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BOOM!!!!
Orthopaedic Trauma
Douglas W. Lundy, MD, MBA, FACS31 July 2014
Orthopaedic Trauma SurgeryResurgens Orthopaedics
Atlanta, Georgia
Conflict
Consultant for
Synthes
Orthopaedics.
Board of Directors of
the OTA, GOS, ABOS
and Resurgens
Orthopaedics.
AAOSCommunications
Cabinet Liaison to the
Council on Advocacy.
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Outcomes
Comparative study
concerning outcomesafter major fracture.
Surgeons more
satisfied with
outcomes than the
patients were. Harris IA, Dao AT, Young JM,
Solomon MJ, Jalaludin BB:Predictors of patient and surgeon
satisfaction after orthopaedic
trauma. Injury40:377-384, 2009.
SF-36
Multi-purpose, short
health survey.
36 questions.
Made available in
standard form in1990.
Cited in 4000
publications.
Scales:
Physical Functioning
Role-Physical
Bodily Pain
General Health
Vitality
Social Functioning
Role-Emotional Mental Health
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Trauma patients with fractures
SF-36 scores: Bodily pain, Physical function,
Role-physical, Mental health,Role-emotional, Social function(p < 0.05).
Patients withorthopaedic injuries haverelatively worsefunctional recovery thantrauma patients without
orthopaedic injuries, andthis worsens with time. Michaels AJ, Madey SM, Krieg JC, Long WB:
Traditional injury scoring underestimates therelative consequences of orthopedic injury. JTrauma. 2001 Mar;50(3):389-395.
Psychological effects
Psychological distress isstrongly associated withpatient outcome--includingfunctional outcome--following trauma.
Psychological distress aftertrauma, with its large impacton trauma outcomes,
remains a substantialproblem that is usuallyignored and untreated. Starr AJ: Fracture repair: successful advances, persistent
problems, and the psychological burden of t rauma. J BoneJoint Surg Am. 2008 Feb;90 Suppl 1:132-7
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The Big Bad Five
Tibial plafond
Talar neck
Calcaneus
Unstable pelvis
Femoral neck
in young people
High mechanism injuries Falls
MVC
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Tibial Plafond Fractures
Plafond = roof.
Difficult surgery.
Prolonged recovery.
Nonunion and pain is
common.
Takes up to two years
to see what the
outcome will be.
Tibial plafond outcomes Tibial plafond
fractures are difficultto manage and mayhave seriouscomplications.
Loss of function andprogression to post-traumatic arthritis are
common after tibialplafond fractures. Harris AM, Patterson BM, Sontich JK, Vallier
HA: Results and outcomes after operativetreatment of high-energy tibial plafondfractures. Foot Ankle Int. 2006 Apr;27(4):256-265.
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Talar neck fractures
Difficult surgery.
Prolongedhealing.
Nonunion andavascularnecrosis is ahuge problem.
May need
pantalar fusion inthe future.
Talar fracture outcome
Osteonecrosis 49%: Collapse of the dome in 31%.
54% had posttraumatic arthritis comminuted fractures (p < 0.07)
open fractures (p = 0.09).
Fractures of the talar neck are associated withhigh rates of morbidity and complications.
Vallier HA, Nork SE, Barei DP, Benirschke SK, Sangeorzan BJ: Talar neck fractures:results and outcomes. J Bone Joint Surg Am. 2004 Aug;86-A(8):1616-1624.
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Calcaneal fractures
People
who fall:
Roofers
Dry
wallers
Framers
Painters
Calcaneal fractures
Most painful fracture
that there is!
Pain and difficulty
walking on uneven
ground.
Wound issues after
surgery.
May need a subtalar
fusion.
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Cost of injury Calcaneal fractures
have beenrecognized as havingrelatively poor clinicaloutcomes and amajor socioeconomicimpact with regard totime lost from work
and recreation. Brauer CA, Manns BJ, Ko M, Donaldson C,Buckley R: An economic evaluation ofoperative compared with nonoperativemanagement of displaced intra-articularcalcaneal fractures. J Bone Joint Surg Am.2005 Dec;87(12):2741-2749.
Wound Complications Smoking, diabetes,
and open fracturesall increase the riskof woundcomplication aftersurgicalstabilization ofcalcaneus
fractures. Folk JW, Starr AJ, Early JS: Earlywound complications of operativetreatment of calcaneus fractures:analysis of 190 fractures. J OrthopTrauma.1999 Jun-Jul;13(5):369-372.
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Fracture Blisters All blisters were unroofed, and
antibiotic cream (Silvadene)
was applied twice daily until theblister bed had re-epithelialized.
