Damage Control Management in the Polytrauma Patient

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Foreword

Orthopedic trauma is largely limited to the stabilization and subsequent surgical

management of fractures and dislocations, with most patients presenting to their
local emergency departments with isolated injuries. Modern techniques and
implants have made outcomes for these injuries more predictable. Intramedullary
nailing, for example, has become standard treatment for a displaced fracture of the
femoral shaft. These conditions can be managed by the majority of general ortho-
pedists being trained today. Interestingly, they most likely do not even understand
or remember that this treatment evolved from the management of the polytrauma-
tized patient with fractures.
The polytraumatized patient is, of course, a completely different matter. For
many years, the only experience with these types of injuries was in casualties
sustained by combatants during armed conflicts. Basic concepts such as anesthe-
sia, blood transfusions, intravenous therapy, wound management, and even the
development of nursing and the modern hospital were all learned and founded in
armed conflicts such as the Crimean War, the Boer War, and World War I. The
Second World War saw improvements in the management of both abdominal and
extremity wounds, and this was further refined in the Korean and Vietnam
Conflicts. These, however, were limited to saving lives and limbs that benefited
from very basic care. Understanding even the most rudimentary physiological
concepts now taken for granted eluded us, and this showed how limited knowl-
edge was at that time.
Beginning in the 1960s, various technological advances occurred that would
radically change the methods of management. The introduction of arterial blood
gas machines, the Swan-Ganz catheter, PEEP, and volume-cycled ventilators all
became commonplace, decreasing the risk of cardiopulmonary failure. Recovery
rooms and intensive care units were developed at this time as well, finally allow-
ing for the monitoring of patients in the peri-operative period. Amazingly, before
that, postoperative cardiopulmonary failure was undiagnosed and left untreated.
After successful resuscitation of the patient from the initial cardiopulmonary
insult, the prolonged septic state ended in a cachectic and malnourished patient.
The development of hyperalimentation was critical in reversing this, only to lead
to the multiple organ system failure syndrome, which was then addressed in the
1970s and 1980s.

vii
viii Foreword

While all this cardiothoracic and thoraco-abdominal care was proceeding, fracture
management was lagging behind. The recognition of the systemic consequences of
leaving a patient in traction became evident in the 1970s, with the understanding of
the fat embolus syndrome. Furthermore, it was shown that the length of time in trac-
tion, and not the Injury Severity Score, was the only variable that correlated to mul-
tiple organ system failure and pulmonary failure in these patients. It also became clear
at this time that cardiopulmonary failure and the septic states of the post-severe
trauma patient were due to treatment modalities employed and not to the original
injury. Similarly, compartment syndromes and their complications were better under-
stood and managed, both in the extremities and abdominal cavity.
At the same time, high speed motor vehicular trauma began a spectacular rise in
the West. Although fatalities from these accidents were initially high, when basic
safety precautions came into being such as the seat belt, patients who formerly
would expire at the scene now became severely traumatized civilian casualties. The
attempt to save these lives brought methods formerly reserved for the military into
everyday use, namely Emergency Medical Service ambulances and the develop-
ment of civilian trauma units. In the United States, one of the first such units was
the Baltimore Shock-Trauma Center. This center managed polytrauma patients
with a minimum of three organ system injuries from a five-state region, using three
helicopters with resuscitative capabilities onboard for rapid transport to the facility.
This was, in essence, a civilian M.A.S.H. unit.
Today, benefits of these advances are apparent. Emergency medical systems
coupled to regional trauma centers allow for the timely response to injuries in
almost any location. Across the world, lessons learned in resuscitation, anesthesia,
and critical care allow for the management of patients with varying degrees of
general and extremity injury. Specialists in each of the many disciplines address
the specific problems of the patient in an orderly, algorithmic manner, maximizing
outcomes based on firm scientific knowledge learned over the last half century.
Truly, this is a better place.
Damage Control Management in the Polytrauma Patient attempts to carefully
collate and combine current knowledge in this field, which in today’s parlance is
known as “Damage Control.” This implies the ability to actually manage these
patients rather than to chase their problems, as was done in the past.
This monumental task has been performed by editors and contributors who have
a deep understanding of the management of severely injured patients who have also
sustained skeletal trauma. The scientific basis for treatment, starting with the epi-
demiology and pathophysiology of the trauma state, is clearly and expertly covered.
Similarly, phases of management as well as treatment of individual organ systems
are explained so that each member of the team will have better insight into the
decision-making process of the other. Finally, a frank discussion of the complica-
tions and limitations associated with these patients is included so that the reader is
aware of where scientific endeavors need to continue in order to solve present-day
problems.
This book is a testament to past limitations, the present concepts of manage-
ment, and where the future lies. The editors are to be commended for putting
Foreword ix

