Chapter 96

Critical Care for the Orthopedic Patient

Although orthopedic patients with isolated extremity injuries or those undergoing elective procedures rarely require care within an intensive care unit (ICU), patients who have sustained multisystem injuries sustained by high-energy impacts or pelvic ring injuries generally require ICU-level care. The sequelae of these injuries can be widespread including, but not limited to, hypotensive shock, sepsis, acute respiratory distress syndrome (ARDS), pulmonary embolism, fat embolism, acute renal failure (ARF), acidosis, and death. This chapter introduces some of the unique aspects of care required for the musculoskeletal polytrauma patient. In addition, it describes musculoskeletal injuries of the extremities and pelvis, including their associated orthopedic procedures.

Approach to the Patient with Multiple Orthopedic Injuries

All trauma patients should be first evaluated and treated in accordance with the Advanced Trauma Life Support (ATLS) protocol outlined by the American College of Surgeons (see Chapter 95). Of note, patients with fractures of the acetabulum, pelvis, or femur may require a large resuscitation upon presentation. Following the initial resuscitation, all patients should undergo a secondary survey of all organ systems, including the musculoskeletal system. The musculoskeletal survey consists of a head-to-toe, systematic examination that begins with observation. The long bones, axial skeleton (spine, clavicle, pelvis), and joints should be palpated with adequate assessment and documentation of neurologic and vascular function. Range of motion of all major joints should be assessed to detect instability or limitations of motion. In addition, the presence of swelling, ecchymosis, crepitus, visible deformity, and pain will guide further intervention.

As part of the initial assessment, a radiographic trauma series can be performed that includes the lateral cervical spine, anteroposterior (AP) chest, and AP pelvis radiographs. In addition, two orthogonal radiographs should be obtained at regions identified from the secondary musculoskeletal survey as potentially injured. In such cases, imaging should include the joint proximal and distal to the region of interest. Increasingly, trauma centers are utilizing comprehensive computed tomography (CT) scans as they have been shown to be more sensitive than traditional radiographic and clinical examinations

Despite a thorough initial musculoskeletal survey, it is possible for injuries to be overlooked, particularly in the polytrauma or critically ill patient. Intensivists should be aware of this possibility and assess for injuries that may have not been detected upon presentation (e.g., developing ecchymoses over a fracture site). In the polytrauma patient, the rate of missed musculoskeletal injuries can be as high as 25%.

There has been an increased appreciation of the systemic impact that orthopedic injuries have on morbidity and mortality in the polytrauma patient. Much of this work has focused on understanding the outcomes associated with early total care (ETC) versus damage control orthopedics (DCO). The latter appears to be superior and involves the staged management and stabilization of the injuries in order to minimize the complications associated with the “second hit” (physiologic overload after acute trauma as a result of operative interventions) (Figure 96.E1) . As a result, an increasing number of patients with multiple orthopedic injuries are managed in the ICU for physiologic stabilization prior to definitive management. In contrast to thoracic and abdominal trauma, few orthopedic injuries require immediate surgical management before medical stabilization and optimization. Although not always visible, the energy that is required to induce a fracture can also significantly injure the surrounding tissue envelope. Such compromised soft tissue is not favorable for surgical intervention and can lead to sequelae such as infection, necrosis, or amputation. However, even patients who are felt to be too unstable for definitive fixation still require stabilization of their long bone injuries, compression of pelvic ring injuries, and reductions of dislocations despite their physiologic status.

Orthopedic Terminology

Knowing the fundamental nomenclature and vocabulary of orthopedics can facilitate greater understanding of the extent of injury as well as help effectively communicate to other physicians involved in the care of the patient.

The fracture location is generally described as diaphyseal (the shaft or mid-portion), metaphyseal (in between the mid-portion and joint), or intra-articular (within the joint). The fracture pattern is described as transverse, oblique or spiral, and simple or comminuted. The location and pattern of a fracture can help discern the particular mechanism of injury. Long bone fractures occur when energy imparted to the extremities cannot be dissipated in the soft tissues. Comminuted fractures are more apt to occur through higher energy mechanisms (such as a motorcycle collision) and may be more frequently associated with soft-tissue injury and exposed bone (i.e., open fracture). The type and rate of stress loading determine the fracture pattern. Slow torque typically causes a spiral fracture, whereas a high-energy direct blow will result in a comminuted fracture.

