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
Nerve Motor Sensation Injury
Femoral Knee extension Anterior knee Pubic rami fracture
Obturator Hip adduction Medial thigh Obturator ring fracture
Posterior tibial Toe flexion Sole of foot Knee dislocation
Superficial peroneal Ankle eversion Lateral dorsum of foot Fibular neck fracture, knee dislocation
Deep peroneal Ankle/toe dorsiflexion Dorsal 1st to 2nd web space Fibular neck fracture, compartment syndrome
Sciatic nerve Plantar and dorsiflexion Foot Posterior hip dislocation
Superior gluteal Hip abduction Acetabular fracture
Inferior gluteal Gluteus maximus hip extension Acetabular fracture
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Upper Extremity
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Nerves- Upper Extremity
Nerve Motor Sensation Injury
Ulnar Index finger abduction Little finger Elbow Injury
Median distal Thenar contraction with opposition Index finger Wrist dislocation
Median, anterior interosseous Index tip flexion Supracondylar fracture of humerus (child)
Musculo-cutaneous Elbow flexion Lateral forearm Anterior shoulder dislocation
Radial Thumb, finger, MCP extension 1st dorsal web space Distal humeral shaft, anterior shoulder dislocation
Axillary Deltoid Lateral shoulder Anterior shoulder dislocation, proximal humerus fracture
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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