together a superb volume on the current state of the art. The surgeon and patient
alike will be better off for having their traumatologist read this text.
Roy Sanders, MD
Chief, Department of Orthopedics
Tampa General Hospital
Director, Orthopedic Trauma Services
Florida Orthopedic Institute
Tampa, Florida
USA
Foreword

The ravages of limb compartment syndrome were first reported by Volkmann in

1881. This led to treatment by releasing compartment pressure using fasciotomy.
General surgeons soon encountered the same phenomenon in the abdomen, primar-
ily related to management of severe liver injuries. The anatomy of the liver was not
well understood, and resectional debridement or formal lobectomy was simply not
done. Treatment consisted of packs, drains, and the electrocautery unit. Attempts to
close the abdomen in such patients were fraught with difficulty, and it was soon
recognized that it was better to stage and delay abdominal closure, an approach now
recognized as damage control.
Compartment syndromes are now recognized to occur in any closed space in
which blood, fluid, or air causes expansion of the space and meets resistance of the
container. Compartment syndrome can occur in the cranial vault and is usually associ-
ated with blood in the epidural and subdural space or intraparenchymal tissue. Each
hemithorax is subject to compartment syndrome that is caused by blood, air, or chyle.
Compartment syndromes in the abdomen, including the retroperitoneum and pelvis,
are frequently common following severe injury. The complexity and the anatomy of
the extremities are such that there are multiple compartments in both the upper and
lower extremity. Even the hand is subject to compartment syndromes.
Although compartment syndromes existed prior to the mid-twentieth century,
they were exacerbated by advances in surgical care and resuscitation. During the
late 1950s, pressure-regulated ventilators were introduced, followed shortly by
surgical intensive care units, and patients were managed on ventilators following
their initial surgery. It was not uncommon to attempt to close all abdominal inci-
sions following major injury, only to have the anesthesiologist tell the surgeon that
the patient was difficult to ventilate. It soon was recognized that this was associated
with an increase in peak inspiratory pressures, and patients often went on to have
multiple pneumothoraces and deterioration of pulmonary function. This did not
improve when volume-regulated ventilators became more popular than the older
pressure-regulated ventilators.
Another advance occurred in 1964 when the work of Shires and others changed
our fluid resuscitation of the trauma patient. During World War II and the Korean
Conflict, acute renal failure occurred in 80% of all patients who presented in shock,
and, of those, a high percentage died until the introduction of renal dialysis.

xi
xii Foreword

In 1964, Shires showed in an animal model that, during resuscitation following

severe shock, the interstitial space was constricted and intracellular water increased,
which could only be addressed by increasing the amount of crystalloid solution
during the resuscitation period. As a consequence, acute renal failure almost disap-
peared as a major problem during the Vietnam Conflict, but a new syndrome was
recognized: Da Nang lung. There is no question that some of these patients were
over-resuscitated with crystalloid since the prevailing concept at that time was that
one had to “fill the pump” to get maximum cardiac output.
Since the Vietnam Conflict, another physiologic phenomenon has been on the
scene: the lethal triad of hypothermia, coagulopathy, and acidosis. A fourth compo-
nent to this lethal triad is reperfusion injury, which also occurs during prolonged
shock when resuscitation is initiated. The combination of these four factors aggra-
vates the pathophysiology of compartment syndromes wherever they occur in the
multiply-injured patient.
In Damage Control Management in the Polytrauma Patient, the editors have
focused on approaching damage control surgery in a logical and comprehensive
fashion. They have appropriately introduced the subject with epidemiology and
pathophysiology. This is comprehensive and primarily focuses on extremity trauma
and the patient with polytrauma. Importantly, the editors have divided damage
control into phases, emphasizing that the problem begins in the prehospital setting
and that prevention is far better than most treatment. The timing of surgery is
addressed. The importance of early second operation when the physiology has been
corrected is also emphasized. Reconstruction during what the editors term phase
four and adjunctive maneuvers are also presented to the reader.
Special aspects of damage control are important and also addressed. The editors
approach this topic from an anatomic standpoint, but they also look at the very young
patient and the older patient. It would have been inappropriate not to have also dis-
cussed the military situation, which is done nicely here. Finally, the editors address
complications and outcomes, emphasizing again that this book is comprehensive and
will be a reference book for orthopedic and general surgery residents and practicing
surgeons, as well as a book that will be referred to often in academic centers.
Donald D. Trunkey, MD
Department of Surgery
Oregon Health and Sciences University
Portland, Oregon
USA
Preface

