Extract
There has been a dramatic change in the approach to the treatment of acute musculoskeletal injuries over the past decade. The previous emphasis on so-called "early total care," which advocated immediate definitive repair of all injuries, has shifted to an approach emphasizing "damage control orthopaedics" for a multiply injured patient. In this new paradigm, definitive repair of fractures is delayed until the patient is stabilized physiologically, associated soft-tissue injuries (if present) have healed, and optimum resources are available. However, there remain situations in which immediate treatment may be needed, such as in a patient with a pelvic ring injury and hemodynamic instability, a compartment syndrome, or an irreducible joint dislocation with associated neurovascular compromise. In these circumstances, there may not be time to safely transfer the patient to a specialized center, and emergent treatment directed at the specific problem must be provided. Emergent treatment of open fractures, compartment syndrome, and hemodynamic instability in a patient with a pelvic fracture as well as damage control in multiply injured patients should be understood by all who treat musculoskeletal injuries. Finally, a less-often discussed but no less important aspect of surgical care that may affect initial treatment decisions and outcome is sleep deprivation and fatigue of the members of the surgical team.
There has been a dramatic change in the approach to the treatment of acute musculoskeletal injuries over the past decade. The previous emphasis on so-called "early total care," which advocated immediate definitive repair of all injuries, has shifted to an approach emphasizing "damage control orthopaedics" for a multiply injured patient. In this new paradigm, definitive repair of fractures is delayed until the patient is stabilized physiologically, associated soft-tissue injuries (if present) have healed, and optimum resources are available. However, there remain situations in which immediate treatment may be needed, such as in a patient with a pelvic ring injury and hemodynamic instability, a compartment syndrome, or an irreducible joint dislocation with associated neurovascular compromise. In these circumstances, there may not be time to safely transfer the patient to a specialized center, and emergent treatment directed at the specific problem must be provided. Emergent treatment of open fractures, compartment syndrome, and hemodynamic instability in a patient with a pelvic fracture as well as damage control in multiply injured patients should be understood by all who treat musculoskeletal injuries. Finally, a less-often discussed but no less important aspect of surgical care that may affect initial treatment decisions and outcome is sleep deprivation and fatigue of the members of the surgical team.
Look for this and other related articles in Instructional Course Lectures, Volume 59, which will be published by the American Academy of Orthopaedic Surgeons in March 2010:
- "Acute Trauma to the Upper Extremity: What to Do and When to Do It," by Jennifer Moriatis Wolf, MD, George S. Athwal, MD, FRCS(C), Alexander Y. Shin, MD, and David G. Dennison, MD
Traditionally, the initial management of open fracture wounds was débridement within six hours after the injury to prevent infection. That guideline was based on animal experiments performed in the 1890s and is not supported by modern human clinical studies. The LEAP study, a prospective multicenter investigation of severe open lower-extremity fractures, showed no relationship between the time from the injury to the surgery and subsequent infection1. Multiple retrospective series of open fractures have also failed to support the "six-hour rule,"2-4 and recent literature reviews have revealed scant support for emergency surgical débridement of open fractures5,6. The current consensus favors prudent early surgery within the first twenty-four hours.
The initial surgical procedure for an open fracture is débridement and irrigation of the open wound. The purpose of débridement is to remove foreign material, contaminating pathogens, and devitalized host tissue. The principles of the surgical procedure include (1) extension of the traumatic wound longitudinally, with the surgeon being careful to consider options for future closure and proceeding systematically through each tissue layer from superficial to deep; (2) careful inspection of surfaces, with preservation of critical tissue such as skin and articular surfaces when possible; and (3) thorough removal of foreign material and dead tissue. Doing this well requires attention, patience, and surgical judgment. Tissue viability is dynamic, and initially it is not possible to determine precisely which tissue will survive. Usually, repeat examination is necessary to ensure adequate removal of dead tissue. Open wounds do not necessarily adequately decompress tissue compartments, and compartment syndrome is a risk with many high-energy fractures. Irrigation of open fracture wounds cleans the wound by removing additional debris and lowering the bacterial load. The irrigation volume, pressure, mode of delivery, and additives are all of potential importance, but little information is available about these parameters. Animal studies suggest that increasing the volume of fluid improves removal of particulate debris and bacteria up to a point7, but there are no clear clinical guidelines regarding this parameter. Although there are no specific data to support this recommendation, we suggest an empiric protocol of using 9 L (three 3-L bags) of fluid for Gustilo type-III open fracture wounds, 6 L (two bags) for a type-II wound, and 3 L for a type-I wound. High-pressure irrigation has been shown to drive contamination into the tissue, damage bone, delay healing, and impair infection resistance in animal models and in vitro experiments8. Pulsatile delivery of fluid has no proven advantage9. Irrigation-fluid additives have included antiseptics, antibiotics, and soaps. Antiseptics such as Betadine (povidone-iodine) or hydrogen peroxide are toxic to host immune cells and should not be used; antibiotics are of no proven value in open fracture wounds. Soap solutions help to remove dirt and bacteria through disruption of the hydrophobic and electrostatic forces that bind them to surfaces. In one prospective clinical study, soap solution was compared with antibiotic solution for open fracture wounds and soap was found to have an advantage10.
