Sss Orthopedicemergencies 2012 Final Samuel-Wong

Orthopaedic Emergencies
Dr. Samuel Wong

RMH Intern
2012
Orthopedic Emergencies
 Open Fractures
 Acute Compartment Syndrome
 Neurovascular injuries
 Dislocations
 Septic Joints
 Cauda Equina Syndrome
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
Open Fractures- Gustilo-Anderson Classification:
 Type I:
 Small wound (<1cm), usually clean, no soft tissue damage and no
skin crushing (i.e. a low energy fracture)
 Type II:
 Moderate wound (>1cm), minimal soft tissue damage or loss,
may have comminution of fracture (i.e. a low-moderate energy
fracture)
 Type III:
 Severe skin wound, extensive soft tissue damage (i.e. high energy
fracture)
 Three grades: A – adequate soft tissue coverage, B – fracture
cover not possible without local/distant flaps, C – arterial injury
that needs to be repaired.
Open Fractures- Management
 ABCDE – check neurovascular status (pulses, cap. refill, sensation,
motor) , fluid resuscitation, blood
 Antibiotics, tetanus prophylaxis – 48-72 hrs
 Surgical debridement – removal of de-vitalised tissue, irrigation
 Stabilization of fracture – internal/external, if closure delayed then
external prefered
 Early definitive wound cover – split skin grafts, local/distant flaps
(involve plastics)
Open Fractures- Complications
 Wound infection – 2% in Type I , >10% in Type III

 Osteomyelitis – staph aureus, pseudomona sp.
 Gas gangrene
 Tetanus
 Non-union/malunion
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 oedema
 Oedema further increase compartment pressure leading to a
vicious cycle
 Extensive muscle and nerve death >4 hours
 Nerve may regenerate but infarcted muscle is replaced by fibrous
tissue (Volkmann’s ischaemic contracture)
ACS- Etiology
 Crush injury
 Circumferential burns
 Snake bites
 Fractures – 75%
 Tourniquets, constrictive
dressings/plasters
 Haematoma – pt with
coagulopathy at increased risk
ACS- Findings
 5 Ps of ischaemia  Severe pain, “bursting”
 Pain (out of proportion to sensation
injury)  Pain with passive stretch
 Paresthesias  Tense compartment
 Paralysis  Tight, shiny skin
 Pulselessness
 Pallor
 Can confirm diagnosis by

measuring
intracompartmental
pressures (Stryker STIC)
120 mm Hg
Difference between
diastolic pressure and
compartment
pressure (delta
Pulse Pressure
pressure)< 30mmHg
is indication for
immediate
decompression
60 mm Hg
Ischemia
30 mm Hg
Elevated Pressure
10 mm Hg
Normal
0 mm Hg
ACS - Mangement
 Early recognition
 Muscle necrosis at delta
pressure < 30mm Hg
 Irreversible injury 4-6 hrs
 Remove cast, bandages and
dressings
 Arrange urgent fasciotomy
Fasciotomy
ACS- Complications
 Volkman ischaemic contractures
 Permanent nerve damage
 Limb ischaemia and amputation
 Rhabdomyolysis and renal failure
Dislocations
 Displacement of bones at a joint from their
normal position
 Do xrays before and after reduction to look for
any associated fractures
Dislocation- Shoulder
 Most common major joint dislocation
 Anterior (95%) - Usually caused by fall on hand
 Posterior (2-4%) – Electrocution/seizure
 May be associated with:
 Fracture dislocation
 Rotator cuff tear
 Neurovascular injury
Dislocation- Knee
 Injury to popliteal artery and vein is common

 Peroneal nerve injury in 20-40% of knee dislocations
 Associated with ligamentous injury
 Anterior (31%)
 Posterior (25%)
 Lateral (13%)
 Medial (3%)
Dislocation- Hip
 Usually high-energy trauma

