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Course Lectures
The American Academy of Orthopaedic Surgeons




Printed with permission of the American Academy of

Orthopaedic Surgeons. This article, as well as other lectures
presented at the Academys Annual Meeting, will be available
in March 2010 in Instructional Course Lectures, Volume 59.
The complete volume can be ordered online at,
or by calling 800-626-6726 (8 A.M.-5 P.M., Central time).
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Adult Trauma: Getting Through the Night

By Andrew H. Schmidt, MD, Jeffrey Anglen, MD, Arvind D. Nana, MD, and Thomas F. Varecka, MD

An Instructional Course Lecture, American Academy of Orthopaedic Surgeons

There has been a dramatic change in the be time to safely transfer the patient to a based on animal experiments per-
approach to the treatment of acute specialized center, and emergent treat- formed in the 1890s and is not sup-
musculoskeletal injuries over the past ment directed at the specific problem ported by modern human clinical
decade. The previous emphasis on so- must be provided. Emergent treatment studies. The LEAP study, a prospective
called early total care, which advo- of open fractures, compartment syn- multicenter investigation of severe open
cated immediate definitive repair of all drome, and hemodynamic instability in lower-extremity fractures, showed no
injuries, has shifted to an approach a patient with a pelvic fracture as well as relationship between the time from the
emphasizing damage control ortho- damage control in multiply injured injury to the surgery and subsequent
paedics for a multiply injured patient. patients should be understood by all infection1. Multiple retrospective series
In this new paradigm, definitive repair who treat musculoskeletal injuries. Fi- of open fractures have also failed to
of fractures is delayed until the patient nally, a less-often discussed but no less support the six-hour rule,2-4 and re-
is stabilized physiologically, associated important aspect of surgical care that cent literature reviews have revealed
soft-tissue injuries (if present) have may affect initial treatment decisions scant support for emergency surgical
healed, and optimum resources are and outcome is sleep deprivation and de bridement of open fractures5,6. The
available. However, there remain situa- fatigue of the members of the surgical current consensus favors prudent early
tions in which immediate treatment team. surgery within the first twenty-four
may be needed, such as in a patient with hours.
a pelvic ring injury and hemodynamic Open Fractures The initial surgical procedure for
instability, a compartment syndrome, or Traditionally, the initial management of an open fracture is de bridement and
an irreducible joint dislocation with open fracture wounds was de bridement irrigation of the open wound. The
associated neurovascular compromise. within six hours after the injury to purpose of de bridement is to remove
In these circumstances, there may not prevent infection. That guideline was foreign material, contaminating patho-
gens, and devitalized host tissue. The
principles of the surgical procedure
Look for this and other related articles in Instructional Course Lectures, include (1) extension of the traumatic
Volume 59, which will be published by the American Academy of wound longitudinally, with the surgeon
Orthopaedic Surgeons in March 2010: being careful to consider options for
future closure and proceeding system-
 Acute Trauma to the Upper Extremity: What to Do and When to Do It, atically through each tissue layer from
by Jennifer Moriatis Wolf, MD, George S. Athwal, MD, FRCS(C), superficial to deep; (2) careful inspec-
Alexander Y. Shin, MD, and David G. Dennison, MD tion of surfaces, with preservation of
critical tissue such as skin and articular

Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. One or more of the
authors, or a member of his immediate family, received, in any one year, payments or other benefits or a commitment or agreement to provide such
benefits from commercial entities (Smith and Nephew [in excess of $10,000] and Medtronic, DGIMed Ortho, Conventus Orthopaedics, Twin Star Medical,
AGA, and Thieme, Inc. [less than $10,000]).