We urge caution when
planning to make a surgical
incision around fractureblisters in diabetic patients
because the zone of injury
might extend beyond theborders of the fracture blister. Strauss EJ, Petrucelli G, Bong M, Koval KJ, Egol
JA: Blisters associated with lower-extremity
fracture: results of a prospective treatmentprotocol. J Orthop Trauma. 2006 Oct;20(9):
618-622.
Open Tibial Fractures
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Definitions
Fracture: a soft tissueinjuryoverlying abroken bone.
Soft tissue trauma is the more important
injury. Norris BL and Kellam JF: Soft-tissue injuries associated with
high-energy extremity trauma: Principles of management. J.Am. Acad. Orthop. Surg.5:37-46, 1997.
Open fracture: any fracture associated
with a laceration or puncture wound on thesame limb segment.
Gustilo and Anderson ClassificationType Description Infection Antibiotics
I Clean, 1 cm, minimal
soft tissue injury
2% to 7% Ancef and
Gentamycin
III Extensive injury,
segmental fx,
GSW, farm injury,
etc.
10% to 25% Above + PCN
Gustilo RB, Anderson JT: Prevention of infection in the treatment of one thousand and twenty-five open fractures oflong bones: retrospective and prospective analyses. J. Bone Joint Surg.58-A:453-458, 1976.
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Gustilo Classification
Gustilo RB, Mendoza RM, Williams DN: Problems in the management of type III (severe) open
fractures: a new classification of type III open fractures. J. Trauma24:742-746, 1984.
Type I
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Definitely IIIC
Type II or IIIA?
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Type II or IIIA?
Antibiotics
A prospective double-blind randomized clinicaltrial comparing ciprofloxacin and cefamandole/gentamicin. No difference in Type I or II open fracture wounds. High failure rate for the ciprofloxacin Type III open
fracture group, with patients being 5.33 times morelikely to become infected than those in thecombination therapy group.
Single-agent antibiotic therapy with ciprofloxacinis effective in treatment of Type I and Type II
open fracture wounds. Patzakis MJ, Bains RS, Lee J, Shepherd L, Singer G, Ressler R, Harvey F, Holtom P.: Prospective,randomized, double-blind study comparing single-agent antibiotic therapy, ciprofloxacin, to combinationantibiotic therapy in open fracture wounds. J Orthop Trauma. 2000 Nov;14(8):529-533.
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LEAP!
LEAP Study 527 patients in this multi-centered study.
Bone loss was least significant variabledetermining limb salvage.
Soft tissue injury severity has the greatestimpact on decision making regarding limbsalvage versus amputation. MacKenzie EJ, Bosse MJ, Kellam JF, Burgess AR, Webb LX, Swiontkowski MF,
Sanders R, Jones AL, McAndrew MP, Patterson B, McCarthy ML, Rohde CA,LEAP Study Group: Factors influencing the decision to amputate or reconstruct
after high-energy lower extremity trauma. J Trauma. 2002 Apr;52(4):641-649.
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LEAP at seven years
397 - amputation orreconstruction.
Physical andpsychosocialfunctioningdeteriorated between24 to 84 months afterthe injury. MacKenzie EJ, Bosse MJ, Pollak AN, Webb
LX, Swiontkowski MF, Kellam JF, Smith DG,Sanders RW, Jones AL, Starr AJ, McAndrewMP, Patterson BM, Burgess AR, Castillo RC:Long-term persistence of disability following
severe lower-limb trauma. Results of a seven-year follow-up. J Bone Joint Surg Am. 2005Aug;87(8):1801-1809.
Poor outcome:
older age
female gender
lower education level
living in a poor household
current or previoussmoking
low self-efficacy
poor self-reported healthstatus before the injury
involvement with the legalsystem in an effort toobtain disability payments.
LEAP at seven years reconstruction for the
treatment of injuries belowthe distal part of the femurtypically results in functionaloutcomes equivalent tothose of amputation.
Regardless of the treatmentoption, however, long-term
functional outcomes arepoor. MacKenzie EJ, Bosse MJ, Pollak AN, Webb LX, Swiontkowski MF,
Kellam JF, Smith DG, Sanders RW, Jones AL, Starr AJ, McAndrewMP, Patterson BM, Burgess AR, Castillo RC: Long-term persistenceof disability following severe lower-limb trauma. Results of a seven-year follow-up. J Bone Joint Surg Am. 2005 Aug;87(8):1801-1809.
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Poor outcomes in severe trauma
LEAP showed that at twoyears, most patients had pooroutcomes, with only half of thepatients returning to work.
By seven years, half of thepatients continued to reportappreciable disability.
more than half of thepatients who were managed
with the current standard ofcare had treatment failure.