Traditional teaching dictates that open fracture wounds should not be closed; however, low-energy wounds that have been adequately débrided and cleaned can be closed safely, if closure can be done without tension. If these conditions cannot be met, the fracture wound should be covered, within a week, by delayed primary closure, skin-grafting, rotational flaps, or free tissue transfer. During the time before definitive coverage, the wound tissues should be protected from desiccation with appropriate dressing techniques. Two methods in use are the antibiotic bead-pouch technique and the Vacuum Assisted Closure device (wound V.A.C.; KCI, San Antonio, Texas). The antibiotic bead-pouch technique is a simple method in which handmade polymethylmethacrylate beads are placed on a strand of heavy suture or 18-gauge surgical wire and placed into the wound; the wound is covered with an occlusive adhesive barrier such as OPSITE Post-Op (Smith and Nephew, Memphis, Tennessee) or Ioban (3M, St. Paul, Minnesota).
Stabilizing open fractures promotes healing and infection resistance. The choice and timing of fixation strategy depends on the characteristics of the patient, the injury, the surgeon, and the operating room resources. In general, immediate plate fixation of open fractures of the lower extremity should be avoided because of an increased risk of infection, although immediate plate fixation of upper-extremity open fractures can often be done safely. Acute intramedullary nail fixation of open fractures of the lower extremity can be acceptable, provided that a clean wound with viable bone and soft tissues is achieved with irrigation and débridement. Temporary external fixation, often spanning injured joints, is a useful strategy to protect soft tissues, allow adequate time for planning, and avoid performing complex procedures in the middle of the night. When done for a severely, multiply injured patient with unresolved physiologic issues, this strategy is known as "damage control orthopaedics."11
Antibiotic treatment is one of the most important aspects of open fracture care. Traditionally, cephalosporin antibiotics were used for three days. For type-III open fractures, aminoglycosides were added and treatment was extended to five days. It has been suggested that penicillin be added to the regimen for agricultural injuries with soil contamination because of the risk of clostridial infection. However, these recommendations are based on poorly designed studies done more than twenty years ago12,13. More recent data support a shorter duration (twenty-four to forty-eight hours) of first-generation cephalosporin antibiotics and no additional drugs for coverage of gram-negative or clostridial organisms14,15.
Acute compartment syndrome can complicate any extremity injury, but it is most common in patients with tibial fracture, especially in men under the age of thirty-five years16. Patients with forearm fracture are the second most common group. Although acute compartment syndrome occurs as a result of the initial injury, it is important to remember that acute surgical stabilization can increase the risk of the syndrome17,18. The diagnosis can be difficult, and it should be considered for all patients with an extremity injury. Acute compartment syndrome is a surgical emergency because a delay in treatment may be associated with substantial short and long-term morbidity related to the degree of muscle necrosis that occurs. In the early phase, morbidity is related to potential renal impairment from rhabdomyolysis, whereas long-term disability is related to the degree of functional impairment caused by muscle fibrosis and neural dysfunction. Not surprisingly, delayed diagnosis of acute compartment syndrome is a common reason for litigation against physicians19,20.
Clinical Diagnosis of Compartment Syndrome
Acute compartment syndrome is typically diagnosed on clinical grounds. The "classic" symptoms of acute compartment syndrome are known as the "five P's"—pain, pallor, pulselessness, paresthesia, and paralysis—but these are late findings. Escalating pain, pain with passive stretch of the involved muscle, and numbness are the clinical clues of an acute compartment syndrome. These criteria are subjective and may be attributed to the associated fracture. This diminishes their diagnostic value. Avoiding regional anesthetic blockade and patient-controlled analgesia, which can completely mask the pain that occurs with acute compartment syndrome, is recommended21. Peripheral nerves are sensitive to ischemia; therefore, hypoesthesia in the distribution innervated by a peripheral nerve located within the involved compartment is an important early finding in acute compartment syndrome22,23. However, neurologic deficits may be due to the initial trauma and are therefore not specific.
The variability in the clinical signs and symptoms of acute compartment syndrome makes the accuracy of clinical diagnosis poor, and the sensitivity and positive predictive value of clinical findings are low24. In contrast, the specificity and negative predictive value of clinical signs are high, meaning that the absence of clinical findings associated with compartment syndrome of the leg is more useful for excluding the diagnosis than the presence of findings is for confirming the diagnosis24. Given the uncertainty in the clinical diagnosis of acute compartment syndrome, a high index of suspicion must be maintained when caring for patients at risk.
Measurement of Intramuscular Pressure
By definition, intramuscular pressure is elevated in cases of acute compartment syndrome, but, because there is wide variation in intramuscular pressure among patients with tibial fractures and since many patients without compartment syndrome can have intramuscular pressures exceeding 30 mm Hg, the direct measurement of intramuscular pressure is not diagnostic25. Intramuscular pressure measurement is an adjunct to the clinical examination and is indicated for any patient with equivocal findings; no reliable diagnostic threshold has yet been described26-28. Intramuscular pressure measurement is the sole means of diagnosis for patients for whom a clinical examination is not possible, such as those who are intoxicated or have a head injury or those who are already intubated. Typically, intramuscular pressure is measured in the anterior, lateral, and deep posterior compartments of the leg with use of either a commercially available device such as the Stryker Intra-Compartmental Pressure Monitor System (Stryker, Kalamazoo, Michigan) or an arterial line manometer. Both techniques have acceptable accuracy29. Intramuscular pressures vary within each compartment, with measurable differences occurring at distances as close as 5 cm from the site at which the highest pressure was recorded30. Intramuscular pressures are also influenced by the position of the adjacent joints31.
The most well-supported threshold for fasciotomy appears to be a perfusion pressure of <30 mm Hg32-34. The perfusion pressure (?P, or "delta P") is equal to the diastolic blood pressure minus the intramuscular pressure. When the perfusion pressure is =30 mm Hg, it is safe to assume that the patient does not have an acute compartment syndrome. Conversely, when ?P is <30 mm Hg for a sustained period of time, compartment syndrome may be present and fasciotomy is recommended.
