Orthopaedic Emergencies

Trauma Patient Work-Up

Etiology

· high energy trauma e.g. motor vehicle accidents, fall from height

· may be associated with spinal injuries or life-threatening visceral injuries

Clinical Presentation

· local swelling, tenderness, deformity of the limbs and instability of the pelvis or spine

· decreased level of consciousness

· consider involvement of alcohol or other substances

Investigations

· trauma survey (see Emergency Medicine. Initial Patient Assessment/Management, ER2)

· x-rays: !at cervical spine, AP chest, abdo x-ray, AP pelvis, AP and lateral of all long bones suspected to be injured

· other views of pelvis: AP, inlet and outlet; Judet view for acetabular fracture (see Table 15 for classification of pelvic fractures)

Treatment

· ABC DEs and initiate resuscitation to life threatening injuries

· assess genitourinary injury (rectal exam/vaginal exam mandatory)

· external or internal fixation of all fractures

· DVT prophylaxis

Complications

· hemorrhage -life threatening (may produce signs and symptoms of hypovolemic shock)

· acute respiratory distress syndrome (ARDS)

· fat embolism syndrome

· venous thrombosis - DVT and PE

· bladder/bowel injury

· neurological damage

· possible obstetrical difficulties in future

· persistent sacro-iliac joint pain

· persistent pain/stiffness/limp/weakness in affected extremities

· post-traumatic arthritis ofjoints with intra-articular fractures

· sepsis if missed open fracture

Open Fractures

Definition

• fractured bone in communication with the external environment

Emergency Measures

· removal of obvious foreign material

· irrigate with normal saline

· cover wound with sterile dressings

· IV antibiotics (see Table 3)

· tetanus status ± booster

· splint fracture

· NPo and prepare for OR (bloodwork, consent, ECG, CXR)

• operative irrigation and debridement within 6-8 hours to decrease risk of infection

• traumatic wound often left open to drain but vac dressing may be used

• re-examine with repeat I&D in 48 hrs

Teble 3. Gustilo Classification of Open Fractures

Septic Joint

Etiology

· most commonly caused by Staphylococcus aureus in adults

· consider coagulase-negative staph in patients with prior joint replacement

· consider Neisseria gonorrhoeae in sexually active adults

· most common route of infection is hematogenous

Clinical Presentation

· inability/refusal to bear weight, localized joint pain, erythema, warmth, swelling with pain on active and passive ROM, ± fever

Investigations

· x-ray (to r/o fracture, tumour, metabolic bone disease), ESR, CRP, WBC, blood cultures

· joint aspirate (WBC >80,000 with >90% neutrophils, protein level >4.4 mg/dL, joint« blood glucose level, No crystals, positive Gram stain results)

· rule out heart murmurs

Treatment

· IV antibiotics, empiric therapy (based on age and risk factors), adjust pending joint aspirate C&S

· for small joints: needle aspiration, serial if necessary until sterile

· for major joints such as knee, hip, or shoulder: urgent decompression and surgical drainage

Osteomyelitis

Etiology

· most common organism is Staphylococcus aureus

· consider Salmonella typhi in patients with sickle cell disease

· neonates and immunocompromised patients are susceptible to Gram-negative organisms

· hematogenous (bacteremia) or exogenous (open fractures, surgery, local infected tissue) spread

Clinical Presentation

· localized extremity pain ± fever or swelling 1 to 2 weeks after respiratory infection or infection at another non-bony site

Investigations

· blood culture, aspirate cultures, ESR, CRP, CBC (leukocytosis)

· x-ray, bone scan (increased uptake within 24-48 hours after onset in majority of patients), MRI most sensitive/specific

Treatment

· IV antibiotics, empiric therapy, adjust pending blood and aspirate cultures

· surgical decortication and drainage± local antibiotics (e_g. antibiotic heads) ifMRI suggests an abscess or if patient does not improve after 36 hours on IV antibiotics

· serial I&D (if required), IV antibiotics eventually changed to PO, splint limb for several weeks followed by protective weight-bearing of the limb

Compartment Syndrome

Definition

· increased interstitial pressure in an anatomical "compartment" (forearm. calf) where muscle and tissue are bounded by fascia and bone (fibro-osseous compartment) with little room for expansion

· interstitial pressure exceeds capillary perfusion pressure leading to muscle necrosis (in 4-6 hrs) and eventually nerve necrosis

Etiology

• intracompartmental: fracture (particularly tibial shaft fractures, pediatric supracondylar fractures, and forearm fractures}, crush injury, revascularization

• extracompartmental: constrictive dressing (circumferential cast), circumferential bum

Figure 8. Pathogenesis of Compartment Syndrome

Physical Examination

· pain with passive stretch

· 5 P's: late sign

Clinical Features

· pain with active contraction of compartment

· pain with passive stretch

· swollen, tense compartment

· suspicious history

Investigations

· usually not necessary as compartment syndrome is a clinical diagnosis

· in children or unconscious patients where clinical exam is unreliable, compartment pressure monitoring with catheter AFTER clinical diagnosis is made (normal = 0 mmHg; elevated 0!:30 mmHg or S30 mmHg of diastolic BP)

Treatment

· non-operative

o remove constrictive dressings (casts, splints}, elevate limb at the level of the heart

· operative

o urgent fasciotomy

o 48-72 hours post-op: wound closure ±necrotic tissue debridement

Specific Complications

· rhabdomyolysis, renal failure secondary to myoglobinuria

· Volkmann's ischemic contracture: ischemic necrosis of muscle, followed by secondary fibrosis and finally calcification; especially following supracondylar fracture of humerus

Cauda Equina Syndrome

• see Neurosurgery.

Hip Dislocation

· full trauma survey

· examine for neurovascular injury PRIOR to open or clo&ed reduction

· reduce hip dislocations ASAP (ideally within 6 hours) to decrease risk of AVN of the femoral head

· hip precautions (No extreme hlp flexion, adduction, internal or external rotation) for 6 weeks post-reduction

· also see Hip Dislocation after THA

ANTERIOR HIP DISLOCATION

· mechaniam: posteriorly directed blow to knee with hlp widely abducted

· clinical features: shortened, abducted. externally rotated limb

· treatment

o clo3ed reduction under conscious sedation/GA

o post -reduction CT to assess joint congruity

POSTERIOR HIP DISLOCAT10N

· most frequent type of hip dislocation

· mechanism: severe force to knee with hip flexed and adducted

o e.g. knee into dashboard in motor vehicle accident (MVA)

· clinical features: shortened, adducted and internally rotated U:mb

· treatment

o closed reduction under conscious sedation/GA only if associated femoral neck fracture

o ORIF if unstable, intra-articular fragments or posterior wall fracture

o post-reduction CT to assess joint congruity and fractures

o if reduction is unstable, put in traction x 4-6 weeks

CENTRAL HIP DISLOCATION (rare)

· traumatic injury where femoral head la pushed through acetabulum toward pelvic cavity

COMPUCAT10NS FOR ALL HIP DISLOCAT10NS

· post-traumatic arthritis

· AVN

· fracture of femoral head. neck. or shaft

· sciatic nerve palsy in 25% (10% permanent)

· heterotopic osslfication (HO)

· thromboembolism- DVT/PE