The sustained improvements in the observed survival rates of polytrauma patients

within the last two decades are attributable to multiple factors. While advances in
rescue and intensive care management have been widely recognized in the past, the
dramatic management changes performed regarding surgical management have
occurred more quietly.
Nevertheless, all surgical subspecialties involved in the care of these patients
have been commonly affected, thus requiring closer cooperation than ever. The
common goal is to control life-threatening conditions first, such as severe hemor-
rhage, impaired oxygenation, and cerebral herniation. Fixation of major pelvic and
extremity fractures then follows, thus preventing secondary hemorrhage and sec-
ondary soft tissue damage. The overall goal is to achieve all these tasks in a timely
fashion, where all surgical specialties must respect the effects of prolonged shock,
coagulopathy, hypothermia, and untreated soft tissue necrosis.
The limitations in the duration of initial operations and the reduction in compli-
cation rates have been so striking that they justify the compromises associated with
this management change. For general surgeons, the downsides may imply inability
to close the abdominal incision initially and to deal with the complications induced
by large abdominal wall defects. For orthopedic surgeons, temporary external fixa-
tion requires re-operations, and local infections can occur along the Schanz screws.
Considerations of these issues are included in this book.
In view of these aspects, the editors have purposefully tried to compile a coop-
erative approach among all major subspecialties involved in the care of polytrauma
patients. The major goal of this book is to improve the overall understanding of
every reader towards a common, integrated approach to polytrauma care. The edi-
tors hope that this book will help combine the vision required to perform life-saving
operations with the vision required to treat limb-threatening conditions, resulting
in the best possible clinical outcome for every individual patient. The editors are
grateful to outstanding clinician scientists who have achieved this difficult task.
Hans-Christoph Pape, MD, FACS
Andrew B. Peitzman, MD
C. William Schwab, MD, FACS
Peter V. Giannoudis, BSc, MB, MD, EEC(ortho)

xiii
Contents

Part I Epidemiology and Pathophysiology

1 The Damage Control Approach................................................................ 3

Claudia E. Goettler, Michael F. Rotondo, and Peter V. Giannoudis

2 Epidemiology of Polytrauma.................................................................... 13
Fiona E. Lecky, Omar Bouamra, Maralyn Woodford,
Roxana Alexandrescu, and Sarah Jane O’Brien

3 Pathogenetic Changes: Isolated Extremity Trauma

and Polytrauma.......................................................................................... 25
Martijn van Griensven

4 Pathogenetic Changes: Secondary Abdominal

Compartment Syndrome........................................................................... 45
Rao R. Ivatury, Ajai K. Malhotra, Michel B. Aboutanos,
Therèse M. Duane, and Julie A. Mayglothling

5 Impact of Head and Chest Trauma on General Condition.................... 53

Otmar Trentz and Philipp M. Lenzlinger

6 Patient Selection: Orthopedic Approach in Isolated Injuries................ 69

Brad A. Prather and Craig S. Roberts

7 Patient Selection: Orthopedic Approach in Polytrauma........................ 83

Hans-Christoph Pape, Christopher C. Tzioupis,
and Peter V. Giannoudis

Part II Phases of Damage Control

8 Phase 0: Damage Control Resuscitation in the Pre-hospital

and Emergency Department Settings....................................................... 101
Andrew B. Peitzman and Babak Sarani

xv
xvi Contents

9 Phase I: Abbreviated Surgery................................................................. 123

General
Gary Lombardo and John P. Pryor

Orthopedics.............................................................................................. 155
Dieter Nast-Kolb, Christian Waydhas, Steffen Ruchholtz,
and Georg Taeger

10 Phase II: The ICU Phase of Damage Control:

Managing the Patient from Door to Door.............................................. 173
Bryan A. Cotton and C. William Schwab

