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The Principles of
Orthopedic
Surgery for
Trauma
From a surgical management perspective, A-type injuries are unlikely to be a source of major bleeding while B type and specifically C types
are increasingly life-threatening. After initial assessment, primary radiology, and consideration of the response to initial resuscitation, pelvic
fractures can be considered by the mechanical stability resulting from the injury and the resultant hemodynamic response (Table 28-2).
When considered in this way the orthopedic care follows a logical pattern. The essential contribution of the orthopedic surgeon is to assess
the injury with regard to the local and associated problems it will produce and to provide pelvic mechanical stability when required. Clearly,
the hemodynamically stable patient with a stable pelvic ring injury does not require major active orthopedic management although it should be
noted that even the most apparently simple injury can rarely cause local bleeding and transfusion may be required.11 The hemodynamically
stable patient with a mechanically unstable pelvic ring injury needs early but nonemergent surgery to restore mechanical stability to the pelvis
for pain relief, normal daily care, and mobilization. Hemodynamically unstable patients need emergent care to restore their physiologic
stability. If the pelvis is mechanically stable, orthopedic intervention has little to offer, either there is an extrapelvic cause for the bleeding or
hemostasis should be obtained by provision of appropriate clotting factors and platelets or angiographically.
3 The patient in hemorrhagic shock with a major unstable pelvic ring is a very different problem.11,12 Early coordinated multidisciplinary
care is essential with appropriate resuscitation within an established massive transfusion protocol. It is well established that the site of
hemorrhage in most bleeding major pelvic fractures is from the fractured bone surfaces and extensive soft tissue injury, and rarely from major
named arteries. Fortunately, the majority of this will slow significantly or stop when skeletal stability is achieved. Unfortunately, rapid
stabilization of the pelvic ring is a major expert intervention at best and is commonly not easily achievable in the acute bleeding situation.
Initial reduction, stability and some local tamponade is provided by a pelvic binder. In critical cases it should not be removed without an
available alternative method to provide stability. Internally rotating the hips, slightly flexing the knees and binding the legs at the thigh should
also be used if possible and provides additional effective control. The provision of early pelvic fixation or a primary angiographic approach
depends on local expertise and protocol. Recently, a move to emergent operative provision of skeletal stability and packing of bleeding areas
has entered practice and is suggested to be a major advance.2,3 This considers the major bleeding pelvic injury similar to a bleeding liver and
where local hemostasis can rarely be achieved and general hemorrhage control with packing for local pressure and provision of appropriate
clotting factors is essential. For the severe pelvic injury, a systematic protocol with pelvic stabilization and packing at the end of an appropriate
decision-making tree is essential.2,3 Emphasizing the importance of not getting out of control or reacting too late, “The Denver Protocol”2,3
begins with a patient with shock, a pelvic ring injury, and a failure to respond to 2 L of crystalloid resuscitation and 2 units of blood transfusion
(Algorithm 28-1). The essential principle is early aggressive surgical management for hemorrhage control with preperitoneal packing and rapid
blood and factor replacement before the patient becomes grossly coagulopathic. From the orthopedic point of view, restoring skeletal stability
is a critical part of this process and close cooperation with the general traumatologist is essential.
Figure 28-1. A–C: Young and Burgess and Tile (AO-OTA) classifications of pelvic fractures (from Wiss DA. Master Techniques in Orthopaedic Surgery: Fractures. 3rd ed.
Philadelphia, PA: Wolters Kluwer Health; 2012.)
