Orthopedic Trauma Postoperative Care and Rehab. Serge Charles Kaska, MD

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1 Orthopedic Trauma Postoperative Care and Rehab Serge Charles Kaska, MD

2 Name that Beach 100$

3 Still 100$

4 75$

5 50$

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7 Omaha June 6 th 1941!st Infantry Division 2000 KIA

8 LIFE OR LIMB THREAT 1. Compartment Syndrome 2. Fat Emboli Syndrome 3. Pulmonary Embolism 4. Shock

9 Compartment syndrome case A 16 year old male was retrieving a tire from his truck bed on the side of the highway in the pouring rain when a car careens off of the road and sandwiches the patients legs between the bumpers at freeway speed.

10 Acute compartment syndrome

Compartment syndrome DEFINED Definition: Elevated tissue pressure within a closed fascial space Pathogenesis Too much in-flow: results in edema

11 Compartment syndrome DEFINED Definition: Elevated tissue pressure within a closed fascial space Pathogenesis Too much in-flow: results in edema or hemorrhage Decreased outflow: results in venous obstruction caused by tight dressing and/or cast. Reduces tissue perfusion Results in cell death

irreversible changes Nerve 2 hours: looses nerve

12 Muscle Compartment syndrome tissue survival 3-4 hours: reversible changes 6 hours: variable damage 8 hours: irreversible changes Nerve 2 hours: looses nerve conduction 4 hours: neuropraxia 8 hours: irreversible changes

13 Physical exam 1. Pain 2. Pain 3. Pain

14 Inspection Swelling, skin is tight and shiny Motion Physical exam Active motion will be refused or unable. Must see dorsiflexion Palpation Severe pain with palpation Alarming pain with passive stretch

15 Dorsiflexion Physical exam

16 Palpation Severe pain with palpation Alarming pain with passive stretch Physical Exam

17 Physical exam Evaluations from nurses, therapists, and orthotech s are CRITICAL If you call a doctor and say that you think the patient has compartment syndrome, the doctor will come to the hospital right away Error on the side of caution but please learn exam

18 Treatment Remove all compressive dressings Elevate the leg to level of the heart Helps promote in-flow to outflow Fasciotomy emergently

$fractures Pod #1 S/P ORIF Mental status changes, agitation RR 24 O2$

19 Fat emboli syndrome 22 year old male dirt bike rider with bilateral femur fractures Pod #1 S/P ORIF Mental status changes, agitation RR 24 O2 saturation 89

$and pelvic fractures Pathogenesis (unknown) Mechanical theory Venules in$ bone held open by bony attachments: marrow content material passes through

bone held open by bony attachments: marrow content material passes through

20 Fat emboli Typical patient Men > Women Common age ranges: Long bone and pelvic fractures Pathogenesis (unknown) Mechanical theory Venules in bone held open by bony attachments: marrow content material passes through heart into lungs Biochemical Theory Embolized fat degrades into toxic intermediaries

21 Symptoms Classic Triad Hypoxemia (desaturation, tachypnea)(96%) Neurologic abnormalities (agitation)(59%) Petechial Rash (20-50%) Red-brown rash in non dependent regions: Head, neck, anterior thorax, axillae, subconjuctiva Fat emboli syndrome

22 Imaging Chest x-ray Shows multiple flocculent shadows (snow storm appearance).

23 Fat emboli starry sky; petechial

$fractures$

24 Fat emboli Diagnosis Clinical tests to rule out other causes Treatment Treat the cause: fix fractures Supportive care: fluids and oxygen

Deep vein thrombosis 15% of all hospital deaths Genetic risk factors: Factor V Leiden Prothrombin gene mutation Acquired risk factors: Advanced age Obesity

25 Deep vein thrombosis 15% of all hospital deaths Genetic risk factors: Factor V Leiden Prothrombin gene mutation Acquired risk factors: Advanced age Obesity History of Previous DVT Cancer Triggering Factors: Surgery Injury Estrogen Therapy/Pregnancy Virchows Triad: Endothelial cell activation, stasis, hypercoagulability.

pain Cough/hemoptysis (pulmonary infarction) Exam: Leg

26 Pulmonary Embolism/DVT Signs and Symptoms Dyspnea sudden onset Tachypnea >20 resp/min Tachycardia >100 Pleuritic chest pain Cough/hemoptysis (pulmonary infarction) Exam: Leg swelling Dilated superficial veins Warmth Tendernous along course of veins

27 Prevention: Start propholaxis as soon as possible When hemorrhage is controlled When you have a DVT: Activity: Aissaoui N et al. A meta analysis of bed rest verus early ambulation in the management of pulmonary embolism, deep vein thrombosis, or both. Int. J Cardiol. 2009; 137:37-41 Sequential stockings Theoretically can lead to PE if DVT present OR protocol screening >72 hours DVT