Starr AJ: Fracture repair: successful advances, persistent problems, and thepsychological burden of trauma. J Bone Joint Surg Am. 2008 Feb;90 Suppl1:132-7
The joys of call
Hey doc, sorry to call
you at 2:30 AM. I
have a really bad
open xxx fracture
here in the ER
xxx =
Tibial
Femoral
Pelvic
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So what is acceptable?
Is it standard of
care to operate
this fracture at
2:30 AM or
should (can) I
wait until
morning?
Timing of debridement
LEAP found that time
from injury to surgicaldebridement was not
contributory factor ofinfection.
Timing from injury to
the definitive
treatment center wasindicative of infection.
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Timing of debridement
Findings should not
be interpreted as anargument that
operativedebridement of open
fractures should not
be accomplishedurgently. Pollak AN, Jones AL, Castillo RC, Bosse MJ,
MacKenzie RJ, LEAP study group: Therelationship between time and surgical
debridement and incidence of infection afteropen high-energy lower extremity trauma. J
Bone Joint Surg92-A:7-15, 2010.
Ex-fix vs. nail? External fixator had
more surgicalprocedures, took longerto achieve full weight-bearing status, and hadmore readmissions thandid those treated with anintramedullary nail. Webb LX, Bosse MJ, Castillo RC,
MacKenzie EJ, LEAP Study Group: Analysisof surgeon-controlled variables in thetreatment of limb-threatening type-III opentibial diaphyseal fractures. J Bone Joint Surg
Am. 2007 May;89(5):923-928.
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Smoking
Patients with unilateralopen tibia fractures weredivided into 3 baselinesmoking categories:never smoked, previoussmoker and currentsmoker.
Smokers 37% less likelyto heal.
Previous smokers were32% less likely to heal. Castillo RC, Bosse MJ, MacKenzie EJ,
Patterson BM, LEAP Study Group: Impact ofsmoking on fracture healing and risk ofcomplications in limb-threatening open tibiafractures. J Orthop Trauma. 2005 Mar;19(3):151-157.
Smoking Current smokers twice as
likely to develop an infection(P = 0.05) and 3.7 times aslikely to developosteomyelitis (P = 0.01).
Smoking places the patientat risk for increased time tounion and complications.Previous smoking historyalso appears to increase therisk of osteomyelitis andincreased time to union. Castillo RC, Bosse MJ, MacKenzie EJ,
Patterson BM, LEAP Study Group: Impact ofsmoking on fracture healing and risk ofcomplications in limb-threatening open tibiafractures. J Orthop Trauma. 2005 Mar;19(3):151-157.
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Return to work
37 type III high-energy open
tibial shaft fractures.
(76%) returned to work.
64% returned to work at asimilar level of manual labor.
Average delay between injuryand return to work was 11
months (range, 3-18 months).
89% reported one or more
subjective complaints. Arangio GA, Lehr S, Reed JF 3rd: Reemployment of patients with
surgical salvage of open, high-energy tibial fractures: an outcomestudy. J Trauma. 1997 May;42(5):942-945.
There are no emergencies in
orthopaedic trauma
Femoral neck fractures
Talar neck fractures
Open fractures
Open book pelvic
fractures
Unreduced dislocations
Compartmentsyndrome
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Rule #1 - Timing is everything
Compartment syndrome (CS) isan emergency/
urgency to save limb and possibly life.
#2 - Compartment syndrome is rare
Incidence is
3.1/100,000 persons
Incidence for men: 7.3
per 100,000.
Incidence for women:0.7 per 100,000.
McQueen MM, Gaston P, Court-BrownCM: Acute compartment syndrome:
Who is at risk?. J Bone Joint Surg 82-B, 200-203, 2000.
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Incidence
1.5% McQueen MM, Christie J, Court-Brown CM.: Compartment pressures after intramedullary
nailing of the tibia. J Bone Joint Surg Br. 1990 May;72(3):395-397.
7% Kutty S, Farooq M, Murphy D, Kelliher C, Condon F, McElwain JP.: Tibial shaft fractures
treated with the AO unreamed tibial nail. Ir J Med Sci.2003 Jul-Sep;172(3):141-142.
14.5% Barei DP, Nork SE, Mills WJ, Henley MB, Benirschke SK.: Complications associated with
internal fixation of high-energy bicondylar tibial plateau fractures utilizing a two-incisiontechnique. J Orthop Trauma. 2004 Nov-Dec;18(10):649-657.
29% Ovre S, Hvaal K, Holm I, Stromsoe K, Nordsletten L, Skjeldal S.: Compartment pressure innailed tibial fractures. A threshold of 30 mmHg for decompression gives 29% fasciotomies.Arch Orthop Trauma Surg. 1998;118(1-2):29-31.
