Case studies in orthopedic injury

Saving Lives By Strengthening Our Region’s Trauma Care System

December 5, 2013 JASON SANSONE, MD

CASE STUDIES IN

ORTHOPEDIC INJURY

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?


• 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)




• 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…


• Can measure compartment pressures• Known to be unreliable and inconsistent


• Mechanism• Swelling due to fracture and/or bleeding increases

pressure in non-compliant fascial compartments


• Mechanism• Swelling due to fracture and/or bleeding increases

pressure in non-compliant fascial compartments


• Mechanism• As tissue pressure increases, veins become

compressed and venous pressure increases• This decreases arterial inflow • FINAL COMMON PATHWAY: ISCHEMIA AND

CELLULAR DEATH


• 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


• 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



• Treatment•Release circumferential dressings/casts• Emergent/urgent fasciotomy

• Obtain immediate orthopedic consultation• If unavailable, transfer emergently



• Hospital Course• Prolonged stay•Multiple I&D•Delayed closure• Skin grafting

• Recommended length of incision= 16 +/- 4 cm



• 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


• 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


• Stabilization of fractures• IM nail•ORIF• External fixation•Ring 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.)



• When flap coverage is necessary, VAC dressings are often placed temporarily


• 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 ppx4. Consider need for surgical intervention

urgent, but not necessarily emergent

Documents

Case studies in orthopedic injury