28 DVT/PE Emboli clog pulmonary arteries Cause ventilation/ perfusion mismatch hypoxia If large enough, reduces cardiac output Syncope Sudden death Electromechanical dissociation

29 Despite propholaxis incidence of DVT exists in high risk patients Screening controversial Current weekly screening protocol is in place at Palomar on high risk patients DVT screening trauma patients

30 Ambulate Avoid sequential stockings Anticoagluation or GreenField Filter DVT treatment

31 shock

32 Shock Blood volume 5L 1 unit of whole blood 450 cc 1 unit of PRBC 300 cc 1 12oz Coke 355

$fractures Missed tibia fractures DO$

33 Secondary survey Missed injuries happen Can be fatal Missed femur fractures Missed tibia fractures DO A HAND OVER HAND EXAM ON EVERY TRAUMA PATIENT.

34 SHOCK Understand signs and symptoms of SHOCK Body tries to maintain homeostasis Remove blood HR increases PVR resistance increases to maintain BP Renal perfusion decreases less UOP

35 Add blood PRBC s FFP Platelets Shock treatment

36 Painful condition Can be fatal Avoid by Nurse Jackie syndrome Returning all pens Answering calls promptly or else She will memorize your cell number Call at 2am for Colace

37 External fixators Infection Pressure Ulcers Contractures Swelling Fracture Blisters POST TRAUMA/POST OP PROBLEM PREVENTION

$Knee, and some open fractures Rapid stabilization Maintains length and alignment Permits$

38 External fixators Mostly all temporary spanning external fixators Damage Control Orthopaedics Preoperative Soft tissue healing ankle. Knee, and some open fractures Rapid stabilization Maintains length and alignment Permits patient mobilization Allows examination and treatment of skin Suspended traction Strict elevation Toes above nose Pressure relief External fixation

39 External fixators Heavy Fix joints in one position leading concentrated prolonged pressure Overhead trapeze Helps with patient repositioning Air beds PRN Pressure ulcers

40 Elevation until you an see skin wrinkles Ice Evidence of efficacy is limited Cochrane database Compression can help but not advisable in acute trauma External fixation swelling

41 External fixator pin care Insufficient evidence exists to recommend one regimen over another Weekly pin site dressing changes are enough

$disturbance 3 months to get extension in distal femur fractures Ankle equinus$ Forefoot pressure transfer Difficulty walking uphill Gait disturbance Upper

Forefoot pressure transfer Difficulty walking uphill Gait disturbance Upper

42 Lower ext Knee flexion contracture Increase patellofemoral pressure Gait disturbance 3 months to get extension in distal femur fractures Ankle equinus Forefoot pressure transfer Difficulty walking uphill Gait disturbance Upper extremity Fingers Elbow and shoulder usually stay immobilized for short term contractures

43 contractures Knee Position of comfort Knee flexed Ankle Sleep and resting position Plantar flexed

44 Contracture prevention Pillow under heel Equinus stretching with rigid strap

recognition Intuition Healing wounds Dry Infected

45 infections Pre-operative antibiotics Open Fractures Post-op antibiotics hours Tetanus Early recognition Intuition Healing wounds Dry Infected wounds or wounds with hematoma Drainage Redness Skin edges won t adhere

Pain management orthopaedic trauma Poor peri-operative pain management negatively effects outcomes Contributes to PTSD Lead to chronic pain Refusal to engage in PT Delayed

46 Pain management orthopaedic trauma Poor peri-operative pain management negatively effects outcomes Contributes to PTSD Lead to chronic pain Refusal to engage in PT Delayed return to work Narcotics Bad Many side effects Nerve blocks Not a good idea in acute trauma Multimodal Pain Management Regimens Ketorlac 48 hours Pregabalin/Gabapentin Tylenol Ice

47 Psychology orthopaedic trauma Underappreciated PTSD Anxiety Depression Worse Functional Outcomes

48 Psychology OrthoPaedic Trauma Recognize symptoms early Early Interventions Meditation Support Groups Pastoral Care

49 THANK YOU

PE and DVT. Dr Anzo William Adiga WatsApp or Call Medical Officer/RHEMA MEDICAL GROUP

PE and DVT. Dr Anzo William Adiga WatsApp or Call Medical Officer/RHEMA MEDICAL GROUP PE and DVT Dr Anzo William Adiga WatsApp or Call +256777363201 Medical Officer/RHEMA MEDICAL GROUP OBJECTIVES DEFINE DVT AND P.E PATHOPHYSIOLOGY OF DVT CLINICAL PRESENTATION OF DVT/PE INVESTIGATE DVT MANAGEMENT