ortho emergencies commonly seen in emergency room

Orthopedic emergency

1. EMERGENCIES
Dr B V SIVA VARA PRASAD
DNB Emergency Medicine
ORTHOPAEDIC

2. Orthopedic Emergencies
Hemorrhage
Crush syndrome
Open Fractures
Acute Compartment Syndrome
Neurovascular injuries
Dislocations
Septic Joints
Spinal cord injury

3. HEMORRHAGE

5. Hemorrhage control is best achieved with direct pressure.
Hemorrhage from long-bone fractures can be significant,
and femoral fractures in particular often result in significant
blood loss into the thigh.
If bleeding persists, apply manual pressure to the artery
proximal to the injury.
If bleeding continues, consider applying a manual
tourniquet (such as a windlass device) or a pneumatic

6. A pneumatic tourniquet may require a pressure as high as 250 mm Hg
in an upper extremity and 400 mm Hg in a lower extremity.
If time to operative intervention is longer than 1 hour, a single
attempt to deflate the tourniquet may be considered in an otherwise
stable patient
if a tourniquet must remain in place for a prolonged period to save a
life, the choice of life over limb must be made
Application of vascular clamps into bleeding open wounds while the
patient is in the ED is not advised, unless a superficial vessel is clearly
identified

10. CRUSH
SYNDROME

11. Crush syndrome, or traumatic rhabdomyolysis,
refers to the clinical effects of injured muscle that,
if left untreated, can lead to acute renal failure
and shock.
This condition is seen in individuals who have
sustained a compression injury to significant
muscle mass, most often to a thigh or calf.
Rhabdomyolysis can lead to metabolic acidosis,
hyperkalemia, hypocalcemia, and disseminated
intravascular coagulation.

13. Myoglobin produces dark amber urine
that tests positive for hemoglobin.
. Amber-colored urine in the presence of
serum creatine kinase of 10,000 U/L or
more is indicative of rhabdomyolysis
when urine myoglobin levels are not
available.

14. Management
Initiating early and aggressive intravenous fluid
therapy during resuscitation is critical to
protecting the kidneys and preventing renal
failure in patients with rhabdomyolysis.
Myoglobin-induced renal failure can be prevented
with intravascular fluid expansion, alkalinization
of the urine by intravenous administration of
bicarbonate, and osmotic diuresis

15. Open Fractures

16. 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

17. Grade I
•Wound: < 1cm
•Contamination:
clean puncture
•Soft Tissue: little
damage/ no crush
•Fracture: simple
transverse/ oblique
with minimal
comminution
•Vascularity intact

18. Grade II
•Wound: > 1cm
•Contamination:
moderate
•Soft Tissue:
moderate
•Fracture: moderate
comminution

19. Grade
III
•Wound: extensive
skin loss,more than
10cm
•Contamination: high
degree
•Soft Tissue:
extensive soft
tissue damage
•Fracture: highly
comminuted
•Includes:
–High velocity
trauma
–Gunshot injuries
–Farmyard injuries
–Fractures requiring
vascular repair

20. Grade IIIa
•Grade III with
– Sufficient tissue to
allow bony cover.

21. Grade IIIb
•Grade III with
–Extensive soft-
tissue damage with
periosteal stripping
and bone exposure.
–Inadequate soft
tissue for bony
cover.

22. Grade IIIc
•Any open fracture
with vascular
injury that
requires repair
(for survival of
the limb).
•Associated
arterial injury

24. Infection & Amputation Rates
Gustilo Grade Infection RateAmputation
Rate
I 0 – 2% -
II 2 – 7% -
IIIa 7% 2.5%
IIIb 10 – 50% 5.6%
IIIc 25 – 50% 25%

25. Open Fractures- Management
ABCDE – check neurovascular status (pulses, cap. refill, sensation,
motor) , fluid resuscitation, blood
Antibiotics, tetanus prophylaxis – 48-72 hrs
Surgical debridement – removal of de-vitalised tissue, irrigation
Stabilization of fracture – internal/external, if closure delayed then
external prefered
Early definitive wound cover – split skin grafts, local/distant flaps
(involve plastics)

