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BOOM!!!!
Orthopaedic Trauma
Douglas W. Lundy, MD, MBA, FACS
31 July 2014
Orthopaedic Trauma Surgery
Resurgens Orthopaedics
Atlanta, Georgia

Conflict
Consultant for
Synthes
Orthopaedics.
Board of Directors of
the OTA, GOS, ABOS
and Resurgens
Orthopaedics.
AAOS
Communications
Cabinet Liaison to the
Council on Advocacy.

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Outcomes
Comparative study
concerning outcomes
after major fracture.
Surgeons more
satisfied with
outcomes than the
patients were.
Harris IA, Dao AT, Young JM,
Solomon MJ, Jalaludin BB:
Predictors of patient and surgeon
satisfaction after orthopaedic
trauma. Injury 40:377-384, 2009.

SF-36
Multi-purpose, short
health survey.
36 questions.
Made available in
standard form in
1990.
Cited in 4000
publications.

Scales:
Physical Functioning
Role-Physical
Bodily Pain
General Health
Vitality
Social Functioning
Role-Emotional
Mental Health

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Trauma patients with fractures

SF-36 scores:
Bodily pain, Physical function,
Role-physical, Mental health,
Role-emotional, Social function
(p < 0.05).

Patients with
orthopaedic injuries have
relatively worse
functional recovery than
trauma patients without
orthopaedic injuries, and
this worsens with time.
Michaels AJ, Madey SM, Krieg JC, Long WB:
Traditional injury scoring underestimates the
relative consequences of orthopedic injury. J
Trauma. 2001 Mar;50(3):389-395.

Psychological effects
Psychological distress is
strongly associated with
patient outcome--including
functional outcome-following trauma.
Psychological distress after
trauma, with its large impact
on trauma outcomes,
remains a substantial
problem that is usually
ignored and untreated.

Starr AJ: Fracture repair: successful advances, persistent

problems, and the psychological burden of trauma. J Bone
Joint Surg Am. 2008 Feb;90 Suppl 1:132-7

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The Big Bad Five

Tibial plafond
Talar neck
Calcaneus
Unstable pelvis
Femoral neck
in young people

High mechanism injuries

Falls
MVC

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Tibial Plafond Fractures

Plafond = roof.
Difficult surgery.
Prolonged recovery.
Nonunion and pain is
common.
Takes up to two years
to see what the
outcome will be.

Tibial plafond outcomes

Tibial plafond
fractures are difficult
to manage and may
have serious
complications.
Loss of function and
progression to posttraumatic arthritis are
common after tibial
plafond fractures.
Harris AM, Patterson BM, Sontich JK, Vallier
HA: Results and outcomes after operative
treatment of high-energy tibial plafond
fractures. Foot Ankle Int. 2006 Apr;27(4):
256-265.

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Talar neck fractures

Difficult surgery.
Prolonged
healing.
Nonunion and
avascular
necrosis is a
huge problem.
May need
pantalar fusion in
the future.

Talar fracture outcome

Osteonecrosis 49%:
Collapse of the dome in 31%.
54% had posttraumatic arthritis
comminuted fractures (p < 0.07)
open fractures (p = 0.09).

Fractures of the talar neck are associated with

high rates of morbidity and complications.
Vallier HA, Nork SE, Barei DP, Benirschke SK, Sangeorzan BJ: Talar neck fractures:
results and outcomes. J Bone Joint Surg Am. 2004 Aug;86-A(8):1616-1624.

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Calcaneal fractures
People
who fall:
Roofers
Dry
wallers
Framers
Painters

Calcaneal fractures
Most painful fracture
that there is!
Pain and difficulty
walking on uneven
ground.
Wound issues after
surgery.
May need a subtalar
fusion.

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Cost of injury
Calcaneal fractures
have been
recognized as having
relatively poor clinical
outcomes and a
major socioeconomic
impact with regard to
time lost from work
and recreation.
Brauer CA, Manns BJ, Ko M, Donaldson C,
Buckley R: An economic evaluation of
operative compared with nonoperative
management of displaced intra-articular
calcaneal fractures. J Bone Joint Surg Am.
2005 Dec;87(12):2741-2749.