Causes
Increase the contents
of the compartment.
Decrease the fascial
volume of the
compartment.
Metabolic insults that
disrupt the
microvasculature.
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#3 - Young people get CS more often
Is a patient younger
than 35 with a tibialfracture more likely to
have a CS than apatient over 35 years
of age?
3 times!
#4 - He cant have a CS he can
still move his toes!
The six dreaded Ps:
Paralysis
Pallor
Pulselessness
Pressure
Paresthesia
Pain out of proportion
What exactly is painout of proportion?
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Pain out of proportion
Pain is highly
subjective.
To know what pain is
proportional, one would
have to know how
much pain a certain
injury produces.
As a CS progresses,
pain may actually
decrease masking theCS.
#5 Pressure measurements are
the best way to diagnose CS
Whitesides method.
STIC monitors.
Arterial pressure
monitor.
Accurately measures
pressure in thecompartment.
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Continuous monitoring
One group with continuous monitoringcompared with control clinical group.
In monitored group, 18% had !p< 30 mm Hg,but none developed compartment syndrome.
Overall compartment syndrome incidence was2.5%.
Continuous monitoring is not indicated in alert
patients. Harris IA, Kadir A, Donald G: Continuous compartment pressure monitoring for tibiafractures: Does it influence outcome? J. Trauma60:1330-1335, 2006.
Traumatic measurements
84% had at least one measurement within 30mm !p, and 58% had at least onemeasurement within 20 mm !p.
None of the patients ever manifested acompartment syndrome.
Quantitative measurements may not accuratelydiagnose compartment syndrome.
Prayson MJ, Chen JL, Hampers D, Vogt M, Fenwick J, Meredick R: Baseline compartmentpressure measurements in isolated lower extremity fractures without clinical compartmentsyndrome. J. Trauma60:1037-1040, 2006.
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Pressure measurements are the best way to
diagnose CS
Clinical exam is key!
Clinical assessment
is still the diagnostic
cornerstone of ACS
(acute compartment
syndrome). Shadgan B, et al: Diagnostic
techniques in acute compartment
syndrome of leg J Orthop Trauma
22:581-587, 2008.
Meta-analysis The positive predictivevalue of the clinicalfindings was 11% to 15%,and the specificity andnegative predictive valuewere each 97% to 98%.
The clinical features ofcompartment syndromeare more useful by theirabsence in excluding the
diagnosisthan they arewhen present in confirmingthe diagnosis. Ulmer T.: The clinical diagnosis of
compartment syndrome of the lower leg:are clinical findings predictive of thedisorder? J Orthop Trauma. 2002 Sep;
16(8):572-577.
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What about the asensate or
head injured patients?
Close monitoring of
clinical exam:
Firmness
High clinical suspicion
Pulses
Release the
compartments if in
doubt.
#6 - To calculate !p, use the intra-
operative DBP
Mean DBP in surgery
was 18mm Hg less
than pre-operative
DBP.
Intra-operative DBP
may be spuriously low
when for deciding to
do a fasciotomy. Kakar S, Firoozabadi R, McKean J,
Tornetta P: Diastolic blood pressure inpatients with tibia fractures under
anaesthesia: implications for the
diagnosis of compartment syndrome. J.
Orthop. Trauma21: 99-103, 2007.
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#7 - Open fractures cant have
compartment syndrome
The tears in the fascia release the compartment
pressure
CS in open fractures
The incidence of
compartment syndrome
was found to be directly
proportional to the degree
of injury to soft tissue and
bone; this complication
occurred most often in
association with a
comminuted, type-IIIopen injury to a
pedestrian. Blick SS, Brumback RJ, Poka A, Burgess
AR, Ebraheim NA.: Compartment
syndrome in open tibial fractures. J Bone
Joint Surg Am. 1986 Dec;68(9):1348-1353.
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#8 - I can tell by the firmness
Well orthopaedic
residents cant!
Positive predictive
value was 70%
Negative predictive
value was 63%. Shuler FD, Dietz MJ: Physicians'
ability to manually detect isolated
elevations in leg intracompartmental
pressure J Bone Joint Surg 92-A;
361-367, 2010.
One incision or two?
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Single incision fasciotomy
Centered over fibula.
Superficial dissection can access anterior, lateral
and superficial posterior compartments.
Dissect posterior to fibula and release deep
compartment.
Post-fasciotomy care
NPWT for several days to a week.
Often dictated by fracture care.
Often require STSG.
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#9 - I missed it Im in trouble!
Liability Increasing time from theonset of symptoms to the
fasciotomy was associatedwith an increased
indemnity payment (p