Page 1654 - Hall et al (2015) Principles of Critical Care-McGraw-Hill

CHAPTER 121: Pelvic Ring Injuries and Extremity Trauma 1173

If the patient has not been optimized or there is some other delay
TABLE 121-3 Gustilo-Anderson Open Fracture Classification
postponing definitive treatment, provisional treatment of the fractures
Type I Low-velocity injuries less than 1 cm long, usually compound from within, by splints, traction, or external fixation may be necessary. In addition,
with minimal soft-tissue injury or comminution of the fracture prophylaxis for DVT should be initiated, as discussed earlier. Attention
Type II Lacerations more than 1 cm long, with minimal to moderate soft-tissue to the skin, especially in dependent areas such as the sacrum, heels, and
crushing posterior scalp, should be maintained, with frequent logrolling and skin
care to avoid the development of decubitus ulcers.
Type III
Definitive fixation of most fractures allows greater ease of mobili-
IIIA High-velocity injuries with severe crushing and the presence of skin flaps. zation for general care and pulmonary toilet. Early mobilization and
No soft-tissue loss; infection rate of 4%; amputation rate of 0% physical therapy also prevent the development of joint contractures and
IIIB Soft-tissue loss with periosteal stripping; infection rate of 52%; amputation muscle atrophy, resulting in a faster recovery and reduced morbidity.
rate of 16% DVT prophylaxis should be maintained during the postoperative period
IIIC Associated vascular injury; infection rate of 42%, amputation rate of 42% until the patient is mobilizing well independently.
■ TREATMENT ■ COMPLICATIONS

Although the initial fracture care is usually done in the emergency Blood loss from fractures alone can be enough to cause hemodynamic
instability. Even without a significant arterial laceration, femur fractures
department, occasionally patients will be admitted to the ICU before any can result in blood loss of up to 2 units, tibia fractures 1 unit, and pelvic
treatment can be initiated. After the initial assessment, any open wounds and acetabular fractures 4 units or more. Aggressive fluid resuscitation
should be flushed with saline and covered with a sterile dressing. Gross must be maintained while reassessing for other causes of hemodynamic
limb deformity and joint dislocations should be reduced and splinted instability. With increasing swelling of the extremities from fracture
and the neurovascular examination repeated. All musculoskeletal inju- bleeding, there must be a high index of suspicion for compartment
ries should be imaged, and repeat fracture reductions or reductions of syndrome.
dislocations may be performed at this time as necessary. The patient
should be prepared for operative intervention if a vascular injury, open Vascular Injury: The vascular status of each limb must be assessed by
fracture, irreducible dislocation, or compartment syndrome is detected. checking for the presence and quality of peripheral pulses, as well as the
In the case of open fractures, intravenous antibiotics should be admin- perfusion of the tissues distal to the zone of injury. Blunt or nonpen-
istered, with gram-positive coverage for all compound fractures and with etrating vascular injuries often are associated with traction or avulsion
the addition of gram-negative and anaerobic coverage for contaminated injuries, fractures, and dislocations. It is important to assess the entire
wounds. The patient’s tetanus status should be determined, and tetanus tox- peripheral vasculature if there are multiple ipsilateral injuries, such
oid and immunoglobulin should be administered as required (Table 121-4). as concomitant femur and tibia fractures. Knee dislocations and tibia
All compound fractures should be treated with urgent irrigation fractures have the highest incidence of arterial injury, followed by femur
and débridement within 8 hours, followed by provisional or definitive fractures and traction injuries to the shoulder girdle. An abnormal
fixation, depending on the condition of the soft tissue envelope and vascular examination may be due to vascular spasm, external com-
the amount of wound contamination. Gustilo-Anderson type I, II, and pression, intimal tear, or disruption of the artery itself. If there is any
many type III fractures can be treated with irrigation and débridement suspicion of vascular injury or the vascular examination is abnormal
and immediate definitive fixation, followed by serial débridements every before or after gross realignment of fractures and reduction of dislo-
48 hours until the wound is clean. Some Type III injuries with severe con- cations, further investigation with an ankle-brachial index (ABI) is
tamination or soft tissue loss may require provisional external fixation recommended. If the ABI is less than 0.9, further investigation with an
28
and serial débridements until the wound is clean enough for definitive angiogram or magnetic resonance angiography is indicated even if
fixation and soft tissue coverage. For type IIIC injuries, the most pressing pulses are palpable due to the increased risk of delayed arterial compro-
concern initially is reestablishment of perfusion to the extremity. After mise secondary to intimal tear or thrombosis. External compression of
provisional fixation and vascular repair, serial débridements again may the artery usually can be relieved by reduction of the fracture or disloca-
be required before definitive fixation can be performed, with soft tissue tion, and vascular spasm usually resolves after reduction as well.
coverage as necessary. Prophylactic fasciotomies are frequently required Penetrating injuries such as gunshot and knife wounds also have a
to prevent reperfusion compartment syndrome. There is an increased high incidence of vascular injury. All structures in the path of the projec-
risk of infection and nonunion with increasing grade of injury. tile should be assessed from entry to exit wounds, including a generous
surrounding area of collateral damage (Fig. 121-8).
If the limb remains dysvascular, urgent operative intervention is
TABLE 121-4 Tetanus immunization Schedule
required because muscle necrosis begins after 6 hours of warm isch-
Tetanus-Prone emic time. The sequence of events for vascular repair usually begins
29
Non-Tetanus-Prone Wounds Wounds with provisional fracture stabilization with an external fixator or rapid
History of Absorbed Tetanus internal fixation followed by the establishment of a provisional shunt
Toxoid Number of Doses Td a TiG b Td TiG to restore perfusion. Definitive vascular repair, ideally with an end-
30
Unknown or less than three Yes No Yes Yes to-end anastamosis or saphenous vein graft, if necessary, then can be
performed, followed by definitive fracture fixation. Reperfusion edema
29
Three or more c No d No No e No and compartment syndrome are common; thus, a prophylactic fasci-
a Td: Tetanus and diphtheria toxoids absorbed—for adult use. For children under 7 years old, diphtheria otomy usually is indicated. Wound coverage by skin graft or free flap
and pertussis (dPT) (Td, if pertussis vaccine is contraindicated) is preferred to tetanus toxoid alone. For can be achieved after the wound has undergone serial débridements to
persons 7 years old and older, Td is preferred to tetanus toxoid alone. minimize the risk of wound infection and sloughing of the graft. 31
b TIG: Tetanus immune globulin—human.
Neurologic Injury: If the patient is awake and cooperative, a detailed neu-
c If only three doses of fluid toxoid have been received, a fourth dose of toxoid, preferably an absorbed rologic examination of each extremity should be done, with particular
toxoid, should be given. attention distal to the zone of injury. If the patient cannot participate
d Yes, if more than 10 years since last dose. in the examination, general observations of gross limb movements
e Yes, if more than 5 years since last dose. (More frequent boosters are not needed and can accentuate and reaction to pain stimulus help establish baseline function. Most
side effects.) peripheral nerve injuries are neuropraxias, which begin to recover

section10.indd 1173 1/20/2015 9:21:27 AM