Orthopedic Emergencies

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Al-Jahra Hospital
Orthopedic Emergencies Dr Fathy Khallaf
Consultant Orthopedic Surgeon
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Definition Orthopedic Emergency is a
musculo-skeletal injury or disease that, if
missed could result in significant complications
or impairment which badly affect the activity of
the patient and would leave an adverse residual
effect.
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• Orthopedic Emergencies
•  
• Open fractures
• Dislocations
• Fracture or dislocation associated
• with vascular injuries
• Acute compartment syndrome
• .

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•  
• Exsanguinating Pelvic Trauma
• Fracture neck of femur
• Fracture neck of talus
• Septic arthritis
• Osteomyelitis

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  Open fractures An open fracture is one in
which a break in the skin and soft tissue
envelope allows for direct communication of the
fracture site or fracture hematoma with the
exterior.
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 Gustilo- Anderson Classification of open
fractures Type I Type II Type III A Type III
B Type IIIC
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•  
• Open fractures management
• Dos
• Cover the wound with sterile dressing
• Control bleeding
• Splint the fracture
• IV antibiotics
• Tetanus prophylaxis
• Anti-Gas gangrene serum

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•  
• DONTs
• - Replace the protruding bone
• - Explore the wound in ED
• - Close the wound in ED
• - Clamp vessels in ED

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•  
• Open fractures complications
• - Soft tissue infection
• - Compartment syndrome
• - Skin gangrene with skin loss
• - Delayed union
• - Non-union
• - Infected pseudo-arthrosis
• - Gas gangrene
• - Tetanus
• - Amputation

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•  
• Acute compartment syndrome
• Etiology
• Fractures
• Direct blow or contusion
• Crushing injuries
• Hematoma
• Prolonged pressure

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•  
• After vascular reconstruction and
  revascularization in acute ischemia due to major
  arterial injury
• Burns
• Snake bites

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 The most common fracture associated with ACS is
tibial diaphyseal fractures which have been
reported to be 3-11. The second most common
cause is soft tissue injury, but the second most
common fracture to be complicated by ACS is
distal radius fracture.
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•  Acute compartment syndrome
• Pathophysiology
• An injury or a condition that causes
• prolonged elevation of interstitial tissue
• pressure
• Increased pressure within enclosed
• fascial compartment leads to impaired
• tissue perfusion.

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•  Prolonged ischemia causes cell damage
• which leads to increase vessels
• permeability
• Plasma leaks in the interstitium causing
• further increase in compartment
• pressure
• Extensive muscles and nerve death if
• this ischemia prolonged more than 8 h.

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•  Acute compartment syndrome
• Symptoms Signs
• Severe continuous pain out of
• proportion of the original injury or
• fracture disturbing the patient's sleep
• Pain on passive stretch
• Pain with active contraction
• Tense swelling in the involved
• compartment

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• Tight shiny skin
• Late findings Paraethesia
• Paralysis
• Pallor
• Pulselessness

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 Investigations Measurements of
intra-compartmental  pressure using the
following methods 1- Needle manometer 2-Wick
catheter 3- Slit catheter 4- Pressure
transducer
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•  Threshold for Decompression in ACS
• Absolute measurement of intra-
• compartmental
• Pressure 30 mm Hg
• Relative measurement of intra-
• compartmental Pressure to diastolic
• blood pressure DBP-ICP 30 mm Hg
• Treatment
• Emergency fasciotomy

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 Dislocations Definition dislocation is the
displacement of bones at a joint from their
normal relation and position
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Dislocation shoulder

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Dislocation elbow
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Dislocation hip
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Dislocation knee
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  Exsanguinating Pelvic Trauma Tile
classification of pelvic fractures The two pelvic
fractures most commonly associated with
significant hemorrhage are 1- Antero-posterior
external rotation injury B1 2- Rotationally
and vertically unstable pelvic injury
whether unilateral or bilateral or
associated with acetabular fracture CI, C2,
C3
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Clinical presentation -Hemo-dynamically
unstable and deteriorating -Destot's
sign -Earle's sign -Roux's sign
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• X-ray and CT scan APC type BI
• or VS type C 1, 2, 3
• -U/S and CT scan abdomen
• revealed no intra-peritoneal
• bleeding

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• Management
• Resuscitation according to ATLS
• guidelines
• Reduction and immobilization of pelvic
• fracture using an external fixator in APC
• B I or pelvic C-clamp in VS C I,2,3 may
• be required to stop the bleeding

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•   Laparotomy with abdominal or pelvic
• packing
• Angiography and??selective
• embolization may also be required.

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FRACTURE NECK OF FEMUR Not emergent but urgent
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FRACTURE NECK OF TALUS Not emergent but urgent

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Septic arthritis Children and
immuno-compromised adults Staphylococcus aureus
is most common organism Hip and knee are the most
affected joints Presentation fever- pain in the
affected joint or limb- toxicity- swelling and
effusion in superficial joints- complete
restriction of active
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or passive movements in the affected joint-
exquisite pain and tenderness on palpating or
moving the affected joint- x-ray is negative-
bone scan and MRI can give positive
data-leukocytosis-high ESR and CRP Treatment
start broad spectrum antibiotic emergent joint
arthrotomy incision drainage
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• Osteomyelitis
• Children and immuno-compromised
• adults
• Staphylococcus aureus is most common
• organism
• lower femoral and upper tibial Metaphysis
• are the most common sites
• Presentation fever- toxicity- pain in
• The affected part of the limb- swelling

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And tenderness along the affected metaphysis-
sympathetic effusion with painful but mildly
limited range of movements- x -ray is
negative-MRI and bone scan are positive-
leukocytosis- high ESR and CRP Treatment start
broad spectrum antibiotic incision drainage
with bone drilling and guttering.
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Thank you