3.orthopedic Trauma

Orthopedic Trauma
considerations
Abraham Tarekegn
Lecturer, Department of Anesthesia
CMHS, University of Gondar
Outline
 Introduction
 Comparison of GA vs RA for orthopedic trauma
 Fat embolism syndrome
 Compartment syndrome
 crush syndrome
 VTE
Objectives
o Upon completion of this session you will be able to:
Describe special anesthetic issues related to orthopedic

trauma.
Utilize appropriate anesthesia options for OT.
Analyze advantages of one anesthetic technique over

the other.
Introduction
• Musculoskeletal injuries are the most frequent indication for

surgery in most trauma centers.
• Because many procedures can be appropriately managed

under RA, familiarity with these techniques is essential.
Introduction …
• The length of many procedures necessitates attention to:
 Body positioning,
 Maintenance of normothermia,
 Fluid balance and
 Preservation of peripheral blood flow

Introduction …
• Emphasis in trauma management of a multiple trauma patient
has included early stabilization of long-bone, spine, pelvic, and
acetabular fractures.
• Failure to do so results in:

 Increased morbidity,
 Pulmonary complications and
 Length of hospital stay

Advantages & Disadvantages of RA
for Trauma Patients
Advantages
o Allows continued assessment of mental status
o Increased vascular flow
o Avoidance of airway instrumentation
o Improved postoperative mental status
o Decreased blood loss
o Decreased incidence of DVT
o Improved postoperative analgesia
o Better pulmonary toilet
o Earlier mobilization
RA for trauma…
Disadvantages
o Peripheral nerve function difficult to assess
o Patient refusal common
o Requirement for sedation
o Hemodynamic instability with placement
o Longer time to achieve anesthesia
o Not suitable for multiple body regions
o May wear off before procedure(s) conclude
Advantages and Disadvantages of
GA for Trauma Patients
Advantages
o Speed of onset
o Duration—can be maintained as long as needed
o Allows multiple procedures for multiple injuries
o Greater patient acceptance
o Allows positive-pressure ventilation

GA for trauma…
Disadvantages
o Impairment of global neurologic examination
o Requirement for airway instrumentation
o Hemodynamic management more complex
o Increased potential for barotrauma

Compartment syndrome
o Compartment syndrome of the extremities is
 a condition in which increased pressure within a limited space

compromises the circulation and function of the tissues within that space.
o In orthopedic trauma the most common cause of compartment

syndrome is edema secondary to muscle injury and associated
hematoma formation.
o Though most commonly associated with traumatic injuries.

Compartment syndrome …
o Compartment syndrome occurs when the pressure within an

osteofascial compartment of muscle causes ischemia and then
necrosis.
o Compartment syndrome can also occur as a result of a number of causes
associated with trauma including:

 reperfusion injury, burns, drug overdose, and prolonged limb compression
o The most common fractures associated with the
development of compartment syndrome are those of:

 the tibial shaft (40%) and
 forearm (18%).
o A further 23% are caused by soft tissue injuries without fracture

Risk Factors for The Development of
Compartment Syndrome
o The classic hallmarks of compartment syndrome have been

described as the “five P's.”
 pulselessness,
 pallor,
 paralysis,
 paresthesia, and
 pain
Management
o Fasciotomy is the only treatment for acute compartment syndrome.
o Fasciotomy is a surgical procedure where the fascia is cut to relieve

tension or pressure commonly to treat the resulting loss of
circulation to an area of tissue or muscle.
o The muscle compartment is cut open to allow muscle tissue to swell,

decrease pressure and restore blood flow.
o Fasciotomy:
 When compartment Pressure approaches 20 to 30 mm Hg below DBP,
 Worsening clinical condition,
 Documented rising tissue Pressure,
 Major soft tissue injury, or
 History of 4 - 6 hours of total ischemia.

Fat embolism syndrome
o Most patients undergoing long-bone fracture manipulation

experience microembolism of fat & marrow.
o No visible problem on most patients, but some will experience a

significant acute inflammatory response.
o Some lung dysfunction occurs in almost all patients (from minor

laboratory abnormalities to FES).
Fat embolism syndrome …
o Clinically significant FES occurs in 3% to 10% of patients.
o FES is classically seen in patients with long bone fractures who develop
sudden tachypnoea and hypoxia. Although sometimes a petechial rash is
seen (check conjunctiva).
o Signs include hypoxia, tachycardia, mental status changes, and a petechial

rash on the upper portions of the body.
o 1 Major and 4 minors (as defined by Gurd) .

Criteria for Diagnosis of FES
Major (at least one)
o Axillary/subconjunctival petechiae
o Hypoxemia (Pao2 <60 mm Hg; FIO2 <0.4)
o CNS depression (disproportionate to hypoxemia)
o Pulmonary edema
Criteria for Diagnosis of FES …
Minor (at least four)
o Tachycardia (>110 beats/min)
o Hyperthermia
o Retinal fat emboli
o Urinary fat globules
o Decreased platelets/hematocrit (unexplained)
o Increased erythrocyte sedimentation rate
o Fat globules in sputum

o Laboratory
 Thrombocytopenia.
 Sudden decrease in hg by 20%.
 Raised ESR.
 Fat macroglobulaemia.
o FES should be considered whenever the alveolararterial O2 gradient
deteriorates together with decreased pulmonary compliance & CNS
deterioration.
o Under GA, the CNS changes will not be apparent but may be
manifested as delayed awakening.
o Diagnosis in the OR is largely based on the clinical findings after ruling

out other causes of hypoxemia.
Treatment of FES
 Early resuscitation and stabilization are vital.
 Early O2 therapy may prevent onset of syndrome.
 May require mechanical ventilation (10–40% of patients).
 Steroid
 FES usually resolves within 7d.

