PROCEDURE 52 Optimizing Perioperative Fracture Care

Dominique M. Rouleau, Marie-Ève Rouleau, G. Yves Laflamme

This chapter describes several perioperative principles and techniques that are of importance in the care of injured patients. The goal of this chapter is to synthesize relevant information, enabling the orthopedic surgeon to provide the best global care for his or her patient based on actual literature.

The subjects selected are Advanced Trauma Life Support, initial care of the injured limb, thromboprophylaxis, antibiotic prophylaxis, psychological reaction to injury, and secondary prevention.

ADVANCED TRAUMA LIFE SUPPORT^*

Indications

Any patient who sustains a moderate- to high-energy injury must be evaluated with the Advanced Trauma Life Support (ATLS) protocol.

Other indications for ATLS evaluation include:

• Pelvis fracture

• Femur fracture

• Decreased level of consciousness or intoxication

• Multiple injuries

PITFALLS

• A young patient can compensate for significant blood loss and maintain normal vital signs.

• An older patient may be unable to increase the heartbeat secondary to cardiac medication.

• An intoxicated patient can be misleading secondary to absence of pain sensation and a poor injury history.

• The orthopedic surgeon must not undertake care of unstable traumatized patients alone. Teamwork is more efficient and must be prioritized when possible. Physicians from emergency medicine, intensive care, anesthesiology, and general surgery are most often involved in ATLS.

PEARLS

• When possible, a complete trauma team must be available on patient arrival.

• In the case of an unstable or severely traumatized patient, three supportive care measures must be instituted on arrival:

Supplemental oxygen

Two large-gauge intravenous access lines

Monitoring

• A complete blood test and blood typing must be done. Complete vital signs must be taken.

• Chin lift or jaw thrust maneuvers can help keep airways open.

• Definitive airway management by orotracheal intubation or cricothyroidotomy must be done by the appropriate caregiver while maintaining the cervical spine in the neutral position by manual immobilization.

Examination/Imaging

The principle of the “golden hour” is now part of standard care in every health center from the small rural health center to the Level One Trauma Center.

ATLS evaluation is done according to the following steps:

• A—Airway (with cervical spine protection)

• B—Breathing

• C—Circulation: includes stopping bleeding

• D—Disability: neurologic status

• E—Exposure (undress)/Environment (temperature control)

Procedure

STEP 1: AIRWAY

Airways are evaluated first in the “primary survey.”

• In the primary survey, physicians must evaluate and treat the patient following the ABCDE sequence (see Examination/Imaging above).

• Injuries must be addressed and treated following logical steps according to vital signs and injury mechanisms.

To assess the airway, the physician must examine the mouth for any foreign body and signs of burns.

A patient who can speak and has a Glasgow score over 8 (see Step 4) is not likely to have airway obstruction.

STEP 2: BREATHING

Breathing is the second step of the ATLS sequence.

Oxygenation (normal: > 95% saturation) and breathing rhythm (normal: 15–20 breaths/min) out of normal range are red flags for deficient air entry.

Ventilation requires proper function of chest wall muscles, diaphragm, and lungs.

PITFALLS

• Posterior sternoclavicular dislocation can be involved in airway obstruction. This rare condition can be identified by palpation of the sternoclavicular joint during tracheal and neck examination. Closed reduction with traction using a towel clamp can be undertaken in extreme situations with the collaboration of a thoracic surgeon. Posterior dislocations have associated intrathoracic injuries in 30% of the cases. The mortality in this subset of patients is reported to be 12.5%, and such associated conditions must be ruled out before attempting reduction.

PEARLS

• Inspection, palpation, and auscultation must be done to identify tension pneumothorax, flail chest, massive hemothorax, open pneumothorax, tracheal or bronchial rupture, or diaphragmatic rupture. Modification of ventilation and chest drainage must be done when necessary.

STEP 3: CIRCULATION

Circulation and hemorrhage control represent the next step.

Increased heart rate, decreased blood pressure, pale skin color, and a decrease of the level of consciousness are all signs of impaired circulation.

Immediate volume repletion must be initiated with 2 L of crystalloid. Units of blood and colloid and coagulation products (platelets and plasma) must be ready for use in patients with unresponsive severe shock.

A systematic review of possible bleeding causes includes external blood loss, thoracic bleeding, abdominal bleeding, pelvic bleeding, and internal hemorrhagic bleeding around a long-bone fracture.

• Immediate immobilization of a fracture decreases bleeding, decreases pain, and slows the inflammatory reaction.

