ORTHOPEDIC EMERGENCIES 2025.power pointtx

The introduction pathophysiology clinical feature and management of orthopedic emergency

1. PRESENTER: TUSEKILE-JOY KAPETA 5 th year MBChB CBU-SOM MODERATOR: DR. LOMBE ORTHOPAEDIC EMERGENCIES

2. Introduction Orthopedic emergencies are acute musculoskeletal conditions that require immediate medical or surgical intervention to prevent limb loss, long-term disability or permanent damage. Delay in management of these conditions can lead to irreversible tissue damage, or loss of limb function.

3. TYPES Orthopedic emergencies include; Compartment syndrome Open fractures Dislocations Septic arthritis Cauda equina

4. Compartment Syndrome

5. INTRODUCTION Compartment syndrome is a surgical emergency characterized by increased pressure within a closed osteofascial compartment, leading to impaired tissue perfusion, muscle and nerve ischemia, and ultimately necrosis if left untreated

6. Compartments are enclosed spaces formed by fascia surrounding groups of muscles, nerves and vessels The fascia is inelastic, so swelling within it rapidly increases pressure The forearm and leg are the most commonly involved The commonest presentation of compartment syndrome in children is after supracondylar fracture of the humerus INTRODUCTION

7. Osteofascial Compartment

8. Etiology Traumatic causes Fractures Crush injuries Soft tissue contusion with bleeding/ swelling Non-traumatic causes Circumferential burns Snake bites Expanding hematoma Iatrogenic causes Tight casts, splints, or bandages Constrictive dressing Failure to remove tourniquet Prolonged surgery or limb elevation

9. PATHOPHYSIOLOGY

10. Clinical features The earliest, and most reliable, sign is pain out of proportion to the injury Later signs include pallor paralyssis paresthesia pulselessness These are known as the 5 Ps of compartment syndrome

11. DIAGNOSIS Compartment syndrome is a clinical diagnosis, and treatment should not be delayed while waiting for investigation results Investigations Compartment pressure measurement ≥ 30 mmHg (or within 30 mmHg of diastolic BP) is diagnostic Urine dipstick assess for myoglobinuria, if rhabdomyolysis is present Creatine kinase markedly elevated Renal function tests assess for AKI

12. Immediate management Imemdiately remove any constricting dressing/ cast Elevate the limb at heart level 30 degrees angle ATLS protocol Adequate analgesia Definitive management Urgent fasciotomy of all affected compartments Debridement of necrotic tissue if present Post-operative care IV fluids (to prevent rhabdomyolysis) Closely monitor urine output and kidney function Cover on broad spectrum antibiotics Physiotherapy MANAGEMENT

13. Loss of function of affected limb Volkmann’s ischemic contracture (permanent flexion deformity, commonly occurs in the forearm) Infection after fasciotomy Amputation Permanent nerve damage Muscle necrosis and fibrosis Chronic pain Rhabdomyolysis Acute renal failure COMPLICATIONS

14. Avoid tight bandages Limb elevation Prompt reduction and fixation of fractures Frequent neurovascular monitoring after fractures, casts, or revascularization Prompt identification of early warning signs prevention

15. OPEN FRACTURES

16. An open fracture is a fracture where there is a break in the skin and underlying soft tissue, leading to communication between the fracture site and the external environment They are also called compound fractures The most common site for compound fractures is the tibia INTRODUCTION

17. Open fractures are usually a result of high energy trauma such as: RTAs, a fall from significant height, industrial accidents, gun shots, etc Etiology by age group Neonates: birth trauma, iatrogenic injury Children: falls, bicycle accidents Adolescents: road traffic accidents, sports etiology

18. Gustilo-Anderson Classification This type of classification looks at 3 parameters -Wound size -Extent of soft tissue injury -Degree or extent of wound contamination

19. investigations 1.Laboratory FBC/DC U and Es +Cr LFTs Group and save 2.Imaging Plain X ray Doppler u/s CT scan MRI

20. complications Early complications Hypovolemic shock Compartment syndrome Fat emboli Tetanus Neurovascular injuries Infection (cellulitis, osteomyelitis) Late complications Non-union/ Delayed union Chronic osteomyelitis Malunion/ deformity Joint stiffness Growth disturbance in children

21. DISLOCATIONS

22. introduction A dislocation is the complete loss of anatomical congruity between joint surfaces, usually due to trauma, that results in pain, deformity, and functional loss They occur when the bones in a joint are forced out of their normal position Common causes include: trauma, sports injuries, falls. Prompt treatment of dislocations is important to prevent neurovascular injury or avascular necrosis.