J Bone Joint Surg Am. 2010;92:490-505

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surfaces when possible; and (3) thor- that have been adequately de brided and type-III open fractures, amino-
ough removal of foreign material and cleaned can be closed safely, if closure glycosides were added and treatment
dead tissue. Doing this well requires can be done without tension. If these was extended to five days. It has been
attention, patience, and surgical judg- conditions cannot be met, the fracture suggested that penicillin be added to the
ment. Tissue viability is dynamic, and wound should be covered, within regimen for agricultural injuries with
initially it is not possible to determine a week, by delayed primary closure, soil contamination because of the risk of
precisely which tissue will survive. skin-grafting, rotational flaps, or free clostridial infection. However, these
Usually, repeat examination is necessary tissue transfer. During the time before recommendations are based on poorly
to ensure adequate removal of dead definitive coverage, the wound tissues designed studies done more than twenty
tissue. Open wounds do not necessarily should be protected from desiccation years ago12,13. More recent data support
adequately decompress tissue compart- with appropriate dressing techniques. a shorter duration (twenty-four to
ments, and compartment syndrome is Two methods in use are the antibiotic forty-eight hours) of first-generation
a risk with many high-energy fractures. bead-pouch technique and the Vacuum cephalosporin antibiotics and no addi-
Irrigation of open fracture wounds Assisted Closure device (wound V.A.C.; tional drugs for coverage of gram-
cleans the wound by removing addi- KCI, San Antonio, Texas). The antibi- negative or clostridial organisms14,15.
tional debris and lowering the bacterial otic bead-pouch technique is a simple
load. The irrigation volume, pressure, method in which handmade polymeth- Compartment Syndrome
mode of delivery, and additives are all of ylmethacrylate beads are placed on Acute compartment syndrome can
potential importance, but little infor- a strand of heavy suture or 18-gauge complicate any extremity injury, but it is
mation is available about these param- surgical wire and placed into the most common in patients with tibial
eters. Animal studies suggest that wound; the wound is covered with an fracture, especially in men under the age
increasing the volume of fluid improves occlusive adhesive barrier such as of thirty-five years16. Patients with fore-
removal of particulate debris and bac- OPSITE Post-Op (Smith and Nephew, arm fracture are the second most
teria up to a point7, but there are no Memphis, Tennessee) or Ioban (3M, St. common group. Although acute com-
clear clinical guidelines regarding this Paul, Minnesota). partment syndrome occurs as a result of
parameter. Although there are no spe- Stabilizing open fractures pro- the initial injury, it is important to
cific data to support this recommenda- motes healing and infection resistance. remember that acute surgical stabiliza-
tion, we suggest an empiric protocol of The choice and timing of fixation tion can increase the risk of the
using 9 L (three 3-L bags) of fluid for strategy depends on the characteristics syndrome17,18. The diagnosis can be
Gustilo type-III open fracture wounds, of the patient, the injury, the surgeon, difficult, and it should be considered for
6 L (two bags) for a type-II wound, and and the operating room resources. In all patients with an extremity injury.
3 L for a type-I wound. High-pressure general, immediate plate fixation of Acute compartment syndrome is a sur-
irrigation has been shown to drive open fractures of the lower extremity gical emergency because a delay in
contamination into the tissue, damage should be avoided because of an in- treatment may be associated with sub-
bone, delay healing, and impair in- creased risk of infection, although stantial short and long-term morbidity
fection resistance in animal models and immediate plate fixation of upper- related to the degree of muscle necrosis
in vitro experiments8. Pulsatile delivery extremity open fractures can often be that occurs. In the early phase, mor-
of fluid has no proven advantage9. done safely. Acute intramedullary nail bidity is related to potential renal
Irrigation-fluid additives have included fixation of open fractures of the lower impairment from rhabdomyolysis,
antiseptics, antibiotics, and soaps. An- extremity can be acceptable, provided whereas long-term disability is related
tiseptics such as Betadine (povidone- that a clean wound with viable bone and to the degree of functional impairment
iodine) or hydrogen peroxide are toxic soft tissues is achieved with irrigation caused by muscle fibrosis and neural
to host immune cells and should not be and de bridement. Temporary external dysfunction. Not surprisingly, delayed
used; antibiotics are of no proven value fixation, often spanning injured joints, diagnosis of acute compartment syn-
in open fracture wounds. Soap solutions is a useful strategy to protect soft tissues, drome is a common reason for litigation
help to remove dirt and bacteria allow adequate time for planning, and against physicians19,20.
through disruption of the hydrophobic avoid performing complex procedures
and electrostatic forces that bind them in the middle of the night. When done Clinical Diagnosis of
to surfaces. In one prospective clinical for a severely, multiply injured patient Compartment Syndrome
study, soap solution was compared with with unresolved physiologic issues, this Acute compartment syndrome is typi-
antibiotic solution for open fracture strategy is known as damage control cally diagnosed on clinical grounds. The
wounds and soap was found to have an orthopaedics.11 classic symptoms of acute compart-
advantage10. Antibiotic treatment is one of the ment syndrome are known as the five
Traditional teaching dictates that most important aspects of open fracture Pspain, pallor, pulselessness, pares-
open fracture wounds should not be care. Traditionally, cephalosporin anti- thesia, and paralysisbut these are late
closed; however, low-energy wounds biotics were used for three days. For findings. Escalating pain, pain with
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passive stretch of the involved muscle, whom a clinical examination is not within 40 mm Hg of their mean arterial
and numbness are the clinical clues of possible, such as those who are intoxi- pressure (an alternative definition of
an acute compartment syndrome. These cated or have a head injury or those who a borderline perfusion pressure), yet
criteria are subjective and may be are already intubated. Typically, intra- none had signs of sequelae of com-
attributed to the associated fracture. muscular pressure is measured in the partment syndrome25. Thus, a rising or
This diminishes their diagnostic value. anterior, lateral, and deep posterior sustained elevated pressure (or inade-
Avoiding regional anesthetic blockade compartments of the leg with use quate perfusion pressure) is a more
and patient-controlled analgesia, which of either a commercially available important indication of an acute com-
can completely mask the pain that device such as the Stryker Intra- partment syndrome and a better in-
occurs with acute compartment syn- Compartmental Pressure Monitor Sys- dicator of the need for fasciotomy than
drome, is recommended21. Peripheral tem (Stryker, Kalamazoo, Michigan) or is a single pressure.
nerves are sensitive to ischemia; there- an arterial line manometer. Both tech- How to accurately assess perfu-
fore, hypoesthesia in the distribution niques have acceptable accuracy 29. In- sion pressure in patients who are under
innervated by a peripheral nerve located tramuscular pressures vary within each anesthesia is not known. While a patient
within the involved compartment is an compartment, with measurable differ- is under anesthesia, the blood pressure
important early finding in acute com- ences occurring at distances as close as may be artificially low, leading to an
partment syndrome22,23. However, neu- 5 cm from the site at which the highest inaccurately small perfusion pressure,
rologic deficits may be due to the initial pressure was recorded30. Intramuscular and to unneeded surgery if that pressure
trauma and are therefore not specific. pressures are also influenced by the is used to decide whether a patient
The variability in the clinical signs position of the adjacent joints31. needs a fasciotomy. Kakar et al. recorded
and symptoms of acute compartment The most well-supported thresh- blood pressures in a series of patients
syndrome makes the accuracy of clinical old for fasciotomy appears to be a per- undergoing tibial nail fixation36. Di-
diagnosis poor, and the sensitivity and fusion pressure of <30 mm Hg32-34. The astolic blood pressure during surgery
positive predictive value of clinical perfusion pressure (DP, or delta P) is was lower than that either before or
findings are low24. In contrast, the equal to the diastolic blood pressure after surgery, but the postoperative
specificity and negative predictive value minus the intramuscular pressure. diastolic blood pressure was predicted
of clinical signs are high, meaning that When the perfusion pressure is 30 mm by the preoperative blood pressure.
the absence of clinical findings associ- Hg, it is safe to assume that the patient Therefore, a more accurate measure-
ated with compartment syndrome of does not have an acute compartment ment of an anesthetized patients per-
the leg is more useful for excluding the syndrome. Conversely, when DP is fusion pressure should be based on the
diagnosis than the presence of findings <30 mm Hg for a sustained period of preoperative diastolic pressure rather
is for confirming the diagnosis24. Given time, compartment syndrome may be than the intraoperative pressure. The
the uncertainty in the clinical diagnosis present and fasciotomy is recommended. only caveat to this is that, if the patient is
of acute compartment syndrome, a high To improve the diagnosis of to remain under anesthesia for some
index of suspicion must be maintained compartment syndrome and eliminate time, the intraoperative blood pressure
when caring for patients at risk. the need to perform multiple serial should be used.
intramuscular pressure measurements,
Measurement of continuous intramuscular pressure Surgical Treatment of
Intramuscular Pressure monitoring has been advocated33,35. Compartment Syndrome
By definition, intramuscular pressure is McQueen et al. demonstrated that Once identified, compartment syn-
elevated in cases of acute compartment continuous pressure monitoring of the drome must be treated with prompt
syndrome, but, because there is wide anterior compartment of the leg in fasciotomy.
variation in intramuscular pressure a cohort of patients with a tibial fracture Early diagnosis of acute com-
among patients with tibial fractures and in whom a compartment syndrome partment syndrome and prompt fasci-
since many patients without compart- developed led to a marked reduction in otomy have been shown to lead to
ment syndrome can have intramuscular the sequelae of acute compartment more rapid union and improved func-
pressures exceeding 30 mm Hg, the syndrome, presumably because the di- tion in patients with a tibial fracture32,33.
direct measurement of intramuscular agnosis was made earlier33. One impor- In contrast, if fasciotomy is done too
pressure is not diagnostic25. Intramus- tant benefit of continuous monitoring is late, the procedure may have little
cular pressure measurement is an ad- that the time trend of intramuscular benefit and may actually be harmful37.
junct to the clinical examination and is pressure is an important variable that Fasciotomy that is performed after
indicated for any patient with equivocal cannot be assessed on the basis of myonecrosis has occurred exposes the
findings; no reliable diagnostic thresh- a single measurement. Prayson et al. necrotic tissue and can lead to bacterial
old has yet been described26-28. Intra- reported that 53% of the patients in colonization and infection. Finkelstein
muscular pressure measurement is the their series had at least one intramus- et al. reviewed the cases of five patients
sole means of diagnosis for patients for cular pressure measurement that was in whom fasciotomy had been per-
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formed more than thirty-five hours after of the tibia. The saphenous vein and order to avoid later contracture, and
the injury. Of these five patients, one nerve should be identified. The fascia then it is continued distally along the
died of multiple organ failure and the of the gastrocnemius-soleus complex volar aspect of the forearm as needed.
others had amputation of the limb37. should be completely released. Distally, Although rarely necessary, the triceps
the soleus bridge (representing the can be decompressed with use of
Technique of Fasciotomy condensation of the anterior and pos- a separate posterior incision. Adequate
The fasciotomy is done by making terior investing fibers of the soleus decompression of the forearm requires
a longitudinal skin and fascial incision muscle) should be specifically released release of a number of potential sites of
over the entire compartment with re- from the posterior aspect of the tibia in compression, including the lacertus
lease of all constricting tissues. An order to completely decompress the fibrosus, all muscle fascia, and the flexor
inadequate skin incision can contribute flexor digitorum longus and tibialis retinaculum. First, the incision is con-
to persistent elevation of intramuscular posterior muscles. tinued along the medial border of the
pressure38. The precise incisions to be Single-incision fasciotomy of the mobile wad, consisting of the brachio-
made and the structures that require leg: To perform a single-incision fasci- radialis and radial wrist extensors,
release vary depending on the situation. otomy, a single lateral incision, ex- which are released. The fascia of the
Two-incision fasciotomy of the leg: tending from the neck of the fibula to digital flexors, supinator, and pronator
Fasciotomy of the leg can be done the lateral malleolus, is made. Fibulec- quadratus is released as needed. Rarely,
safely and easily with use of two tomy is not necessary39. The anterior a separate dorsal forearm fasciotomy is
incisions: one lateral and one medial. and lateral compartments are released needed. Finally, a standard carpal tunnel
The anterior and lateral compartments in the manner described for the release is performed at the wrist, with
are released separately through the two-incision fasciotomy. The superfi- the incision again crossing the wrist
lateral incision. The superficial poste- cial posterior compartment (the flexion crease in a zigzag fashion to
rior compartment may be released gastrocnemius-soleus muscle complex) avoid contracture. Injury to the palmar
through either incision. The deep is released by elevating the skin poste- cutaneous branch of the median nerve
posterior compartment is released riorly. Finally, a parafibular approach is must be avoided. If the hand is also
through the medial incision. The in- used to decompress the deep posterior involved, release of the thenar, hypoth-
tervening skin flap is at risk for necrosis compartment. The peroneal muscles are enar, and interosseous muscles of the
if there has been damage to the anterior retracted anteriorly, and the dissection hand is performed separately with
tibial artery. Therefore, when the is carried posteriorly to the fibula. With use of longitudinal dorsal incisions
anterior tibial artery is known to be or the lateral head of the gastrocnemius- between the second and third meta-
suspected of being injured, a single- soleus retracted posteriorly, the septum carpals and between the fourth and fifth
incision four-compartment release dividing the superficial and deep pos- metacarpals.
from a lateral approach is recom- terior compartments can be identified Management of fasciotomy
mended. To perform a two-incision and released. If access to the deep wounds: An advance in the management
fasciotomy, initially a lateral incision posterior compartment is difficult, of fasciotomy wounds is the wound
is made midway between the fibula a medial incision can always be made as V.A.C. device. When applied at the time
and the anterior crest of the tibia. The described above. of fasciotomy, the wound V.A.C. device
skin is gently retracted anteriorly and Upper-extremity fasciotomy: The may allow earlier closure of the fascio-
posteriorly to expose the fascia of the muscles of the entire upper extremity tomy site and a decreased need for skin-
anterior and lateral compartments, can be decompressed with use of an grafting40. Closure of the fasciotomy site
respectively. The lateral intermuscular extended anterior incision extending before five days is not recommended
septum that divides the anterior and from the shoulder to the wrist. In the and can be associated with recurrent
lateral compartments and the superfi- upper arm, anterior release of the biceps compartment syndrome41. Skin-grafting
cial peroneal nerve are identified. The and brachialis can be extended across is associated with fewer complications
peroneal muscle fascia is usually re- the elbow and incorporated into a volar than is either primary or delayed wound
leased first. Finally, the anterior com- fasciotomy of the forearm. In turn, the closure42.
partment fascia is completely released. volar forearm release can be extended
Alternatively, the fascia overlying one into the palm of the hand to release the Damage Control Orthopaedics
compartment can be released, followed median (carpal tunnel) and ulnar The understanding of the role of
by division of the intermuscular sep- nerves (Guyon canal). Beginning with orthopaedic resuscitation in the overall
tum to decompress the other com- the upper arm, an anterior incision is management of multiply injured pa-
partment. However, iatrogenic injury made along the medial edge of the tients has changed dramatically in re-
to the superficial peroneal nerve may biceps. The fascia of the biceps and cent years. The potential benefits of
be more likely with this technique39. underlying brachialis are released. The optimal fracture care in this patient
Next, the medial incision is made 1 cm incision is extended across the flexion population include (1) facilitating
posterior to the posteromedial border crease of the elbow in a zigzag fashion in overall patient care, (2) controlling
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coagulopathy in patients exsanguinating Damage control orthopaedics is

