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Floating knee with vascular compromise - management

Floating knee with vascular compromise - management. AOK team. Glan Clwyd Hospital * Dept of Orthopaedics. Review. Scope of the problem Classification Anatomy Emergency department Orthopod Management options ? Treatment algorithm. Scope. Severe soft tissue involvement

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Floating knee with vascular compromise - management

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  1. Floating knee with vascular compromise - management AOK team Glan Clwyd Hospital * Dept of Orthopaedics

  2. Review • Scope of the problem • Classification • Anatomy • Emergency department • Orthopod • Management options ? • Treatment algorithm

  3. Scope.... • Severe soft tissue involvement • Other serious injuries • Trauma =97 % ,gunshot, fall from height • Male 20-30 years

  4. Scope.... • Head 42% Chest 28% Abdo 16% • Open #s 50%,Vascular injuries 30 % Nerve injuries 10% • Knee ligament injuries 30% • Children uncommon

  5. Classification Floating knee – Blake and Mc Bryde 1975

  6. Anatomy • Popliteal artery at risk for being tethered • Adductor hiatus • Soleus arch • If blood flow through popliteal artery disrupted Inadequate blood supply distally

  7. Pre hospital On site resus - paramedics Fluids Tourniquet Helicopter ?

  8. Deal with-potential problems!! Open fracture Irreducible dislocations 70 kg 5 lit Vascular injury Femur # ~ 2lit/Tibia # ~ 1lit Amputation 3/5x100% = 60% Compartment syndrome Unstable pelvic fracture/ hemodynamic instability Multiply-injured patient Spinal cord injury Displaced femoral neck < 65 and talar neck fractures ABC approach of ATLS Guides!!

  9. ED and Orthopods Temp 26 * Ph 6.4, she has a condition I have not seen before ‘’Asystole’’ • ATLS • BOA BAPRAS Guidance for open fractures • Look up transfer protocol to tertiary institution Resuscitate/Tourniquet Assess/Order investigations Photograph Splint Call for help

  10. Think !! Who goes first?-Discuss with vascular surgeon Temporary shunts-Will benefit some patients Fracture stabilization-Consider provisional ex fix Salvage vs amputation-Trend toward salvage (LEAP) Fasciotomies-Prophylactic after Ischemia

  11. Why ? Vascular injury clock stats clicking • Progressive ischemia • Compartment syndrome • Tissue necrosis • Blood loss Irreversible damage after 6 hours When to intervene ? NOW !!

  12. Assuming - Floating knee + vascular injuryOptions • Vascular • Bone

  13. Physical exam Major hemorrhage/hypotension Arterial bleeding Expanding hematoma Altered distal pulses Pallor Temperature differential between extremities Injury to anatomically-related nerve

  14. Diagnosis Physical exam Doppler pressure (ABI) Duplex scanning Arteriogram Exploration Careful physical exam and high index of suspicion are most important !

  15. Consequences of vascular injury Blood loss Ischemia Compartment syndrome Tissue necrosis Amputation Death

  16. Prognostic factors Level and type of vascular injury Collateral circulation Shock/hypotension Tissue damage (crush injury) Warm ischemia time Patient factors/medical conditions

  17. Speed is crucial Rapid resuscitation Complete, rapid evaluation Urgent surgical treatment PROTOCOL IS ESSENTIAL !

  18. Options-Vascular injuryThe new “paradigm” <C> A B C Direct pressure Hemostatic packs Tourniquets Positioning Pressure points “No patient should die from ext hemorrhage !”

  19. Immediate treatment Control bleeding Replace volume loss Cover wounds Reduce fractures & dislocations Splint Re-evaluate

  20. Gauze –cellulose • Chitosan P-NAG • Hemcon- cream side down ! • Zeolite • Polysaccharides • Fibrin • No ideal hemostatic pack developed yet

  21. Options-VascularTourniquets – C A Ts

  22. Asymmetric pulses warrant doppler examination (determine ABI) Absent pulses warrant emergent vascular consultation/surgical exploration

  23. Doppler Ultrasound Determine presence/absence of arterial supply Assess adequacy of flow PRESENCE OF SIGNAL DOES NOT EXCLUDE ARTERIAL INJURY !

  24. Duplex Scanning Noninvasive Safe Rapid Reliable for Injury to arteries and veins A-V fistulas Pseudo aneurysms

  25. Angiography Locates site of injury Characterizes injury Defines status of vessels proximal and distal May afford therapeutic intervention

  26. CT Angiography Alternative Good sensitivity and specificity Costs much more ANGIOGRAPHY WILL DELAY REVASCULARISATION It is not indicated in cases with absent pulses/complete transection, which should go immediately to surgery Redmond, et al. Orthopedics 2008

  27. Operative angiography Single view in operating room Rapid Excellent for detecting site of injury

  28. Surgical exploration Immediate exploration is indicated for: Obvious arterial injury on exam No doppler signal Site of injury is apparent Prolonged warm ischemia time

  29. Continued evaluation Vascular injuries are dynamic Evaluation should continue after the initial injury or surgery Additional debridement and/or fixation undertaken after successful revascularization

  30. Continued evaluation Circulation Neurologic function Compartment pressures

  31. Fracture fixation External fixation with vascular repair Nailing ? 2nd sitting in 2 weeks Intramedullary nailing - antegrade femur and tibia -retrograde femur,antegrade tibia ORIF plate and screws,MIPO

  32. Followed by Tibial compartments decompression Fasciotomy

  33. Discussion

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