Orthopedic Emergencies

 Definition of an orthopedic emergency: you must operate w in 6 hrs


Open fracture:

  • Fractured bone in communication w external environment
  • It is limb threating, do ABC’s first (30% chance of other life-threatening injuries)

Classification: based on the degree on soft tissue injury

  • Gunshot: skin puncture is < 1 cm, but severe soft tissue damage -> makes it grade 3
  • Segmental fx (bone is broken at 2 places): by default, grade 3 (regardless of skin opening size)

Management:

  • ER: full assessment, ABCs, reduce and splint, clean the wound, tetanus, Abx
  • OR: win 6 hrs, I&D, reduction and fixation
GUSTILO CLASSIFICATION OF OPEN FRACTURES
Class Definition Contamination Antibiotics
Type I Skin wound < 1 cm, simple fx w minimal comminution Clean, minimal 1st gen cephalosporin (Cefazolin) for 24h after closure

If allergic: fluoroquinolones or clindamycin

If MRSA: use vancomycin

Type II Skin wound 1 – 10 cm, moderate comminution Moderate
Type III A Skin wound > 10 cm, severe comminution or fragmented, soft tissue damage, periosteal stripping, but adequate bone coverage High 1st gen cephalosporin (Cefazolin) + Aminoglycoside (gentamicin) for 72 h after I&D

If farm injury or soil contaminated: + penicillin (for anaerobicclostridial coverage)

If allergic: fluoroquinolones or clindamycin

If MRSA: use vancomycin

Type III B Skin wound > 10 cm, severe comminution or fragmented, extensive soft tissue damage, severe periosteal stripping and bone exposure, requires soft tissue coverage (flap)
Type III C Skin wound > 10 cm, severe comminution or fragmented, extensive soft tissue damage, severe periosteal stripping and bone exposure, vascular injury that requires repair

 


Septic arthritis: 

  • Joint infection w progressive destruction if left untreated

Routes:

  • Hematogenous: most common
  • Direct inoculation: trauma, surgery
  • Contiguous from adjacent site: osteomyelitis, cellulitis)

Risk factors: abnormal joint (trauma, arthritic), immunocompromised (Ca, DM)

Organisms:

  • Most common: staph aureus > Neisseria gonorrhea (in young, sexually active)
  • Sickle cell: salmonella
  • Trauma: anything, gram negatives

Clinical features: pain, swelling, red, hot, decreased funcx, painful ROM, fever (esp peds)

Investigations:

  • Labs: CBCd (high WBC), CRP and ESR (sensitive but not specific)
  • X-ray: usually normal, done to ro other causes (fx, OA)
  • US: useful in peds in deep joints like hip (they present w limping and fever) shows collection and guides drainage. (If no collection; it might be femur head osteomyelitis)

Joint aspiration: send for cell count, culture, crystals, gram stain

  • Cloudy yellow fluid, WBC > 50,000 w >90% neutrophils, protein >4.4mgdL, joint glucose <60% blood glucose, no crystals, positive gram stain

Treatment: empiric IV Abx, I&D (either open or arthroscopic)

  • If you don’t have the facility to do arthroscopic drainage, do you refer the pt to another hospital, or do open I&D? Open; bc you may not have time before joint destruction

 


Compartment syndrome:

  • Increased interstitial pressure in an anatomical compartment -> compromised circulation -> muscle necrosis (4-6 hrs) (first thing affected) -> nerve necrosis (late)

Clinical features:

  • Pain out of proportion = not responding to analgesia, splinting (first and most imp symptoms)
  • Pain w passive stretching of the muscle (most imp and sensitive sign)
  • Hypo-Paresthesia in the distribution of nerves of the compartment
  • Paralysis, pallor, pulseless (late findings) [having a pulse doesn’t mean the pt doesn’t have compartment, bc arterial pressure is higher the compartment pressure]
  • Swollen, tense compartment

 

Pathophysiology:

  • Decreased compartment size: constrictive dressingscast, thermal injuriesfrost bites
  • Increased compartment contents: fractures, bleedinghematoma, arterial thrombosis

Diagnosis: mostly clinical, but if there’s suspicion, use:

  • Compartment pressure measurement:
  • Indications: unconscious pt, difficult to assess (peds), multiple concomitant injuries (spinal cord injury and tibial fx for example).
  • If there’s clinical suspicion but you don’t have pressure measurement? give the pt the benefit of the doubt + Tx as compartment and do fasciotomy
  • If pt is hypotensive and compartment pressure is low? Pt might still have compartment even if the compartment pressure is not high, bc the perfusion to the compartment is already low. So, we have a lower threshold if the pt is hypotensive
  • If diastolic pressure – compartment pressure is < 30 => it’s compartment
  • For example; pt presented to ER, BP is 8040, tibial fracture, and clinical picture suspicious of compartment, pressure measurement is 20?
  • The difference is 20, so it’s compartment!

Treatment: fasciotomy.

Complications:

  • Volkmann’s ischemic contracture: ischemic muscle necrosis -> secondary fibrosis -> calcification. (esp in supracondylar fx of humerus)
  • Rhabdomyolysis and myoglobinuria -> renal failure

Joint dislocations:

  • Loss of contact of articular surface
  • Requires anatomical reduction (either under sedation in ER under GA in OR -> open if closed failed), assessment of NVS before and after

Hip dislocation:

  • Anterior: limb will be ext rotated, abducted. (femoral N)
  • Posterior: limb will be int rotated, adducted. (sciatic N) (more common; MOI is usually knee into dashboard in MVA)
  • Requires reduction ASAP due to high risk of AVN

Elbow dislocation:

  • Mostly are posterior dislocations
  • MOI: elbow hyperextension via FOOSH

Treatment:

  • Usually closed reduction under conscious sedation followed by long-arm splint w elbow in 90° flexion
  • ORIF indications:
  1. Unstable reductions: require flexion of > 50-60° to maintain reduction
  2. Complex dislocations: associated w fractures

Shoulder dislocation:

refer Toronto Notes, or my summary “Upper Limb Fractures” 

Knee dislocation:

  • Needs a tear of at least 3 out of the 4 knee ligaments to cause dislocation
  • High risk of vascular injury (popliteal artery is a fixed structure)
  • First sign of vascular injury is asymmetrical pulse -> sign of intimal injury

 


Cauda equina syndrome:

  • Compression of lumbosacral nerve roots below conus medularis (below L2)
  • Causes: central disc hernia, post op hematoma, abscess
  • Diagnosis: urgent MRI
  • Tx: surgical decompression win 6 hrs to preserve bladderbowel and sexual function
CLINICA FEATURES
Motor Sensory Autonomic
Bilateral motor weakness

Dec deep tendon reflexes

Lower back pain radiating to both legs (sciatica)

Aggravated by Valsalva and sitting

Relieved by laying down

Saddle anesthesia (S2-5)

Loss of anal sphincter tone

Urinary retention or overflow incontinence

Fecal incontinence

Sexual dysfunx

 


Download the PDF version: here


References:

  • Dr. Abdullah Alturki’s lecture
  • Toronto notes
  • Orthobullets.com

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