TABLE I Specific Markers and from penetrating abdominal trauma45. defined as the provisional stabilization
Mediators of Damage
Control Surgery
In 1993, the report by Pape et al. of of musculoskeletal injuries in order to
increased pulmonary complications in allow the patients overall physiology to
Base deficit or serum lactate multiply injured patients undergoing improve. The primary tactic of damage
(hypovolemic shock) immediate femoral nailing44 ushered in control orthopaedics is to use traction
Soluble thrombomodulin the era of damage control orthopae- or external fixation as the means of
(endothelial injury) dics, and the new paradigm is best provisional stabilization. The purpose
Polymorphonuclear elastase described as optimal surgery rather of damage control orthopaedics is to
(tissue injury) than maximal surgery. avoid the worsening of physiologic
Interleukin-6 (pro-inflammatory In the past decade, substantial parameters related to the second hit of
cytokine) work has been done to define which a major orthopaedic procedure by
Interleukin-10 (anti-inflammatory group of patients can be safely treated delaying definitive fracture repair until
cytokine) with maximal fixation and which the patients physiology is optimized. In
Human leukocyte antigen DR should have damage control surgery this approach, the focus is on control-
(resistance to infection) only. In general, the early death of ling the bleeding, managing the injuries
a multiply injured patient is caused to the soft tissues, and achieving pro-
by primary brain injuries and major visional fracture stability.
bleeding, (3) decreasing additional soft- blood loss, whereas late death is due
tissue injury, (4) avoiding further acti- to secondary brain injury and host Pathophysiology of Trauma
vation of the systemic inflammatory defense failure46. The first hit (initial Cytokines, leukocytes, the vascular
response, (5) removal of devitalized trauma) results in hypoxia, hypoten- endothelium, and endothelial-
tissue, (6) prevention of ischemia/ sion, organ and soft-tissue injuries, leukocyte interactions are the key
reperfusion injury, and (7) pain relief. and fractures. The second and sub- determinants of the response to injury.
Until recently, appropriate fracture sequent hits (surgical procedures Typical physiologic changes that occur
care in a multiply injured patient was and sepsis) lead to hypoperfusion, after trauma are increased capillary
considered to be fixation of all fractures hypoxia/ischemia, reperfusion, blood permeability in the lung, gut, blood
as soon as possible. This was thought to loss due to acute endothelial injury, vessels, and muscle. The lung paren-
decrease the inflammatory load through and tissue damage causing local chyma is most affected in trauma
stabilization of bone and soft tissue, necrosis, inflammation, and acidosis. patients. The largest capillary bed in
and all long-bone fractures were de- Any type of surgical procedure that the body is found in the lung, and
finitively stabilized within twenty-four induces substantial bleeding and/or pulmonary edema is a frequent sign
hours (or as soon as possible) so that the soft-tissue damage can be sufficiently of increased pulmonary permeability.
patient could be positioned upright for traumatic to the patient to represent As is the case in the lung, increased
adequate pulmonary toilet. The para- a second hit. permeability of the blood vessels leads
digm at the time was This patient is too
sick not to be treated surgically. In
a landmark study, Bone et al. showed
that this type of management resulted in TABLE II Parameters to Consider When Deciding to Implement Damage Control
Orthopaedic Protocol
fewer days of ventilator treatment, fewer
days in the intensive-care unit, and lower Polytrauma with Injury Severity Score of >20 points and additional thoracic trauma
prevalences of multiple organ failure and 83
(Abbreviated Injury Scale score of >2 points)
mortality43. Polytrauma with abdominal and pelvic injuries and hemorrhagic shock (systolic blood
About fifteen years ago, published pressure of <90 mm Hg)
reports began to suggest that, in some Injury Severity Score of 40 points without additional thoracic injury
cases, this aggressive initial management Initial pulmonary artery pressure of >24 mm Hg
might be harmful44. The term damage
Increased pulmonary artery pressure of >6 mm Hg during intramedullary nailing
control was originally coined by the
United States Navy to describe the Difficult resuscitation
repair of damaged sea vessels in combat Platelet count <90,000/mL (<90 109/L)
to allow continued use. An approach Hypothermia (e.g., temperature of <35C)
best described as damage control Transfusion of >10 units of blood
surgery was reported by Rotondo et al., Bilateral lung contusion on initial chest radiograph
who used rapid but nondefinitive con- Multiple long-bone fractures and truncal injury
trol of hemorrhage to avoid the lethal
Prolonged duration of anticipated surgery (>90 min)
triad of acidosis, hypothermia, and
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been shown to play a role with IL-6,

