Pelvic fractures - functional significance

• Green areas• Painful• Rarely need

stabilisation

• Red areas• Affect function• Surgery often

indicated

Pelvic fracture Decision Tree

Assess width

% overlap at SI joint

Intact mechanical axes

Pain control

Try conservative management

Surgicaltreatment

<50%≥50%

<67%≥67%

UnacceptableAcceptable

Acetabular fracture

No Yes

Case - Ziuta

• 2 year old, F, domestic cat

• 3.3 kg

• Not walking following fall from1st floor window

• Trauma series – normal

• Blood loss treated withtransfusion

Case - radiographs

Case - fracture tracing

Case - iliac plating

Case - external fixator

Reported for use in cats and small dogs. Complianceproblems. Acute stabilisation (humans).

Case - conservative management

• Acceptable only if pelvic width >67%

• Painful – cage rest for 4–6 weeks

• Suboptimal treatment if weight-bearing zones areinvolved

Case - actual surgery

Summary

• Evaluate fractures in terms of function

• Determine if conservative management is sufficient• Consider repeat radiography after 4-5 days

• Stabilise

• If surgical:• Aim for surgery within 5-7 days (max)• Neurological recovery may be uncertain

Fracture scoring - concept

• What is it?

• Why do it?

• How do we do it?

Fracture scoring

Mechanical

Fracturetype

Otherinjuries

Patientsize

Fracture scoring

Biological

Patientage

Healthstatus

Tissuedamage

Fracture scoring

Clinical

Ownertype

Patienttype

Fracture scoring - summary

Fracture scoring gives us an idea of how:

• Fast it will heal

• Strong the repair must be

• Compliant the owner (patient) will be

Checklist - the actual ’score is less relevant

Fracture scoring – appliedSnoop 20167, 11 months old M Affenpinscher (3kg)Non-weightbearing on both fore limbs after fall frombalcony:

• Mechanical?

• Biological?

• Clinical?

Fracture scoring – applied

Louis 19929, 18 months old M Welsh Springer (20 kg)Hit by car, no other injuries:

• Mechanical?

• Biological?

• Clinical?

What do we want?

• Anatomical reduction vsalignment

• Stable fixation

• Preservation of blood-supply

• Early mobilisation

What happens next?

100% 100% 20% 10% 2%

The different tissues involved in healing have differentstrain tolerances.

Bone healing in action

Compare these films with the abnormal healing on slide 82

Fracture healing times

3 6 12 12+

Patient age (months)

ESF or IM pin

bone plate

...can we relate these healing times to fracture stability?Slide 70/110 — James Miles — Orthopaedics III: Basic Fracture Management — 1.12.15

Why the difference?

30 min 2 days 4 days

Removed

Intact • Rat model

• Bilateral femoral fracture+ IM pin

• Haematoma removed at30min, 2d or 4d

• Fracture rigidity testedat 4 weeks

From: Grundnes (1993) in Acta Orthop 64(3):340–342

Timing of repair

Depends on several factors:

• Patient stability (DCO vs ETC)

• Fracture severity

• Possible wait for equipment/surgeon

In general:

• Joint fractures – within 24 hours

• Salter Harris/immature animals – within 24–48 hours

• Other – within 2–3 days

• Simple to apply

• Resists bendingand rotation

• Stable fracturesonly

• Does not resistaxial forces

• Complicationslimit use

Intramedullary pins

• Simple surgery

• Minimalequipment

• Resists bending

• Not for radius

• Does not resistrotation or axialforces

External fixation

• Simple tocomplex surgery

• Moderateequipment

• Resists all forces

• MIO possible

• Owner +/orpatientcompliance

• Post-op care

• Pin tracts

Plating systems

• Minimal post-opcare

• MIO possible

• Complex surgery

• Training required

• Risk of failure

• Expensiveequipment

Plate-rod combinations

• MIO possible

• Complex surgery

• Risk of failure

Interlocking nails

• MIO possible

• Complex surgery

• Risk of failure

Screws

• Anatomicalreduction

• Fragmentcompression

• Complex surgery

Pin and tension band

• Simple surgery

• Minimalequipment

• Fragmentcompression

• Cerclage twistingrequires practice

Stabilisation - aims

• Anatomical reduction

• Stable fixation

• Preservation of blood-supply

• Early mobilisation

• Compatible with skill level – refer?

Post-operative management

• Rest!

• Regularcheck-ups

• Clinical• Radiographic

• Look out for• Healing• Progress• Complications

Compare these films with the normal healing on slide 69

Infections

• ESF pin tractinfections arecommon but minor

• ESF is a goodchoice for revisionor primary repair ofinfected fractures

• Fractures will heal ifstable

Clinical signs

Radiographic signs

Fracture andimplantsunstable

Fracture andimplantsstable

Revise repair& antibiotics

Removeimplants when

healed

Antibiotics

Looking at radiographs

So far, you have not had any teaching in radiology. Lookingat the following case radiographs may therefore seemimpossible.

Try to think of the radiographs as black and whitephotographs of the bones you have seen in your anatomybooks and as skeletons.

Remember that (for our purposes) the only things that canbe seen on a radiograph are – in increasing order ofdensity – air, fat, soft tissue (or fluid) and bone.

Looking at radiographs

Working in small groups, look at the radiographs and try to:

• identify which bone it is

• identify the joints above and below the bone

• follow the cortices (denser white) and see where theystart or end

• identify where the main fragments are

• decide if the fracture is ’reconstructable’ (like a jigsawor puslespil) or not

• think about what forces are working on this fracture(from muscles, ground, body mass)

Case 1 - Jonesy

• 1 year old, F, domestic cat

• 3.3 kg

• Acutely lame on the right hindlimb following fall from 4thfloor window

• Trauma series – normal

Case 1 - radiographs

Case 2 - Hilde

• 9 year old, F, British shorthaircat

• 4.5 kg

• Lame right hind – no knowntrauma (indoor/outdoor cat)

• Clinical examinationunremarkable apart frommetatarsal pain

Case 2 - radiographs

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