Orthopaedic Emergencies

 Aetiology

• high energy trauma e.g. motor vehicle accidents, fall from height
• maybe 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 the involvement of alcohol or other substances

 Investigations

• trauma survey (see Emergency Medicine. Initial Patient Assessment/Management, ER2)
• x-rays: !at the cervical spine, AP chest, abdo x-ray, AP pelvis, AP and lateral of all long bones suspected to be injured
• other views of the 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

• haemorrhage -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 sacroiliac joint pain
• persistent pain/stiffness/limp/weakness in affected extremities
• post-traumatic arthritis of joints with intra-articular fractures
• sepsis if the missed open fracture

Open Fractures

 Definition

• a 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 the 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

 Table 3. Gustilo Classification of Open Fractures

Septic Joint

Aetiology

• 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
• a 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 the knee, hip, or shoulder: urgent decompression and surgical drainage

Osteomyelitis

Aetiology

• the 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 the 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) fMRI suggests an abscess or if the 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

Aetiology

• 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 the 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 the 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 the risk of AVN of the femoral head
• hip precautions (No extreme hip flexion, adduction, internal or external rotation) for 6 weeks post-reduction
• also, see Hip Dislocation after THA

ANTERIOR HIP DISLOCATION

• mechanism: posteriorly directed blow to knee with hip 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

• a most frequent type of hip dislocation
• mechanism: severe force to knee with hip flexed and adducted

o       e.g. knee into the dashboard in a 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 the reduction is unstable, put in traction x 4-6 weeks

CENTRAL HIP DISLOCATION (rare)

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

COMPUCAT10NS FOR ALL HIP DISLOCAT10NS

• post-traumatic arthritis
• AVN
• fracture of the femoral head. neck. or shaft
• sciatic nerve palsy in 25% (10% permanent)
• heterotopic ossification (HO)
• thromboembolism- DVT/PE