Orthopedic Emergencies and Urgencies

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Orthopedic Emergencies and Urgencies

• Scott Playford
• LCDR, MC, USNR

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Objectives

• Define orthopedic emergencies/urgencies
• Discuss relevance to our practice
• Review specific categories and examples
• Discuss initial management

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Definition

• A musculoskeletal injury or condition that, if
  missed, could result in additional complications,
  significant impairment, or death

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Implications/Importance

• missed Lawsuit
• additional complications Lawsuit
• impairments Lawsuit
• death Lawsuit

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Orthopedic Emergencies

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

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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

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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

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Open Fractures- Classifications

• Type I
• Small wound (lt1cm), usually clean low energy
• Type II
• Moderate wound (gt1cm), minimal soft tissue damage
  or loss low energy
• Type III
• Severe skin wound, extensive soft tissue damage
  high velocity

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Quiz Time
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Open Fractures- Complications

• Soft tissue infection
• Osteomyelitis
• Gas gangrene
• Tetanus
• Crush syndrome
• Skin loss
• Non-union

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Open Fractures- Management

• DOs
• Control the bleeding
• Cover with sterile dressing
• Splint
• IV antibiotics
• Tetanus prophylaxis
• Anti Gas Gangrene Serum (AGGS, Clostridium
  perfringes)

• DONTs
• Scream and pass out
• Replace protruding bone
• Explore wound
• Clamp vessels

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One more thing

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

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Orthopedic Emergencies

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

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Neurovascular Injuries

• Vascular trauma
• Trauma to peripheral nerves
• Acute compartment syndrome

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Neurovascular- Etiology

• Fracture
• Humerus, femur
• Dislocation
• Elbow, knee
• Direct/penetrating trauma
• Embolism
• Direct Compression
• Cast, unconscious

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Lower Extremity
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Nerves- Lower Extremity
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Upper Extremity
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Nerves- Upper Extremity
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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 gt8 hours

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ACS- Etiology

• Direct blow or contusion
• Crush injury
• Burns
• Snake bites
• Fractures
• Hematoma
• Prolonged pressure

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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

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120 mm Hg
Pulse Pressure
60 mm Hg
Ischemia
30 mm Hg
Elevated Pressure
10 mm Hg
Normal
0 mm Hg
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ACS- Anatomy

• Upper Extremity
• Deltoid
• Brachium
• Anteroir
• Posterior
• Antebrachium
• Volar
• Dorsal
• Mobile wad
• Hand
• Thenar
• Hypothenar
• Adductor
• Interosseous
• Carpal canal
• Finger

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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

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Quiz Time

• Superficial posterior
• Gastrocnemius
• Soleus
• Sural nerve
• Deep posterior
• Flexor digitorum longus
• Flexor hallucis longus
• Posterior tibialis
• Posterior tibial nerve
• Posterior tibial artery
• Peroneal artery

• 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

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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.

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Orthopedic Emergencies

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

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Dislocations

• Displacement of bones at a joint from their
  normal position
• May be associated with neurovascular injury

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Dislocation- Finger
Finger
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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

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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

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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

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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

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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

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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

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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

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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

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Orthopedic Emergencies

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

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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)

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Septic Joint- Etiology

• Direct inoculation
• Trauma
• Iatrogenic
• Hematogenously
• Adjacent osteomyelitis
• Soft tissue infection

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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

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Septic Joint- Risk Factors

• Prosthetic joint
• Skin infection
• Joint surgery
• Rheumatoid arthritis
• Elderly
• Diabetes Mellitus
• IV drug use

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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

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Septic Joint- Treatment

• IV antibiotics
• Drainage
• Repeated aspirations
• Consider lavage

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Septic Joint- Treatment

• Open surgical drainage indications
• Difficult joint aspiration
• Persistent fever and symptoms gt24 hours
• Leukocytosis persists gt48-72 hours
• Positive repeat blood or joint cultures gt48 hours
• Infected joint prosthesis

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Septic Joint- Complications

• Rapid destruction of joint with delayed treatment
  (gt24 hours)
• Degenerative joint disease
• Soft tissue injury
• Osteomyelitis
• Joint fibrosis
• Sepsis
• Death

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Final Thought

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

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The End