Orthopedic Trauma Postoperative Care

and Rehab

Serge Charles Kaska, MD

Name that Beach100$

Still 100$

75$

50$

1$

Omaha

• June 6th 1941

• !st Infantry Division

• 2000 KIA

LIFE OR LIMB THREAT

1. Compartment Syndrome

2. Fat Emboli Syndrome

3. Pulmonary Embolism

4. Shock

Compartment syndrome case

A 16 year old male was retrieving a tire from his truck bed on the side of the highway in the pouring rain when a car careens off of the road and sandwiches the patients legs between the bumpers at freeway speed.

Acute compartment syndrome

Compartment syndrome DEFINED

Definition: Elevated tissue pressure within a closed fascial space

• Pathogenesis

– Too much in-flow: results in edema or hemorrhage

– Decreased outflow: results in venous obstruction caused by tight dressing and/or cast.

• Reduces tissue perfusion

• Results in cell death

Compartment syndrometissue survival

• Muscle– 3-4 hours: reversible changes

– 6 hours: variable damage

– 8 hours: irreversible changes

• Nerve– 2 hours: looses nerve conduction

– 4 hours: neuropraxia

– 8 hours: irreversible changes

Physical exam

1. Pain

2. Pain

3. Pain

Physical exam• Inspection

– Swelling, skin is tight and shiny

• Motion– Active motion will be refused or unable. Must see dorsiflexion

• Palpation– Severe pain with palpation

• Alarming pain with passive stretch

Physical exam

• Dorsiflexion

Physical Exam• Palpation

– Severe pain with palpation

• Alarming pain with passive stretch

Physical exam• Evaluations from nurses, therapists, and orthotech’s are CRITICAL

• If you call a doctor and say that you think the patient has compartment syndrome, the doctor will come to the hospital right away

• Error on the side of caution but please learn exam

Treatment• Remove all compressive

dressings

• Elevate the leg to level of the heart

– Helps promote in-flow to out-flow

• Fasciotomy emergently

Fat emboli syndrome• 22 year old male dirt bike rider

with bilateral femur fractures

• Pod #1 S/P ORIF

• Mental status changes, agitation

• RR 24

• O2 saturation 89

Fat emboli• Typical patient

– Men > Women

– Common age ranges: 10-40

– Long bone and pelvic fractures

• Pathogenesis (unknown)

• Mechanical theory

– Venules in bone held open by bony attachments: marrow content material passes through heart into lungs

• Biochemical Theory

– Embolized fat degrades into toxic intermediaries

Fat emboli syndrome• Symptoms

– Classic Triad

• Hypoxemia– (desaturation,

tachypnea)(96%)

• Neurologic abnormalities– (agitation)(59%)

• Petechial Rash (20-50%)

• Red-brown rash in non dependent regions:– Head, neck, anterior thorax,

axillae, subconjuctiva

Imaging• Chest x-ray

– Shows multiple flocculent shadows (snow storm appearance).

Fat embolistarry sky; petechial

Fat emboli

• Diagnosis

– Clinical tests to rule out other causes

• Treatment

– Treat the cause: fix fractures

– Supportive care: fluids and oxygen

Deep vein thrombosis15% of all hospital deaths

• Genetic risk factors:– Factor V Leiden

– Prothrombin gene mutation

• Acquired risk factors:– Advanced age

– Obesity

– History of Previous DVT

– Cancer

• Triggering Factors:– Surgery

– Injury

– Estrogen Therapy/Pregnancy

Virchows Triad: Endothelial cell activation, stasis, hypercoagulability.