To improve the diagnosis of compartment syndrome and eliminate the need to perform multiple serial intramuscular pressure measurements, continuous intramuscular pressure monitoring has been advocated33,35. McQueen et al. demonstrated that continuous pressure monitoring of the anterior compartment of the leg in a cohort of patients with a tibial fracture in whom a compartment syndrome developed led to a marked reduction in the sequelae of acute compartment syndrome, presumably because the diagnosis was made earlier33. One important benefit of continuous monitoring is that the time trend of intramuscular pressure is an important variable that cannot be assessed on the basis of a single measurement. Prayson et al. reported that 53% of the patients in their series had at least one intramuscular pressure measurement that was within 40 mm Hg of their mean arterial pressure (an alternative definition of a borderline perfusion pressure), yet none had signs of sequelae of compartment syndrome25. Thus, a rising or sustained elevated pressure (or inadequate perfusion pressure) is a more important indication of an acute compartment syndrome and a better indicator of the need for fasciotomy than is a single pressure.
How to accurately assess perfusion pressure in patients who are under anesthesia is not known. While a patient is under anesthesia, the blood pressure may be artificially low, leading to an inaccurately small perfusion pressure, and to unneeded surgery if that pressure is used to decide whether a patient needs a fasciotomy. Kakar et al. recorded blood pressures in a series of patients undergoing tibial nail fixation36. Diastolic blood pressure during surgery was lower than that either before or after surgery, but the postoperative diastolic blood pressure was predicted by the preoperative blood pressure. Therefore, a more accurate measurement of an anesthetized patient's perfusion pressure should be based on the preoperative diastolic pressure rather than the intraoperative pressure. The only caveat to this is that, if the patient is to remain under anesthesia for some time, the intraoperative blood pressure should be used.
Surgical Treatment of Compartment Syndrome
Once identified, compartment syndrome must be treated with prompt fasciotomy.
Early diagnosis of acute compartment syndrome and prompt fasciotomy have been shown to lead to more rapid union and improved function in patients with a tibial fracture32,33. In contrast, if fasciotomy is done too late, the procedure may have little benefit and may actually be harmful37. Fasciotomy that is performed after myonecrosis has occurred exposes the necrotic tissue and can lead to bacterial colonization and infection. Finkelstein et al. reviewed the cases of five patients in whom fasciotomy had been performed more than thirty-five hours after the injury. Of these five patients, one died of multiple organ failure and the others had amputation of the limb37.
Technique of Fasciotomy
The fasciotomy is done by making a longitudinal skin and fascial incision over the entire compartment with release of all constricting tissues. An inadequate skin incision can contribute to persistent elevation of intramuscular pressure38. The precise incisions to be made and the structures that require release vary depending on the situation.
Two-incision fasciotomy of the leg:
Fasciotomy of the leg can be done safely and easily with use of two incisions: one lateral and one medial. The anterior and lateral compartments are released separately through the lateral incision. The superficial posterior compartment may be released through either incision. The deep posterior compartment is released through the medial incision. The intervening skin flap is at risk for necrosis if there has been damage to the anterior tibial artery. Therefore, when the anterior tibial artery is known to be or suspected of being injured, a single-incision four-compartment release from a lateral approach is recommended. To perform a two-incision fasciotomy, initially a lateral incision is made midway between the fibula and the anterior crest of the tibia. The skin is gently retracted anteriorly and posteriorly to expose the fascia of the anterior and lateral compartments, respectively. The lateral intermuscular septum that divides the anterior and lateral compartments and the superficial peroneal nerve are identified. The peroneal muscle fascia is usually released first. Finally, the anterior compartment fascia is completely released. Alternatively, the fascia overlying one compartment can be released, followed by division of the intermuscular septum to decompress the other compartment. However, iatrogenic injury to the superficial peroneal nerve may be more likely with this technique39. Next, the medial incision is made 1 cm posterior to the posteromedial border of the tibia. The saphenous vein and nerve should be identified. The fascia of the gastrocnemius-soleus complex should be completely released. Distally, the soleus bridge (representing the condensation of the anterior and posterior investing fibers of the soleus muscle) should be specifically released from the posterior aspect of the tibia in order to completely decompress the flexor digitorum longus and tibialis posterior muscles.
Single-incision fasciotomy of the leg:
To perform a single-incision fasciotomy, a single lateral incision, extending from the neck of the fibula to the lateral malleolus, is made. Fibulectomy is not necessary39. The anterior and lateral compartments are released in the manner described for the two-incision fasciotomy. The superficial posterior compartment (the gastrocnemius-soleus muscle complex) is released by elevating the skin posteriorly. Finally, a parafibular approach is used to decompress the deep posterior compartment. The peroneal muscles are retracted anteriorly, and the dissection is carried posteriorly to the fibula. With the lateral head of the gastrocnemius-soleus retracted posteriorly, the septum dividing the superficial and deep posterior compartments can be identified and released. If access to the deep posterior compartment is difficult, a medial incision can always be made as described above.