23. Elbow dislocations This the most common dislocation in children and is the second most common in adults, often posterior due to a fall on an outstretched hand. Clinical Presentation Pain Swelling Deformity Limited range of motion Management Reduction: traction-countertraction method under sedation Imaging : Pre and post reduction x rays to rule out fracture Early mobilization Complications Neurovacular inury Stiffness Recurrent instability

24. Shoulder dislocations Clinical Presentation Pain Swelling Inability to move shoulder Squared off appearance of the shoulder Management Reduction techniques: Stimson, Milch, or traction-countertraction methods Imaging : Pre and post reduction x rays to assess for Bankert lesions Complications Axillary nerve inury Recurrent dislocations

25. Hip dislocations Clinical Presentation Severe pain Inability to bear weight Leg shortening Internal rotation Management Emergent reduction under aneasthesia within 6hours to minimize risk of avascular necrosis. Imaging: Pre and Post reduction X-rays or CT to assess for fractures

26. SEPTIC ARTHRITIS

27. introduction Septic arthritis is a serious joint condition caused by infection, usually bacterial. Most common causative agent is S. aureus. The commonly affected joint is the knee, but the hip, shoulder, ankle and wrist could also be affected.

28. etiology Etiology by age Neonates: Staph aureus, Group B streptococcus, E. coli Infants: Staph aureus, Strep pneumoniae Adolescents: Staph aureus, Neisseria gonorrhea

29. mode of infection Hematogenous spread this is the most common in children Direct inoculation from trauma, surgery, injections Contingous spread from nearby osteomyelitis

30. clinical presentation Acute onset of joint pain Swelling Warmth Erythema Fever Inability to move joint

31. Diagnosis Joint aspiration FBC/DC ESR/CRP X-ray U/S MRI

32. management Urgent joint drainage IV empirical antibiotics Adequate analgesia Immobilize the joint Physiotherapy post-infection will be reuired to restore function

33. complications Joint destruction Chronic osteomyelitis Growth disturbance in children Sepsis/ septic shock Arthritis. ankylosis Recurrence, if drainage is incomplete

34. CAUDA EQUINA

35. introduction Cauda Equina Syndrome (CES) is a rare but serious neurological condition caused by compression of the cauda equina, a bundle of nerve roots at the lower end of the spinal cord (lumbosacral region: L2-S5) These nerves control motor and sensory function to the lower limbs, bladder, bowel, and pelvic organs CES is considered a surgical emergency because delayed treatment can lead to permanent paralysis, loss of bladder and bowel control, and severe disability

36. Causes by mechanism : Congenital spinal stenosis Herniated disc large lumbar disc herniation of L4-L5, L5-S1 Trauma fractures or dislocations of lumbar vertebrae Infections epidural abscess, TB spine (Pott’s disease) Tumors spinal metastasis or primary spinal cord tumor Vascular arteriovenous malformations Iatrogenic complications post-surgery etiology

37. Low back pain radiating to the legs Bilateral sensory loss or pain Bladder dysfunction (urinary retention ) Bowel dysfunction incontinence (fecal incontinence ) Weakness in lower limbs clinical features

38. High index of suspicion based on presentation Urgent MRI of the lumbar spine is the gold standard CT, if MRI is unavailable diagnosis

39. Surgical decompression within 48 hours offer the best outcomes. Time is critical in CES Supportive management Adequate analgesia Physiotherapy Bladder and bowel care Prevention of pressure sores management

40. Permanent urinary retention/ incontinence Bowel incontinence Lower limb paralysis/ paresis Chronic pain and gait abnormalities complications

41. 1. Orthobullets (n.d.) Orthopedic Emergencies: https://www.orthobullets.com 2. American Academy of Orthopaedic Surgeons (AAOS) (n.d.) Emergency Management of Orthopedic Injuries. https://www.aaos.org 3. Journal of Orthopaedic Trauma (n.d.) Management of Acute Orthopedic Emergencies: A Practical Guide.[Journal Website] references