I suppose the title
above is a bit facetious and I really don’t mean it, but there have been times
over the years when collaborating with my Orthopedic Surgery colleagues has
caused sleepless nights; some I didn’t deserve.
Almost all these joint
ventures have been on major trauma cases where severe bone injury has been
paired with major vascular damage. Priority of repair, that is, who gets to go
first is a common discussion. The answer to the question depends on the patient
and the injury. In general life and limb threatening injury take precedence.
Such was the case of
Mary, who suffered a closed fracture of her proximal tibia and fibula with
associated occlusion of her popliteal artery and ischemia of her leg. The
severe vascular injury could have led to Mary losing her leg and mending of the
artery took precedence over the bony repair.
But, how could I have had
the prescience to know that during the process of repairing the tibial fracture
the orthopedic surgeon would cause a bony fragment to compress the artery which
had just been patched and cleared of thrombus, (a blood clot which was
occluding the vessel)? The vessel became occluded again. My protests went
unheeded and I was forced to bite the bullet and redo the vascular repair
utilizing a vein graft to bypass around the injured area.
At least I didn’t have
to drive back to the hospital. As a resident I learned to never leave the
vicinity until the bone doctor had driven his or her last screw, nailed the
last nail and placed the final skin staple. Only after checking my work would it
be safe to leave, secure with the knowledge that my orthopedic colleague could
not wreak anymore havoc.
Mary, by the way,
recovered uneventfully.
Then there was Glenn.
It was a Friday night
and I was not on call. My family and I had just walked in the door after dining
out when my phone went off and there was a message. Dr. Black was consulting me
to see Glenn, who was admitted to the hospital with a fracture of the proximal
right humerus. The nurse was concerned because she could not feel a pulse and
Glenn complained of his hand being numb. It was about eight o’clock in the
evening.
I called and talked to
the nurse and then headed in to the hospital. Glenn was in his mid fifties,
lived with his parents and had no significant medical problems other than being
“a little slow” to use his expression.
He told me had tripped while on his parent’s front porch and fallen down the
three stairs to the sidewalk, landing on his right arm and shoulder. This had
occurred at 11:00 am, now almost ten hours earlier.
My exam confirmed that
he had almost certainly injured his brachial artery. There was a large hematoma
(collection of blood) in the upper arm and axilla, he could not move his hand,
which was also numb, and there was no pulse in the arm, radial or brachial.
I called down to the OR
where they weren’t very busy and told the crew that Glenn needed surgery
immediately. Next I called Dr. Black and reported my findings and he responded that
he was on his way to the hospital
I called the OR, again,
and asked how quickly they would be ready, informing them, again, that this was
a limb threatening emergency and that the patient should have had his surgery
hours before.
“We’re opening now and
anesthesia is on their way in,” was the reply.
I have to admit I was a
more than a little frustrated. Mostly it was the lack of attention that
threatened to cause serious harm to Glenn that bothered me. It’s not right for
a patient to languish in the hospital with such an injury.
Dr. Black finally
arrived.
“The ER physician told
me it was an uncomplicated fracture. I had planned to fix it tomorrow,” he
explained without my ever asking a question or making a comment.
Finally, at 10:00 the
OR team was ready and Glenn was wheeled down to surgery. The operation began
about thirty minutes later. Glenn’s arm had been ischemic for almost twelve
hours.
I began to work,
starting with an incision over the area where the subclavian artery emerges
from beneath and behind the clavicle, following the rules and obtaining what’s
called proximal control. What this means is that the artery is identified and
dissected free in area closer to the heart than the injured area. Blood flows
from the heart out to the organs under considerable pressure. Proximal control
allows flow into the injured area to be interrupted should bleeding develop
during the course of isolating the damaged artery.
I followed the artery
out to the axilla, dissecting it free from the pectoralis major muscle and then
into the upper arm where I encountered a large hematoma (collection of blood).
This is where the artery had bled before the pressure caused by the blood
spilling into Glenn’s tissues along with the body’s normal clotting mechanism
caused the bleeding to stop. If this mechanism had failed Glenn would have bled
to death, but the human body is remarkable in its ability to fend off such
calamity.
I evacuated the large
blood clot and found one end of the transected artery, pulsing away, but not
actively bleeding as the end had efficiently clotted.
Next I had to find the
other end of the artery. Rather than start digging through the bloody, damaged
tissue at the site of injury, I decide it would be more prudent to start at a
site beyond the injury. The distal artery was easily dissected free and then
followed back to the other injured end.