Treatment of FES …
o Lung infiltrates seen on chest radiography confirm the presence
of lung injury.
o This needs appropriate ventilatory management with O2,

higher PEEP, & possible longer term MV.
o Treatment includes: early recognition, administration of O2,

and judicious fluid management.
Crush syndrome
o Is the general manifestation of crush injury caused by
continuous prolonged pressure on extremities.
o Muscle injury 2o to ischemia  Myoglobinuria  ARF &

subsequent profound electrolyte disturbances.
o The most critical treatment consists of crystalloid fluid

resuscitation.
Crush syndrome …
o Osmotic diuresis with mannitol and alkalinization of urine
with sodium bicarbonate.
o The preferred therapy for ARF 2o to rhabdomyolysis is
continuous renal replacement therapy and hemofiltration.
o Anesthetic concerns
 Myoglobinuria  ARF
 Electrolyte disturbance (K)
 Fluid disturbance
Venous Thromboembolism
o Thromboembolic complications remain one of the leading causes
of morbidity and mortality after orthopedic surgery.
o THA, total knee arthroplasty (TKA), and hip and pelvic

fracture surgery have the highest incidence of venous
thromboembolism, including DVT and PE.
o Patients with DVT and PE are at risk for short-term and

long-term morbidity and mortality.
Venous Thromboembolism …
o Patients with symptomatic PE have an 18-fold higher risk of

death than patients with a DVT alone.
o The short-term complications of survivors of acute DVT and PE

include prolonged hospitalization, bleeding complications related
to DVT and PE treatments, local extension of DVT, and further
embolization.
o Long-term complications include post-thrombotic syndrome,

pulmonary hypertension, and recurrent DVT.
Venous Thromboembolism …
Risk factors:
o advanced age greater than 60 years,
o obesity,
o prolonged immobility or bed rest more than 4 days,
o prior history of thromboembolism,
o cancer,
o pre-existing hypercoaguable state
o major surgery.
o procedures lasting more than 30 min,
o use of a tourniquet,
o lower extremity fracture
What to do for VTE
What to do for VTE …
Management
o Pharmacological prophylaxis and the routine use of mechanical

devices such as intermittent pneumatic compression (IPC) have
been shown to decrease the incidence of DVT and PE.
o While mechanical thromboprophylaxis should be considered for

every patient, the use of pharmacological anticoagulants must
be balanced against the risk of major bleeding.
Management …
o For patients at increased risk for DVT but having “normal” bleeding
risk,
 mechanical prophylaxis
 low-dose subcutaneous unfractionated heparin (LUFH),
 warfarin, or
 low-molecular-weight heparin (LMWH)
o Patients at significantly increased risk of bleeding may be managed

with mechanical prophylaxis alone until bleeding risk decreases.
Thank You!!!

3.orthopedic Trauma

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Orthopedic Trauma

 Comparison of GA vs RA for orthopedic trauma

 Fat embolism syndrome

Describe special anesthetic issues related to orthopedic

Utilize appropriate anesthesia options for OT.

Analyze advantages of one anesthetic technique over

• Musculoskeletal injuries are the most frequent indication for

• Because many procedures can be appropriately managed

 Fluid balance and

 Preservation of peripheral blood flow

• Failure to do so results in:

 Pulmonary complications and

 Length of hospital stay

o Duration—can be maintained as long as needed

o Allows multiple procedures for multiple injuries

o Greater patient acceptance

o Allows positive-pressure ventilation

o Requirement for airway instrumentation

o Hemodynamic management more complex

o Increased potential for barotrauma

 a condition in which increased pressure within a limited space

o In orthopedic trauma the most common cause of compartment

o Though most commonly associated with traumatic injuries.

o Compartment syndrome occurs when the pressure within an

o Compartment syndrome can also occur as a result of a number of causes

associated with trauma including:

o The most common fractures associated with the

development of compartment syndrome are those of:

o A further 23% are caused by soft tissue injuries without fracture

o The classic hallmarks of compartment syndrome have been

o Fasciotomy is the only treatment for acute compartment syndrome.

o Fasciotomy is a surgical procedure where the fascia is cut to relieve

o The muscle compartment is cut open to allow muscle tissue to swell,

 When compartment Pressure approaches 20 to 30 mm Hg below DBP,

 Worsening clinical condition,

 Documented rising tissue Pressure,

 Major soft tissue injury, or

 History of 4 - 6 hours of total ischemia.

o Most patients undergoing long-bone fracture manipulation

o No visible problem on most patients, but some will experience a

o Some lung dysfunction occurs in almost all patients (from minor

o Clinically significant FES occurs in 3% to 10% of patients.

o Signs include hypoxia, tachycardia, mental status changes, and a petechial

o 1 Major and 4 minors (as defined by Gurd) .

Major (at least one)

o Hypoxemia (Pao2 <60 mm Hg; FIO2 <0.4)

o CNS depression (disproportionate to hypoxemia)

o Retinal fat emboli

o Urinary fat globules

o Decreased platelets/hematocrit (unexplained)

o Increased erythrocyte sedimentation rate

o Fat globules in sputum

 Sudden decrease in hg by 20%.

o Diagnosis in the OR is largely based on the clinical findings after ruling

 Early resuscitation and stabilization are vital.

 Early O2 therapy may prevent onset of syndrome.

 May require mechanical ventilation (10–40% of patients).

 FES usually resolves within 7d.

o This needs appropriate ventilatory management with O2,

o Treatment includes: early recognition, administration of O2,

o Muscle injury 2o to ischemia  Myoglobinuria  ARF &

o The most critical treatment consists of crystalloid fluid

o THA, total knee arthroplasty (TKA), and hip and pelvic