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Orthopedic Emergencies and Urgencies. Scott Playford LCDR, MC, USNR. Objectives. Define orthopedic emergencies/urgencies Discuss relevance to our practice Review specific categories and examples Discuss initial management. Definition.

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orthopedic emergencies and urgencies

Orthopedic Emergencies and Urgencies

Scott Playford

LCDR, MC, USNR

objectives
Objectives
  • Define orthopedic emergencies/urgencies
  • Discuss relevance to our practice
  • Review specific categories and examples
  • Discuss initial management
definition
Definition
  • A musculoskeletal injury or condition that, if missed, could result in additional complications, significant impairment, or death
implications importance
Implications/Importance
  • “missed” = Lawsuit
  • “additional complications” = Lawsuit
  • “impairments” = Lawsuit
  • “death” = Lawsuit
orthopedic emergencies
Orthopedic Emergencies
  • Open Fractures or Joints
  • Neurovascular Injuries
  • Dislocations
  • Septic Joints
open fractures
Open Fractures
  • An open (or compound) fracture occurs when the skin overlying a fracture is broken, allowing communication between the fracture and the external environment
open fractures classifications
Open Fractures- Classifications
  • Compound from within (inside-out):
    • The broken end of the bone breaks through or pierces the skin
  • Compound from without (outside-in):
    • External violence causes laceration or tissue trauma
    • Higher likelihood of contamination
open fractures classifications8
Open Fractures- Classifications
  • Type I:
    • Small wound (<1cm), usually clean; low energy
  • Type II:
    • Moderate wound (>1cm), minimal soft tissue damage or loss; low energy
  • Type III:
    • Severe skin wound, extensive soft tissue damage; high velocity
open fractures complications
Open Fractures- Complications
  • Soft tissue infection
  • Osteomyelitis
  • Gas gangrene
  • Tetanus
  • Crush syndrome
  • Skin loss
  • Non-union
open fractures management
DOs:

Control the bleeding

Cover with sterile dressing

Splint

IV antibiotics

Tetanus prophylaxis

Anti Gas Gangrene Serum (AGGS, Clostridium perfringes)

DON’Ts:

Scream and pass out

Replace protruding bone

Explore wound

Clamp vessels

Open Fractures- Management
one more thing
One more thing…

Any open wound over or near a joint should be assumed to extend to the joint until proven otherwise

slide13

Orthopedic Emergencies

  • Open Fractures or Joints
  • Neurovascular Injuries
  • Dislocations
  • Septic Joints
neurovascular injuries
Neurovascular Injuries
  • Vascular trauma
  • Trauma to peripheral nerves
  • Acute compartment syndrome
neurovascular etiology
Neurovascular- Etiology
  • Fracture
    • Humerus, femur
  • Dislocation
    • Elbow, knee
  • Direct/penetrating trauma
  • Embolism
  • Direct Compression
    • Cast, unconscious
acute compartment syndrome
Acute Compartment Syndrome
  • An injury or condition that causes prolonged elevation of interstitial tissue pressures
  • Increased pressure within enclosed fascial compartment leads to impaired tissue perfusion
  • Prolonged ischemia causes cell damage which leads to increased vessel permeability
  • Plasma leaks into interstitium causing further increase in compartment pressure
  • Extensive muscle and nerve death >8 hours
acs etiology
ACS- Etiology
  • Direct blow or contusion
  • Crush injury
  • Burns
  • Snake bites
  • Fractures
  • Hematoma
  • Prolonged pressure
acs findings
5 Ps

Pain

Paresthesias

Paralysis

Pulses

Palpation

Severe pain

Pain with stretch

Tense compartment

Tight, shiny skin

Late findings

Paresthesias

Paralysis

Loss of pulses

ACS- Findings
slide23

120 mm Hg

Pulse Pressure

60 mm Hg

Ischemia

30 mm Hg

Elevated Pressure

10 mm Hg

Normal

0 mm Hg

acs anatomy
ACS- Anatomy

Upper Extremity

  • Deltoid
  • Brachium
    • Anteroir
    • Posterior
  • Antebrachium
    • Volar
    • Dorsal
    • Mobile wad
  • Hand
    • Thenar
    • Hypothenar
    • Adductor
    • Interosseous
    • Carpal canal
    • Finger
acs anatomy25
ACS- Anatomy

Lower Extremity

  • Gluteal
    • Tensor fascia lata
    • Gluteus medius and minimus
    • Gluteus maximus
  • Thigh
    • Anterior
    • Posterior
  • Leg
    • Anterior
    • Lateral
    • Superficial posterior
    • Deep posterior
  • Foot
slide26
Anterior

Extensor hallucis longus

Extensor digitorum longus

Peroneus tertius

Tibialis anterior

Deep peroneal nerve

Anterior tibial artery

Lateral

Peroneus longus

Peroneus brevis

Superficial peroneal nerve

Superficial posterior

Gastrocnemius

Soleus

Sural nerve

Deep posterior

Flexor digitorum longus

Flexor hallucis longus

Posterior tibialis

Posterior tibial nerve

Posterior tibial artery

Peroneal artery

Quiz Time

acs final thought
ACS- Final Thought

Always check neurovascular status after moving patient, manipulating injured limb, before and after applying cast or splint, and at frequent intervals if transfer is delayed.

