DAMAGE CONTROL ORTHOPAEDICS case 2

A 37-year-old, male motorcyclist was struck by another vehicle at highway speeds. He was intubated in the field. On arrival to the trauma bay his GCS is 3T, heart rate is 130 beats per minute, blood pressure is 90/58 mm Hg, lactate is 8, and his base deficit is 6. He is found to have a grade IV splenic laceration, multiple rib fractures, a pelvic ring injury, a closed left femur fracture, a comminuted Gustilo–Anderson 3C tibia fracture, and a small intraparenchymal hemorrhage (Fig. 6–42A–C). He is stabilized in the trauma bay and taken directly to the operating room by the general surgery team for exploratory laparotomy.

 

 

 

Figure 6–42 A–C

 

What is the best indicator of end-organ perfusion in this patient?

1. Blood pressure

2. Heart rate

3. Glasgow Coma Scale

4. Base deficit

5. Lactate

 

Discussion

The correct answer is (E). This patient is in Class III shock. However, the most sensitive marker for end-organ perfusion is lactate <2 mmol/L. While blood pressure, heart rate and base deficit are all important markers to consider when

evaluating adequate resuscitation, these are most irregular in a state of uncompensated shock. Following initial resuscitation, when the above markers have normalized, adequate tissue perfusion may still be compromised and is most appropriately evaluated using lactate. The classes for shock can be reviewed in Table 6–6.

 

Table 6–6 CLASSIFICATION OF SHOCK

 

Class	Heart Rate (bpm)	Blood Pressure	Urine (mL/hr)	% Blood Loss	pH
I	Normal	Normal	>30	<15%	Normal
II	>100	Normal	20–30	15–30%	Normal
III	>120	Decreased	5–15	30–40%	Decreased
IV	>140	Decreased	Negligible	>40%	Decreased

 

What is the most appropriate management of his extremity injuries?

1. Pelvic external fixator placement, irrigation and debridement, and external fixation of the tibia and of the femur

2. Pelvic external fixator placement, irrigation and debridement of the tibia followed by wound closure and intramedullary nail, external fixation of the femur

3. External fixator placement with irrigation and debridement of the tibia and skeletal traction of the femur

4. Pelvic external fixator placement, irrigation and debridement and external fixation of the tibia and open reduction and internal fixation of femur

5. Pelvic external fixator placement, irrigation and debridement of tibia with wound coverage and intramedullary nailing of tibia and retrograde intramedullary nailing of femur

Discussion

The correct answer is (A). This patient is inadequately resuscitated and should be treated via damage control orthopaedic principles. Stabilization of pelvis and long bones should be conducted expeditiously as to not provide an additional insult to the patient’s physiologic state. This should be ideally completed in less than 2 hours. Furthermore, the patient is most susceptible to additional ischemic brain injury during the first 24 hours and, as such, additional insults should be minimized. Once fully stabilized, the patient’s pelvis and long bone fractures should be addressed,

ideally converting the external fixators of the tibia and femur to definitive fixation within the following 2 weeks.

What complication has been shown to increase as the interval between external fixator conversion and internal fixation increases?

1. Nonunion

2. Infection

3. Pulmonary embolism

4. Deep venous thrombosis

5. Wound necrosis

 

Discussion

The correct answer is (B). Multiple studies have shown that infection rates increase with a longer conversion interval between external fixation and internal fixation of long bone fractures. Although low in closed femur fractures, increased infection rates have been shown after only 2 days of external fixation. In open tibia fractures, external fixation for greater than 2 weeks has been shown to have greater infection rates.

 

Objectives: Did you learn...?

 

 

Basic principles of damage control orthopaedics? Determination of appropriate trauma resuscitation?

 

Timing of external fixation to definitive fixation of long bone fractures?