Upper-extremity fasciotomy:
The muscles of the entire upper extremity can be decompressed with use of an extended anterior incision extending from the shoulder to the wrist. In the upper arm, anterior release of the biceps and brachialis can be extended across the elbow and incorporated into a volar fasciotomy of the forearm. In turn, the volar forearm release can be extended into the palm of the hand to release the median (carpal tunnel) and ulnar nerves (Guyon canal). Beginning with the upper arm, an anterior incision is made along the medial edge of the biceps. The fascia of the biceps and underlying brachialis are released. The incision is extended across the flexion crease of the elbow in a zigzag fashion in order to avoid later contracture, and then it is continued distally along the volar aspect of the forearm as needed. Although rarely necessary, the triceps can be decompressed with use of a separate posterior incision. Adequate decompression of the forearm requires release of a number of potential sites of compression, including the lacertus fibrosus, all muscle fascia, and the flexor retinaculum. First, the incision is continued along the medial border of the mobile wad, consisting of the brachioradialis and radial wrist extensors, which are released. The fascia of the digital flexors, supinator, and pronator quadratus is released as needed. Rarely, a separate dorsal forearm fasciotomy is needed. Finally, a standard carpal tunnel release is performed at the wrist, with the incision again crossing the wrist flexion crease in a zigzag fashion to avoid contracture. Injury to the palmar cutaneous branch of the median nerve must be avoided. If the hand is also involved, release of the thenar, hypothenar, and interosseous muscles of the hand is performed separately with use of longitudinal dorsal incisions between the second and third metacarpals and between the fourth and fifth metacarpals.
Management of fasciotomy wounds:
An advance in the management of fasciotomy wounds is the wound V.A.C. device. When applied at the time of fasciotomy, the wound V.A.C. device may allow earlier closure of the fasciotomy site and a decreased need for skin-grafting40. Closure of the fasciotomy site before five days is not recommended and can be associated with recurrent compartment syndrome41. Skin-grafting is associated with fewer complications than is either primary or delayed wound closure42.
The understanding of the role of orthopaedic resuscitation in the overall management of multiply injured patients has changed dramatically in recent years. The potential benefits of optimal fracture care in this patient population include (1) facilitating overall patient care, (2) controlling bleeding, (3) decreasing additional soft-tissue injury, (4) avoiding further activation of the systemic inflammatory response, (5) removal of devitalized tissue, (6) prevention of ischemia/reperfusion injury, and (7) pain relief.
Until recently, appropriate fracture care in a multiply injured patient was considered to be fixation of all fractures as soon as possible. This was thought to decrease the inflammatory load through stabilization of bone and soft tissue, and all long-bone fractures were definitively stabilized within twenty-four hours (or as soon as possible) so that the patient could be positioned upright for adequate pulmonary toilet. The paradigm at the time was "This patient is too sick not to be treated surgically." In a landmark study, Bone et al. showed that this type of management resulted in fewer days of ventilator treatment, fewer days in the intensive-care unit, and lower prevalences of multiple organ failure and mortality43.
About fifteen years ago, published reports began to suggest that, in some cases, this aggressive initial management might be harmful44. The term "damage control" was originally coined by the United States Navy to describe the repair of damaged sea vessels in combat to allow continued use. An approach best described as "damage control surgery" was reported by Rotondo et al., who used rapid but nondefinitive control of hemorrhage to avoid the lethal triad of acidosis, hypothermia, and coagulopathy in patients exsanguinating from penetrating abdominal trauma45. In 1993, the report by Pape et al. of increased pulmonary complications in multiply injured patients undergoing immediate femoral nailing44 ushered in the era of "damage control orthopaedics," and the new paradigm is best described as "optimal surgery" rather than "maximal surgery."
In the past decade, substantial work has been done to define which group of patients can be safely treated with maximal fixation and which should have damage control surgery only. In general, the early death of a multiply injured patient is caused by primary brain injuries and major blood loss, whereas late death is due to secondary brain injury and host defense failure46. The first "hit" (initial trauma) results in hypoxia, hypotension, organ and soft-tissue injuries, and fractures. The second and subsequent "hits" (surgical procedures and sepsis) lead to hypoperfusion, hypoxia/ischemia, reperfusion, blood loss due to acute endothelial injury, and tissue damage causing local necrosis, inflammation, and acidosis. Any type of surgical procedure that induces substantial bleeding and/or soft-tissue damage can be sufficiently traumatic to the patient to represent a "second hit."
Damage control orthopaedics is defined as the provisional stabilization of musculoskeletal injuries in order to allow the patient's overall physiology to improve. The primary tactic of damage control orthopaedics is to use traction or external fixation as the means of provisional stabilization. The purpose of damage control orthopaedics is to avoid the worsening of physiologic parameters related to the second hit of a major orthopaedic procedure by delaying definitive fracture repair until the patient's physiology is optimized. In this approach, the focus is on controlling the bleeding, managing the injuries to the soft tissues, and achieving provisional fracture stability.
Pathophysiology of Trauma
Cytokines, leukocytes, the vascular endothelium, and endothelial-leukocyte interactions are the key determinants of the response to injury. Typical physiologic changes that occur after trauma are increased capillary permeability in the lung, gut, blood vessels, and muscle. The lung parenchyma is most affected in trauma patients. The largest capillary bed in the body is found in the lung, and pulmonary edema is a frequent sign of increased pulmonary permeability. As is the case in the lung, increased permeability of the blood vessels leads to movement of fluid into the third space. Increased tissue permeability also results in translocation of bacteria in the gut. In muscle, edema and bleeding can lead to compartment syndrome.
The inflammatory response to injury (first hit or second hit) includes the systemic inflammatory response syndrome, which is mediated by pro-inflammatory cytokines, arachidonic acid metabolites, proteins of the acute phase/coagulation systems, complement factors, and hormonal mediators. Systemic inflammatory response syndrome can lead to adult respiratory distress syndrome and/or multiple organ failure. Simultaneous with the onset of systemic inflammatory response syndrome is the counter-regulatory anti-inflammatory response syndrome, which can cause immunosuppression and subsequent infection. The counter-regulatory anti-inflammatory response syndrome is described as endothelial cell damage, accumulation of leukocytes, disseminated intravascular coagulopathy, and microcirculatory imbalances that lead to apoptosis and necrosis of parenchymal cells.