Wound Complications
Smoking, diabetes,
and open fractures
all increase the risk
of wound
complication after
surgical
stabilization of
calcaneus
fractures.
Folk JW, Starr AJ, Early JS: Early
wound complications of operative
treatment of calcaneus fractures:
analysis of 190 fractures. J Orthop
Trauma. 1999 Jun-Jul;13(5):369-372.

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Fracture Blisters
All blisters were unroofed, and
antibiotic cream (Silvadene)
was applied twice daily until the
blister bed had re-epithelialized.
We urge caution when
planning to make a surgical
incision around fracture
blisters in diabetic patients
because the zone of injury
might extend beyond the
borders of the fracture blister.
Strauss EJ, Petrucelli G, Bong M, Koval KJ, Egol
JA: Blisters associated with lower-extremity
fracture: results of a prospective treatment
protocol. J Orthop Trauma. 2006 Oct;20(9):
618-622.

Open Tibial Fractures

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Definitions
Fracture: a soft tissue injury overlying a
broken bone.
Soft tissue trauma is the more important
injury.
Norris BL and Kellam JF: Soft-tissue injuries associated with
high-energy extremity trauma: Principles of management. J.
Am. Acad. Orthop. Surg. 5:37-46, 1997.

Open fracture: any fracture associated

with a laceration or puncture wound on the
same limb segment.

Gustilo and Anderson Classification

Type

Description

Infection Antibiotics

Clean, <1 cm

0% to 2%

II
III

Ancef

>1 cm, minimal

2% to 7%
Ancef and
soft tissue injury
Gentamycin
Extensive injury, 10% to 25% Above + PCN
segmental fx,
GSW, farm injury,
etc.

Gustilo RB, Anderson JT: Prevention of infection in the treatment of one thousand and twenty-five open fractures of
long bones: retrospective and prospective analyses. J. Bone Joint Surg. 58-A:453-458, 1976.

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Gustilo Classification

Gustilo RB, Mendoza RM, Williams DN: Problems in the management of type III (severe) open
fractures: a new classification of type III open fractures. J. Trauma 24:742-746, 1984.

Type I

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Definitely IIIC

Type II or IIIA?

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Type II or IIIA?

Antibiotics
A prospective double-blind randomized clinical
trial comparing ciprofloxacin and cefamandole/
gentamicin.
No difference in Type I or II open fracture wounds.
High failure rate for the ciprofloxacin Type III open
fracture group, with patients being 5.33 times more
likely to become infected than those in the
combination therapy group.

Single-agent antibiotic therapy with ciprofloxacin

is effective in treatment of Type I and Type II
open fracture wounds.

Patzakis MJ, Bains RS, Lee J, Shepherd L, Singer G, Ressler R, Harvey F, Holtom P.: Prospective,
randomized, double-blind study comparing single-agent antibiotic therapy, ciprofloxacin, to combination
antibiotic therapy in open fracture wounds. J Orthop Trauma. 2000 Nov;14(8):529-533.

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LEAP!

LEAP Study
527 patients in this multi-centered study.
Bone loss was least significant variable
determining limb salvage.
Soft tissue injury severity has the greatest
impact on decision making regarding limb
salvage versus amputation.
MacKenzie EJ, Bosse MJ, Kellam JF, Burgess AR, Webb LX, Swiontkowski MF,
Sanders R, Jones AL, McAndrew MP, Patterson B, McCarthy ML, Rohde CA,
LEAP Study Group: Factors influencing the decision to amputate or reconstruct
after high-energy lower extremity trauma. J Trauma. 2002 Apr;52(4):641-649.

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LEAP at seven years

397 - amputation or Poor outcome:
reconstruction.
older age
Physical and
female gender
psychosocial
lower education level
functioning
living in a poor household
deteriorated between
current or previous
24 to 84 months after
smoking
the injury.
MacKenzie EJ, Bosse MJ, Pollak AN, Webb
low self-efficacy
LX, Swiontkowski MF, Kellam JF, Smith DG,
Sanders RW, Jones AL, Starr AJ, McAndrew
MP, Patterson BM, Burgess AR, Castillo RC:
poor self-reported health
Long-term persistence of disability following
severe lower-limb trauma. Results of a sevenyear follow-up. J Bone Joint Surg Am. 2005
status before the injury
Aug;87(8):1801-1809.
involvement with the legal
system in an effort to
obtain disability payments.

