Difference between revisions of "Open reduction and interal fixation of the tibial plateau fracture"
From WikiAnesthesia
(Created page with "{{Infobox surgical procedure | anesthesia_type = General | airway = ETT | lines_access = PIV | monitors = Standard ASA Monitors | considerations_preoperative = | considerations_intraoperative = | considerations_postoperative = }} Provide a brief summary here. == Overview == === Indications === === Surgical procedure === == Preoperative management == === Patient evaluation<!-- Describe the unique and important aspects of preoperative evaluation. Add or remove row...") |
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{{Infobox surgical procedure | {{Infobox surgical procedure | ||
| anesthesia_type = General | | anesthesia_type = General | ||
| airway = ETT | | airway = standard ETT, or specific to situation (if trauma) | ||
| lines_access = PIV | | lines_access = standard PIV, more if indicated based on trauma or comorbidities | ||
| monitors = Standard ASA Monitors | | monitors = Standard ASA Monitors, more if indicated based on trauma or comorbidities | ||
| considerations_preoperative = | | considerations_preoperative = unlikely to be candidate for nerve block/catheter (although literature equivocal about risks); if trauma watch for fat embolism, myoglobinuria, hyperkalemia | ||
| considerations_intraoperative = | | considerations_intraoperative = if trauma, likely will need RSI; standard maintenance, fluid management; X-rays, may need NMB to facilitate surgical manipulation | ||
| considerations_postoperative = | | considerations_postoperative = PACU, possibly ICU if trauma patient; pain control may be more difficult; compartment syndrome | ||
}} | }} | ||
Tibial plateau fracture account for about 1% of all fractures, often associated with high energy mechanisms. Associated with injury to nearby soft tissue and ligaments (Cunningham). With age, increased incidence of osteoporotic fracture. Fracture pattern described by Schatzker types 1-6 (with 1-3 being on the simpler side) (Wang). | |||
== Overview == | == Overview == | ||
| Line 35: | Line 35: | ||
|- | |- | ||
|Pulmonary | |Pulmonary | ||
| | |Bone fractures may lead to fat embolism, assess oxygenation | ||
|- | |- | ||
|Gastrointestinal | |Gastrointestinal | ||
| Line 41: | Line 41: | ||
|- | |- | ||
|Hematologic | |Hematologic | ||
| | |Assess bleeding and hypovolemia | ||
|- | |- | ||
|Renal | |Renal | ||
| | |Myoglobinemia and hyperkalemia from crush injuries | ||
|- | |- | ||
|Endocrine | |Endocrine | ||
| Line 50: | Line 50: | ||
|- | |- | ||
|Other | |Other | ||
| | |Likely trauma as cause, need to assess other organs that may be involved (eg neck, thorax) | ||
|} | |} | ||
=== Labs and studies<!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. --> === | === Labs and studies<!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. --> === | ||
* CBC, BMP, consider checking CPK, urine drug screen | |||
* ECG and/or ECHO as indicated | |||
=== Operating room setup<!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --> === | === Operating room setup<!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --> === | ||
* Standard setup | |||
* If trauma, may need additional equipment for airway and infusion of blood products | |||
* Arterial line and CVC setup as indicated | |||
=== Patient preparation and premedication<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --> === | === Patient preparation and premedication<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --> === | ||
* For elective cases, consider PO acetaminophen and/or PONV prophylaxis | |||
=== Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --> === | === Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --> === | ||
* Usually not offered due to concern for post-op missed compartment syndrome (Hyder, Dwyer; although there are case reports of missed compartment syndrome with regional anesthesia, there are also case reports of diagnosing compartment syndrome with regional anesthesia onboard) | |||
* Study examining single shot RA in patients with tibial plateau fracture without evidence of compartment syndrome (Cunningham n = 60) | |||
* Ask surgical team about consideration | |||
== Intraoperative management == | == Intraoperative management == | ||
=== Monitoring and access<!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --> === | === Monitoring and access<!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --> === | ||
* 1-2x 14-16G PIV | |||
* Consider arterial line, or CVC (large blood loss, continued need for mechanical ventilation post-op) | |||
=== Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --> === | === Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --> === | ||
* Elective cases, standard induction | |||
* If trauma, RSI to prevent aspiration; may need specific airway equipment if patient with limited neck mobility (eg in C-collar) | |||
=== Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --> === | === Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --> === | ||
* Supine, or slightly lateral | |||
=== Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> === | === Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> === | ||
* Standard anesthesia maintenance | |||
* Maintain euvolemia -> goal directed fluid management with crystalloids and blood products as needed | |||
* Active warming especially for trauma patients, including convection blanket, active humidifier, warm fluids | |||
* If use of tourniquet, MAP may drop with release of tourniquet | |||
* TXA IV or topical may decrease blood loss with overall minimal side effects (Wang) | |||
=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> === | === Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> === | ||
* PONV prophylaxis | |||
* Especially for trauma patients, wait until full return of protective airway reflexes before extubation | |||
== Postoperative management == | == Postoperative management == | ||
=== Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --> === | === Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --> === | ||
* PACU, or ICU if trauma patient | |||
=== Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --> === | === Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --> === | ||
* Multimodal PO and IV medications | |||
=== Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> === | === Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> === | ||
* Compartment syndrome (usually clinical diagnosis), may lead to hyperkalemia and myoglobinuria/emia | |||
* Fat embolism (symptoms of hypoxemia, increased heart rate, tachypnea, respiratory alkalosis, mental status changes, petechiae) | |||
* Wound infection | |||
* DVT | |||
* Peripheral nerve damage | |||
=== ERAS === | |||
* For elective cases, standard guidelines; consider PO acetaminophen for pain control and PO aprepitant for PONV prophylaxis | |||
== Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). --> == | == Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). --> == | ||
| Line 119: | Line 163: | ||
== References == | == References == | ||
Cunningham DJ, LaRose M, Zhang G, Patel P, Paniagua A, Gadsden J, Gage MJ. Regional Anesthesia Associated With Decreased Inpatient and Outpatient Opioid Demand in Tibial Plateau Fracture Surgery. Anesth Analg. 2022 May 1;134(5):1072-1081. doi: 10.1213/ANE.0000000000005980. PMID: 35313323. | |||
Dwyer T, Burns D, Nauth A, Kawam K, Brull R. Regional anesthesia and acute compartment syndrome: principles for practice. Reg Anesth Pain Med. 2021 Dec;46(12):1091-1099. doi: 10.1136/rapm-2021-102735. Epub 2021 Jun 29. PMID: 34187911. | |||
Hyder N, Kessler S, Jennings AG, De Boer PG. Compartment syndrome in tibial shaft fracture missed because of a local nerve block. J Bone Joint Surg Br. 1996 May;78(3):499-500. PMID: 8636198. | |||
Anesthesiologist's manual of surgical procedures [[ISBN (identifier)|ISBN]][[Special:BookSources/978-1-4963-0594-7|978-1-4963-0594-7]][[OCLC (identifier)|OCLC]]888551588 | |||
Wang Z, Lu Y, Wang Q, Song L, Ma T, Ren C, Li Z, Yang J, Zhang K, Zhang B. Comparison of the effectiveness and safety of intravenous and topical regimens of tranexamic acid in complex tibial plateau fracture: a retrospective study. BMC Musculoskelet Disord. 2020 Nov 12;21(1):739. doi: 10.1186/s12891-020-03772-7. PMID: 33183258; PMCID: PMC7659088. | |||
[[Category:Surgical procedures]] | [[Category:Surgical procedures]] | ||
Latest revision as of 21:05, 11 November 2022
Open reduction and interal fixation of the tibial plateau fracture
| Anesthesia type |
General |
|---|---|
| Airway |
standard ETT, or specific to situation (if trauma) |
| Lines and access |
standard PIV, more if indicated based on trauma or comorbidities |
| Monitors |
Standard ASA Monitors, more if indicated based on trauma or comorbidities |
| Primary anesthetic considerations | |
| Preoperative |
unlikely to be candidate for nerve block/catheter (although literature equivocal about risks); if trauma watch for fat embolism, myoglobinuria, hyperkalemia |
| Intraoperative |
if trauma, likely will need RSI; standard maintenance, fluid management; X-rays, may need NMB to facilitate surgical manipulation |
| Postoperative |
PACU, possibly ICU if trauma patient; pain control may be more difficult; compartment syndrome |
| Article quality | |
| Editor rating | |
| User likes | 0 |
Tibial plateau fracture account for about 1% of all fractures, often associated with high energy mechanisms. Associated with injury to nearby soft tissue and ligaments (Cunningham). With age, increased incidence of osteoporotic fracture. Fracture pattern described by Schatzker types 1-6 (with 1-3 being on the simpler side) (Wang).
