Orthopedic Emergencies and Urgencies

1. Orthopedic Emergencies and Urgencies Scott Playford LCDR, MC, USNR

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

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

4. Implications/Importance • “missed” = Lawsuit • “additional complications” = Lawsuit • “impairments” = Lawsuit • “death” = Lawsuit

5. Orthopedic Emergencies • Open Fractures or Joints • Neurovascular Injuries • Dislocations • Septic Joints

6. 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

7. 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

8. 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

9. Quiz Time

10. Open Fractures- Complications • Soft tissue infection • Osteomyelitis • Gas gangrene • Tetanus • Crush syndrome • Skin loss • Non-union

11. 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

12. One more thing… Any open wound over or near a joint should be assumed to extend to the joint until proven otherwise

13. Orthopedic Emergencies • Open Fractures or Joints • Neurovascular Injuries • Dislocations • Septic Joints

14. Neurovascular Injuries • Vascular trauma • Trauma to peripheral nerves • Acute compartment syndrome

15. Neurovascular- Etiology • Fracture • Humerus, femur • Dislocation • Elbow, knee • Direct/penetrating trauma • Embolism • Direct Compression • Cast, unconscious

16. Lower Extremity

17. Nerves- Lower Extremity

18. Upper Extremity

19. Nerves- Upper Extremity

20. 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

21. ACS- Etiology • Direct blow or contusion • Crush injury • Burns • Snake bites • Fractures • Hematoma • Prolonged pressure

22. 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

23. 120 mm Hg Pulse Pressure 60 mm Hg Ischemia 30 mm Hg Elevated Pressure 10 mm Hg Normal 0 mm Hg

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

25. 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

26. 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

27. 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.

28. Orthopedic Emergencies • Open Fractures or Joints • Neurovascular Injuries • Dislocations • Septic Joints

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

30. Dislocation- Finger Finger

31. 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

32. 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

33. 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

34. 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

35. 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

36. 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%

37. 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

38. 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

39. Orthopedic Emergencies • Open Fractures or Joints • Neurovascular Injuries • Dislocations • Septic Joints

40. 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)

41. Septic Joint- Etiology • Direct inoculation • Trauma • Iatrogenic • Hematogenously • Adjacent osteomyelitis • Soft tissue infection

42. 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%

43. Septic Joint- Risk Factors • Prosthetic joint • Skin infection • Joint surgery • Rheumatoid arthritis • Elderly • Diabetes Mellitus • IV drug use

44. 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

45. Septic Joint- Treatment • IV antibiotics • Drainage • Repeated aspirations • Consider lavage

46. 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

47. Septic Joint- Complications • Rapid destruction of joint with delayed treatment (>24 hours) • Degenerative joint disease • Soft tissue injury • Osteomyelitis • Joint fibrosis • Sepsis • Death

48. Final Thought • Open Fractures or Joints • Neurovascular Injuries • Dislocations • Septic Joints

49. The End