floating knee with vascular compromise - management

AOK team

Glan Clwyd Hospital * Dept of Orthopaedics

ø Scope of the problemø Classificationø Anatomyø Emergency department ø Orthopodø Management options ?ø Treatment algorithm

ø Severe soft tissue involvementø Other serious injuriesø Trauma =97 % ,gunshot, fall from heightø Male 20-30 years

ø Head 42% Chest 28% Abdo 16%ø Open #s 50%,Vascular injuries 30 % Nerve

injuries 10%ø Knee ligament injuries 30%ø Children uncommon

Floating knee – Blake and Mc Bryde 1975

• Popliteal artery at risk for being tethered • Adductor hiatus

• Soleus arch

• If blood flow through popliteal artery disrupted Inadequate blood supply distally

On site resus - paramedicsFluidsTourniquet Helicopter ?

Open fractureIrreducible dislocations 70 kg 5 litVascular injury Femur # ~ 2lit/Tibia # ~ 1litAmputation 3/5x100% = 60%Compartment syndromeUnstable pelvic fracture/ hemodynamic instabilityMultiply-injured patientSpinal cord injuryDisplaced femoral neck < 65 and talar neck fractures

ABC approach of ATLS Guides!!ABC approach of ATLS Guides!!

ø ATLSø BOA BAPRAS Guidance for open fractures ø Look up transfer protocol to tertiary institution

Temp 26 * Ph 6.4, she has a condition I have

not seen before ‘’Asystole’’

Resuscitate/TourniquetAssess/Order investigations

PhotographSplint

Call for help

Who goes first?-Discuss with vascular surgeon

Temporary shunts-Will benefit some patients

Fracture stabilization-Consider provisional ex fix

Salvage vs amputation-Trend toward salvage (LEAP)

Fasciotomies-Prophylactic after Ischemia

ø Progressive ischemiaø Compartment syndromeø Tissue necrosisø Blood loss

Irreversible damage after 6 hours

ø Vascular ø Bone

Major hemorrhage/hypotensionArterial bleedingExpanding hematomaAltered distal pulsesPallorTemperature differential between extremitiesInjury to anatomically-related nerve

Physical exam

Doppler pressure (ABI)

Duplex scanning

Arteriogram

Exploration

Careful physical exam and high index of suspicion are most important !

Blood loss

Ischemia

Compartment syndrome

Tissue necrosis

Amputation

Death

Level and type of vascular injury

Collateral circulation

Shock/hypotension

Tissue damage (crush injury)

Warm ischemia time

Patient factors/medical conditions

Rapid resuscitation

Complete, rapid evaluation

Urgent surgical treatment

PROTOCOL IS ESSENTIAL !

Direct pressureHemostatic packsTourniquetsPositioning Pressure points

“No patient should die from ext hemorrhage !”

Control bleeding

Replace volume loss

Cover wounds

Reduce fractures & dislocations

Splint

Re-evaluate

ø Gauze –celluloseø Chitosan P-NAGø Hemcon- cream side down !ø Zeoliteø Polysaccharidesø Fibrin

No ideal hemostatic pack developed yet

Asymmetric pulses warrant doppler examination (determine ABI)

Absent pulses warrant emergent vascular consultation/surgical exploration

Determine presence/absence of arterial supply

Assess adequacy of flow

PRESENCE OF SIGNAL DOES NOT EXCLUDE ARTERIAL INJURY !

NoninvasiveSafeRapidReliable for

Injury to arteries and veinsA-V fistulasPseudo aneurysms

Locates site of injury

Characterizes injury

Defines status of vessels proximal and distal

May afford therapeutic intervention

Alternative

Good sensitivity and specificity

Costs much more

ANGIOGRAPHY WILL DELAY REVASCULARISATION

It is not indicated in cases with absent pulses/complete transection, which should go immediately to surgery

Redmond, et al. Orthopedics 2008

Single view in operating room

Rapid

Excellent for detecting site of injury

Immediate exploration is indicated for:

Obvious arterial injury on exam

No doppler signal

Site of injury is apparent

Prolonged warm ischemia time

Vascular injuries are dynamicEvaluation should continue after the initial injury or

surgeryAdditional debridement and/or fixation undertaken

after successful revascularization

Circulation

Neurologic function

Compartment pressures

External fixation with vascular repairNailing ?2nd sitting in 2 weeksIntramedullary nailing - antegrade femur and tibia -retrograde femur,antegrade tibiaORIF plate and screws,MIPO

Tibial compartments decompression

Fasciotomy

DiscussionDiscussion