The two ends were a bit
macerated and had retracted such that a direct end to end anastamosis (like
reconnecting two ends of a pipe) was not feasible. Luckily I had the foresight
to prep out Glenn’s groin so that it was already sterile and I could harvest a
segment of saphenous vein. This is the same vein commonly used for heart bypass
surgery. Before starting on Glenn’s leg I placed a shunt between the two
divided ends of the injured artery, allowing blood to flow to the distal arm,
thus giving the starved tissue a “drink” of blood, delivering oxygen and
nutrients.
An adequate segment of
vein was removed from his leg and the reconstruction proceeded without
incident. I added a fasciotomy to my procedure, which means I divided the
fibrous tissue around the muscular compartments of the forearm to allow the
muscle additional room to swell after it was reperfused, thus preventing what
is termed “compartment syndrome.” This condition can lead to muscle and nerve
damage as the tissue swelling which can occur after prolonged periods of
ischemia becomes confined by the tight, closed space of a muscular compartment.
I felt the strong pulse
in the artery beyond my repair and saw that the muscle, although pale, looked
viable and I believed Glenn would be left with a functional arm.
At this point I must
add I had considered allowing Dr. Black to do his repair first. I could have
placed the shunt to allow the arm to be perfused and then done the definitive
repair after Dr. Black had finished. But, he assured me it was a simple
fracture which was minimally displaced. He anticipated an uncomplicated ORIF
(Open Reduction Internal Fixation). Being the trusting soul that I am performed
the more vital arterial repair first.
However, I am not 100% naïve.
I did stay around until Dr. Black finished. I’m glad I did. It was about 1:00
am when I lay down on the couch in the doctor’s lounge and dozed off and on.
Over the years I’ve never slept well at the hospital and I’ve always opted for
driving home for a couple of hours sleep in my own bed rather than getting an
extra thirty minutes in the less comfortable confines of a hospital call room.
In this case, however, it was fortunate that I did not leave.
The phone in the lounge
rang at about 3:00 am.
“Dr. Gelber, you need
to come check this arm,” more of a command than request from the circulating
nurse.
“Is Dr. Black finished?”
I queried.
“Finished and gone, but
you need to come.”
“OK, OK, I’ll be there
in a minute.”
I made a quick pit
stop, donned my hat and mask and went back to the OR room where the surgical
tech recounted the sad and tragic “saga of Glenn’s repair.”
“Well, he was doing the
repair with a Rush rod and it only took a few minutes. I thought we’d be home
by two, but then I picked up the arm and asked him if the rod was supposed to
come out the back of the arm? So he had to pull it out and that took a while. Then
he had to do it again. I’m no Orthopedic Surgeon, but I don’t think it’s
positioned very well. But, fFor what it’s worth, he’s done.”
The circulator then
spoke up.
“The hand looks white.”
Sure enough there was
no pulse or Doppler signal. So I was back at square one. I opened the wound and
looked at my repair. There was an excellent pulse at the site of the repair and
for at least three or four centimeters distal. I started dissecting farther and
it wasn’t long before I found the problem.
Dr. Black had not only
driven that Rod through the back of Glenn’s arm, but he had also managed to put
it through the brachial artery at a point beyond the original injury. So, I
repaired the artery a second time. At least I didn’t have to do another
fasciotomy.
I finished at around
5:00 am. Glenn woke and had much improved function of his hand. He could move
it and there was some sensation. He maintained good perfusion of his arm, but
did have to have the orthopedic reconstruction revised at a later date.
Eventually he regained 100% full, normal function of his arm and hand.
Dr. Black never talked
about this particular case with me. A couple of years later he gave up the
practice of Orthopedics. He was, overall a competent surgeon and his retirement
from Orthopedics was for personal and health reasons, unrelated to Glenn’s
case..
I hope that anyone who
reads these words does not believe that I have no regard or respect for my
Orthopedic colleagues. I could never do what they do and most are excellent
physicians and surgeons. They do, however, have a singlemindedness in their
approach to their patients. Their job is to fix, reconstruct and otherwise mend
broken, worn out, degenerated bones and joints. Orthopedic surgical procedures
are designed to stay away from vital structures such as nerves, major blood
vessels and other organs which are soft and not amenable to nails, screws and plates.
What I’ve learned is
that injuries and medical conditions which bring me into the Orthopedic Surgeon’s
realm require that I maintain my utmost vigilance. And, never completely trust
a bone doctor.
