Orthopedic Trauma Postoperative Care and Rehab Serge Charles Kaska, MD Name that Beach 100$ Still 100$ 75$ 50$ 1$ Omaha • June 6th 1941 • !st Infantry Division • 2000 KIA LIFE OR LIMB THREAT 1. Compartment Syndrome 2. Fat Emboli Syndrome 3. Pulmonary Embolism 4. Shock Compartment syndrome case A 16 year old male was retrieving a tire from his truck bed on the side of the highway in the pouring rain when a car careens off of the road and sandwiches the patients legs between the bumpers at freeway speed. Acute compartment syndrome Compartment syndrome DEFINED Definition: Elevated tissue pressure within a closed fascial space • Pathogenesis – Too much in-flow: results in edema or hemorrhage – Decreased outflow: results in venous obstruction caused by tight dressing and/or cast. • Reduces tissue perfusion • Results in cell death Compartment syndrome tissue survival • Muscle – 3-4 hours: reversible changes – 6 hours: variable damage – 8 hours: irreversible changes • Nerve – 2 hours: looses nerve conduction – 4 hours: neuropraxia – 8 hours: irreversible changes Physical exam 1. Pain 2. Pain 3. Pain Physical exam • Inspection – Swelling, skin is tight and shiny • Motion – Active motion will be refused or unable. Must see dorsiflexion • Palpation – Severe pain with palpation • Alarming pain with passive stretch Physical exam • Dorsiflexion Physical Exam • Palpation – Severe pain with palpation • Alarming pain with passive stretch Physical exam • Evaluations from nurses, therapists, and orthotech’s are CRITICAL • If you call a doctor and say that you think the patient has compartment syndrome, the doctor will come to the hospital right away • Error on the side of caution but please learn exam Treatment • Remove all compressive dressings • Elevate the leg to level of the heart – Helps promote in-flow to out- flow • Fasciotomy emergently Fat emboli syndrome • 22 year old male dirt bike rider with bilateral femur fractures • Pod #1 S/P ORIF • Mental status changes, agitation • RR 24 • O2 saturation 89 Fat emboli • Typical patient – Men > Women – Common age ranges: 10-40 – Long bone and pelvic fractures • Pathogenesis (unknown) • Mechanical theory – Venules in bone held open by bony attachments: marrow content material passes through heart into lungs • Biochemical Theory – Embolized fat degrades into toxic intermediaries Fat emboli syndrome • Symptoms – Classic Triad • Hypoxemia – (desaturation, tachypnea)(96%) • Neurologic abnormalities – (agitation)(59%) • Petechial Rash (20-50%) • Red-brown rash in non dependent regions: – Head, neck, anterior thorax, axillae, subconjuctiva Imaging • Chest x-ray – Shows multiple flocculent shadows (snow storm appearance). Fat emboli starry sky; petechial Fat emboli • Diagnosis – Clinical tests to rule out other causes • Treatment – Treat the cause: fix fractures – Supportive care: fluids and oxygen Deep vein thrombosis 15% of all hospital deaths • Genetic risk factors: – Factor V Leiden – Prothrombin gene mutation • Acquired risk factors: – Advanced age – Obesity – History of Previous DVT – Cancer • Triggering Factors: – Surgery – Injury – Estrogen Therapy/Pregnancy Virchows Triad: Endothelial cell activation, stasis, hypercoagulability. Pulmonary Embolism/DVT Signs and Symptoms • Dyspnea sudden onset • Tachypnea >20 resp/min • Tachycardia >100 • Pleuritic chest pain • Cough/hemoptysis (pulmonary infarction) • Exam: – Leg swelling – Dilated superficial veins – Warmth – Tendernous along course of veins DVT • Prevention: – Start propholaxis as soon as possible – When hemorrhage is controlled • When you have a DVT: Activity: – Aissaoui N et al. A meta analysis of bed rest verus early ambulation in the management of pulmonary embolism, deep vein thrombosis, or both. Int. J Cardiol. 2009; 137:37-41 • Sequential stockings – Theoretically can lead to PE if DVT present – OR protocol screening – >72 hours DVT/PE • Emboli clog pulmonary arteries • Cause ventilation/ perfusion mismatch hypoxia • If large enough, reduces cardiac output • Syncope • Sudden death • Electromechanical dissociation DVT screening trauma patients • Despite propholaxis incidence of DVT exists in high risk patients • Screening controversial • Current weekly screening protocol is in place at Palomar on high risk patients DVT treatment • Ambulate • Avoid sequential stockings • Anticoagluation or GreenField Filter shock Shock • Blood volume 5L • 1 unit of whole blood 450 cc • 1 unit of PRBC 300 cc • 1 12oz Coke 355 Secondary survey • Missed injuries happen • Can be fatal – Missed femur fractures – Missed tibia fractures • DO A HAND OVER HAND EXAM ON EVERY TRAUMA PATIENT. SHOCK • Understand signs and symptoms of SHOCK • Body tries to maintain homeostasis • Remove blood • HR increases • PVR resistance increases to maintain BP • Renal perfusion decreases less UOP Shock treatment • Add blood • PRBC’s • FFP • Platelets Nurse Jackie syndrome • Painful condition • Can be fatal • Avoid by – Returning all pens – Answering calls promptly or else – She will memorize your cell number – Call at 2am for Colace POST TRAUMA/POST OP PROBLEM PREVENTION • External fixators • Infection • Pressure Ulcers • Contractures • Swelling • Fracture Blisters External fixation • External fixators – Mostly all temporary spanning external fixators • Damage Control Orthopaedics • Preoperative Soft tissue healing ankle. Knee, and some open fractures – Rapid stabilization – Maintains length and alignment – Permits patient mobilization – Allows examination and treatment of skin • Suspended traction – Strict elevation – Toes above nose – Pressure relief Pressure ulcers • External fixators – Heavy – Fix joints in one position leading concentrated prolonged pressure • Overhead trapeze – Helps with patient repositioning • Air beds PRN External fixation swelling • Elevation until you an see skin wrinkles • Ice • Evidence of efficacy is limited • Cochrane database • Compression can help but not advisable in acute trauma External fixator pin care • Insufficient evidence exists to recommend one regimen over another • Weekly pin site dressing changes are enough contractures • Lower ext • Knee flexion contracture – Increase patellofemoral pressure – Gait disturbance – 3 months to get extension in distal femur fractures • Ankle equinus – Forefoot pressure transfer – Difficulty walking uphill – Gait disturbance • Upper extremity • Fingers • Elbow and shoulder usually stay immobilized for short term contractures • Knee – Position of comfort – Knee flexed • Ankle – Sleep and resting position – Plantar flexed Contracture prevention • Pillow under heel • Equinus stretching with rigid strap infections • Pre-operative antibiotics • Open Fractures – Post-op antibiotics 48-72 hours • Tetanus • Early recognition • Intuition • Healing wounds – Dry • Infected wounds or wounds with hematoma – Drainage – Redness – Skin edges won’t adhere Pain management orthopaedic trauma • Poor peri-operative pain management negatively effects outcomes – Contributes to PTSD – Lead to chronic pain – Refusal to engage in PT – Delayed return to work • Narcotics – Bad – Many side effects • Nerve blocks – Not a good idea in acute trauma • Multimodal Pain Management Regimens – Ketorlac – 48 hours – Pregabalin/Gabapentin – Tylenol – Ice Psychology orthopaedic trauma • Underappreciated • PTSD • Anxiety • Depression • Worse Functional Outcomes Psychology OrthoPaedic Trauma • Recognize symptoms early • Early Interventions – Meditation – Support Groups – Pastoral Care THANK YOU.