TABLE III End Points for Damage Control Resuscitation IL-10, tumor necrosis factor (TNF),
84 and HLA-DR47. A base deficit or
elevated serum lactate level is consid-
Stable hemodynamics
ered evidence of continued metabolic
Stable oxygen saturation
acidosis. A serum lactate level of
Lactate level of <2 mmol/L
>2.5 mmol/L can indicate occult
No coagulopathy
hypoperfusion and can be used to
Normal temperature judge a patients suitability for surgery.
Urinary output of >1 mL/kg/hr Crowl et al. showed that, when a nail
No inotropic support is used to stabilize a femoral fracture
Tscherne et al. within twenty-four hours after the
No increasing infiltrate on chest radiograph injury, there is a twofold higher in-
Balanced or negative fluid balance cidence of postoperative complica-
PaO2/FiO2 (arterial oxygen tension/fraction of inspired oxygen) of >250 tions if the serum lactate level is
Pulmonary artery pressure of <24 mm Hg >2.5 mmol/L48. Four hours after fem-
Maximal inspiratory airway pressure of <35 cm H2O oral nailing (with or without reaming),
Platelet count of >95,000/mL (>95 109/L) markers associated with the systemic
White blood-cell count of <12,000/mL (>12 109/L) inflammatory response are elevated49.
Intracranial pressure of <15 cm H2O Waydhas et al. demonstrated that
patients with a high polymorphonu-
clear elastase level combined with
to movement of fluid into the third tase, interleukin (IL)-6, IL-10, and a high C-reactive protein level and
space. Increased tissue permeability human leukocyte antigen (HLA) DR thrombocytopenia have a 79% in-
also results in translocation of bacteria (Table I). Genetic influences have also cidence of lung, liver, or kidney
in the gut. In muscle, edema and
bleeding can lead to compartment
The inflammatory response to
injury (first hit or second hit) includes
the systemic inflammatory response
syndrome, which is mediated by pro-
inflammatory cytokines, arachidonic
acid metabolites, proteins of the acute
phase/coagulation systems, complement
factors, and hormonal mediators. Sys-
temic inflammatory response syndrome
can lead to adult respiratory distress
syndrome and/or multiple organ failure.
Simultaneous with the onset of systemic
inflammatory response syndrome is the
counter-regulatory anti-inflammatory
response syndrome, which can cause
immunosuppression and subsequent
infection. The counter-regulatory anti-
inflammatory response syndrome is
described as endothelial cell damage,
accumulation of leukocytes, disseminated
intravascular coagulopathy, and micro-
circulatory imbalances that lead to apo-
ptosis and necrosis of parenchymal cells.
Measurement of specific markers
can help to quantify the inflammatory
responses. These markers include base Fig. 1-A
deficit or serum lactate, soluble thrombo- A severely displaced distal radial fracture, which was associated with evolving median
modulin, polymorphonuclear elas- nerve symptoms.
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failure50. IL-6 concentration has also expression is associated with sepsis orthopaedic protocols are followed,
been shown to be a reliable index of and death54. initial stabilization of fractures is
the magnitude of injury (burden of Timely analysis of specific achieved with minimal blood loss,
trauma) and of the second hit pro- markers and factors may not be fluid shifts, hypothermia, or pro-
duced by the surgical procedure49. If possible in many facilities. In the longed surgical time. Options for
the initial IL-6 level is >500 pg/dL (>5 absence of precise biomarker data, the fracture stabilization in damage con-
mg/L), then definitive surgery should orthopaedic surgeon may have to rely trol orthopaedic protocols include
be delayed for at least four days after on physiologic and clinical parameters skeletal traction, splints or casts,
provisional stabilization surgery51. to guide decision-making (Table II). intramedullary nail fixation, conven-
Patients with a high Injury Severity The following injuries are usually best tional plates, minimally invasive
Score52 have an elevated IL-6 level for managed with the damage control plates, and external fixation. External
more than five days. The potent anti- orthopaedic protocol: femoral shaft fixation is the preferred method of
inflammatory cytokine IL-10 also in- fracture in a multiply injured patient, initial stabilization because it can be
hibits TNF-a and IL-1 expression and pelvic ring injuries with substantial done quickly with minimal blood loss.
negatively regulates HLA-DR expres- hemorrhage, and polytrauma in a ge- Nana and Kessinger showed that use of
sion. Giannoudis et al. showed that riatric patient. Pape et al. described the spanning external fixation for complex
elevated initial and persistently ele- criteria for implementing the damage distal tibial fractures that are treated
vated IL-10 levels correlate with sep- control orthopaedic protocol to include immediately improves skin
sis53. HLA-DR is an indicator of a serum lactate level of >2.5 mmol/L, perfusion56.
resistance to infection and is expressed a base excess of >8 mmol/L, a pH of After provisional stability has
by circulating monocytes. It is re- <7.24, a temperature of <35C, sur- been obtained, definitive surgery is
quired for antigen presentation and gical time of more than ninety min- considered only after the patient has
helper T-lymphocytes and thus plays utes, coagulopathy, and transfusion of been adequately resuscitated. End
a central role in the immune response more than ten units of packed red points for resuscitation with use of
to infection. Diminished HLA-DR blood cells55. When damage control damage control principles are