Pulmonary Embolism/DVTSigns and Symptoms

• Dyspnea sudden onset

• Tachypnea >20 resp/min

• Tachycardia >100

• Pleuritic chest pain

• Cough/hemoptysis (pulmonary infarction)

• Exam:– Leg swelling

– Dilated superficial veins

– Warmth

– Tendernous along course of veins

DVT• Prevention:

– Start propholaxis as soon as possible

– When hemorrhage is controlled

• When you have a DVT:Activity:– Aissaoui N et al. A meta analysis

of bed rest verus early ambulation in the management of pulmonary embolism, deep vein thrombosis, or both. Int. J Cardiol. 2009; 137:37-41

• Sequential stockings– Theoretically can lead to PE if

DVT present– OR protocol screening– >72 hours

DVT/PE• Emboli clog pulmonary arteries

• Cause ventilation/ perfusion mismatch hypoxia

• If large enough, reduces cardiac output

• Syncope

• Sudden death

• Electromechanical dissociation

DVT screeningtrauma patients

• Despite propholaxis incidence of DVT exists in high risk patients

• Screening controversial

• Current weekly screening protocol is in place at Palomar on high risk patients

DVTtreatment

• Ambulate

• Avoid sequential stockings

• Anticoagluation or GreenFieldFilter

shock

Shock

• Blood volume 5L

• 1 unit of whole blood 450 cc

• 1 unit of PRBC 300 cc

• 1 12oz Coke 355

Secondary survey• Missed injuries happen

• Can be fatal

– Missed femur fractures

– Missed tibia fractures

• DO A HAND OVER HAND EXAM ON EVERY TRAUMA PATIENT.

SHOCK• Understand signs and symptoms

of SHOCK

• Body tries to maintain homeostasis

• Remove blood

• HR increases

• PVR resistance increases to maintain BP

• Renal perfusion decreases less UOP

Shocktreatment

• Add blood

• PRBC’s

• FFP

• Platelets

Nurse Jackie syndrome• Painful condition

• Can be fatal

• Avoid by

– Returning all pens

– Answering calls promptly or else

– She will memorize your cell number

– Call at 2am for Colace

POST TRAUMA/POST OPPROBLEM PREVENTION

• External fixators

• Infection

• Pressure Ulcers

• Contractures

• Swelling

• Fracture Blisters

External fixation• External fixators

– Mostly all temporary spanning external fixators

• Damage Control Orthopaedics

• Preoperative Soft tissue healing ankle. Knee, and some open fractures– Rapid stabilization

– Maintains length and alignment

– Permits patient mobilization

– Allows examination and treatment of skin

• Suspended traction– Strict elevation

– Toes above nose

– Pressure relief

Pressure ulcers• External fixators

– Heavy

– Fix joints in one position leading concentrated prolonged pressure

• Overhead trapeze

– Helps with patient repositioning

• Air beds PRN

External fixationswelling

• Elevation until you an see skin wrinkles

• Ice

• Evidence of efficacy is limited

• Cochrane database

• Compression can help but not advisable in acute trauma

External fixatorpin care

• Insufficient evidence exists to recommend one regimen over another

• Weekly pin site dressing changes are enough

contractures• Lower ext

• Knee flexion contracture – Increase patellofemoral pressure

– Gait disturbance

– 3 months to get extension in distal femur fractures

• Ankle equinus– Forefoot pressure transfer

– Difficulty walking uphill

– Gait disturbance

• Upper extremity

• Fingers• Elbow and shoulder usually stay

immobilized for short term

contractures• Knee

– Position of comfort

– Knee flexed

• Ankle

– Sleep and resting position

– Plantar flexed

Contracture prevention• Pillow under heel

• Equinus stretching with rigid strap

infections• Pre-operative antibiotics

• Open Fractures

– Post-op antibiotics 48-72 hours

• Tetanus

• Early recognition

• Intuition

• Healing wounds

– Dry

• Infected wounds or wounds with hematoma– Drainage

– Redness

– Skin edges won’t adhere

Pain management orthopaedic trauma

• Poor peri-operative pain management negatively effects outcomes– Contributes to PTSD– Lead to chronic pain– Refusal to engage in PT– Delayed return to work

• Narcotics– Bad – Many side effects

• Nerve blocks– Not a good idea in acute trauma

• Multimodal Pain Management Regimens– Ketorlac – 48 hours– Pregabalin/Gabapentin– Tylenol– Ice

Psychologyorthopaedic trauma

• Underappreciated

• PTSD

• Anxiety

• Depression

• Worse Functional Outcomes

PsychologyOrthoPaedic Trauma

• Recognize symptoms early

• Early Interventions

– Meditation

– Support Groups

– Pastoral Care

THANK YOU