LEAP at seven years

reconstruction for the
treatment of injuries below
the distal part of the femur
typically results in functional
outcomes equivalent to
those of amputation.
Regardless of the treatment
option, however, long-term
functional outcomes are
poor.

MacKenzie EJ, Bosse MJ, Pollak AN, Webb LX, Swiontkowski MF,
Kellam JF, Smith DG, Sanders RW, Jones AL, Starr AJ, McAndrew
MP, Patterson BM, Burgess AR, Castillo RC: Long-term persistence
of disability following severe lower-limb trauma. Results of a sevenyear follow-up. J Bone Joint Surg Am. 2005 Aug;87(8):1801-1809.

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Poor outcomes in severe trauma

LEAP showed that at two
years, most patients had poor
outcomes, with only half of the
patients returning to work.
By seven years, half of the
patients continued to report
appreciable disability.
more than half of the
patients who were managed
with the current standard of
care had treatment failure.

Starr AJ: Fracture repair: successful advances, persistent problems, and the
psychological burden of trauma. J Bone Joint Surg Am. 2008 Feb;90 Suppl
1:132-7

The joys of call

Hey doc, sorry to call
you at 2:30 AM. I
have a really bad
open xxx fracture
here in the ER
xxx =
Tibial
Femoral
Pelvic

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So what is acceptable?
Is it standard of
care to operate
this fracture at
2:30 AM or
should (can) I
wait until
morning?

Timing of debridement
LEAP found that time
from injury to surgical
debridement was not
contributory factor of
infection.
Timing from injury to
the definitive
treatment center was
indicative of infection.

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Timing of debridement
Findings should not
be interpreted as an
argument that
operative
debridement of open
fractures should not
be accomplished
urgently.

Pollak AN, Jones AL, Castillo RC, Bosse MJ,

MacKenzie RJ, LEAP study group: The
relationship between time and surgical
debridement and incidence of infection after
open high-energy lower extremity trauma. J
Bone Joint Surg 92-A:7-15, 2010.

Ex-fix vs. nail?

External fixator had
more surgical
procedures, took longer
to achieve full weightbearing status, and had
more readmissions than
did those treated with an
intramedullary nail.
Webb LX, Bosse MJ, Castillo RC,
MacKenzie EJ, LEAP Study Group: Analysis
of surgeon-controlled variables in the
treatment of limb-threatening type-III open
tibial diaphyseal fractures. J Bone Joint Surg
Am. 2007 May;89(5):923-928.

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Smoking
Patients with unilateral
open tibia fractures were
divided into 3 baseline
smoking categories:
never smoked, previous
smoker and current
smoker.
Smokers 37% less likely
to heal.
Previous smokers were
32% less likely to heal.
Castillo RC, Bosse MJ, MacKenzie EJ,
Patterson BM, LEAP Study Group: Impact of
smoking on fracture healing and risk of
complications in limb-threatening open tibia
fractures. J Orthop Trauma. 2005 Mar;19(3):
151-157.

Smoking
Current smokers twice as
likely to develop an infection
(P = 0.05) and 3.7 times as
likely to develop
osteomyelitis (P = 0.01).
Smoking places the patient
at risk for increased time to
union and complications.
Previous smoking history
also appears to increase the
risk of osteomyelitis and
increased time to union.
Castillo RC, Bosse MJ, MacKenzie EJ,
Patterson BM, LEAP Study Group: Impact of
smoking on fracture healing and risk of
complications in limb-threatening open tibia
fractures. J Orthop Trauma. 2005 Mar;19(3):
151-157.

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Return to work
37 type III high-energy open
tibial shaft fractures.
(76%) returned to work.
64% returned to work at a
similar level of manual labor.
Average delay between injury
and return to work was 11
months (range, 3-18 months).
89% reported one or more
subjective complaints.

Arangio GA, Lehr S, Reed JF 3rd: Reemployment of patients with

surgical salvage of open, high-energy tibial fractures: an outcome
study. J Trauma. 1997 May;42(5):942-945.

There are no emergencies in

orthopaedic trauma

Femoral neck fractures

Talar neck fractures
Open fractures
Open book pelvic
fractures
Unreduced dislocations
Compartment
syndrome

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Rule #1 - Timing is everything

Compartment syndrome (CS) is an emergency/
urgency to save limb and possibly life.

