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Orthopaedic Emergencies
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