Perioperative Anesthetic Management of Orthopedic Injuries

Before the 1980s, multiple-injured patients arriving to the hospital might undergo emergency surgery to repair head, neck, and thoracoabdominal injuries; however, orthopedic injuries, such as an open femoral fracture, were splinted and debrided, but definitive repair was not performed until some future date. This practice placed patients at risk for fat embolism secondary to fracture fragment motion, sepsis caused by infection, and impaired ventilation because these patients were maintained at bedrest.” 41 The concept of early fracture repair was introduced in the 1980s, when LaDuca et alB published a report describing only a 4% incidence of infection and no cases of fat embolism or posttraumatic cardiopulmonary failure in 42 patients with 50 open fractures undergoing immediate repair. In this study, 27 patients suffered multiple injuries. Care was taken to adequately debride and clean open fractures, even if it took many hours during the initial surgery. There were two postoperative deaths, one from suicide and one from a ruptured thoracic aorta. Thus, LaDuca et alB demonstrated that early fracture fixation could allow early mobilization, diminish wound complications, and elinkate casts, thereby improving wound care. Johnson et all8 at Parkland Memorial Hospital in Dallas noticed that the incidence of adult respiratory distress syndrome (ARDS) increased as time to repair of fractures was prolonged. In an examination comparing time of repair and severity of injury, they were able to demonstrate that the incidence of ARDS was significantly diminished with early fracture fixation despite the level of injury severity score (ISS) (Fig. 1). The study included trauma victims from motor vehicle accidents, motorcycle accidents, automobilepedestrian accidents,