slide28

Orthopedic Emergencies

  • Open Fractures or Joints
  • Neurovascular Injuries
  • Dislocations
  • Septic Joints
dislocations
Dislocations
  • Displacement of bones at a joint from their normal position
  • May be associated with neurovascular injury
dislocation knee
Dislocation- Knee
  • Anterior (31%)
    • Caused by hyperextension
    • Often ACL and PCL both torn
    • MCL and/or LCL usually injured
    • Popliteal artery- intimal tear
  • Posterior (25%)
    • ACL and PCL torn
    • Possible tear of extensor mechanism
    • Avulsion or disruption of popliteal artery
  • Lateral (13%)
  • Medial (3%)
  • Rotary (4%)- usually posterolateral
dislocation knee32
Dislocation- Knee
  • Injury to popliteal artery and vein is common
  • Peroneal nerve injury in 20-40% of knee dislocations
  • With peroneal nerve injury, suspect vascular injury
dislocation elbow
Dislocation- Elbow
  • Second most common major joint dislocation
  • Usually closed and posterior
  • Fall on extended elbow
  • Posterior, posterolateral, posteromedial, lateral, medial, or divergent
  • Complex- dislocation with fracture (35-40%)
    • Radial head fracture most common
  • Simple- dislocation without fracture
    • Rupture of capsule, rupture of MCL and lateral ligaments, rupture of flexor pronator mass, possible injury to brachialis muscle and rupture of brachial artery
dislocation elbow34
Dislocation- Elbow
  • Nerve inury
    • Neuropraxia involving median or ulnar nerve in 20% of elbow dislocations
    • Ulnar nerve palsies more common in pediatric
    • Most neuro deficits are transient
dislocation sternoclavicular
Dislocation- Sternoclavicular
  • Anterior
    • More common
    • Traumatic or atraumatic
  • Posterior
    • Rare
    • Soft tissue swelling may give false impression of anterior dislocation
    • Up to 25% complication rate
      • Hemorrhage, tracheal or esophageal injuries, pneumothorax
dislocation hip
Dislocation- Hip
  • Usually high-energy trauma
  • More frequent in young patients
  • Anterior- hip in external rotation
  • Posterior- hip in internal rotation
  • Central acetabular fracture dislocation
  • May result in avascular necrosis
  • Sciatic nerve injury in 10-35%
dislocation shoulder
Dislocation- Shoulder
  • Most common major joint dislocation
  • May be associated with:
    • Bankart lesion
    • Fracture dislocation
    • Hill sachs lesion
    • SLAP lesion
    • Rotator cuff tear
    • Nerve injury- axillary, posterior cord, musculocutaneous
dislocation shoulder38
Dislocation- Shoulder
  • Anterior (95%)
    • Arm abducted and externally rotated
  • Posterior (2-4%)
    • Arm adducted and internally rotated
    • Electrocution, seizure
  • Inferior (1%)
    • Hyperabduction
    • Usually associated with significant trauma
slide39

Orthopedic Emergencies

  • Open Fractures or Joints
  • Neurovascular Injuries
  • Dislocations
  • Septic Joints
septic joint septic arthritis
Septic Joint/Septic Arthritis
  • Inflammation of a synovial membrane with purulent effusion into the joint capsule
  • Usually monoarticular
  • 2-10 cases per 100,000 in general population
  • Gonococcal vs nongonococcal
  • 80% are from gram-positive aerobes (S aureus, beta-hemolytic streptococci, and Streptococcus pneumoniae)
septic joint etiology
Septic Joint- Etiology
  • Direct inoculation
  • Trauma
  • Iatrogenic
  • Hematogenously
  • Adjacent osteomyelitis
  • Soft tissue infection
septic joint location
Septic Joint- Location
  • Knee- 40-50%
  • Hip- 20-25%*
    • *Hip is the most common in infants and very young children
  • Wrist- 10%
  • Shoulder, ankle, elbow- 10-15%
septic joint risk factors
Septic Joint- Risk Factors
  • Prosthetic joint
  • Skin infection
  • Joint surgery
  • Rheumatoid arthritis
  • Elderly
  • Diabetes Mellitus
  • IV drug use
septic joint signs and symptoms
Septic Joint- Signs and Symptoms
  • Rapid onset
  • Joint pain
  • Joint swelling
  • Joint warmth
  • Joint erythema
  • Fever
  • Decreased range of motion
  • Pain with active and passive ROM
septic joint treatment
Septic Joint- Treatment
  • IV antibiotics
  • Drainage
    • Repeated aspirations
    • Consider lavage
septic joint treatment46
Septic Joint- Treatment
  • Open surgical drainage indications
    • Difficult joint aspiration
    • Persistent fever and symptoms >24 hours
    • Leukocytosis persists >48-72 hours
    • Positive repeat blood or joint cultures >48 hours
    • Infected joint prosthesis
septic joint complications
Septic Joint- Complications
  • Rapid destruction of joint with delayed treatment (>24 hours)
  • Degenerative joint disease
  • Soft tissue injury
  • Osteomyelitis
  • Joint fibrosis
  • Sepsis
  • Death
slide48

Final Thought

  • Open Fractures or Joints
  • Neurovascular Injuries
  • Dislocations
  • Septic Joints