 More frequent in young patients
 Posterior- hip in internal rotation, most common
 Anterior- hip in external rotation
 Central - acetabular fracture
 May result in avascular necrosis of femoral head
 Sciatic nerve injury in 10-35%
Neurovascular Injuries
 Fractures and dislocations can be associated with vascular and nerve
damage
 Always check neurovascular status before and after reduction
Neurovascular Injuries - Etiology
 Fracture
 Humerus, femur
 Dislocation
 Elbow, knee
 Direct/penetrating trauma
 Thrombus
 Direct Compression/
Acute Compartment Syndrome
 Cast, unconscious
Common vascular injuries
Injury Vessel
1st rib fracture Subclavian artery/vein
Shoulder dislocation Axillary artery
Humeral supracondylar fracture Brachial artery
Elbow Dislocation Brachial artery
Pelvic fracture Presacral and internal iliac
Femoral supracondylar fracture Femoral artery
Knee dislocation Popliteal artery/vein
Proximal tibial Popliteal artery/vein
Clinical Features & Mx
 Paraesthesia/numbness
 Injured limb cold, cyanosed, pulse weak/absent
 Call for help!
 Remove all bandages and splints
 Reduce the fracture/ dislocation and reassess circulation
 If no improvement then vessels must be explored by operation
 If vascular injury suspected angiogram should be performed
immediately
Common nerve injuries
Injury Nerve
Shoulder dislocation Axillary
Humeral shaft fracture Radial
Humeral supracondylar fracture Radial or median
Elbow medial condyle Ulnar
Monteggia fracture-dislocation Posterior-interosseous
Hip dislocation Sciatic
Knee dislocation Peroneal
Clinical Features & Mx
 Paraesthesia and weakness to supplied area
 Closed injuries: nerve seldom severed, 90% recovery in 4 months.
If not do nerve conduction studies +/- repair
 Open injuries: Nerve injury likely complete. Should be explored at
time of debridement/repair
 Indications for early exploration:
 Nerve injury associated with open fracture
 Nerve injury in fracture that needs internal fixation
 Presence of concomitant vascular injury
 Nerve damage diagnosed after manipulation of fracture
Septic Joint/Septic Arthritis
 Inflammation of a synovial membrane with purulent effusion into

the joint capsule. Followed by articular cartilage erosion by
bacterial and cellular enzymes.
 Usually monoarticular
 Usually bacterial
 Staph aureus
 Streptococcus
 Neisseria gonorrhoeae
Septic Joint- Etiology
 Direct invasion through penetrating

wound, intra-articular injection,
arthroscopy
 Direct spread from adjacent bone abcess
 Blood spread from distant site
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%
Septic Joint- Risk Factors
 Prosthetic joint
 Joint surgery
 Rheumatoid arthritis
 Elderly
 Diabetes Mellitus
 IV drug use
 Immunosupression
 AIDS
Septic Joint- Signs and Symptoms
 Rapid onset
 Joint pain
 Joint swelling
 Joint warmth
 Joint erythema
 Decreased range of motion
 Pain with active and passive ROM
 Fever, raised WCC/CRP, positive
blood cultures
Septic Joint- Treatment
 Diagnosis by aspiration
 Gram stain, microscopy, culture
 Leucocytes >50 000/ml highly
suggestive of sepsis
 Joint washout in theatre
 IV Abx 4-7 days then orally for another 3 weeks
 Analgesia
 Splintage
Septic Joint- Complications
 Rapid destruction of joint with delayed treatment (>24 hours)
 Growth retardation, deformity of joint (children)
 Degenerative joint disease
 Osteomyelitis
 Joint fibrosis and ankylosing
 Sepsis
 Death
Cauda Equina Syndrome
 Compression of lumbosacral nerve roots below conus medullaris
secondary to large central herniated disc/extrinsic
mass/infection/trauma
Clinical Features
 motor (LMN signs)

-weakness/paraparesis in multiple root distribution
-reduced deep tendon reflexes (knee and ankle)
-sphincter disturbance (urinary retention and fecal
incontinence due to loss of anal sphincter tone)
 sensory
-saddle anesthesia (most common sensory deficit)
-pain in back radiating to legs, crossed straight leg test
-bilateral sensory loss or pain: involving multiple
dermatomes
Management
 Surgical emergency - requires urgent investigation and
decompression (<48 hrs) to preserve bowel and bladder function
The End

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Orthopaedic Emergencies

Dr. Samuel Wong

 Wound infection – 2% in Type I , >10% in Type III

 An injury or condition that causes prolonged elevation of

 Can confirm diagnosis by

 Injury to popliteal artery and vein is common

 Usually high-energy trauma

 Inflammation of a synovial membrane with purulent effusion into

 Direct invasion through penetrating

 motor (LMN signs)

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