provisional stability & damage control in orthopaedic surgery michael t. archdeacon, m.d.,...
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![Page 1: Provisional Stability & Damage Control In Orthopaedic Surgery Michael T. Archdeacon, M.D., M.S.E. Director, Division of Musculoskeletal Trauma Professor](https://reader035.vdocuments.net/reader035/viewer/2022062421/56649d9c5503460f94a84d49/html5/thumbnails/1.jpg)
Provisional Stability & Damage Control In
Orthopaedic Surgery
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
ResuscitationResuscitation
Injury Surveys
Emergent InterventionEmergent
Intervention
Surgical Intervention
Surgical Intervention
DefinitiveInterventionDefinitive
Intervention
Damage Control Orthopaedics
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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 SurveyMake A Limb Look Like A LimbRe-assess Neurovascular StatusProvisionally 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
ImagesPlain FilmsContralateral SideCT Scans
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Orthopaedic Priorities
• Emergent Intervention
• Surgical Intervention
• Definitive Intervention
Provisional Pelvic Stability
Correct IschemiaReduction &
Splinting
Pelvic Ex FixWound Debridement Provisional Stability
ORIF & IM NailsWound Coverage /
Closure
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Damage Control
Orthopaedics
Aggressive ResuscitationAggressive
Resuscitation
Rapid Long Bone & Pelvic Temporary Stabilization
Emergent InterventionEmergent
Intervention Staged, Definitive, Reconstructive
Surgical 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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• 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 &
ManagementTeam / Multiple Disciplinary ApproachATLS Protocols
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ASSOCIATED INJURIES
• Pelvic Fx’sShock – 25 -
67%Neurologic – 27
- 60%ARDS – 6 - 19%Thoracic – 19 –
43%Urologic – 0 -
16%Mortality – 14 -
37%
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Managing the Hemodynamically Unstable Pelvic Fx
• Identify Patient At RiskHypotensionPelvic ExamRadiographic
Evaluation• ATLS
Resuscitation
• Determine Orthopaedic Intervention (If Any)Pelvic
ImmobilizationReduction Of
Hip DxExternal
FixationAngiography
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Emergent Pelvic Immobilization
• GoalsDecrease
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+/- High-Dose Steroids
• Temp ImmobilizationCranial Tong TxHalo 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
• Can Be Life ThreateningControl
Hemorrhage• Direct Pressure• Rare – Tourniquet
Or BP CuffReduce 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 ThreateningMust 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 ThreateningMust 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
• A Clinical DiagnosisYour Patient Will
Tell You They Have It• Pain Out Of
Proportion• Pain With Passive
Stretch• Paresthesias• Pallor• Pulselessness
• Measuring PressuresObtunded PatientsConfirms Clinical Suspicion
• Δ PDifference Between Diastolic Pressure
And Tissue Compartment
Emergent Decompression
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INAdequate Decompression
17 cm Incisions
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Orthopaedic Trauma -Summary
• Team Approach• Few (True) Life
Threatening Orthopaedic Injuries
• ProtocolsPrimary Secondary Tertiary