Measurement of specific markers can help to quantify the inflammatory responses. These markers include base deficit or serum lactate, soluble thrombomodulin, polymorphonuclear elastase, interleukin (IL)-6, IL-10, and human leukocyte antigen (HLA) DR (Table I). Genetic influences have also been shown to play a role with IL-6, IL-10, tumor necrosis factor (TNF), and HLA-DR47. A base deficit or elevated serum lactate level is considered evidence of continued metabolic acidosis. A serum lactate level of >2.5 mmol/L can indicate occult hypoperfusion and can be used to judge a patient's suitability for surgery. Crowl et al. showed that, when a nail is used to stabilize a femoral fracture within twenty-four hours after the injury, there is a twofold higher incidence of postoperative complications if the serum lactate level is >2.5 mmol/L48. Four hours after femoral nailing (with or without reaming), markers associated with the systemic inflammatory response are elevated49. Waydhas et al. demonstrated that patients with a high polymorphonuclear elastase level combined with a high C-reactive protein level and thrombocytopenia have a 79% incidence of lung, liver, or kidney failure50. IL-6 concentration has also been shown to be a reliable index of the magnitude of injury (burden of trauma) and of the "second hit" produced by the surgical procedure49. If the initial IL-6 level is >500 pg/dL (>5 µg/L), then definitive surgery should be delayed for at least four days after provisional stabilization surgery51. Patients with a high Injury Severity Score52 have an elevated IL-6 level for more than five days. The potent anti-inflammatory cytokine IL-10 also inhibits TNF-a and IL-1 expression and negatively regulates HLA-DR expression. Giannoudis et al. showed that elevated initial and persistently elevated IL-10 levels correlate with sepsis53. HLA-DR is an indicator of resistance to infection and is expressed by circulating monocytes. It is required for antigen presentation and helper T-lymphocytes and thus plays a central role in the immune response to infection. Diminished HLA-DR expression is associated with sepsis and death54.
Timely analysis of specific markers and factors may not be possible in many facilities. In the absence of precise biomarker data, the orthopaedic surgeon may have to rely on physiologic and clinical parameters to guide decision-making (Table II). The following injuries are usually best managed with the damage control orthopaedic protocol: femoral shaft fracture in a multiply injured patient, pelvic ring injuries with substantial hemorrhage, and polytrauma in a geriatric patient. Pape et al. described the criteria for implementing the damage control orthopaedic protocol to include a serum lactate level of >2.5 mmol/L, a base excess of >8 mmol/L, a pH of <7.24, a temperature of <35°C, surgical time of more than ninety minutes, coagulopathy, and transfusion of more than ten units of packed red blood cells55. When damage control orthopaedic protocols are followed, initial stabilization of fractures is achieved with minimal blood loss, fluid shifts, hypothermia, or prolonged surgical time. Options for fracture stabilization in damage control orthopaedic protocols include skeletal traction, splints or casts, intramedullary nail fixation, conventional plates, minimally invasive plates, and external fixation. External fixation is the preferred method of initial stabilization because it can be done quickly with minimal blood loss. Nana and Kessinger showed that use of spanning external fixation for complex distal tibial fractures that are treated immediately improves skin perfusion56.
After provisional stability has been obtained, definitive surgery is considered only after the patient has been adequately resuscitated. End points for resuscitation with use of damage control principles are outlined in Table III. A simplified guideline is to proceed with definitive surgery when fluid balance is negative.
Up to 40% of patients with an unstable pelvic ring injury die from their injuries, and hemodynamic instability is the main predictor of death. The initial management of patients with a pelvic ring injury, including the assessment and management of hemodynamic instability and acute (rather than definitive) stabilization of the pelvic injury, is critical. There are several key points to remember:
- Pelvic ring injuries are markers of violent injury and are associated with life-threatening hemorrhage and injuries to other organs and sites, including the abdominal viscera and genitourinary system. It should not be assumed that the pelvis is the source of bleeding in an unstable patient.
- Although the anatomic and mechanistic classifications of pelvic ring injuries are useful, they are not perfectly predictive of the risk of bleeding.
- Pelvic ring compression with sheets is a simple and effective treatment for immediate management of bleeding in patients with an open-book injury.
- The role of immediate angiography instead of operative exploration remains controversial and probably varies depending on institutional resources and injury patterns.
- The key to the correct initial assessment of a pelvic ring injury is careful evaluation of the radiographs for evidence of deformity and instability.
Assessment of Pelvic Ring Injury
The physical examination of patients with a pelvic ring injury is primarily aimed at defining the neurovascular status of the lower extremities. The motor function and the sensation in the lower extremities should be documented. The examiner should look for asymmetry and/or deformity of the iliac crest, limb-length inequality, and skin lesions (including any open wounds and areas of closed degloving). Every patient should have a rectal examination, the prostate should be examined in males, and the vagina should be examined in females, as lacerations in these locations may be the site of an open pelvic fracture.
Standard imaging of the pelvic ring includes both plain radiographs and computed tomography scans. Radiographs should include anteroposterior, inlet, and outlet views. A cystogram should be done in all patients, and a retrograde urethrogram should be performed in male patients prior to passage of a Foley catheter. Computed tomography is done primarily to define the posterior part of the pelvic ring; axial views best demonstrate sacroiliac joint injuries and sacral fractures. Vertical displacement is underestimated on anteroposterior radiographs and cannot be measured on axial computed tomography cuts. Vertical displacement can be determined on the inlet and outlet radiographs of the pelvis.