Fig. 1-B
The wrist after immediate temporary treatment with an external fixator.
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outlined in Table III. A simplified is the source of bleeding in an unstable motor function and the sensation in the
guideline is to proceed with defini- patient. lower extremities should be docu-
tive surgery when fluid balance is 2. Although the anatomic and mented. The examiner should look for
negative. mechanistic classifications of pelvic ring asymmetry and/or deformity of the iliac
injuries are useful, they are not perfectly crest, limb-length inequality, and skin
Hemodynamic Instability in predictive of the risk of bleeding. lesions (including any open wounds and
Patients with a Pelvic Ring Injury 3. Pelvic ring compression with areas of closed degloving). Every patient
Up to 40% of patients with an unstable sheets is a simple and effective treatment should have a rectal examination, the
pelvic ring injury die from their injuries, for immediate management of bleeding prostate should be examined in males,
and hemodynamic instability is the in patients with an open-book injury. and the vagina should be examined in
main predictor of death. The initial 4. The role of immediate angiog- females, as lacerations in these locations
management of patients with a pelvic raphy instead of operative exploration may be the site of an open pelvic
ring injury, including the assessment remains controversial and probably fracture.
and management of hemodynamic in- varies depending on institutional re- Standard imaging of the pelvic
stability and acute (rather than de- sources and injury patterns. ring includes both plain radiographs
finitive) stabilization of the pelvic 5. The key to the correct initial and computed tomography scans. Ra-
injury, is critical. There are several key assessment of a pelvic ring injury is diographs should include anteroposte-
points to remember: careful evaluation of the radiographs for rior, inlet, and outlet views. A cystogram
1. Pelvic ring injuries are evidence of deformity and instability. should be done in all patients, and
markers of violent injury and are a retrograde urethrogram should be
associated with life-threatening hem- Assessment of Pelvic Ring Injury performed in male patients prior to
orrhage and injuries to other organs The physical examination of patients passage of a Foley catheter. Computed
and sites, including the abdominal with a pelvic ring injury is primarily tomography is done primarily to define
viscera and genitourinary system. It aimed at defining the neurovascular the posterior part of the pelvic ring;
should not be assumed that the pelvis status of the lower extremities. The axial views best demonstrate sacroiliac
joint injuries and sacral fractures. Ver-
tical displacement is underestimated on
anteroposterior radiographs and cannot
be measured on axial computed to-
mography cuts. Vertical displacement
can be determined on the inlet and
outlet radiographs of the pelvis.
Deformity and instability should
be established when radiographs of an
injured pelvis are evaluated. Deformity
is assessed on the basis of the relative
degree of internal or external rotation of
the iliac wing as well as anteroposterior
and/or vertical displacement of the
posterior aspect of the pelvis. A pelvic
fracture is considered to be unstable
when there is symphysis diastasis of
>2.5 cm, >1 cm of displacement of the
posterior part of the pelvis, complete
widening of the posterior sacroiliac
joint, and/or any neurologic injury.

