TIMING OF FRACTURE FIXATION IN

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TIMING OF FRACTURE FIXATION IN POLYTRAUMA PATIENTS
ANAESTHESIOLOGISTS PERSPECTIVES
Dr.R.Selvakumar
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POLYTRAUMA-NIGHTMARE FOR THE PATIENT
AS WELL AS FOR THE ANAESTHESIOLOGIST
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SURGEON ANAESTHETIST
having

• Opposite Views

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Why anaesthetist wants to avoid?

• - prolonged hours of surgery
• - Unexpected response

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• Polytrauma
• Hypovolemia
• Multiple system involvement
• less time for evaluation
• missed injuries (head abdomen)
• prolonged surgery
• massive blood transfusion
• difficulty in monitoring
• surgical difficulties

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Unique problem

• increased incidence of respiratory failure
• ARDS

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Why there is an increased incidence of
respiratory failure? ARDS ? fat
embolism
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Fat embolism in polytrauma

• Pathophysiology
• ? in intra medullary pressure ?fat droplets
  ? get filtered in the pulmonary circulation
• minute droplets go through pulmonary
  circulation get trapped in cerebral circulation
• alveolar lipase ? hydrolysis of fat ?
• release of fatty acids (palmitic, stearic,
  oleic)
• Neutralisation by albumin

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Pathophysiology of Fat Embolism - contd

• failure of neutralistion by albumin
• fatty acids calcium ?intercellular septa
  rupture ? diffuse areas of haemorrhage oedema
  in pulmonary interstitium alveolar space

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Pathophysiology of Fat Embolism - contd

• Integrins CD11b CD18 cause adherence of
  neutrophils endothelium
• Injured pnumocytes stop surfactant production?
  collapse of alveoli
• ? shunt and dead space

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Just to relax
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Secondary injury

• FE incidence in a polytrauma -30-90
• If surgery is performed following polytrauma,
• will reaming further increase the incidence
  of
• FE?

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Will it produce a second hit ?
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Medullary reaming Cementation

• Normal I.M pressure - 30 50mm of Hg.
• Violent force in the bone - I.M pressure ?many
  fold.
• Reaming increases I.M.P ? up to 400-600 mm of Hg.
• Cementation ? 650-1500 of Hg.

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What they did.

• In 1960s
• Ill development of pulmonary care
• Wait till FES resolves
• Kuntschers three recommendations

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Kuntschers recommendations

• 1. Dont nail as long as symptoms of FE are
  
• present
• 2. Take special precaution for patients with
• multiple fracture and extensive soft
  tissue
• injuries
• 3. Dont nail immediately, but wait a few days

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Negative effects of delayed fixation

• prolonged immobilisation
• pneumonia, bedsore, renal failure, inadequate
  nutrition, vascular abnormalities
• poor results

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A word about hyponatraemia

• old age
• ? appetite
• depression
• social conditions

restlessness,disorientation etc
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Drastic changes in the 1980s

• Early fixation
• better understanding of pathophysiology of trauma
• improvement in critical care

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Changes in the 1980s..

• It led to aggressive management without improving
  the supportive care
• Bad results

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Damage control orthopaedics

• Pack the major sources of haemorrhage
• Resuscitation and stabilisation of the
• general condition
• Temporary immobilisation of bone
• fractures

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Current recommendations

• Classify the patients according to their
  physical status
• 1. stable grade I
• 2. borderline grade II
• 3. unstable grade II
• 4. In extremis grade IV

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Creteria used in the physical status
classification

• Shock B.P, No of blood units,
• lactate levels,B.D,ATLS
• Coagulation status
• Temperature
• Soft tissue injuries

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Stable patients

• Do whatever you want.

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Borderline patients who respond to resuscitation

• proceed with definitive fixation
• limit the surgical duration within 2 hours

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Remember

• A bad surgeon can shift the ASA
• Grade II to IV easily..

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Borderline patients

• Continuous reassessment
• Pao2/F102 should not drop below 200mm of Hg
• Temperature should not drop below 32C
• Requirement of fluids should not exceed 3L or
  5units of blood
• Absence of significant coagulopathy
• If not ? DCO

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Unstable and patients in extremis

• Life saving surgeries
• External fixation
• Resuscitation and stabilization simultaneously

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Strategy in patients with head injury

• Beware of the fact that cerebral auto regulation
  goes off following head injury
• Extensive sympathetic block due to regional
  anaesthesia may hamper CBF
• Severe head injury ? only life saving procedures

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Strategy in patients with chest injury

• Rib fracture or lung contusion
• Monitoring with pulseoximeter or ABG
• Incidence of ARDS
• Severe chest injury ?only life saving
  procedures

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What to do to prevent the incidence of FES?

• Avoid increase in IM pressure
• Medullary channel depletion
• Venting the medullary channel
• Uncemented prosthesis

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summary

• In polytrauma, immediate fixation may lead
• to secondary complication
• Classify the patients according to their
• Physical status
• Grade I and II Immediate surgery
• Grade III and IV resuscitation,DCO,
• Delayed fixation

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Conclusion
Pre-operative status of the patient decides the
timing of the fracture fixation in the
poly-trauma patients.
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THANK YOU
Dr.R.SELVAKUMAR M.D.,D.A.DNB ASSOCIATE
PROFESSOR COIMBATORE MEDICAL COLLEGE COIMBATORE