#2 - Compartment syndrome is rare

Incidence is
3.1/100,000 persons
Incidence for men: 7.3
per 100,000.
Incidence for women:
0.7 per 100,000.

McQueen MM, Gaston P, Court-Brown

CM: Acute compartment syndrome:
Who is at risk?. J Bone Joint Surg 82B, 200-203, 2000.

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Incidence
1.5%
McQueen MM, Christie J, Court-Brown CM.: Compartment pressures after intramedullary
nailing of the tibia. J Bone Joint Surg Br. 1990 May;72(3):395-397.

7%
Kutty S, Farooq M, Murphy D, Kelliher C, Condon F, McElwain JP.: Tibial shaft fractures
treated with the AO unreamed tibial nail. Ir J Med Sci. 2003 Jul-Sep;172(3):141-142.

14.5%
Barei DP, Nork SE, Mills WJ, Henley MB, Benirschke SK.: Complications associated with
internal fixation of high-energy bicondylar tibial plateau fractures utilizing a two-incision
technique. J Orthop Trauma. 2004 Nov-Dec;18(10):649-657.

29%

Ovre S, Hvaal K, Holm I, Stromsoe K, Nordsletten L, Skjeldal S.: Compartment pressure in

nailed tibial fractures. A threshold of 30 mmHg for decompression gives 29% fasciotomies.
Arch Orthop Trauma Surg. 1998;118(1-2):29-31.

Causes
Increase the contents
of the compartment.
Decrease the fascial
volume of the
compartment.
Metabolic insults that
disrupt the
microvasculature.

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#3 - Young people get CS more often

Is a patient younger
than 35 with a tibial
fracture more likely to
have a CS than a
patient over 35 years
of age?
3 times!

#4 - He cant have a CS he can

still move his toes!
The six dreaded Ps:
Paralysis
Pallor
Pulselessness
Pressure
Paresthesia
Pain out of proportion
What exactly is pain
out of proportion?

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Pain out of proportion

Pain is highly
subjective.
To know what pain is
proportional, one would
have to know how
much pain a certain
injury produces.
As a CS progresses,
pain may actually
decrease masking the
CS.

#5 Pressure measurements are

the best way to diagnose CS
Whitesides method.
STIC monitors.
Arterial pressure
monitor.
Accurately measures
pressure in the
compartment.

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Continuous monitoring
One group with continuous monitoring
compared with control clinical group.
In monitored group, 18% had p < 30 mm Hg,
but none developed compartment syndrome.
Overall compartment syndrome incidence was
2.5%.
Continuous monitoring is not indicated in alert
patients.
Harris IA, Kadir A, Donald G: Continuous compartment pressure monitoring for tibia
fractures: Does it influence outcome? J. Trauma 60:1330-1335, 2006.

Traumatic measurements
84% had at least one measurement within 30
mm p, and 58% had at least one
measurement within 20 mm p.
None of the patients ever manifested a
compartment syndrome.
Quantitative measurements may not accurately
diagnose compartment syndrome.
Prayson MJ, Chen JL, Hampers D, Vogt M, Fenwick J, Meredick R: Baseline compartment
pressure measurements in isolated lower extremity fractures without clinical compartment
syndrome. J. Trauma 60:1037-1040, 2006.

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Pressure measurements are the best way to

diagnose CS

Clinical exam is key!

Clinical assessment
is still the diagnostic
cornerstone of ACS
(acute compartment
syndrome).
Shadgan B, et al: Diagnostic
techniques in acute compartment
syndrome of leg J Orthop Trauma
22:581-587, 2008.

Meta-analysis
The positive predictive
value of the clinical
findings was 11% to 15%,
and the specificity and
negative predictive value
were each 97% to 98%.
The clinical features of
compartment syndrome
are more useful by their
absence in excluding the
diagnosis than they are
when present in confirming
the diagnosis.
Ulmer T.: The clinical diagnosis of
compartment syndrome of the lower leg:
are clinical findings predictive of the
disorder? J Orthop Trauma. 2002 Sep;
16(8):572-577.

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What about the asensate or

head injured patients?
Close monitoring of
clinical exam:
Firmness
High clinical suspicion
Pulses

Release the
compartments if in
doubt.