Deformity and instability should be established when radiographs of an injured pelvis are evaluated. Deformity is assessed on the basis of the relative degree of internal or external rotation of the iliac wing as well as anteroposterior and/or vertical displacement of the posterior aspect of the pelvis. A pelvic fracture is considered to be unstable when there is symphysis diastasis of >2.5 cm, >1 cm of displacement of the posterior part of the pelvis, complete widening of the posterior sacroiliac joint, and/or any neurologic injury.
Classification of Pelvic Ring Injuries
A fracture classification system should group together fractures that have a similar injury pattern, treatments, potential complications, and sequelae. With pelvic fractures, all of these are primarily related to the condition of the posterior aspect of the pelvic ring because stability, neurologic injury, pelvic asymmetry, limb-length inequality, and persistent lumbosacral pain are determined by the extent of injury to the posterior aspect of the pelvic ring.
Tile Classification
Pennal, Tile, and colleagues classified injuries into three types57. Type-A injuries are stable with an intact posterior arch. Type-B injuries are rotationally unstable, with incomplete disruption of the posterior arch. These are subdivided into open-book or external rotation injuries (Type B1), lateral compression or internal rotation injuries (Type B2), and bilateral injuries (Type B3). Finally, Type-C injuries are both rotationally and vertically unstable, and they are subdivided into different types depending on the nature of the posterior injury.
Young-Burgess Classification
Young, Burgess, and colleagues proposed a mechanistic classification of pelvic ring injury, noting a correlation between the mechanism of injury and associated complications58. They proposed four types of injuries: anteroposterior compression (APC), lateral compression (LC), vertical shear (VS), and combined. Each of these major groups is further subtyped on the basis of the degree of displacement, deformity, and instability.
Hemodynamic Instability
Hemodynamic instability is defined by shock (low blood pressure), metabolic parameters (base deficit), and the need for blood products. The risk of bleeding is correlated with the fracture pattern, but hemodynamic instability can occur with any pelvic fracture59. Anteroposterior compression (APC) pelvic injuries are more likely to be associated with posterior bleeding, whereas lateral compression injuries are more often associated with anterior vessel injury. Sarin et al. reviewed the cases of 283 patients with a pelvic ring injury who were in shock (a systolic blood pressure of <90 mm Hg) at the time of presentation60. Thirteen percent required embolization because of persistent hypotension. In that series, the fracture pattern and orthopaedic management did not differ between the stable patients and those needing angiography. Advanced age was significantly correlated with an increased need for embolization in women only (the mean age of the women who needed embolization was fifty-five years compared with forty years for women not needing embolization), while the Injury Severity Score correlated with the need for embolization in men but not in women60.
Treatment Options
Fluid replacement is the initial treatment for a patient with a pelvic ring injury who is hemodynamically unstable. Fluid replacement alone can increase bleeding in some instances and should be used judiciously. If the patient does not respond to fluid replacement, or initially responds but becomes hypotensive again, the source of bleeding should be found. Ultrasonographic examination of the abdomen and pelvis and computed tomography-angiography are the most common and expeditious means with which to evaluate bleeding. If there are no other sources of bleeding except the pelvic fracture, angiography, circumferential compression (by means of a sheet, pelvic binder, or external fixation), or an exploratory laparotomy with vascular repair and packing of the pelvis are three ways to control the bleeding. The most appropriate choice is institution and/or physician-dependent, and the options have not been standardized.
Angiography has a limited role in the management of patients with pelvic ring injuries. Most bleeding after a pelvic ring injury is venous, and embolizable arterial lesions are uncommon. Large-vessel embolization has also been shown to cause extensive necrosis of the hip abductor muscles61. Balogh et al. reported increased adherence to the key steps of the guidelines and better clinical outcomes after institution of evidence-based practice guidelines that included abdominal clearance with diagnostic peritoneal aspiration/lavage or ultrasound (FAST [Focused Assessment with Sonography in Trauma] examination), noninvasive pelvic binding within fifteen minutes after presentation, pelvic angiography within ninety minutes after admission, and pelvic external fixation within twenty-four hours62. In the period after the guidelines were instituted, the transfusion of packed red blood cells in the first twenty-four hours decreased from 16 ± 2 units to 11 ± 1 units and the mortality rate decreased from 35% to 7% (p < 0.05).
Fangio et al. used angiography in thirty-two patients with an average Injury Severity Score of 39 points who remained hypotensive despite controlled fluid resuscitation (500 mL of normal saline solution) and dopamine infusion and who did not have thoracic and abdominal bleeding, cardiac tamponade, or tension pneumothorax63. Twenty-five patients had positive results on angiography and underwent embolization. There was no relationship between the presence of an arterial lesion and the pelvic fracture pattern; in fact the only significant differences between those with and those without a lesion on angiography were the initial blood pressure (65 compared with 78 mm Hg) and the amount of blood products received. Thirteen patients had a laparotomy because of expanding intraabdominal fluid; three of six laparotomy procedures that were done before angiography revealed negative findings, whereas only one of seven done after angiography revealed negative findings. Twenty-five patients underwent embolization; pelvic arterial bleeding was stopped in twenty-four (96%) of them and was followed by hemodynamic improvement in twenty-one (84%)63.
