Acute trauma patients who arrive at hospitals that don’t have the necessary resources to care for them should be transferred immediately to the nearest appropriate facility, according to trauma surgeon Lisa K. Cannada, MD. “Additional diagnostic tests only delay definitive care,” she explained during an instructional course lecture (ICL) held at the AAOS 2018 Annual Meeting.

“But what happens, for example, on a Friday night when there’s a blizzard, wildfire, or severe storm that prohibits the transport helicopter from flying? How do you address the trauma patient then?” she asked.

For surgeons who take call and may find themselves in similar circumstances, Dr. Cannada recommends a practical approach. “Survey the situation, temporize when you can, and don’t forget the basics. Orthopaedic trauma injuries can be divided into three categories: life-threatening, limb-threatening, and function-threatening. Ask yourself the following questions: ‘What can the patient tolerate? What can the limb tolerate? What can the skin tolerate?’” she said.

Making it through the night

Dr. Cannada offered advice for managing some of the orthopaedic trauma injuries that on-call surgeons may encounter. For example, for pelvic fractures, a sheet or pelvic binder can immobilize the injury. “The key is knowing where and how to place it,” she said. “The best location is centered at the level of the greater trochanter. Many surgeons want to put it higher, but that puts increased pressure on the abdomen—something you don’t want to do, especially if the patient has abdominal injuries. You can also put an external fixator on, but only if you are comfortable doing so and you know the indications.”

The mortality rate for bilateral femur fractures used to be as high as 25 percent, but more recent studies put the rate at about 5.6 percent, Dr. Cannada noted. “What changed? Treatments options from the earlier literature. In the past, before retrograde nailing became an accepted method of treatment, most surgeons would use antegrade nails,” she explained. “Knowing when damage-control orthopaedics versus early total care should be used has improved outcomes and is also helpful in treating bilateral femur fractures. For those not comfortable treating femur fractures, skeletal traction is OK, too.”

For limb-threatening injuries, such as open fractures, Dr. Cannada recommends external fixators. “A long external fixator is much better than a shorter one. Also remember that the patient will swell, so leave adequate distance between the pin and bars; don’t put the pins in the open fracture area because they can get contaminated, and try to place a frame to stabilize the injury.”

Compartment syndrome is a serious complication that can be difficult to diagnose. Because it develops over time, serial examinations are critical, Dr. Cannada stressed. “Vigilance and maintaining a high index of suspicion are very important. You really cannot palpate compartment syndrome—true positive palpation sensitivity is only 54 percent. If it’s obvious, don’t measure compartment pressures—it’s a clinical diagnosis, so go ahead and perform the release,” she said.

Dr. Cannada presented videos demonstrating compartment syndrome release, including a two-incision fasciotomy for a leg compartment syndrome with an unstable fracture. “It’s very difficult to do a fasciotomy on a floppy leg. So, if the leg is floppy and there could be damage to the neurovascular structures, place a quick two-pin external fixator to stabilize the fracture,” she said. She emphasized that all planned incisions should be drawn and be generous enough to allow for full compartment decompression (Fig. 1). “When ensuring you have a complete release, it’s important to realize that the skin acts as a restraint,” she said.

For acute knee dislocations, ankle-brachial indices are the standard of care. “Look for subtle signs of knee dislocation, keeping in mind that although a radiograph is static, the injury is dynamic. Reduce and stabilize the dislocation, and monitor the patient closely,” Dr. Cannada advised.

“To make it through the night,” she concluded, “remember that you don’t have to do everything emergently. Consider your patient, temporize when necessary, and avoid temptations.”

Courtesy of Lisa K. Cannada, MD

Look at the big picture

Course moderator Julie E. Adams, MD, a hand surgery specialist at Mayo Clinic Health System in Minnesota, said she takes a simple approach to managing hand and wrist problems. Her first piece of advice was to listen to patients, as their complaints often provide clues for diagnosis. “For patients who complain of hand spasms or a weak grip, think trigger finger or ulnar nerve problem. Patients who complain of pain while pinching, turning a key, or opening a door often have thumb carpometacarpal arthritis,” she said.

With respect to Dupuytren’s contracture, Dr. Adams noted that surgical treatment of this condition has decreased dramatically in recent years. “I think there are better options now for some patients,” she said. “Needle aponeurotomy is great for treating many metacarpophalangeal joint contractures. It is important to know the correct way of billing for this procedure, however. Although you may perform needle aponeurotomy for release of multiple fingers at an office visit, the CPT code (26040) specifies that it is a procedure done in the palm, so it should be billed only once per palm per visit.”

Dr. Adams also said she likes collagenase injections for the treatment of Dupuytren’s contractures. During the procedure, collagenase is injected into the affected cord, then the patient is sent home. When the patient returns to the office, usually within 24–72 hours, the surgeon numbs the hand and manipulates the cord to rupture it and release the contracture. “I prefer to wait and bring patients back a week later (off label) to manipulate the hand. I’ve found that the outcome is the same or better when the collagenase has a longer time to work, and the patient has fewer skin tears,” she said.

Although surgeons will most commonly encounter “garden-variety Dupuytren’s,” according to Dr. Adams, they should be aware of paraneoplastic syndrome. A classic example, she said, is “the middle-aged perimenopausal woman with an occult malignancy and bilateral painful palmar fasciitis.”

When assessing distal radius fractures, Dr. Adams uses Lafontaine’s criteria. “Patients with three or more of the following—initial dorsal angulation greater than 20 degrees, comminution, osteopenia/osteoporosis, intra-articular fracture, or an ulnar styloid fracture—may not maintain closed reduction, and surgery may be recommended,” she said. “I counsel patients regarding this—I think it is very helpful to provide them with a predictive mechanism.”

When a distal radius fracture does require surgical treatment, Dr. Adams uses a mini C-arm to reduce radiation exposure. She also prefers to use an arm board, which can easily swing out of the way, rather than an arm table. She added, “Surgeons often forget that volar translation of the carpus is a great reduction maneuver. Keep in mind that not every fracture can or should be treated with a volar plate—don’t forget about an external fixator or some other form of fixation.”

A game changer for hand surgery, Dr. Adams believes, is the WALANT (Wide Awake, Local Anesthetic, and No Tourniquet) technique. “I was taught during medical school not to use epinephrine because it kills fingers and toes. That’s absolutely a myth. There are multiple well-done studies that show the safety and effectiveness of lidocaine with epinephrine in hand surgery,” she said.

Dr. Adams shared several tricks for performing the technique. “To get good hemostasis from the epinephrine, it helps to inject the lidocaine with epinephrine in advance of the procedure (30 or more minutes) and let it set up. Pain can be decreased by injecting slowly and using bicarbonate as a buffer. The technique is great for trigger finger release, carpal tunnel releases, and treating tendon repairs, and patients love it,” she said.

Hand and wrist problems are often straightforward, Dr. Adams summarized. “When treating them, it’s often best to keep it simple and look at the big picture.”

Additional faculty presenters during the “Top Tips for YOUR Practice” ICL were Wudbhav N. Sankar, MD, and Kristy L. Weber, MD.

Maureen Leahy is assistant managing editor of AAOS Now. She can be reached at leahy@aaos.org.

References

1. Cannada LK, Taghizadeh S, Murali J, et al: Retrograde intramedullary nailing in treatment of bilateral femur fractures. J Orthop Trauma. 2008;22:530-534.
2. Schuler FD, Dietz MJ: Physicians’ ability to manually detect isolated elevations in leg intracompartmental pressure. J Bone Joint Surg Am. 2010;92:361-367.