• A pelvic fracture can be immobilized by a simple draping around the greater trochanter and at the knees (Fig. 1).

FIGURE 1

PITFALLS

• Direct manual pressure is the safest way to stop external bleeding. Hemostatic clamps can damage neurologic structures when used in a suboptimal setting in the emergency room.

• A pneumatic tourniquet must not be used when the extremity is salvageable because the tourniquet can cause irreversible limb ischemia.

PEARLS

• The orthopedic surgeon must be particularly attentive to external bleeding of the extremities, unstable pelvis fractures, and femoral fractures.

Instrumentation/Implantation

• Specialized pelvic belts must be available in multiple sizes in trauma centers.

• Long-bone fractures can be stabilized by longitudinal skin traction and a well-padded splint.

• External bleeding must be controlled by direct manual pressure.

PEARLS

• This evaluation is not possible after sedation and intubation. When possible, a quick neurologic assessment can be done before the use of sedation.

PITFALLS

• The physician must remember that patients with spine or head injury can develop neurogenic shock. Typically bradycardia and low blood pressure are associated with that kind of shock.

PEARLS

• Hypothermia is a frequent consequence of trauma; therefore, room temperature in the trauma suite must be adjusted according to patient need.

PITFALLS

• The contraindication to urinary catheterization is a suspected urethral injury.

• If the cribriform plate is fractured, a gastric tube must be inserted orally to prevent intracranial passage.

STEP 4: DISABILITY (NEUROLOGIC STATUS)

Evaluation for neurologic disability must be done at the end of the primary survey using pupillary size and reaction, lateralizing signs, and level of spinal cord injury.

The Glasgow Coma Scale score is used to quantify the level of consciousness. Three responses are tested, and the scores for each are totaled:

• Eye opening

♦ Spontaneous: 4

♦ To speech: 3

♦ To pain: 2

♦ None: 1

• Best motor response

♦ Obeys commands: 6

♦ Localizes pain: 5

♦ Normal flexion (withdrawal): 4

♦ Abnormal flexion (decorticate): 3

♦ Extension (decerebrate): 2

♦ None (flaccid): 1

• Verbal response

♦ Oriented: 5

♦ Confused conversation: 4

♦ Inappropriate words: 3

♦ Incomprehensible sounds: 2

♦ None: 1

STEP 5: EXPOSURE/ENVIRONMENT

Finally, patients must be completely undressed to complete the assessment.

Control of the patient’s body temperature should be obtained.

At this point, an electrocardiogram can be obtained, and urinary and gastric catheterization can be done.

STEP 6: SECONDARY SURVEY AND TRANSFER DECISION

Before undertaking the secondary survey, results of blood tests and arterial blood gases must be verified.

Judicious radiologic and abdominal tests must be requested.

• In the situation of an unstable patient, anteroposterior radiographs of the chest and pelvis can provide important information. Lateral cervical spine radiographs can also be obtained at this time.

• Abdominal ultrasonography and diagnostic peritoneal lavage are useful tools when used by an experienced physician.

After the primary survey, the physician in charge often has enough information to determine if transfer to a trauma center is needed. Criteria for transfer are:

• Glasgow score under 13

• Systolic blood pressure under 90 mm Hg

• Respiratory rate under 10 or over 29 breaths/min

• Flail chest

• Multiple long-bone fractures

• Amputation

• Penetrating trauma to head, neck, torso, or extremity proximal to elbow or knee

• Open or depressed skull fracture

• Limb paralysis

• Unstable pelvic fracture

• Major burns

• Significant mechanism of injury

• Significant previous comorbidity

• Pediatric patients

PEARLS

• Initial treatment of life-threatening injuries or limb salvage can be undertaken before transfer in agreement with the consultant trauma center.

• All fractures must be stabilized in a splint or traction before transfer.

• Transfer of patients with pelvic fractures must be done with a stabilization device.

PITFALLS

• A normal or inadequate radiograph does not exclude spinal injury. When in doubt, the entire spine must be protected at all times.

• The orthopedic team must ensure that the patient does not evidence any limb-threatening injuries. These injuries are easy to miss in a polytrauma patient or unconscious patient.

• Nondisplaced fractures or isolated dislocations can also be neglected. Liberal use of radiography, vascular Doppler examinations, and compartment pressure monitoring must be done if any doubt arises during physical examination or because of injury mechanism.

After completion of the primary survey and the resuscitation phase, a second survey can begin. This is done only when the patient is stable and has normal vital signs.