Cook et al. reviewed the cases of twenty-three patients with a pelvic fracture who underwent angiography and found that the fracture morphology was not predictive of the location of the vascular injury64. Six of ten patients who died had had angiography as the first therapeutic intervention. Five of the ten patients had a fracture pattern that produced an increase in pelvic volume (APC or VS pattern), and two of those patients died during angiography. Cook et al. believed that these patients would have been better treated with external fixation before the angiography. Shapiro et al. demonstrated that repeat pelvic angiography might be necessary in patients with persistent hypotension after previous angiography, whether or not arterial bleeding was identified during the initial session65.
Circumferential compression, external fixation, and pelvic packing to control pelvic stability are valuable methods to help control bleeding. They reduce bleeding, lessen pain, and allow the patient to be mobilized. Pelvic stability should be achieved as soon as possible after the injury and initial assessment. Simple wrapping of the pelvis with a sheet is now commonplace in the United States for any patient suspected of having a pelvic ring injury. It is cheap and simple, and it can be very effective.
Bottlang et al. investigated stabilization of pelvic ring fractures with slings in cadavers66. They demonstrated that circumferential compression with a noninvasive pelvic sling is an effective and safe method for reducing and stabilizing open-book pelvic fractures (Young-Burgess APC II, APC III, and LC II) at an emergency scene66. Provisional pelvic external fixation as an initial method of controlling bleeding works but has a 21% rate of complications, which consist mostly of pin-track infections without sequelae67. Cothren et al. reported a reduction in blood product requirements and no deaths due to bleeding after instituting a protocol of preperitoneal pelvic packing and pelvic external fixation68.
Recommended Algorithm for Treatment of Bleeding in Patients with Pelvic Ring Injury
All patients identified with a pelvic ring injury during initial resuscitation should be treated with a pelvic binder and a Foley catheter (after a retrograde urethrogram and cystogram), and additional pelvic radiographs including inlet and outlet views and a pelvic computed tomography scan should be obtained. Fluid resuscitation is given with continuous monitoring of urine output, the base deficit, hemoglobin levels, and coagulation function. Mechanical instability of the pelvis is determined and, in patients with persistent hypotension, subsequent management depends on the fracture pattern:
Rotationally unstable injuries:
Patients with these fracture patterns may respond to wrapping of the pelvis with a sheet or application of a binder. If appropriate resources and expertise are available, anterior pelvic external fixation or symphyseal plate fixation can be done. Plate fixation is performed if the patient undergoes a laparotomy; otherwise, an external fixator is applied. Some apparent open-book injuries include vertically unstable posterior injuries for which posterior iliosacral fixation is also warranted. The challenge is to identify these.
Lateral compression injuries:
These are more stable, and early pelvic fixation is not beneficial. If these patients remain hemodynamically unstable, angiography or laparotomy is indicated.
Rotationally and vertically unstable injuries:
Rarely, posterior pelvic clamping in the operating room is done after angiography if the patient is persistently hemodynamically unstable.
The one absolute, nondeferrable, middle-of-the-night upper-extremity surgical emergency procedure is the attempted replantation of an amputated finger or limb. While a lengthy discussion of this subject is beyond the scope of this review, it is important to bear in mind that replantation is time-sensitive. Restoration of arterial inflow and venous outflow is vital for the successful salvage of the amputated part and recovery of as much function as possible.
Infectious processes require early, if not immediate, intervention. Infection causes fibrosis, adhesions, edema, stiffness, and other detrimental effects that adversely affect the normal sliding and excursion of delicate hand and upper-extremity structures. Immediate evacuation of pus and surgical control of infection are mandatory as soon as they are feasible. Suppurative tenosynovitis and septic arthritis caused by human bites, animal bites, or other penetrating injuries need immediate surgical treatment and antibiotic coverage with a third-generation cephalosporin. Ceftriaxone, or a similar antibiotic, should be used until specific culture and sensitivity results are available. An infectious disease consultation should be considered.
Deteriorating neurologic function is an indication for at least provisional, if not definitive, stabilization of an upper-extremity fracture (Figs. 1-A, 1-B, and 1-C). A distal radial fracture due to a high-energy injury is particularly noteworthy, if not notorious, in this regard, with respect to median nerve compromise. There are three possible situations that can arise after distal radial fracture that may lead to acute dysfunction of the median nerve:
- The median nerve is found to be impaired or nonfunctional at the time of presentation. Under such circumstances, the nerve was probably injured at the time of impact, by stretch or laceration (uncommon), and immediate or early intervention will not change the natural history of the nerve's recovery. Emergent surgery is not warranted.
- The neurologic function deteriorates during the process of examination, initial treatment, or early observation. This is essentially an impending compartment syndrome of the carpal tunnel and requires emergent carpal tunnel decompression (Figs. 2-A and 2-B). Fracture reduction alone can result in adequate "decompression" of the median nerve (in cases in which neurologic compromise is caused by pressure from a displaced bone fragment).
- Nerve function changes over a period of several days or weeks. This most likely represents alteration in nerve physiology secondary to inflammation, hematoma organization, or accumulation of acute phase mediators. Nerve decompression and irrigation are indicated, but this should be done on an urgent, not an emergent, basis.
Orthopaedic conditions in the lower extremity that are emergent problems include hip dislocation, displaced femoral neck fracture in any patient in whom femoral head salvage is desirable (most patients less than sixty-five years of age), knee dislocation, talar neck fracture with displacement, and subtalar dislocation.
Dislocation of the hip joint is usually a high-energy injury that can interrupt the blood supply to the femoral head and cause cartilage necrosis. Relocation should be done emergently to prevent irreversible damage to the joint, although reported time guidelines in the literature range from six to twenty-four hours. There are conflicting and strong opinions from various experts, but good data are lacking69. Theoretically, an associated acetabular fracture changes the urgency by decompressing both the soft-tissue tension and the hematoma. An expeditious relocation of the dislocated hip makes sense, if only from the point of view of reducing the patient's pain. Certainly, patients should not be transferred to other centers with a hip that is still dislocated.