11 Phase III: Second Operation Repair of All Injuries

General and Orthopedics........................................................................ 211

General
Benjamin Braslow and C. William Schwab

Orthopedics.............................................................................................. 229
Hans-Christoph Pape and Peter V. Giannoudis

12 Phase IV: Late Reconstruction Abdominal Wall Closure:

Staged Management Technique.............................................................. 239
Timothy C. Fabian

13 Phase IV: Late Reconstruction: Reconstruction

of Posttraumatic Soft Tissue Defects...................................................... 249
Jörn Redeker and Peter M. Vogt

14 The Role of Interventional Radiology.................................................... 265

Thomas M. Scalea and Patrick C. Malloy

Part III Special Aspects of Damage Control

15 Head Injuries in Polytrauma Patients.................................................... 279

James M. Schuster

16 Spinal Injuries in Polytrauma Patients.................................................. 291

Clinton James Devin, Gbolahan O. Okubadejo, and Joon Y. Lee

17 Pelvic Fractures in Polytrauma Patients................................................ 299

Peter V. Giannoudis, Christopher C. Tzioupis,
and Hans-Christoph Pape
Contents xvii

18 Vascular Injuries in Polytrauma Patients.............................................. 315

Luke P. H. Leenen and Frans L. Moll

19 Pediatric Trauma and Polytrauma Pediatric Patients.......................... 331

Yigit S. Guner, Henri R. Ford, and Jeffrey S. Upperman

20 Damage Control in Elderly Polytrauma Patients................................. 357

Robert V. Cantu and Kenneth J. Koval

21 Mass Casualties: Military and Civilian.................................................. 367

A Militarry Perspective
Alan D. Murdock and Donald H. Jenkins

A Civilian Perspective.............................................................................. 387

Yoram A. Weil and Rami Mosheiff

Part IV Complications and Outcomes

22 Complications and Outcomes: Abdominal, General,

and Extremity Complications................................................................. 405
George C. Velmahos and Malek Tabbara

23 Critical Decision Points in Managing the Open Abdomen.................. 425

Nathan T. Mowery and John A. Morris Jr

24 Functional Long-Term Outcomes in Polytrauma Patients

with Orthopedic Injuries......................................................................... 439
Boris A. Zelle, Andrew Marcantonio, and Ivan S. Tarkin

Index.................................................................................................................. 453
Contributors

Michel B. Aboutanos, MD, MPH, FACS

Associate Professor of Surgery, Virginia Commonwealth University Health
System, Division of Trauma and Critical Care, Department of Surgery,
Richmond, VA, USA
Roxana Alexandrescu, MD, MPH
University of Manchester/Hope Hospital, TARN, Salford, Manchester,
United Kingdom
Omar Bouamra, PhD
University of Manchester, Department of Medicine, TARN at Hope Hospital,
Salford, Manchester, United Kingdom
Benjamin Braslow, MD
Assistant Professor of Surgery, Department of Surgery, University of Pennsylvania
School of Medicine, Philadelphia, PA, USA
Robert V. Cantu, MD
Assistant Professor of Orthopedic Surgery, Dartmouth Hitchcock Medical Center,
Department of Orthopedics, Lebanon, NH, USA
Bryan A. Cotton, MD
Assistant Professor of Surgery, Vanderbilt University School of Medicine,
Department of Surgery, Nashville, TN, USA
Clinton James Devin, MD
Fondren Orthopedics at Texas Orthopedic Hospital, Houston, TX, USA
Therèse M. Duane, MD
Associate Professor of Surgery, Virginia Commonwealth University Health
System, Department of Surgery, Richmond, VA, USA
Timothy C. Fabian, MD, FACS
Harwell Wilson Alumni Professor and Chairman, University of Tennessee
Health Science Center, Department of Surgery, Memphis, TN, USA