Overview
Indications
Surgical procedure
Preoperative management
Patient evaluation
| System | Considerations |
|---|---|
| Airway | |
| Neurologic | |
| Cardiovascular | |
| Pulmonary | Bone fractures may lead to fat embolism, assess oxygenation |
| Gastrointestinal | |
| Hematologic | Assess bleeding and hypovolemia |
| Renal | Myoglobinemia and hyperkalemia from crush injuries |
| Endocrine | |
| Other | Likely trauma as cause, need to assess other organs that may be involved (eg neck, thorax) |
Labs and studies
- CBC, BMP, consider checking CPK, urine drug screen
- ECG and/or ECHO as indicated
Operating room setup
- Standard setup
- If trauma, may need additional equipment for airway and infusion of blood products
- Arterial line and CVC setup as indicated
Patient preparation and premedication
- For elective cases, consider PO acetaminophen and/or PONV prophylaxis
Regional and neuraxial techniques
- Usually not offered due to concern for post-op missed compartment syndrome (Hyder, Dwyer; although there are case reports of missed compartment syndrome with regional anesthesia, there are also case reports of diagnosing compartment syndrome with regional anesthesia onboard)
- Study examining single shot RA in patients with tibial plateau fracture without evidence of compartment syndrome (Cunningham n = 60)
- Ask surgical team about consideration
Intraoperative management
Monitoring and access
- 1-2x 14-16G PIV
- Consider arterial line, or CVC (large blood loss, continued need for mechanical ventilation post-op)
Induction and airway management
- Elective cases, standard induction
- If trauma, RSI to prevent aspiration; may need specific airway equipment if patient with limited neck mobility (eg in C-collar)
Positioning
- Supine, or slightly lateral
Maintenance and surgical considerations
- Standard anesthesia maintenance
- Maintain euvolemia -> goal directed fluid management with crystalloids and blood products as needed
- Active warming especially for trauma patients, including convection blanket, active humidifier, warm fluids
- If use of tourniquet, MAP may drop with release of tourniquet
- TXA IV or topical may decrease blood loss with overall minimal side effects (Wang)
Emergence
- PONV prophylaxis
- Especially for trauma patients, wait until full return of protective airway reflexes before extubation
Postoperative management
Disposition
- PACU, or ICU if trauma patient
Pain management
- Multimodal PO and IV medications
Potential complications
- Compartment syndrome (usually clinical diagnosis), may lead to hyperkalemia and myoglobinuria/emia
- Fat embolism (symptoms of hypoxemia, increased heart rate, tachypnea, respiratory alkalosis, mental status changes, petechiae)
- Wound infection
- DVT
- Peripheral nerve damage
ERAS
- For elective cases, standard guidelines; consider PO acetaminophen for pain control and PO aprepitant for PONV prophylaxis
Procedure variants
| Variant 1 | Variant 2 | |
|---|---|---|
| Unique considerations | ||
| Position | ||
| Surgical time | ||
| EBL | ||
| Postoperative disposition | ||
| Pain management | ||
| Potential complications |
References
Cunningham DJ, LaRose M, Zhang G, Patel P, Paniagua A, Gadsden J, Gage MJ. Regional Anesthesia Associated With Decreased Inpatient and Outpatient Opioid Demand in Tibial Plateau Fracture Surgery. Anesth Analg. 2022 May 1;134(5):1072-1081. doi: 10.1213/ANE.0000000000005980. PMID: 35313323.
Dwyer T, Burns D, Nauth A, Kawam K, Brull R. Regional anesthesia and acute compartment syndrome: principles for practice. Reg Anesth Pain Med. 2021 Dec;46(12):1091-1099. doi: 10.1136/rapm-2021-102735. Epub 2021 Jun 29. PMID: 34187911.
Hyder N, Kessler S, Jennings AG, De Boer PG. Compartment syndrome in tibial shaft fracture missed because of a local nerve block. J Bone Joint Surg Br. 1996 May;78(3):499-500. PMID: 8636198.
Anesthesiologist's manual of surgical procedures ISBN978-1-4963-0594-7OCLC888551588
Wang Z, Lu Y, Wang Q, Song L, Ma T, Ren C, Li Z, Yang J, Zhang K, Zhang B. Comparison of the effectiveness and safety of intravenous and topical regimens of tranexamic acid in complex tibial plateau fracture: a retrospective study. BMC Musculoskelet Disord. 2020 Nov 12;21(1):739. doi: 10.1186/s12891-020-03772-7. PMID: 33183258; PMCID: PMC7659088.