A variety of reduction maneuvers have been described, including the Allis, Bigelow, Stimson, and East Baltimore lift70 maneuvers. Adequate pain control, relaxation, and assistance are required. If one or two gentle and controlled attempts at reduction are unsuccessful, additional treatment should be carried out in an operating room with the patient under general anesthesia and with the facilities available for open reduction. Repeated, forceful attempts are ill-advised. The inability to reduce a dislocation is often due to interposed fragments from the femoral head or from the acetabulum, and such a dislocation should be treated in the operating room, where trochanteric osteotomy may be necessary to facilitate reduction71,72. If a patient has an unstable closed reduction or a dislocation with interposed fragments, skeletal traction should be used until definitive surgical treatment is accomplished.
A femoral neck fracture in a young patient requires emergent reduction and fixation to protect the blood supply to the femoral head, and a controllable factor in outcome is the quality of the reduction. An anatomic reduction is recommended even if it must be performed in an open fashion. Fixation with three screws placed peripherally in an inverted-triangle configuration provides good stability. The necessity for a capsulotomy to release the hemarthrosis is controversial. In a young patient with a nondisplaced or minimally displaced fracture, the capsule may be competent and the formation of a tense hemarthrosis may compress the blood vessels supplying the femoral head. In that setting, an open or percutaneous capsulotomy may improve the blood flow to the head, although this remains unproven. However, there are risks to this procedure, including damage to those very same blood vessels.
Dislocation of the knee joint (that is, the femorotibial articulation, as opposed to the patellofemoral articulation) is a high-energy injury and can be limb-threatening because of associated vascular injury. If there is an abnormality of the pulses or of perfusion in the limb, emergent evaluation and treatment are indicated. If the pulses can be palpated and are clinically normal, and the ankle-brachial index is >0.9, arteriography is not necessary. If the limb is obviously not perfused, arteriography also is not necessary because the patient should be taken directly to the operating room for vascular exploration and repair. Delay of the vascular repair is an important risk factor for subsequent amputation73-75.
The knee should be gently reduced and stabilized with a splint or external fixation to allow close monitoring of the neurovascular status and compartment pressures. There is no advantage to emergent ligament repair. Rarely, the dislocation is irreducible by closed means. This is usually due to the medial femoral condyle tearing through the capsule and becoming button-holed, with capsular-ligamentous tissue being caught in the intercondylar notch. If the patient is neurovascularly intact, this situation is not necessarily an emergency, but the patient should be monitored closely and taken on an urgent basis to the operating room for an open reduction.
Talar neck fracture is considered an emergency by some because of the tenuous nature and retrograde flow of the blood supply to the talar dome, but emergent reduction and fixation have not been shown to improve outcomes76-78. However, if the displacement compromises the skin, as evidenced by tight blanched medial skin without capillary refill, the patient should be treated emergently to save the skin from dying. The same principle holds true for subtalar dislocation. If the skin is compromised, emergent reduction is warranted. Reduction can usually be accomplished in a closed fashion, but occasionally a surgical procedure is required if there is interposition of tendons.
As with any orthopaedic emergency, the timing of the definitive procedure depends on multiple factors: availability of a suitable operating room, availability and operational integrity of appropriate equipment, availability of experienced assistants and scrub personnel, and other factors. Often overlooked, however, is the state of readiness of the surgeon. When deciding whether surgical treatment should be done in the middle of the night, surgeons are not always the most reliable judges of their own capabilities. Fatigue and sleeplessness have subtle but real negative influences on surgeons’ performances79.
Because of the similar types of responsibilities and decision-making involved with their jobs, surgeons are often compared with airline pilots with respect to performance accuracy and performance deterioration as fatigue comes into play. Sexton et al. reported that >70% of surgeons refused to admit to fatigue-induced deterioration in performance as compared with only 23% of airline pilots80. Like surgery, flying airplanes requires a coordinated and skilled team. Over 90% of pilots were able to relinquish some authority and responsibility when they were overly fatigued, as opposed to about 55% of surgeons. Our medical colleagues do a much better job of recognizing fatigue; anesthesiologists are much better at preserving cohesiveness and team function when they are fatigued, doing almost twice as well as surgeons in these performance domains. Even residents and house officers far surpass us80. Fischer et al. studied petrochemical shift workers and found work performance and alertness were markedly impaired when they worked the nighttime shift81. Not surprisingly, these parameters showed a marked tendency to worsen further as the nocturnal work shift passed. Bartel et al. evaluated a cohort of anesthesiologists before and after a twenty-four-hour period of call82. The study group was tested for their ability to accurately complete a set of increasingly complex psychomotor tests. After a night on call, 30% of the doctors showed more than a 15% increase in simple-task reaction time and more than one-half showed similar increases in reaction times for more complex tasks.
Surgeons are not the only ones affected by fatigue-induced deficits in accuracy and performance; however, we tend to be much less likely to recognize and acknowledge the fatigue effect.
Unfortunately, errors of commission probably take center stage more frequently than do most other errors when late-night or middle-of-the-night procedures are undertaken. Fatigue and accompanying decreases in decision-making accuracy and deterioration in motor skills can lead to imprecise reductions, inaccurate fixation, and incomplete treatment. Such circumstances often lead to poor outcomes and, worse, the need for revision surgery (Figs. 3-A through 4-B). Complex articular reconstructions are best deferred until the entire surgical team is well rested and ready to undertake these orthopaedic challenges.
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