xix
xx Contributors

Henri R. Ford, MD, FACS, FAAP

Post-Doctoral Research Fellow, Vice-President and Surgeon-in-Chief,
Childrens Hospital Los Angeles, Vice Dean for Medical Education, Keck School
of Medicine, University of Southern California, Department of Pediatric Surgery,
Los Angeles, CA, USA
Peter V. Giannoudis, BSc, MB, MD, EEC(ortho)
Professor, University of Leeds, Leeds General Infirmary University Hospital,
Trauma and Orthopedic Surgery, Leeds, Yorkshire, United Kingdom
Claudia E. Goettler, MD, FACS
Assistant Professor, Department of Surgery, Brody School of Medicine,
East Carolina University, Greenville, NC, USA
Yigit S. Guner, MD
Post-Doctoral Research Fellow, Childrens Hospital Los Angeles/University
of Southern California, University of California Davis Medical Center,
Resident in General Surgery, Department of Pediatric Surgery, Los Angeles,
CA, USA
Rao R. Ivatury , MD, FACS
Professor of Surgery, Chief, Trauma, Critical Care, and Emergency Surgery,
Virigina Commonwealth University Health System, Department of Surgery,
Richmond, VA, USA
Donald H. Jenkins, Col, USAF, MC, MD
Trauma Medical Director, Chairman of General Surgery, Assistant Professor
of Surgery, Wildord Hall USAF Medical Center, Uniformed Services University
(Bethesda, Maryland), Lackland Air Force Base, TX, USA
Kenneth J. Koval, MD
Professor, Dartmouth Hitchcock Medical Center, Department of Orthopedics,
Lebanon, NH, USA
Fiona E. Lecky, CS(Ed), PhD, FCEM
University of Manchester, Trauma Audit and Research Network,
Salford Royal Hospital, Alford, Manchester, United Kingdom
Joon Y. Lee, MD
Assistant Professor, University of Pittsburgh Medical Center, Department
of Orthopedics and Neurological Surgery, Pittsburgh, PA, USA
Luke P.H. Leenen, MD, PhD, FACS
Professor of Trauma, University Medical Center Utrecht, Department
of Surgery, Utrecht, The Netherlands
Philipp M. Lenzlinger, MD
University Hospital Zürich, Department of Surgery, Zürich, Switzerland
Contributors xxi

Gary Lombardo, MD
Assistant Professor of Surgery, New York Medical College, Westchester Medical
Center, Department of Trauma, Surgical Critical Care, and Emergency Surgery,
Valhalla, NY, USA
Ajai K. Malhotra, MBBS(MD), MS, DNB, FRCS, FACS
Associate Professor and Vice Chair, Division of Trauma, Critical Care,
and Emergency General Surgery, Associate Medical Director, Level I Trauma
Center, Virginia Commonwealth University Health System,
Department of Surgery, Richmond, VA, USA
Patrick C. Malloy, MD
Interventional Radiologist, Hartford Hospital, Department of Radiology,
Hartford, CT, USA
Andrew Marcantonio, DO
Orthopedic Trauma Fellow, University of Pittsburgh School of Medicine,
Department of Orthopedic Surgery, Pittsburgh, PA, USA
Julie A. Mayglothling, MD
Assistant Professor, Virginia Commonwealth University Health System,
Department of Surgery, Division of Trauma/Critical Care,
Department of Emergency Surgery, Richmond, VA, USA
Frans L. Moll, MD, PhD
Professor of Vascular Surgery, Utrecht University Hospital, Department
of Vascular Surgery, Utrecht, The Netherlands
John A. Morris Jr., MD
Professor of Surgery, Director, Division of Trauma and Surgical Critical Care,
Vanderbilt University, Division of Trauma and Surgical Critical Care,
Department of Surgery, Nashville, TN, USA
Rami Mosheiff, MD
Associate Professor, Director, Orthopedic Trauma Center, Hadassah Hebrew
University Medical Center, Department of Orthopedic Surgery, Jerusalem, Israel
Nathan T. Mowery, MD
Assistant Professor of Surgery/Trauma Services, Wake Forest University,
Department of Surgery, Winston-Salem, NC, USA
Alan D. Murdock, Lt Col, USAF, MC, MD
Consultant to the Surgeon General for Surgical Services, Wilford Hall USAF
Medical Center, Trauma/Surgical Critical Care, Lackland Air Force Base,
TX, USA
Dieter Nast-Kolb, MD
Professor, University Hospital Essen, Department of Trauma Surgery,
Essen, Germany
xxii Contributors

