Orthopaedic Emergencies

2021-02-19 12:00 AM

Trauma Patient Work-Up, investigation and treatment

 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