Case studies in orthopedic injury

Report
CASE STUDIES
IN
ORTHOPEDIC
INJURY
December 5, 2013
JASON SANSONE, MD
Saving Lives By Strengthening Our Region’s Trauma Care System
CASE 1
• History
• 51 y/o female
• Fell from bicycle onto L knee
• Abrasions left arm
• No LOC
• PMH: alcoholism
CASE 1: RADIOGRAPHS
CASE 1: CONSIDERATIONS
• With these radiographs, what complication
needs to at least be considered, and
monitored for?
CASE 1: CONSIDERATIONS
• With these radiographs, what complication
needs to at least be considered, and
monitored for?
• COMPARTMENT SYNDROME
CASE 1: COMPARTMENT SYNDROME
• Most common cause: Tibial shaft fracture
• Other common causes to be aware of:
• Any fracture
• Crush injury without fracture (esp. in patient on
anticoagulation)
• High energy open fractures
• Tight-fitting casts or compressive wraps
• Reperfusion following prolonged ischemia
• Burns (especially circumferential)
• Penetrating trauma (GSW)
CASE 1: COMPARTMENT SYNDROME
CASE 1: COMPARTMENT SYNDROME
CASE 1: COMPARTMENT SYNDROME
• Diagnosis—5 P’s
• Pain with passive flexion/extension and out of proportion
with examination
• Paresthesias
• Paralysis
• Pallor/pulselessness (late)
• Poikilothermia (late)
• Clinical diagnosis, but…
CASE 1: COMPARTMENT SYNDROME
• Can measure compartment pressures
• Known to be unreliable and inconsistent
CASE 1: COMPARTMENT SYNDROME
• Mechanism
• Swelling due to fracture and/or bleeding increases
pressure in non-compliant fascial compartments
CASE 1: COMPARTMENT SYNDROME
• Mechanism
• Swelling due to fracture and/or bleeding increases
pressure in non-compliant fascial compartments
CASE 1: COMPARTMENT SYNDROME
• Mechanism
• As tissue pressure increases, veins become
compressed and venous pressure increases
• This decreases arterial inflow
• FINAL COMMON PATHWAY: ISCHEMIA AND
CELLULAR DEATH
CASE 1: COMPARTMENT SYNDROME
• Heckman, et al., JOT, 1993
• Ischemic threshold of muscle= 8 hours
• Of nerve: 1-2 hours?
• Pressure threshold to induce ischemia:
• Within 30 mm Hg of MAP
• Within 20 mm Hg of diastolic pressure
CASE 1: COMPARTMENT SYNDROME
• Ischemic injury results in…
• Muscle and nerve necrosis
• Contractures and dysfunctional limb
• Foot drop
• Loss of plantar sensation
• Toe/ankle contracture*
*Can also occur in the arm, forearm, hand, gluteals, thigh, foot
CASE 1: COMPARTMENT SYNDROME
CASE 1: COMPARTMENT SYNDROME
• Treatment
• Release circumferential dressings/casts
• Emergent/urgent fasciotomy
• Obtain immediate orthopedic consultation
• If unavailable, transfer emergently
CASE 1: COMPARTMENT SYNDROME
CASE 1: COMPARTMENT SYNDROME
• Hospital Course
• Prolonged stay
• Multiple I&D
• Delayed closure
• Skin grafting
• Recommended length of incision= 16 +/- 4 cm
CASE 1: COMPARTMENT SYNDROME
CASE 1: COMPARTMENT SYNDROME
• Expected Outcomes (if diagnosed correctly)
• Delayed healing (vascular insult)
• Stiffness
• Cosmesis
• Sheridan, et al., JBJS, 1976
• If treated <12 hours: 68% “normal function” at final f/u
• If treated >12 hours: 8% “normal function” at final f/u
• Finkelstein, et al., J Trauma, 1996
• 5 pts., >36 hours from dx: 1 death, 4 amputations
CASE 1
CASE 2
• History
• 38 y/o male
• Fell from roof onto L arm
• No other injuries
• No LOC
• PMH: Negative
• Reports needing to apply belt to arm in the field to stop
bleeding
CASE 2: RADIOGRAPHS
CASE 2: CONSIDERATIONS
• What is the optimal management of an open
fracture?
