Case studies in orthopedic injury

1. Case studies in orthopedic injury

2. Case 1 • History • 51 y/o female • Fell from bicycle onto L knee • Abrasions left arm • No LOC • PMH: alcoholism

3. Case 1: radiographs

4. Case 1: considerations • With these radiographs, what complication needs to at least be considered, and monitored for?

5. Case 1: considerations • With these radiographs, what complication needs to at least be considered, and monitored for? • COMPARTMENT SYNDROME

6. 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)

7. Case 1: compartment syndrome

8. Case 1: compartment syndrome

9. 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…

10. Case 1: compartment syndrome • Can measure compartment pressures • Known to be unreliable and inconsistent

11. CASE 1: COMPARTMENT SYNDROME • Mechanism • Swelling due to fracture and/or bleeding increases pressure in non-compliant fascial compartments

12. CASE 1: COMPARTMENT SYNDROME • Mechanism • Swelling due to fracture and/or bleeding increases pressure in non-compliant fascial compartments

13. 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

14. 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

15. 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

16. Case 1: compartment syndrome

17. Case 1: compartment syndrome • Treatment • Release circumferential dressings/casts • Emergent/urgent fasciotomy • Obtain immediate orthopedic consultation • If unavailable, transfer emergently

18. Case 1: compartment syndrome

19. Case 1: compartment syndrome • Hospital Course • Prolonged stay • Multiple I&D • Delayed closure • Skin grafting • Recommended length of incision= 16 +/- 4 cm

20. Case 1: compartment syndrome

21. 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

22. Case 1

23. 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

24. Case 2: radiographs

25. Case 2: considerations • What is the optimal management of an open fracture? • Antibiotics/tetanus ppx • Surgical debridement • Fracture fixation • Definitive soft tissue coverage

26. 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

27. 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

28. Case 2: grade i/ii

29. Case 2: grade IIIb/c

30. 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)

31. 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

32. 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)

33. 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

34. Case 2: open fractures (fixation) • Stabilization of fractures • IM nail • ORIF • External fixation • Ring fixation

35. Case 2: open fractures (fixation)

36. Case 2: open fractures (fixation)

37. Case 2: open fractures (fixation)

38. 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.)

39. Case 2: open fractures (coverage)

40. Case 2: open fractures (coverage) • When flap coverage is necessary, VAC dressings are often placed temporarily

41. 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%

42. Take home points • Compartment syndrome is a true orthopedic emergency • Requires awareness, vigilant/serial examination, and timely treatment or transfer • Open fractures need IV abx and tetanus ppx • Consider need for surgical intervention urgent, but not necessarily emergent