provisional stability & damage control in orthopaedic surgery michael t. archdeacon, m.d.,...
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Provisional Stability & Damage Control In
Orthopaedic Surgery
Provisional Stability & Damage Control In
Orthopaedic Surgery
Michael T. Archdeacon, M.D., M.S.E.
Director, Division of Musculoskeletal Trauma
Professor & Vice Chairman Department of Orthopaedic Surgery
University of Cincinnati Medical Center
Assessing Injury
• Resuscitation• Injury Surveys• Emergent
Intervention• Surgical Intervention• Definitive Intervention
Dynamic / Integrated Process
ResuscitationResuscitation
Injury Surveys
Emergent InterventionEmergent
Intervention
Surgical Intervention
Surgical Intervention
DefinitiveInterventionDefinitive
Intervention
Damage Control Orthopaedics
Primary Orthopaedic Survey
Hemodynamic Instability
Obvious Deformity Or Open Wounds
Vascular Compromise To Limb
Neurologic Deficit
Orthopaedic Management –
Survey Of Injury• Secondary SurveyMake A Limb Look Like A LimbRe-assess Neurovascular StatusProvisionally Stabilize Long
Bones & Pelvis• Tertiary Survey
Re-evaluate All Tenderness, Crepitus, Ecchymosis
Radiograph Any Suspected Injury• 11-18% Fractures Missed On Initial Surveys
Initial Treatment• Bring The Limb Out
To Length• Restore Gross
Alignment• Obtain Adequate
ImagesPlain FilmsContralateral SideCT Scans
Orthopaedic Priorities
• Emergent Intervention
• Surgical Intervention
• Definitive Intervention
Provisional Pelvic Stability
Correct IschemiaReduction &
Splinting
Pelvic Ex FixWound Debridement Provisional Stability
ORIF & IM NailsWound Coverage /
Closure
Damage Control
Orthopaedics
Aggressive ResuscitationAggressive
Resuscitation
Rapid Long Bone & Pelvic Temporary Stabilization
Emergent InterventionEmergent
Intervention Staged, Definitive, Reconstructive
Surgical Intervention
Staged, Definitive, Reconstructive
Surgical Intervention
Definitive Care
Windows Of Opportunity Will Occur Which Allow For Definitive Treatment
Repeat Wound Debridements
Conversion Ex Fix To Definitive Fixation
Articular Reconstructions
Wound Closure / Coverage
• Problem Defined• Assessment
Strategy• Treatment
Outlined
What Will Kill You?
Kill You• Pelvic
Fractures• Multiple
Long Bone Fractures
• Spinal Cord Injury
Pelvic Fx
• High Energy to Significantly Fracture Pelvis
• Potentially Life-Threatening Injury• Aggressive Evaluation &
ManagementTeam / Multiple Disciplinary ApproachATLS Protocols
ASSOCIATED INJURIES
• Pelvic Fx’sShock – 25 -
67%Neurologic – 27
- 60%ARDS – 6 - 19%Thoracic – 19 –
43%Urologic – 0 -
16%Mortality – 14 -
37%
Managing the Hemodynamically Unstable Pelvic Fx
• Identify Patient At RiskHypotensionPelvic ExamRadiographic
Evaluation• ATLS
Resuscitation
• Determine Orthopaedic Intervention (If Any)Pelvic
ImmobilizationReduction Of
Hip DxExternal
FixationAngiography
Emergent Pelvic Immobilization
• GoalsDecrease
Pelvic Volume
Provisional Stabilization
Prevent Further Hemorrhage
Pelvic Binder
Pelvic Clamp
Sheet Wrap
Multiple Long Bone Fractures
Multiple Long Bone Fx’s • Aggressive
Resuscitation• Temp Immobilization• Urgent or Emergent
Stabilization• Early Mobility /
Ambulation
NA Goal: Fixation w/in 24 hours
Spinal Cord Injury
Spinal Cord Injury
• Aggressive Resuscitation+/- High-Dose Steroids
• Temp ImmobilizationCranial Tong TxHalo Vest
• Urgent or Emergent Decompression / Stabilization
• Early Mobility / Ambulation
Hurt You Really Bad• Amputations• Dysvascular Limb• Crush Injuries• Compartment
Syndrome
Amputations
Amputations
• Can Be Life ThreateningControl
Hemorrhage• Direct Pressure• Rare – Tourniquet
Or BP CuffReduce Infection
Risk• Sterile Wound
Dressing• Prophylactic ATB• Tetanus Update
Surgical Debridement
Primary Closure of Traumatic Amputation
Dysvascular Limb
Dysvascular Limb
• Limb ThreateningMust Recognize
The Injury• Don’t Forget To
Assess The Hypotensive Pt’s Limbs During / After Resuscitation
Reduction Fx / Dx’s
Involve Vascular Sx• + / - Angiogram
• 6 Hour Warm Ischemia Time
Crush Injury
Crush Injury
• Limb ThreateningMust Eval For
Compartment Syndrome
Debridement Of Devitalized Tissue
Bony Stabilization
Follow For Rhabodomyolysis
Compartment Syndrome
Compartment Syndrome
• A Clinical DiagnosisYour Patient Will
Tell You They Have It• Pain Out Of
Proportion• Pain With Passive
Stretch• Paresthesias• Pallor• Pulselessness
• Measuring PressuresObtunded PatientsConfirms Clinical Suspicion
• Δ PDifference Between Diastolic Pressure
And Tissue Compartment
Emergent Decompression
INAdequate Decompression
17 cm Incisions
Orthopaedic Trauma -Summary
• Team Approach• Few (True) Life
Threatening Orthopaedic Injuries
• ProtocolsPrimary Secondary Tertiary