Classification of Pelvic Ring Injuries

A fracture classification system should
group together fractures that have
a similar injury pattern, treatments,
potential complications, and sequelae.
With pelvic fractures, all of these are
primarily related to the condition of the
Fig. 1-C posterior aspect of the pelvic ring
After definitive fixation with a volar plate. because stability, neurologic injury,
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pelvic asymmetry, limb-length in-

equality, and persistent lumbosacral
pain are determined by the extent of
injury to the posterior aspect of the
pelvic ring.

Tile Classification
Pennal, Tile, and colleagues classified
injuries into three types57. Type-A in-
juries are stable with an intact posterior
arch. Type-B injuries are rotationally
unstable, with incomplete disruption of
the posterior arch. These are subdivided
into open-book or external rotation
injuries (Type B1), lateral compression
or internal rotation injuries (Type B2),
and bilateral injuries (Type B3). Finally,
Type-C injuries are both rotationally and
vertically unstable, and they are subdi-
vided into different types depending on
the nature of the posterior injury.

Young-Burgess Classification
Young, Burgess, and colleagues pro-
posed a mechanistic classification of
pelvic ring injury, noting a correlation
between the mechanism of injury and
associated complications58. They pro-
Fig. 2-A
posed four types of injuries: antero-
A high-energy distal radial fracture with acute carpal tunnel syndrome caused by a displaced
posterior compression (APC), lateral
volar fragment that was not reducible by closed means (arrow).
compression (LC), vertical shear (VS),
and combined. Each of these major
groups is further subtyped on the basis sion. In that series, the fracture potensive again, the source of bleeding
of the degree of displacement, defor- pattern and orthopaedic management should be found. Ultrasonographic
mity, and instability. did not differ between the stable examination of the abdomen and
patients and those needing angi- pelvis and computed tomography-
Hemodynamic Instability ography. Advanced age was signifi- angiography are the most common and
Hemodynamic instability is defined cantly correlated with an increased expeditious means with which to eval-
by shock (low blood pressure), meta- need for embolization in women only uate bleeding. If there are no other
bolic parameters (base deficit), and the (the mean age of the women who sources of bleeding except the pelvic
need for blood products. The risk of needed embolization was fifty-five fracture, angiography, circumferential
bleeding is correlated with the fracture years compared with forty years for compression (by means of a sheet,
pattern, but hemodynamic instability women not needing embolization), pelvic binder, or external fixation), or
can occur with any pelvic fracture59. while the Injury Severity Score corre- an exploratory laparotomy with vascu-
Anteroposterior compression (APC) lated with the need for embolization lar repair and packing of the pelvis are
pelvic injuries are more likely to be in men but not in women60. three ways to control the bleeding. The
associated with posterior bleeding, most appropriate choice is institution
whereas lateral compression injuries Treatment Options and/or physician-dependent, and the
are more often associated with ante- Fluid replacement is the initial treat- options have not been standardized.
rior vessel injury. Sarin et al. reviewed ment for a patient with a pelvic ring Angiography has a limited role in
the cases of 283 patients with a pelvic injury who is hemodynamically un- the management of patients with pelvic
ring injury who were in shock stable. Fluid replacement alone can ring injuries. Most bleeding after a pel-
(a systolic blood pressure of <90 mm increase bleeding in some instances and vic ring injury is venous, and emboli-
Hg) at the time of presentation60. should be used judiciously. If the patient zable arterial lesions are uncommon.
Thirteen percent required emboliza- does not respond to fluid replacement, Large-vessel embolization has also been
tion because of persistent hypoten- or initially responds but becomes hy- shown to cause extensive necrosis of the
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(96%) of them and was followed by

