Timing of Definitive Management

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Timing of Definitive Management

• Patrick B. Leach, MD
• Orthopedic Specialists of Southwest Florida

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Damage Control Orthopaedics (DCO)

• Extension of concept developed in abdominal
  surgery
• Attempt to improve outcomes in patients with
  triad of hyporthermia, acidosis, and coagulopathy
• Prevention of SIRS (Systemic Inflammatory
  Response Syndrome)

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Focuses

• Control of hemorrhage
• Management of soft-tissue injury
• Achievement of provisional fracture stability
• Avoiding additional insult to patient

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Benefits of DCO

• Win Win for patient and surgeon
• Allows for definitive fracture fixation when both
  patient and surgeon are optimized for best
  outcomes
• Allows for standardization of initial management
  and subsequent transfer to tertiary care center

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Venti Red-Eye
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AED or Cardizem
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Patient Selection

• Remains a clinical decision
• Biomechanical and genetic markers can predict but
  testing is not practical
• No trauma scoring system that assists in
  decision-making during the acute resuscitation
  phase

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Patient Selection

• Stable
• Borderline
• Unstable
• In extremis

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Patient Selection

• Polytrauma injury severity score of gt20 points
  and additional thoracic trauma
• (abbreviated injury score gt2 points)
• Polytrauma with abdominal/pelvic trauma (Moore
  score75 gt3 points) and hemorrhagic
• shock (initial blood pressure lt90 mm Hg)
• Injury severity score of 40 points in the
  absence of additional thoracic injury
• Radiographic findings of bilateral lung contusion
• Initial mean pulmonary arterial pressure of gt24
  mm Hg
• Increase of gt6 mm Hg in pulmonary arterial
  pressure during intramedullary nailing

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Patient Selection

• Criteria you can remember
• pH lt7.24
• Temperature lt35oC
• Operative time gt90 minutes
• Coagulopathy
• Transfusion gt10 PRBCs
• Geriatric patient (physiologic age gt65)

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Pelvic Fractures

• Sheet or binder very effective initial management
• Add traction pin for vertically unstable pelvic
  fractures
• Angiography or packing
• Exploratory laparotomy offers opportunity for
  anterior fixation

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Femur Fractures

• Consider associated head and/or chest injuries
• Cautious with bilateral femur fractures
• 2 differences between ex/fix and IM nail
• Reaming
• Surgical time

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Limb Damage Control Orthopaedics

• DCO principles applied to a single, severely
  injured limb
• High energy tibial plateau fractures
• Tibial plafond fractures
• Grade III B and C open fractures
• Mangled extremties

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Secondary Procedures

• Days 2, 3, and 4 are not recommended
• Objective tests
• Lactic acid/pH
• Coagulation studies
• IL-6
• HLA-DR class-II molecules

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Orthopaedic Emergencies

• Dislocations
• Vascular compromise
• Compartment syndrome
• Hemodynamically unstable pelvic fractures

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Dislocations

• Closed reduction with staged definitive
  management
• Dislocations associated with fractures
• Proximal humerus fracture with humeral head
  dislocation
• Femoral neck fracture with hip dislocation

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Dislocations
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Vascular Compromise

• Penetrating injuries
• Mangled extremity
• Spaghetti wrist
• Knee dislocations

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Compartment Syndrome

• When in doubt, release

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Orthopaedic Urgencies

• Open fractures
• Soft tissue injuries
• Displaced fractures
• Femoral neck fractures
• Talar neck fractures
• Pediatric supracondylar humerus fractures

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Open Fracture

• When to debride?
• When to fix?
• When to close/cover?

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Timing of Debridement

• 6 hour rule based on Freidrichs study of
  bacteria replication rates
• Only one study supports the 6 hour rule, while
  seven studies over the last 30 years show no
  significant difference
• No published level I studies comparing early vs.
  late debridement, and would be very difficult to
  perform

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Timing of Debridement

• LEAP study
• Measured outcome was incidence of infection
  within first 6 months
• Time to debridement did not predict infection
• Time to admission did correlate with infection
• Antibiotic administration
• Resuscitation

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Timing of Debridement

• Ultimately, quality of debridement is most
  important

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Timing of Fixation

• May be performed at time of initial debridement
  for grade I, II, IIIa fractures
• Consider delayed fixation for fractures grossly
  contaminated with dirt, stagnant water or
  farmyard related injuries.
• Delayed fixation and utilization of bead pouches
  and/or VAC dressings for fractures requiring soft
  tissue coverage
• Reaming of open fractures well supported

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Timing of Closure

• The early closure of open fractures grade I, II,
  IIIa is recommended with the exception of wounds
  grossly contaminated with dirt, stagnant water or
  farmyard related injuries
• Second look debridement warranted when there is
  concern for further tissue compromise or high
  initial contamination
• Free flaps may outperform local flaps

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Timing of Closure

• Cultures in acute open fractures have not been
  shown to correlate with the development of
  infection or with the ID of bacteria when
  infection occurs
• Postdebridement cultures have theoretical value

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Conclusion

• Damage Control Orthopaedics (DCO) should always
  be considered as an alternative to Early Total
  Care (ETC)
• DCO principles can be applied to the multi-trauma
  patient or the severly traumatized single
  extremity
• Unresolved issues
• What constitutes the borderline patient
• Optimal management of femur fractures with
  associated head and/or chest trauma

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Thank You!