#6 - To calculate p, use the intraoperative DBP

Mean DBP in surgery

was 18mm Hg less
than pre-operative
DBP.
Intra-operative DBP
may be spuriously low
when for deciding to
do a fasciotomy.

Kakar S, Firoozabadi R, McKean J,

Tornetta P: Diastolic blood pressure in
patients with tibia fractures under
anaesthesia: implications for the
diagnosis of compartment syndrome. J.
Orthop. Trauma 21: 99-103, 2007.

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#7 - Open fractures cant have

compartment syndrome
The tears in the fascia release the compartment
pressure

CS in open fractures
The incidence of
compartment syndrome
was found to be directly
proportional to the degree
of injury to soft tissue and
bone; this complication
occurred most often in
association with a
comminuted, type-III
open injury to a
pedestrian.
Blick SS, Brumback RJ, Poka A, Burgess
AR, Ebraheim NA.: Compartment
syndrome in open tibial fractures. J Bone
Joint Surg Am. 1986 Dec;68(9):1348-1353.

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#8 - I can tell by the firmness

Well orthopaedic
residents cant!
Positive predictive
value was 70%
Negative predictive
value was 63%.
Shuler FD, Dietz MJ: Physicians'
ability to manually detect isolated
elevations in leg intracompartmental
pressure J Bone Joint Surg 92-A;
361-367, 2010.

One incision or two?

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Single incision fasciotomy

Centered over fibula.
Superficial dissection can access anterior, lateral
and superficial posterior compartments.
Dissect posterior to fibula and release deep
compartment.

Post-fasciotomy care
NPWT for several days to a week.
Often dictated by fracture care.
Often require STSG.

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#9 - I missed it Im in trouble!

Liability
Increasing time from the
onset of symptoms to the
fasciotomy was associated
with an increased
indemnity payment (p <
0.05).
A fasciotomy performed
within eight hours after the
first presentation of
symptoms was uniformly
associated with a
successful defense.
Bhattacharyya T, Vrahas MS.: The
medical-legal aspects of compartment
syndrome. J Bone Joint Surg Am. 2004
Apr;86-A(4):864-868.

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Timing of Surgery
Study comparing the
time of day or night
when nailing femoral
or tibial fractures.
Need for revision
surgery:
27% from nighttime
surgery.
3% from daytime
surgery.

Complications

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So what is acceptable?
Is it standard of
care to operate
this fracture at
2:30 AM or
should (can) I
wait until
morning?
All depends

But sometimes you HAVE to

operate

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23 yo in MVC

CHI, liver/splenic lacs, PTX, bilateral

femur fx, open book pelvic fx

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Damage Control Orthopaedics

Damage Control Orthopaedics

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Ten days later

Damage Control Surgery

Initially developed
as a strategy for
exsanguinating
patients with severe
visceral injuries.
First stage: rapid
surgery to control
hemorrhage and
contamination.

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Damage Control Surgery

Second stage: further
resuscitation,
rewarming and
correction of
coagulopathy.
Final stage: surgical
re-exploration and
definitive repair.
Rotondo MF, Schwab CW,
McGonigal MD et al: Damage
control: an approach for improved
survival in exanguinating
penetrating abdominal trauma. J
Trauma 1993; 35:375-382.

History
Era of secondary
fracture stabilization
Era of early definitive
fracture treatment
Borderline era
Era of damagecontrol orthopaedics

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History
Era of secondary fracture stabilization
Multiply-injured patients are too unstable to
undergo surgical stabilization of their injuries.
Complex lab tests are unavailable and patient
status is determined by clinical assessment.
The big problem is fat emboli syndrome.
Patients are treated in traction until they are
stable enough (if ever) for definitive fixation.
Hildebrand F, Giannoudis P, Krettek C, Pape, HC: Damage control:
extremities. Injury 2004;35:678-689.

History
Changing thought:
Surgeons started stabilizing orthopaedic
injuries in multiply injured patients.
Early mobilization is essential for patients
with multiple long bone fractures associated
with other injuries in order to avoid
complications.
Riska EB, vonBonsdorff H, Hakkinen S, Jaroma H, Kiviluoto O,
Paavilainen T: Primary operative fixation of long bone fractures in
patients with multiple injuries. J Trauma 1977; 17: 111-121.