hemodynamic improvement in twenty-
one (84%)63.
Cook et al. reviewed the cases of
twenty-three patients with a pelvic
fracture who underwent angiography
and found that the fracture morphology
was not predictive of the location of the
vascular injury64. Six of ten patients who
died had had angiography as the first
therapeutic intervention. Five of the ten
patients had a fracture pattern that
produced an increase in pelvic volume
(APC or VS pattern), and two of those
patients died during angiography. Cook
et al. believed that these patients would
have been better treated with external
fixation before the angiography. Shapiro
et al. demonstrated that repeat pelvic
angiography might be necessary in
patients with persistent hypotension
after previous angiography, whether or
not arterial bleeding was identified
during the initial session65.
Circumferential compression, ex-
ternal fixation, and pelvic packing to
control pelvic stability are valuable
methods to help control bleeding. They
Fig. 2-B
reduce bleeding, lessen pain, and allow
Immediate open reduction and volar plate fixation with carpal tunnel release
the patient to be mobilized. Pelvic sta-
was performed.
bility should be achieved as soon as
possible after the injury and initial as-
hip abductor muscles61. Balogh et al. fluid resuscitation (500 mL of normal sessment. Simple wrapping of the pelvis
reported increased adherence to the key saline solution) and dopamine infusion with a sheet is now commonplace in the
steps of the guidelines and better clinical and who did not have thoracic and United States for any patient suspected
outcomes after institution of evidence- abdominal bleeding, cardiac tamponade, of having a pelvic ring injury. It is cheap
based practice guidelines that included or tension pneumothorax63. Twenty-five and simple, and it can be very effective.
abdominal clearance with diagnostic patients had positive results on angi- Bottlang et al. investigated stabi-
peritoneal aspiration/lavage or ultra- ography and underwent embolization. lization of pelvic ring fractures with
sound (FAST [Focused Assessment with There was no relationship between the slings in cadavers66. They demonstrated
Sonography in Trauma] examination), presence of an arterial lesion and the that circumferential compression with
noninvasive pelvic binding within fif- pelvic fracture pattern; in fact the only a noninvasive pelvic sling is an effective
teen minutes after presentation, pelvic significant differences between those and safe method for reducing and
angiography within ninety minutes after with and those without a lesion on stabilizing open-book pelvic fractures
admission, and pelvic external fixation angiography were the initial blood pres- (Young-Burgess APC II, APC III, and
within twenty-four hours62. In the sure (65 compared with 78 mm Hg) and LC II) at an emergency scene66. Pro-
period after the guidelines were in- the amount of blood products received. visional pelvic external fixation as an
stituted, the transfusion of packed red Thirteen patients had a laparotomy be- initial method of controlling bleeding
blood cells in the first twenty-four hours cause of expanding intraabdominal fluid; works but has a 21% rate of complica-
decreased from 16 2 units to 11 1 three of six laparotomy procedures that tions, which consist mostly of pin-track
units and the mortality rate decreased were done before angiography revealed infections without sequelae67. Cothren
from 35% to 7% (p < 0.05). negative findings, whereas only one of et al. reported a reduction in blood
Fangio et al. used angiography in seven done after angiography revealed product requirements and no deaths
thirty-two patients with an average In- negative findings. Twenty-five patients due to bleeding after instituting a pro-
jury Severity Score of 39 points who underwent embolization; pelvic arterial tocol of preperitoneal pelvic packing
remained hypotensive despite controlled bleeding was stopped in twenty-four and pelvic external fixation68.
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Recommended Algorithm for available, anterior pelvic external fixa- surgical emergency procedure is the
Treatment of Bleeding in tion or symphyseal plate fixation can be attempted replantation of an amputated
Patients with Pelvic Ring Injury done. Plate fixation is performed if the finger or limb. While a lengthy discus-
All patients identified with a pelvic ring patient undergoes a laparotomy; other- sion of this subject is beyond the scope
injury during initial resuscitation should wise, an external fixator is applied. of this review, it is important to bear in
be treated with a pelvic binder and Some apparent open-book injuries in- mind that replantation is time-sensitive.
a Foley catheter (after a retrograde clude vertically unstable posterior in- Restoration of arterial inflow and ve-
urethrogram and cystogram), and addi- juries for which posterior iliosacral nous outflow is vital for the successful
tional pelvic radiographs including inlet fixation is also warranted. The challenge salvage of the amputated part and
and outlet views and a pelvic computed is to identify these. recovery of as much function as
tomography scan should be obtained. Lateral compression injuries: These possible.
Fluid resuscitation is given with contin- are more stable, and early pelvic fixation Infectious processes require early,
uous monitoring of urine output, the is not beneficial. If these patients remain if not immediate, intervention. Infec-
base deficit, hemoglobin levels, and hemodynamically unstable, angiogra- tion causes fibrosis, adhesions, edema,
coagulation function. Mechanical insta- phy or laparotomy is indicated. stiffness, and other detrimental effects
bility of the pelvis is determined and, in Rotationally and vertically unstable that adversely affect the normal sliding
patients with persistent hypotension, injuries: Rarely, posterior pelvic clamp- and excursion of delicate hand and
subsequent management depends on ing in the operating room is done after upper-extremity structures. Immediate
the fracture pattern: angiography if the patient is persistently evacuation of pus and surgical control
Rotationally unstable injuries: Pa- hemodynamically unstable. of infection are mandatory as soon as
tients with these fracture patterns may they are feasible. Suppurative tenosyn-
respond to wrapping of the pelvis with Upper-Extremity Emergencies ovitis and septic arthritis caused by
a sheet or application of a binder. If The one absolute, nondeferrable, human bites, animal bites, or other
appropriate resources and expertise are middle-of-the-night upper-extremity penetrating injuries need immediate

Fig. 3-A Fig. 3-B

Fig. 3-A A comminuted femoral fracture presenting late in the evening. Fig. 3-B Immediate nailing was done during the
middle of the night. Postoperative radiographs revealed a missed distal interlocking screw (arrow).
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surgical treatment and antibiotic cover- diate or early intervention will not done on an urgent, not an emergent,
age with a third-generation cephalo- change the natural history of the nerves basis.
sporin. Ceftriaxone, or a similar recovery. Emergent surgery is not
antibiotic, should be used until specific warranted. Lower-Extremity Emergencies
culture and sensitivity results are avail- 2. The neurologic function de- Orthopaedic conditions in the lower
able. An infectious disease consultation teriorates during the process of exam- extremity that are emergent problems
should be considered. ination, initial treatment, or early include hip dislocation, displaced fem-
Deteriorating neurologic func- observation. This is essentially an im- oral neck fracture in any patient in
tion is an indication for at least pro- pending compartment syndrome of the whom femoral head salvage is desirable
visional, if not definitive, stabilization of carpal tunnel and requires emergent (most patients less than sixty-five years
an upper-extremity fracture (Figs. 1-A, carpal tunnel decompression (Figs. 2-A of age), knee dislocation, talar neck
1-B, and 1-C). A distal radial fracture and 2-B). Fracture reduction alone can fracture with displacement, and subtalar
due to a high-energy injury is particu- result in adequate decompression of dislocation.
larly noteworthy, if not notorious, in the median nerve (in cases in which Dislocation of the hip joint is
this regard, with respect to median neurologic compromise is caused by usually a high-energy injury that can
nerve compromise. There are three pressure from a displaced bone interrupt the blood supply to the
possible situations that can arise after fragment). femoral head and cause cartilage ne-
distal radial fracture that may lead to 3. Nerve function changes over crosis. Relocation should be done
acute dysfunction of the median nerve: a period of several days or weeks. This emergently to prevent irreversible
1. The median nerve is found to most likely represents alteration in damage to the joint, although reported
be impaired or nonfunctional at the nerve physiology secondary to inflam- time guidelines in the literature range
time of presentation. Under such cir- mation, hematoma organization, or from six to twenty-four hours. There
cumstances, the nerve was probably accumulation of acute phase media- are conflicting and strong opinions
injured at the time of impact, by stretch tors. Nerve decompression and irriga- from various experts, but good data are
or laceration (uncommon), and imme- tion are indicated, but this should be lacking69. Theoretically, an associated

Fig. 3-C
Revision surgery was required to replace the distal interlocking screw.
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Fig. 4-A Fig 4-B

Fig. 4-A Postoperative anteroposterior radiograph of a malreduced bicondylar tibial plateau fracture, with un-
acceptable residual articular step-off (arrow). Fig. 4-B Anteroposterior radiograph after revision fixation showing
anatomic reduction of the articular surface.