26. •Open fractures
Management
Local:
-Take a picture!
-If dirty, irrigate with normal saline to remove
gross contamination
-If bone sticking out try to reduce gently then
immobilize and re-check neurovascular
status
-Cover with sterile wet gauze
-If bleeding apply direct pressure on wound

27. IMMOBILISATION
The goal of initial fracture
immobilization is to realign
the injured extremity in as
close to anatomic position as
possible and prevent
excessive fracture-site motion
Proper application of a splint
helps control blood loss,
reduces pain, and prevents
further neurovascular
compromise and soft-tissue
injury.

28. Immobilization must include the joint
above and below the fracture.
After splinting, be sure to reassess the
neurologic and vascular status of the
extremity
Femoral fractures
Femoral fractures are immobilized
temporarily with traction splints.
The traction splint’s force is applied
distally at the ankle.
Do not apply traction in patients with an
ipsilateral tibia shaft fracture.

29. KNEE
Knee immobilizer or a posterior long-leg plaster splint is
effective in maintaining comfort and stability.
Do not immobilize the knee in complete extension, but
with approximately 10 degrees of flexion to reduce
tension on the neurovascular structures.
TIBIA
Plaster splints immobilizing the lower thigh, knee, and
ankle are preferred
ANKLE
Ankle fractures may be immobilized with a well-padded
splint, thereby decreasing pain while avoiding pressure
over bony prominences

30. Upper extremity and Hand injuries
The hand may be temporarily splinted in an ana- tomic, functional
position with the wrist slightly dorsiflexed and the fingers gently
flexed 45 degrees at the metacarpophalangeal joints.
The forearm and wrist are immobilized flat on padded or pillow
splints.
The elbow is typically immobilized in a flexed position, either by using
padded splints or by direct immobilization with respect to the body
using a sling-and-swath device.
The upper arm may be immobilized by splinting it to the body or
applying a sling or swath, which can be augmented by a
thoracobrachial bandage.
Shoulder injuries are managed by a sling-and-swath device or a hook

32. STABILIZATIONOFFRACTURE
Important in reducing the likelihood of infection
and assisting in recovery of the soft tissues
The methods of fixation depends on :
-the degree of contamination,
-the length of time from injury to operation
-the amount of soft tissue damage.
If there is no obvious contamination, open
fractures of all grades up to type IIIA, can be
treated as for closed injury; cast splintage,
intramedulary nailing/external fixation.
Severe injuries might require a soft tissue cover.

33. •Open fractures
Management
Tetanus prevention:
Wound types:
1.Clean wounds:
➡ <6 hours from injury
➡ Not a farm injury
➡No significant devitalized tissue
➡Non immersed wound
➡Non contaminated wound
2.Other wounds

34. •Open fractures
Management
:
Clean wounds Other wounds
Completed
vaccination
Not
completed or
unknown
Completed
vaccination
Not
completed or
unknown
Booster < 10
years
Booster >10
years
Td 0.5ml IM
Booster <
5years
Booster > 5
years TIG 250U
And
Td 0.5ml IM
nothing Td 0.5 ml IM nothing Td 0.5ml IM

35. Treat all patients with open
fractures as soon as
possible with intravenous
antibiotics using weight-
based dosing.

36. Aftercare
•Limb is elevated and circulation is
carefully watched
•Antibiotic cover is continued
•Culture is obtained, if needed, different
antibiotic is subtituted
•If wound is left open, inspect at 2-3
days
•Delayed primary suture is then often
safe
•If there is much skin loss – split-skin
graft or skin flap applied

39. Open Fractures- Complications
Wound infection – 2% in Type I , >10% in Type III
Osteomyelitis – staph aureus, pseudomona sp.
Gas gangrene
Tetanus
Non-union/malunion