Sarah Jane O’Brien, MB, BS, DTM&H, MFPHM

Professor, University of Manchester, School of Translational Medicine,
Hope Hospital, Salford, Manchester, United Kingdom
Gbolahan O. Okubadejo, MD
Orthopedic Surgeon, University of Pittsburgh Medical Center,
Department of Orthopedic Surgery, Pittsburgh, PA, USA
Hans-Christoph Pape, MD, FACS
Professor, University of Pittsburgh, Department of Orthopedic Surgery,
Pittsburgh, PA, USA
Andrew B. Peitzman, MD
Mark M. Ravitch Professor, Executive Vice-Chairman, Department of Surgery,
University of Pittsburgh, Pittsburgh, PA, USA
Brad A. Prather, MD
University of Louisville, Department of Orthopedic Surgery,
Louisville, KY, USA
John P. Pryor, MD
Assistant Professor of Surgery, Trauma Program Director, Division
of Traumatology and Surgical Critical Care, University of Pennsylvania
Medical Center, Philadelphia, PA, USA
Jörn Redeker, MD
Professor, Hannover Medical School, Department of Plastic, Hand,
and Reconstructive Surgery, Hannover, Germany
Craig S. Roberts, MD
Professor, University of Louisville, Department of Orthopedic Surgery,
Louisville, KY, USA
Michael F. Rotondo, , MD, FACS
Professor and Chairman, Chief, Trauma and Surgical Critical Care,
Department of Surgery, Brody School of Medicine, East Carolina University,
Greenville, NC, USA
Steffen Ruchholtz, MD
Professor of Surgery, University of Marburg, Department of Trauma,
Hand, and Reconstructive Surgery, Marburg, Germany
Babak Sarani, MD
Assistant Professor of Surgery, University of Pennsylvania, Department
of Surgery, Division of Traumatology and Surgical Critical Care,
Philadelphia, PA, USA
Thomas M. Scalea, MD
Physician-in-Chief, R. Adams Cowley Shock-Trauma Center, Baltimore,
MD, USA
Contributors xxiii

James M. Schuster, MD, PhD

Assistant Professor of Neurosurgery, Trauma Coordinator, University
of Pennsylvania, Department of Neurosurgery, Philadelphia, PA, USA
C. William Schwab, MD, FACS
Professor of Surgery, University of Pennsylvania School of Medicine, University
of Pennsylvania Medical Center, Department of Surgery, Philadelphia, PA, USA
Malek Tabbara, MD
Research Fellow in Surgery, Harvard Medical School, Massachusetts General
Hospital, Department of Surgery, Boston, MA, USA
Georg Taeger, MD, PhD
Assistant Director, Department of Trauma Surgery, University Hospital Essen,
Essen, Germany
Ivan S. Tarkin, MD
Assistant Professor, University of Pittsburgh School of Medicine,
Department of Orthopedic Surgery, Pittsburgh, PA, USA
Otmar Trentz, MD
Professor, University Hospital Zürich, Department of Surgery, Zürich, Switzerland
Christopher C. Tzioupis, MBBS, MD, EEC (ortho)
Trauma Fellow, University of Leeds School of Medicine, Leeds General Infirmary,
Trauma and Orthopedic Surgery, Leeds, Yorkshire, United Kingdom
Jeffrey S. Upperman, MD
Director, Trauma Program, Associate Professor of Surgery, Childrens Hospital
Los Angeles, Keck School of Medicine, University of Southern California,
Department of Pediatric Surgery, Los Angeles, CA, USA
Martijn van Griensven, MD, PhD
Professor, Ludwig Boltzmann Institute for Experimental and Clinical
Traumatology, Vienna, Austria
George C. Velmahos, MD, PhD, MSEd
Professor of Surgery, Harvard Medical School, Department of Surgery,
Boston, MA, USA
Peter M. Vogt, MD, PhD
Professor and Chief, Hannover Medical School, Department of Plastic,
Hand, and Reconstructive Surgery, Hannover, Germany
Christian Waydhas, MD
Professor, Department of Trauma Surgery, University Hospital Essen,
Essen, Germany
Yoram A. Weil, MD
Attending, Hadassah Hebrew University Hospital, Orthopedic Trauma Service,
Jerusalem, Israel
xxiv Contributors

Maralyn Woodford, BSc

University of Manchester, Trauma Audit and Research Network,
Salford Royal Hospital, Alford, Manchester, United Kingdom
Boris A. Zelle, MD
Orthopedic Resident, University of Pittsburgh School of Medicine,
Department of Orthopedic Surgery, Pittsburgh, PA, USA