acetabular fracture changes the urgency due to interposed fragments from the release the hemarthrosis is controversial.
by decompressing both the soft-tissue femoral head or from the acetabulum, In a young patient with a nondisplaced
tension and the hematoma. An expedi- and such a dislocation should be or minimally displaced fracture, the
tious relocation of the dislocated hip treated in the operating room, where capsule may be competent and the
makes sense, if only from the point of trochanteric osteotomy may be neces- formation of a tense hemarthrosis may
view of reducing the patients pain. sary to facilitate reduction71,72. If a pa- compress the blood vessels supplying the
Certainly, patients should not be trans- tient has an unstable closed reduction femoral head. In that setting, an open
ferred to other centers with a hip that is or a dislocation with interposed frag- or percutaneous capsulotomy may im-
still dislocated. ments, skeletal traction should be used prove the blood flow to the head,
A variety of reduction maneuvers until definitive surgical treatment is although this remains unproven. How-
have been described, including the accomplished. ever, there are risks to this procedure,
Allis, Bigelow, Stimson, and East Bal- A femoral neck fracture in including damage to those very same
timore lift70 maneuvers. Adequate pain a young patient requires emergent blood vessels.
control, relaxation, and assistance are reduction and fixation to protect the Dislocation of the knee joint
required. If one or two gentle and blood supply to the femoral head, and (that is, the femorotibial articulation,
controlled attempts at reduction are a controllable factor in outcome is the as opposed to the patellofemoral ar-
unsuccessful, additional treatment quality of the reduction. An anatomic ticulation) is a high-energy injury
should be carried out in an operating reduction is recommended even if it and can be limb-threatening because
room with the patient under general must be performed in an open fashion. of associated vascular injury. If there is
anesthesia and with the facilities avail- Fixation with three screws placed an abnormality of the pulses or of
able for open reduction. Repeated, peripherally in an inverted-triangle perfusion in the limb, emergent eval-
forceful attempts are ill-advised. The configuration provides good stability. uation and treatment are indicated.
inability to reduce a dislocation is often The necessity for a capsulotomy to If the pulses can be palpated and are
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clinically normal, and the ankle- experienced assistants and scrub per- Surgeons are not the only ones
brachial index is >0.9, arteriography sonnel, and other factors. Often over- affected by fatigue-induced deficits in
is not necessary. If the limb is obviously looked, however, is the state of accuracy and performance; however, we
not perfused, arteriography also is readiness of the surgeon. When de- tend to be much less likely to recognize
not necessary because the patient ciding whether surgical treatment and acknowledge the fatigue effect.
should be taken directly to the oper- should be done in the middle of the Unfortunately, errors of com-
ating room for vascular exploration night, surgeons are not always the most mission probably take center stage
and repair. Delay of the vascular repair reliable judges of their own capabilities. more frequently than do most other
is an important risk factor for sub- Fatigue and sleeplessness have subtle errors when late-night or middle-of-
sequent amputation73-75. but real negative influences on sur- the-night procedures are undertaken.
The knee should be gently re- geons performances79. Fatigue and accompanying decreases
duced and stabilized with a splint or Because of the similar types of in decision-making accuracy and de-
external fixation to allow close mon- responsibilities and decision-making terioration in motor skills can lead
itoring of the neurovascular status and involved with their jobs, surgeons are to imprecise reductions, inaccurate
compartment pressures. There is no often compared with airline pilots fixation, and incomplete treatment.
advantage to emergent ligament re- with respect to performance accuracy Such circumstances often lead to poor
pair. Rarely, the dislocation is irre- and performance deterioration as fa- outcomes and, worse, the need for
ducible by closed means. This is tigue comes into play. Sexton et al. revision surgery (Figs. 3-A through
usually due to the medial femoral reported that >70% of surgeons re- 4-B). Complex articular reconstruc-
condyle tearing through the capsule fused to admit to fatigue-induced tions are best deferred until the entire
and becoming button-holed, with deterioration in performance as com- surgical team is well rested and ready
capsular-ligamentous tissue being pared with only 23% of airline pilots80. to undertake these orthopaedic
caught in the intercondylar notch. If Like surgery, flying airplanes requires challenges.
the patient is neurovascularly intact, a coordinated and skilled team. Over
this situation is not necessarily an 90% of pilots were able to relinquish
emergency, but the patient should be some authority and responsibility
monitored closely and taken on an when they were overly fatigued, as
urgent basis to the operating room for opposed to about 55% of surgeons. Andrew H. Schmidt, MD
an open reduction. Our medical colleagues do a much Thomas F. Varecka, MD
Department of Orthopedic Surgery,
Talar neck fracture is considered better job of recognizing fatigue; Hennepin County Medical Center,
an emergency by some because of the anesthesiologists are much better at Mail Code G2, 701 Park Avenue,
tenuous nature and retrograde flow of preserving cohesiveness and team Minneapolis,
the blood supply to the talar dome, function when they are fatigued, doing MN 55415.
but emergent reduction and fixation almost twice as well as surgeons in E-mail address for A.H. Schmidt:
have not been shown to improve out- these performance domains. Even
comes76-78. However, if the displacement residents and house officers far surpass
compromises the skin, as evidenced by us80. Fischer et al. studied petrochem- Jeffrey Anglen, MD
tight blanched medial skin without ical shift workers and found work Department of Orthopaedic Surgery,
Indiana University School of Medicine,
capillary refill, the patient should be performance and alertness were
541 Clinical Drive, Suite 600,
treated emergently to save the skin from markedly impaired when they worked Indianapolis, IN 46202-5111
dying. The same principle holds true for the nighttime shift81. Not surprisingly,
subtalar dislocation. If the skin is these parameters showed a marked
Arvind D. Nana, MD
compromised, emergent reduction is tendency to worsen further as the Department of Orthopaedic Surgery,
warranted. Reduction can usually be nocturnal work shift passed. Bartel University of North Texas Health Science
accomplished in a closed fashion, but et al. evaluated a cohort of anesthesi- Center, 855 Montgomery Street,
occasionally a surgical procedure is ologists before and after a twenty- 5th Floor, Fort Worth,
required if there is interposition of four-hour period of call82. The study TX 76107.
tendons. group was tested for their ability to E-mail address:
accurately complete a set of increas-
Surgeon Performance and Fatigue ingly complex psychomotor tests. Af- Printed with permission of the American
As with any orthopaedic emergency, ter a night on call, 30% of the doctors Academy of Orthopaedic Surgeons. This article,
the timing of the definitive procedure showed more than a 15% increase in as well as other lectures presented at the
Academys Annual Meeting, will be available in
depends on multiple factors: availabil- simple-task reaction time and more March 2010 in Instructional Course Lectures,
ity of a suitable operating room, than one-half showed similar increases Volume 59. The complete volume can be
availability and operational integrity of in reaction times for more complex ordered online at, or by calling
appropriate equipment, availability of tasks. 800-626-6726 (8 A.M.-5 P.M., Central time).
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60th Annual Meeting of the American Academy of
the rates of infection and need of secondary surgical
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