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Published byClifton White Modified over 9 years ago
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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
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Assessing Injury Resuscitation Injury Surveys Emergent Intervention
Surgical Intervention Definitive Intervention
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Dynamic / Integrated Process
Resuscitation Injury Surveys Damage Control Orthopaedics Emergent Intervention Definitive Intervention Surgical Intervention
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Primary Orthopaedic Survey
Hemodynamic Instability Obvious Deformity Or Open Wounds Vascular Compromise To Limb Neurologic Deficit
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Orthopaedic Management – Survey Of Injury
Secondary Survey Make A Limb Look Like A Limb Re-assess Neurovascular Status Provisionally Stabilize Long Bones & Pelvis Tertiary Survey Re-evaluate All Tenderness, Crepitus, Ecchymosis Radiograph Any Suspected Injury 11-18% Fractures Missed On Initial Surveys
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Initial Treatment Bring The Limb Out To Length Restore Gross Alignment
Obtain Adequate Images Plain Films Contralateral Side CT Scans
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Orthopaedic Priorities
Provisional Pelvic Stability Correct Ischemia Reduction & Splinting Emergent Intervention Surgical Intervention Definitive Intervention Pelvic Ex Fix Wound Debridement Provisional Stability ORIF & IM Nails Wound Coverage / Closure
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Damage Control Orthopaedics
Rapid Long Bone & Pelvic Temporary Stabilization Aggressive Resuscitation Emergent Intervention Staged, Definitive, Reconstructive Surgical Intervention
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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
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What Will Kill You? Problem Defined Assessment Strategy
Treatment Outlined What Will Kill You?
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Kill You Pelvic Fractures Multiple Long Bone Fractures
Spinal Cord Injury
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Pelvic Fx High Energy to Significantly Fracture Pelvis
Potentially Life-Threatening Injury Aggressive Evaluation & Management Team / Multiple Disciplinary Approach ATLS Protocols
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ASSOCIATED INJURIES Pelvic Fx’s Shock – 25 - 67% Neurologic – 27 - 60%
ARDS – % Thoracic – 19 – 43% Urologic – % Mortality – %
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Managing the Hemodynamically Unstable Pelvic Fx
Identify Patient At Risk Hypotension Pelvic Exam Radiographic Evaluation ATLS Resuscitation Determine Orthopaedic Intervention (If Any) Pelvic Immobilization Reduction Of Hip Dx External Fixation Angiography
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Emergent Pelvic Immobilization
Goals Decrease Pelvic Volume Provisional Stabilization Prevent Further Hemorrhage
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Pelvic Binder
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Pelvic Clamp
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Sheet Wrap
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Multiple Long Bone Fractures
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Multiple Long Bone Fx’s
Aggressive Resuscitation Temp Immobilization Urgent or Emergent Stabilization Early Mobility / Ambulation NA Goal: Fixation w/in 24 hours
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Spinal Cord Injury
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Spinal Cord Injury Aggressive Resuscitation Temp Immobilization
+/- High-Dose Steroids Temp Immobilization Cranial Tong Tx Halo Vest Urgent or Emergent Decompression / Stabilization Early Mobility / Ambulation
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Hurt You Really Bad Amputations Dysvascular Limb Crush Injuries
Compartment Syndrome
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Amputations
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Amputations Primary Closure of Traumatic Amputation
Can Be Life Threatening Control Hemorrhage Direct Pressure Rare – Tourniquet Or BP Cuff Reduce Infection Risk Sterile Wound Dressing Prophylactic ATB Tetanus Update Surgical Debridement Primary Closure of Traumatic Amputation
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Dysvascular Limb
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Dysvascular Limb Limb Threatening 6 Hour Warm Ischemia Time
Must 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
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Crush Injury
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Crush Injury Limb Threatening Must Eval For Compartment Syndrome
Debridement Of Devitalized Tissue Bony Stabilization Follow For Rhabodomyolysis
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Compartment Syndrome
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Compartment Syndrome Emergent Decompression A Clinical Diagnosis
Your Patient Will Tell You They Have It Pain Out Of Proportion Pain With Passive Stretch Paresthesias Pallor Pulselessness Measuring Pressures Obtunded Patients Confirms Clinical Suspicion Δ P Difference Between Diastolic Pressure And Tissue Compartment
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INAdequate Decompression
17 cm Incisions
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Orthopaedic Trauma -Summary
Team Approach Few (True) Life Threatening Orthopaedic Injuries Protocols Primary Secondary Tertiary
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