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History
Era of early definitive fracture
treatment
Implication was to stabilize long
bone injuries within 24 hours
especially in patients with increased
severity of their injuries.
178 femoral fractures those fixed
within 24 hours (rather than greater
than 48 hours) had less ventilator
time and decreased ICU
management.
Bone L, Johnson K, Weigelt J, Scheinberg R:
Early versus delayed stabilization of femoral
fractures. A prospective randomized study. J
Bone Joint Surg 1989; 71A: 336-340.

History
Borderline era
Questioned the dogma of early fracture care.
The borderline patient was identified that is
the patient would may not benefit from
extensive early fracture care.
Identified with clinical and laboratory findings.
The big question remained Who exactly are
these patients that are too unstable for early
fracture care?.

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History
Era of damage control
orthopaedics
Many patients are
stable enough for early
fracture care, but the
unstable subgroup
should undergo rapid
and minimally
traumatic stabilization
of their injuries.
External fixation is the
mainstay of this form
of treatment.

External Fixation
Increase in primary
external fixation of
femoral fractures in
trauma patients:
ETC = early total care
(1981-1989).
Intermediate
(1990-1992).
DCO = damage
control orthopaedics
(1993-2000).

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Reamed IM nails
Decrease in use of
primary reamed
intramedullary femoral
nails:
ETC = early total care
(1981-1989).
Intermediate (1990-1992).
DCO = damage control
orthopaedics (1993-2000).
Pape HC, Hildebrand F, Petschy S, et al:
Changes in the management of femoral shaft
fractures in polytrauma patients: From early
total care to damage control orthopaedic
surgery. J Trauma 2002; 53: 452-461.

DCO
First stage: early,
rapid, temporary
fixation to minimize
blood and heat loss.
Second stage:
physiologic
stabilization.
Third stage: planned
definitive fixation.
Covey DC: Combat orthopaedics:
a view from the trenches. J Am
Acad Orthop Surg 2006: 14; S10S17.

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Who are these patients?

Polytrauma + ISS > 20 Initial mean pulmonary
artery pressure (PAP)>24
and additional thoracic
mmHg.
trauma (AIS>2).
Increase in PAP during
Polytrauma +
IM nailing of > 6 mmHg.
abdominal/pelvic
Pape HC, Giannoudis P, Krettek C:
trauma and
The timing of fracture treatment in
hemorrhagic shock
polytrauma patients: relevance of
damage control orthopaedic surgery
(initial BP<90 mmHg).
Am J Surg 2002; 183: 622-629.
Bilateral lung
contusions on CXR.

Second hit
Patient outcome
depends upon:
The first hit is the
initial trauma.
The second hit:
Patients biological
condition.
The timing and
quality of subsequent
medical intervention.

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Second hit
Factors contributing to
the second hit:
Blood loss
Sepsis
Ischemia

Lesser second hits:

Blood transfusions
Volume depletion

Timing of surgery
Early total care (ETC).
Stepwise approach:
Acute (1-2 hrs) life
saving.
Primary (1st day) open fx,
compartment syndrome.
Secondary (48-72 hrs)
generally avoid surgery.
Tertiary (>72 hrs) open
reduction and internal
fixation of intraarticular
injuries.

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DCO in pelvic fractures

Major concern is
hemorrhage.
2-20% of pelvic
fractures are
hemodynamically
unstable.
Treatment:
Volume resuscitation.
Close volume.
Arterial embolization.
Pelvic packing.

DCO in pelvic fractures

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So what procedures are DCO?

Femoral
fractures:
External fixation
to establish
length and
alignment if
possible.
Traction if
external fixation
is not possible.

So what procedures are DCO?

Severe tibial fractures may be splinted and soft
tissue injuries treated at the bedside.
Spanning fixation of severe periarticular injuries
should be done as soon as practical.

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So what procedures are DCO?

Open fractures
irrigate and
debride if at all
possible.
May be done in
ICU if
necessary.
At least cover
wound(s) and
administer IV
antibiotics.

So what procedures are DCO?

Intraarticular
fractures span
with external
fixation and
perform definitive
fixation on a
delayed basis.

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Trauma

Thank you

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