40. Acute
Compartment
Syndrome

41. 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 oedema
Oedema further increase compartment pressure leading to a vicious
cycle
Extensive muscle and nerve death >4 hours
Nerve may regenerate but infarcted muscle is replaced by fibrous
tissue (Volkmann’s ischaemic contracture)

43. ACS- Etiology
Crush injury
Circumferential burns
Snake bites
Fractures – 75%
Tourniquets, constrictive dressings/plasters
Haematoma – pt with
coagulopathy at increased risk

44. ACS- Findings
5 Ps of ischaemia
Pain (out of proportion to
injury)
Paresthesias
Paralysis
Pulselessness
Pallor
Severe pain, “bursting”
sensation
Pain with passive stretch
Tense compartment
Tight, shiny skin
Can confirm diagnosis by
measuring intracompartmental
pressures (Stryker STIC)

45. 0 mm Hg
10 mm Hg
30 mm Hg
60 mm Hg
120 mm Hg
Pulse Pressure
Ischemia
Elevated Pressure
Normal
Difference between
diastolic pressure and
compartment pressure
(delta pressure)<
30mmHg is indication
for immediate
decompression

46. ACS - Mangement
Early recognition
Muscle necrosis at delta
pressure < 30mm Hg
Irreversible injury 4-6 hrs
Remove cast, bandages and
dressings
Arrange urgent fasciotomy

47. ACS- Complications
Volkman ischaemic contractures
Permanent nerve damage
Limb ischaemia and amputation
Rhabdomyolysis and renal failure

48. Dislocatio
ns

49. Dislocations
Displacement of bones at a joint from their
normal position
Do xrays before and after reduction to look for
any associated fractures

50. Dislocation- Shoulder
Most common major joint dislocation
Anterior (95%) - Usually caused by fall on hand
Posterior (2-4%) – Electrocution/seizure
May be associated with:
Fracture dislocation
Rotator cuff tear
Neurovascular injury

51. •Dislocation- Elbow
•Second most common major joint dislocation
•Usually closed and posterior
•Fall on extended elbow
•Complex- dislocation with fracture (35-40)
•Radial head fracture most common
•Simple- dislocation without fracture
Neuropraxia involving median or ulnar nerve
Ulnar nerve palsies more common in pediatric

52. Dislocation- Knee
Injury to popliteal artery and vein is common
Peroneal nerve injury in 20-40% of knee dislocations
Associated with ligamentous injury
Anterior (31%)
Posterior (25%)
Lateral (13%)
Medial (3%)

53. Dislocation- Hip
Usually high-energy trauma
More frequent in young patients
Posterior- hip in internal rotation, most common
Anterior- hip in external rotation
Central - acetabular fracture
May result in avascular necrosis of femoral head
Sciatic nerve injury in 10-35%

54. •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

55. Ankle
Lateral is most common
Externally rotated, prominent
medial malleolus
Subtalar joint
Lateral is most common
Laterally displaced os calcis
(calcaneus)

56. To exclude occult dislocation and
concomitant injury, x-ray films
must include the joints above and
below the suspected

57. Neurovascular
Injuries

58. Neurovascular Injuries
Fractures and dislocations can be associated with vascular and nerve
damage
Always check neurovascular status before and after reduction

59. Fractures with nerve or vascular
injuries
Mechanisms:
-Penetrating trauma
-High energy blunt trauma
-Significant fracture
displacement

60. Direct laceration
Traction and
shearing

61. Neurovascular Injuries - Etiology
Fracture
Humerus, femur
Dislocation
Elbow, knee
Direct/penetrating trauma
Thrombus
Direct Compression/
Acute Compartment Syndrome
Cast, unconscious

62. Common vascular injuries
Injury Vessel
1
st
rib fracture Subclavian artery/vein
Shoulder dislocation Axillary artery
Humeral supracondylar fracture Brachial artery
Elbow Dislocation Brachial artery
Pelvic fracture Presacral and internal iliac
Femoral supracondylar fracture Femoral artery
Knee dislocation Popliteal artery/vein
Proximal tibial Popliteal artery/vein