Pelvic Packing
The procedure of packing a pelvis for hemorrhage is not complicated and well within the capabilities of most surgeons but some form of pelvic
bony stability has to be achieved first to give a solid base to pack into. In the emergency situation this commonly means the application of an
anterior external fixation frame although if available and possible, internal fixation has many advantages. Occasionally, emergency provision
of posterior stability with emergent percutaneous sacroiliac fixation or application of a “C clamp” can be dramatically effective in restoring
stability and markedly slowing bleeding. Preperitoneal packing is done through a small anterior incision just above the pubis. After separating
the rectus muscles (which may be avulsed from the pubis), the cavity created by the trauma is entered, the hematoma evacuated and rapid
mechanical stability obtained (often temporarily, with an immediate anterior clamp across the pubis). The cavity is then packed with as many
packs required. These should be placed as far back into the true pelvis as possible. The hematoma cavity created by the injury will be obvious
and it is not required or desirable to extend the dissection outside this area but it is essential to get the packs right to the back of the cavity.
Assuming hemostasis is achieved, the packs are left in, often for 48 hours and under an open but sealed abdomen before they are changed or
simply removed depending on the physiologic response.
Algorithm 28-1. The Denver Protocol for management of major pelvic fractures. (Reproduced with permission and copyright © of the British Editorial Society of Bone and Joint
Surgery. Mauffrey C, Cuellar DO 3rd, Pieracci F, et al. Strategies for the management of hemorrhage following pelvic fractures and associated trauma-induced coagulopathy. Bone
Joint J 2014;96(9):1143–1154.)
Complex urologic injuries are commonly seen with specific patterns of pelvic fracture. A significant APC injury is commonly associated
with an extraperitoneal bladder rupture of the anterior bladder wall directly in line with the plane of injury. LC injuries may be associated with
urethral tears as the inferior ramus cuts the male membranous urethra as it is forced across the midline by the injury. In all cases the presence of
hematuria or blood at the meatus is the pathognomonic sign of injury and necessitates appropriate investigation and joint management with the
urologic service. Again from the orthopedic point of view no soft tissue reconstruction can work without an underlying stable bony skeleton to
support the repair and prevent reinjury. In many situations, the best access the urologist will have is at the time of the primary bony
stabilization and early urologic repair or diversion avoids many problems. While a staged urologic procedure may be required, very early
combined surgery has much to recommend it.
Figure 28-2. Early damage control of extensive limb injuries with external fixation.
Appropriate and adequate open fracture debridement is one of the most difficult surgical procedures, it should not be relegated to
inexperienced staff and if possible not attempted at night unless the limb is very seriously threatened. The whole zone of injury must be
assessed and all dead and dying tissue removed, only nerve and vessel must be preserved and poor muscle specifically removed. Any free bone
or fragments attached by flimsy soft tissue should also be removed and the resulting defect dealt with accordingly, although only rarely is a
significant defect produced. Wound extensions need to be placed with specific consideration for the later closure and must not make the soft
tissue reconstruction more complex. An adequate appropriate debridement must be performed the first time. Repeated debridements “to make
sure” are a result of an inadequate initial operation and massively increase delay and the infection rate. This should be avoided at all costs.
6 Establishing early bone stability is essential, and ideally the definitive bone stabilization should be performed at the primary procedure.
This reduces the chance of late infection and facilitates the subsequent soft tissue reconstruction. In truth, the ability to perform an adequate
debridement and the best bony reconstruction depends directly on the orthopedic surgeons’ confidence in the subsequent soft tissue closure and
thus the working relationship with the plastic surgery team. While soft tissue reconstruction is often delayed for practical reasons there is
excellent evidence that the earlier a healthy closure is obtained the better. This is true to the extent that the best data in the most complex (IIIb)
injuries are with immediate flap cover after an adequate initial debridement and definitive bony reconstruction as one primary procedure (Fig.
28-3). Few units can achieve this at primary presentation, such that definitive debridement, fracture stabilization, and appropriate soft tissue
assessment at the primary procedure followed by definitive soft tissue cover at the second visit to the OR (at about 48 hours) after the patient
has been appropriately counseled are probably the best achievable standard. Cooperative care with the plastic surgical service from the start is
essential.44–49
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May 5, 2017 | Posted by admin in GENERAL SURGERY | Comments Off on The Principles of Orthopedic Surgery for Trauma