Closed Fractures

Fractures without soft-tissue injury such that the bone is not exposed are termed closed fractures. Fractures with a superficial laceration or abrasion near or at the fracture site are still considered to be closed. An intact soft-tissue envelope is associated with improved outcomes. Most closed fractures do not require immediate surgical fixation and can be temporized using external fixation, traction, or splints. However, delayed treatment of long bone injuries (e.g., femoral shaft fracture) or hip fractures, particularly in the elderly population, is associated with poor outcomes. Similarly, patients with soft-tissue compromise (i.e., a bone fragment tenting the skin) or progressive neurovascular compromise (i.e., worsening sciatic nerve function after a hip dislocation) should also be brought to the operating room (OR) on an urgent basis to prevent permanent damage.

Open Fractures

Fractures with soft-tissue injuries allowing the bone to communicate with the environment are termed open fractures. Open fractures are often associated with high-energy mechanisms or penetrating trauma. These fractures have an increased rate of complications due to soft-tissue disruption and colonization of bacterial flora within the wound. In addition to the general strategies utilized for closed fracture care, open fractures are often taken to the OR on an emergent basis to help prevent infection.

Figure 96.E1 Algorithmic care of the polytrauma orthopedic patient.

Dislocations

When sufficient translational, rotational, or distractive forces are exerted across a joint, the surrounding soft tissues, including ligamentous and tendinous structures, may become compromised. This can result in a dramatic disruption of the articular congruity of the joint, termed traumatic dislocation (Figure 96.E2) . Dislocations sustained from higher energy mechanisms are more prone to neurovascular injury, avascular necrosis, and posttraumatic arthritis. Such dislocations need to be reduced emergently by the orthopedic surgeon. Patients with unstable dislocations may require splinting or external fixation.

In patients who have had a dislocation reduced, it is imperative that the associated neurovascular status be monitored at least every 2 hours for the first 24 hours to detect further neurovascular damage should the joint spontaneously dislocate. High-energy dislocations are especially prone to neurovascular injury with up to 50% of high-energy knee dislocations associated with neurovascular injury of the popliteal structures.

Dislocation of the hip manifests symptomatically as pain and shortening. Depending on the direction of the dislocation, examination of the injured limb will reveal persistent rotation, flexion/extension, or an abduction/adduction deformity. Dislocations associated with acetabular fractures have the worst prognosis. Patients presenting to the ICU after having been reduced will often have some form of traction or abduction pillow present to help stabilize the limb. Flexion, internal rotation, and adduction should be avoided. Keeping the limb in its reduced position is critical to maintaining joint congruity. Dislocation of the hip can result in sciatic nerve palsy or avascular necrosis of the femoral head. When such an injury is present, the neurovascular status and the limb alignment should be assessed frequently.

Elbow dislocations usually occur as a result of falling on an outstretched forearm. Patients may need operative treatment for grossly unstable elbow fractures. Prior to operative intervention the elbow should be held in a splint or sling in pronation. Shoulder dislocations often require patients to be completely immobilized in a brace for up to 3 weeks following injury. As with all dislocations, the patient’s neurovascular status should be monitored and documented regularly.

Patients with unreduced dislocations and concomitant head injury are at an extremely high risk for heterotopic ossification. This excess bone formation can complicate outcomes as patients improve from their head injury. It is imperative that patients who have a traumatic brain injury be closely assessed for dislocations, particularly of the elbow, hip, and shoulder, to limit further long-term disability. Heterotopic ossification can lead to limitation in joint mobility, contractures, and problems with hygiene, soft-tissue breakdown, and neurologic complications. If severe, patients may require an amputation.

Orthopedic Care and the ICU

Open Fracture Care

The hallmark of open fracture treatment is preventing infection and maintaining the soft-tissue envelope. Open fractures require emergent surgical debridement for the removal of nonviable tissue and irrigation for decontamination of viable tissue. Debridement and irrigation should be performed within 6 hours from the time of injury. Other priorities in the immediate period include tetanus prophylaxis, intravenous (IV) antibiotics (e.g., generally a cephalosporin with or without an aminoglycoside), clean dressing for the wound, and removal of gross contamination. These efforts are vital for preventing loss of limb, osteomyelitis, gangrene, and sepsis.

Prophylactic antibiotic treatment is guided by the type of open fracture (Table 96.1). Open fracture typing is based on the degree of soft-tissue involvement and the energy of the injury. The degree and type of contamination must also be considered

TABLE 96.1

Gustilo-Anderson Classification of Open Fractures