• Antibiotics/tetanus ppx
• Surgical debridement
• Fracture fixation
• Definitive soft tissue coverage
CASE 2: OPEN FRACTURES
• Gustilo and Anderson Classification
• Grade I: <1 cm, minimal contamination/muscle
damage, minimal periosteal stripping
• Grade II: >1 cm, moderate contamination
• Grade IIIA: >10 cm, severe contamination, fracture
comminution
• Grade IIIB: requires flap coverage
• Grade IIIC: vascular injury
CASE 2: OPEN FRACTURES
• Gustilo and Anderson Classification
• Grade I: <1 cm, minimal contamination/muscle
damage, minimal periosteal stripping
• Grade II: >1 cm, moderate contamination
• Grade IIIA: >10 cm, severe contamination, fracture
comminution
• Grade IIIB: requires flap coverage
• Grade IIIC: vascular injury
CASE 2: GRADE I/II
CASE 2: GRADE IIIB/C
CASE 2: OPEN FRACTURES (ABX)
• Needs coverage of both Gram positive and
Gram negative organisms
• Cefazolin (Gram +)
• Gentamicin (Gram -)
• Tobramycin
• 3rd generation cephalosporin
• Add PCN if…
• Concern for anaerobic infection (farm, vascular injury)
CASE 2: OPEN FRACTURES (I&D)
• “Six hour rule”… Dogma
• 1898 Sir Paul Leopold Friedrich
• Inoculates guinea pigs with mold and stair dust
• Finds that after 6 hours, debridement is unsuccessful at
preventing infection
• 1976 Gustilo and Anderson: “There is universal
agreement that open fractures require emergency
treatment including adequate debridement and
irrigation of the wound”
• No citation
CASE 2: OPEN FRACTURES (I&D)
• Since then, many studies have
demonstrated no difference in infection rate
between patients undergoing I&D at <6
hours versus 6-24 hours
• Primary factors that do relate to infection risk
• Grade of injury (Grade I: 0-2%; Grade III: 10-50%)
• Time to administration of IV abx (<12 hours?)
• Fracture location (tibia)
CASE 2: OPEN FRACTURES (FIXATION)
• Stabilization of fractures
• Enhances host response to bacteria
• Improves soft tissue health
• Limits pain
• Simplifies nursing care
• Allows for serial examination of the injured limb
• Allows for early mobilization of adjacent joints
CASE 2: OPEN FRACTURES (FIXATION)
• Stabilization of fractures
• IM nail
• ORIF
• External fixation
• Ring fixation
CASE 2: OPEN FRACTURES (FIXATION)
CASE 2: OPEN FRACTURES (FIXATION)
CASE 2: OPEN FRACTURES (FIXATION)
CASE 2: OPEN FRACTURES (COVERAGE)
• It is acceptable to close an open fracture
wound immediately
• Some wounds cannot be closed with local
tissue and require either pedicle flaps
(gastrocnemius, soleus) or free flaps
(latissimus, serratus, etc.)
CASE 2: OPEN FRACTURES (COVERAGE)
CASE 2: OPEN FRACTURES (COVERAGE)
• When flap coverage is necessary, VAC
dressings are often placed temporarily
CASE 2: OPEN FRACTURES (COVERAGE)
• BUT… VAC dressings do not extend the time
allowed for definitive wound coverage
• Recommendation: Within 3-7 days
• Godina, Plast Recon Surg, 1986
• <72 hours: flap failure <1%, infection 1.5%
• >72 hours: flap failure 12%, infection 18%
TAKE HOME POINTS
1. Compartment syndrome is a true orthopedic
emergency
2. Requires awareness, vigilant/serial
examination, and timely treatment or
transfer
3. Open fractures need IV abx and tetanus ppx
4. Consider need for surgical intervention
urgent, but not necessarily emergent

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