1. Pathophysiology of Trauma: Influence on surgical timing and implant selection Piotr Blachut MD FRCSC University of British Columbia Vancouver, Canada

2. 23 yr old male skiing accident 4 hours ago isolated, closed injury neurovascular normal

3. 19 yr old male head on MVA Head injury –GCS 6 Multiple fractures

4. Investigations –CXR - normal –C spine - normal –Pelvis - normal –CT head cerebral edema hemispheric hemo. foci SA blood L tripod # –CT abdo normal

6. 54 yr old male fall from 25 ft. no LOC chest pain / SOB pelvic / R ankle / L thigh pain hypotensive cold

8.  WhatWhat do we need to fix? WhenWhen should we fix it? HowHow should we fix it?

9. Priorities Life threatening Limb threatening Function threatening

10. Priorities Life threatening Limb threatening Function threatening - pelvic hemorrhage

11. Priorities Life threatening Limb threatening Function threatening - pelvic hemorrhage -vascular injury - compartment syndrome - open fracture - irreducible dislocation

12. Priorities Life threatening Limb threatening Function threatening - pelvic hemorrhage -vascular injury - compartment syndrome - open fracture - irreducible dislocation - articular fracture - distal extremity frac.

13. Priorities Life threatening Limb threatening Function threatening - pelvic hemorrhage -vascular injury - compartment syndrome - open fracture - irreducible dislocation - articular fracture - distal extremity frac. Long bone fracture ?

14. Thomas splint War experiences Splintage Early evacuation Early definitive treatment

15. 1960’s & 1970’s System of operative fracture stabilization first applied to isolated injuries later application to polytrauma Improvement in anesthesia / critical care management

16. Eric Riska, Finland 1977 47 pts. multiple trauma all long bone fractures fixed with stable fixation 1 death (80 y.o.)

17. Vivoda, Meek, 1978 71 pts., all multiple trauma, all ICU two groups no difference in AGE or ISS Mortality CONSERVATIVE 14/49 (28.5%) OPERATIVE …… 1/22 (4.5%) ( 5:1 ratio)

18. 1980’s Early Total Care (ETC) fracture stabilization (especially long bone fracture within 24 hrs) –Riska 1982  FES –Goris 1982 stabilization -  ventilation –Johnson 19851/5 rate of ARDS –Border1/5 rate “pulm. septic state”

19. 1980’s Cause of complications with delayed stabilization fat embolism syndrome supine position -> atelectasis -> sepsis  narcotic use inflammatory mediator release from hematoma / soft tissue injury Seibel, Ann Surg 1985

20. 1980’s Early Total Care (ETC) –Bone et al., Dallas 1989 Prospective randomized studyProspective randomized study Early vs. late femoral nailing  pulmonary complications  ICU length of stay  hospital costs

21. 1980’s reamed IM nailing the standard of care for femoral shaft fractures known marrow embolization

22.  1990’s Three types of patients: Isolated injuries Multiple fractures Multiple system Does ETC apply to all ?

23.  1990’s Three types of patients: Isolated injuries Multiple fractures Multiple system Does ETC apply to all ? Three types of patients: Isolated injuries Multiple fractures Multiple system Does ETC apply to all ?

24.  1990’s In severely injured patient –significant chest injury –significant head injury Is there a detrimental effect of added major surgery –  stress –  blood loss –fluid shifts

25.  1990’s HowHow show we fix it?

26.  1990’s CHEST INJURYCHEST INJURY

27. Pape, Hannover,1993 pts with pulmonary contusion and early reamed femoral nail increase in ARDS and death ? unreamed femoral nail / delayed nail ? femur group sicker

28. Charash, 1994 replicated Pape study without chest trauma pulmonary complications lower in early fixation group (10% VS 38%) with severe chest trauma pulmonary complications lower in early fixation group ( 16% VS 56%)

29. Bosse et al, 1997 institution randomized series early plating vs. early IM nailing 453 patients no  ARDS, PE, MOF, pneumonia or death compared to plating or chest injury alone

30. Dunham et al., 2001 Practice Management Guidelines for the Optimal Timing of Long-Bone Fracture Stabilization in Polytrauma Patients: The EAST Practice Management Guidelines Work Group There is no compelling evidence that early long- bone stabilization in patients with chest injury either enhances or worsens outcome.