• Each part of the body must be examined from head to toe.

• A past medical history and a history of the mechanism of injury must be obtained at this point. The AMPLE mnemonic is used to obtain a complete history:

♦ A— Allergies

♦ M— Medications

♦ P— Past illnesses/Pregnancy

♦ L— Last meal

♦ E— Events/Environment related to the injury

The role of the orthopedic surgeon in the secondary survey is to identify all significant musculoskeletal injuries, guided by injury mechanism and energy level.

• The first step is to look for deformity, redness, edema, wounds, or any sign of blunt trauma. Every part of the body must be examined.

• A careful mobilization must be done “en bloc” to examine the back, buttocks, and posterior aspect of the legs (see Logrolling Mobilization Technique below).

• Pelvic and femoral fracture identification is important because either can lead to significant blood loss.

The orthopedic surgeon must also check carefully for signs of any limb-threatening injuries.

• Vascular injury

♦ Decreased or absent pulse

♦ Cold limb

♦ Pale or white limb

♦ Slow capillary refill

♦ Significant bleeding from an open wound

• Compartment syndrome

♦ Tense edema

♦ Positive stretch test

♦ Severe pain

♦ Paresthesia

♦ Paresis

• Open fracture

♦ Open wound

♦ Anal or vaginal bleeding (pelvic fracture)

LOGROLLING MOBILIZATION TECHNIQUE

Indications

Every patient at risk of spinal injury must be mobilized using the logrolling technique.

This technique must be used during every patient mobilization until the complete spinal evaluation has showed no lesion.

PITFALLS

• Logrolling a patient with an unstable pelvis fracture can increase blood loss and cause a decrease of blood pressure. An intravenous fluid bolus must be give before logrolling in these patients.

• The logrolling side must be chosen with respect to the patient’s injury. The side with more injuries must be kept up.

• The appropriate analgesia must also be given to prevent excessive pain during mobilization.

Positioning

A careful mobilization must be done “en bloc” to examine the back, buttocks, and posterior aspect of the legs. The technique of mobilization is important to minimize spinal movement.

Three persons are needed.

• One person stabilizes the head and neck. This person must lead every step in patient mobilization.

• Two others stand together on the side of the patient that is the least injured.

♦ The second person, standing at trunk level, places one hand on the shoulder furthest from him or her and the other hand on the greater trochanter.

♦ The third person is at pelvic level and places one hand at the T12 level and the other hand at thigh level.

All movements are done in a coordinated way to keep the patient’s spine as straight as possible.

PEARLS

• Verbal and visual contact among the three persons responsible for patient mobilization is essential.

PEARLS

• The person responsible for head and neck immobilization must give a clear order to ensure a coordinated movement of the mobilization team: “On my count, we will turn the patient on his right side at 3, slowly:…1,…2,…3,…turn.”

PEARLS

• A fourth person must be available to examine the patient’s back, to remove all foreign bodies, or to change drapes.

Procedure

STEP 1

The person holding the patient’s head must ensure that the team is well positioned to do the logrolling.

Figure 2A shows the logrolling starting position.

• Note that a rigid cervical collar must be used in a trauma patient.

FIGURE 2

STEP 2

The person holding the patient’s head coordinates logrolling of the patient onto his or her less injured side (Fig. 2B).

STEP 3

The patient’s back, buttocks, and posterior aspect of the legs are examined while he or she is stabilized on the less injured side.

STEP 4

The person holding the patient’s head coordinates logrolling of the patient back to the supine position.

INITIAL CARE OF THE INJURED LIMB

This topic seems very straightforward. Adequate immobilization, sufficient pain management, and providing walking aids are three easy things to do.

However, a study undertaken at our center revealed alarming rates of low-level care quality by referring first-line physicians or referring orthopedic surgeons. In our study, 166 patients referred to the fracture clinic for a limb injury were evaluated during a 4-month period (Rouleau et al., 2009

Only gold members can continue reading. Log In or Register to continue

Share this:

• Click to share on Twitter (Opens in new window)
• Click to share on Facebook (Opens in new window)

Related

Related posts:

16: Perilunate Injuries 29: Proximal Tibia Fractures: Intramedullary Nailing 11: Open Reduction and Internal Fixation of Olecranon Fractures 48: Treatment of Open Fractures 2: Glenoid Fracture 44: Anterior Approaches to the Acetabulum

Stay updated, free articles. Join our Telegram channel

Join

Full access? Get Clinical Tree