63. Vascular injuries
Assessment
Always check:
Pulse, Color, Capillary refill, Temperature, compartment
pressure
Keep high index of suspicion:
-High energy trauma
Associated nerve injuries
Fractures/ Dislocations around the knee

64. Vascular injuries
Assessment

65. Vascular injuries
Assessment
Hard signs > realignment of limb > if persistant >
➡vascular intervention
Hard signs > realignment of limb > improved >
➡ Close observation
➡Realignment can result in unkincking of vessels,
lowering compartment pressure, relaxation of arterial
spasm

66. Vascular injuries
Assessment
ABI
-< 0.9 associated with vascular pathology
-Rarely can give false negative result (Ex. Profunda
femoris)
-Always used in high risk fractures (knee)
-If positive > Urgent vascular intervention

67. Vascular injuries
Assessment
Angiography, CT
angiography
Gold standard

69. Nerve injuries
Closed fractures not requiring surgery with nerve
injuries:
➡ Usually good outcome >80%
➡ Usually managed conservatively in the early stages
➡ Recovery may take more than 6 months

70. Common nerve injuries
Injury Nerve
Shoulder dislocation Axillary
Humeral shaft fracture Radial
Humeral supracondylar fracture Radial or median
Elbow medial condyle Ulnar
Monteggia fracture-dislocation Posterior-interosseous
Hip dislocation Sciatic
Knee dislocation Peroneal

71. Clinical Features & Mx
Paraesthesia and weakness to supplied area
Open injuries: Nerve injury likely complete. Should be explored at
time of debridement/repair
Indications for early exploration:
Nerve injury associated with open fracture
Nerve injury in fracture that needs internal fixation
Presence of concomitant vascular injury
Nerve damage diagnosed after manipulation of fracture

72. Septic Joint
Septic Arthritis

73. Septic Joint/Septic Arthritis
Inflammation of a synovial membrane with purulent effusion into the
joint capsule. Followed by articular cartilage erosion by bacterial and
cellular enzymes.
Usually monoarticular
Usually bacterial
Staph aureus
Streptococcus
Neisseria gonorrhoeae

74. Septic Joint- Etiology
Direct invasion through penetrating wound,
intra-articular injection, arthroscopy
Direct spread from adjacent bone abcess
Blood spread from distant site

75. 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%

76. Septic Joint- Risk Factors
Prosthetic joint
Joint surgery
Rheumatoid arthritis
Elderly
Diabetes Mellitus
IV drug use
Immunosupression
AIDS

77. Septic Joint- Signs and Symptoms
Rapid onset
Joint pain
Joint swelling
Joint warmth
Joint erythema
Decreased range of motion
Pain with active and passive ROM
Fever, raised WCC/CRP, positive blood
cultures

78. Septic Joint- Treatment
Diagnosis by aspiration
Gram stain, microscopy, culture
Leucocytes >50 000/ml highly
suggestive of sepsis
Protein>4.4mg/dl
Glucose <60% of blood glucose
No crystals
Positive gram stain

80. TREATMENT
Joint washout in theatre
IV Abx 4-7 days then orally for another
3 weeks
Analgesia
Splintage

81. Septic Joint- Complications
Rapid destruction of joint with delayed treatment (>24 hours)
Growth retardation, deformity of joint (children)
Degenerative joint disease
Osteomyelitis
Joint fibrosis and ankylosing
Sepsis
Death

82. Spinal cord
injury

83. Suspected Spinal Injury
High speed crash
Unconscious
Multiple injuries
Neurological deficit
Spinal pain/tenderness

84. PROTECTION  PRIORITY
Detection  Secondary

“Log-rolling”

85. Effective pain relief usually requires the administration of
narcotics, which should be given in small doses
intravenously
Regional nerve blocks play a role in pain relief and the
reduction of appropriate fractures. It is essential to assess
and document any peripheral nerve injury before
administering a nerve block.
Always keep the risk of compartment syndrome in mind, as
this condition may be masked in a patient who has
undergone nerve block

86. MISSED
INJURIES