31.  1990’s HEAD INJURYHEAD INJURY

32. Head injury Secondary brain injury in severe head injury if exposed to: – hypotension –hypoxemia –increased ICP (intercranial pressure) –reduced CPP (cerebral perfusion pressure)

33. Head injury Early Fracture Fixation May Be Deleterious After Head Injury Jaicks RR, Cohn SM, Moller BA, J Trauma 42(1):1-6, 1997 EarlyDelayed 19 14  fluid requirement  neuro complic.  hypoxia intra op  ICU stay  hypotension  hospital stay  GCS on discharge

34. Head injury EARLY FIXATION Hofman 1991 Poole 1992 McKee 1997 Starr 1998 Smith 2000 Brundage 2002 DELAYED FIXATION Jaicks 1997 Townsend 1998 All retrospective studies !!!

35. Head injury EARLY FIXATION  length of stay  mortality  pulm. complic DELAYED FIXATION  fluid requirement  hypoxia All retrospective studies !!! neuro outcome ?

36. Dunham, 2001 Practice Management Guidelines for the Optimal Timing of Long-Bone Fracture Stabilization in Polytrauma Patients: The EAST Practice Management Guidelines Work Group There is no compelling evidence that early long-bone stabilization in mild, moderate, or severe brain injured patients either enhances or worsens outcome.

37. Evolving concepts of pathophysiology course after severe blunt trauma dependant on: –initial injury ( “first hit” ) –individual biologic response –type of treatment ( “second hit” )

39. Biological response Therapy: 2 nd HIT Stable Borderline Unstable In extremis Clinical outcome: ARDS, MOF, SIRS ETC Intermediate Damage control Prehospital ER ICU Kellam 2003 1 st HIT

40.  Second hit from the management of skeletal injuries is under the control of the surgeon Determine the patients ability to withstand a second hit from trauma surgery How to minimize the second hit 2 nd HIT

41. “Borderline Patient” Polytrauma +ISS>20 + thoracic trauma (AIS>2) Polytrauma + abdominal/pelvic trauma and hemodynamic shock (initial BP< 90 mmHg) ISS >40 Bilateral lung contusions on x-ray Initial mean pulmonary arterial pressure >24mmHg Pulmonary artery pressure increase during IM nailing > 6mmHG

42. Factors associated with BAD outcome Unstable difficult resuscitation Coagulopathy (platelets<90,000) Hypothermia (<32°C) Shock + 25 units blood Head Injury: GCS < 8, bleeding, edema

43. 1990’s & 2000’s Damage control surgery Damage control orthopaedic surgery (DCO)

44. Damage control orthopaedic surgery ≠ Non- operative treatment

45. Priorities Life threatening Limb threatening Function threatening - pelvic hemorrhage -vascular injury - compartment syndrome - open fracture - irreducible dislocation - articular fracture - distal extremity frac.

46. Damage control orthopaedic surgeryAvoid: excessive fluid shifts hypothermia coagulopathy pulmonary compromise Provide stability: pain control  inflammatory mediator release  fat embolism  mobilization

47. rapid external fixation delayed definitive fixation Damage control orthopaedic surgery

48. Timing of secondary surgery 2-4 days  multiple organ failure  inflammatory markers  multiple organ failure  inflammatory markers 6-8 days Pape et al, 2001

49. Damage control orthopaedic surgery  risk of local complications –infection –poorer joint reconstruction not borne out in clinical experience (so far) –Scalea, 2000 –Nowotarski 2000

50. ETC versus DCO Pape et al., J Trauma, 2002 prospective randomized multicentre series 17 versus 18 patients early IM nailing -> sustained inflammatory response ( IL-6) no clinical difference (complication rate / LOS)

51. What to do in 2010? Clinical status? stable borderline unstable resuscitate reevaluate ETC ?DCO stabilized uncertain

52. 23 yr old male skiing accident 4 hours ago isolated, closed injury neurovascular normal

54. 19 yr old MVA

55. Anesthestic management critical !!!!! Consider DCO !!!

56. 54 yr old male

57. 

58. Thank You !!