ORTHOPAEDIC EMERGENCIES
Gede Chandra P. Yudha
ORTHOPAEDIC EMERGENCIES
• Definition :
– Any musculoskeletal problem requiring emergency
management
– Life threatening
– Limb threatening
ORTHOPAEDIC EMERGENCIES
1.
2.
3.
4.
5.
6.
Open fracture
Compartment syndrome
Dislocation
Vascular injury
Unstable pelvic fracture
Septic arthritis
OPEN FRACTURE
• Definition :
– Osseus disruption in which a break in the skin and underlying soft
tissue communicates directly with the fracture and its hematoma
• 1/3 of patients with open fractures are multiply injured
• Any wound occuring on the same limb segment as a fracture
must be suspected to be a consequence of an open fracture
until proven otherwise
OPEN FRACTURE
• Mechanism of injury
– High energy
– In out
– Out in
OPEN FRACTURE
PRIMARY
SURVEY
• AIRWAY
• BREATHING
• CIRCULATION
• DISABILITY
• ENVIRONMENT
SECONDARY
SURVEY
• HEAD TO TOE
EXAMINATION
ASSES
EXTREMITY
INJURY
• DEGREE OF SOFT
TISSUE INJURY
• DEGREE OF SKELETAL
INJURY
• NEUROVASCULAR
STATUS
OPEN FRACTURE
• Radiographic evaluation
– Trauma survey  lateral view cervical spine, AP
view of the chest and pelvis
– Extremity radiographs are obtained as indicated
by clinical setting, injury pattern, and patient
complaints
OPEN FRACTURE
• Classification (Gustillo &
Anderson)
Open Fracture Grade I
Open Fracture Grade II
Open Fracture Grade III A
Open Fracture Grade III B
OPEN FRACTURE
• Management
– Emergency room management
•
•
•
•
Perform careful clinical and radiographic evaluation
Initiate parenteral antibiotics
Symptomatic treatment
Assess skin and soft tissue damage, place a salinesoaked sterile dressing on the wound
• Perform provisional reduction of fracture and then
splint
• Antibiotics
• Tetanus prophylaxis
OPEN FRACTURE
• Management
– Operative treatment
• Debridement
– Irrigation
– Removal of devitalized tissue
– Removal of foreign bodies
• Reduction
• Fixation
– Internal
– External
COMPARTMENT SYNDROME
• Compartment :
– groupings of muscles, nerves,
and blood vessels in
extremities, covered by fascia
• Definition :
– Increased intracompartment
pressure to a level that can
compromise tissue perfusion
– May cause irreversible muscle
and nerve damage
– ICP (intra compartmental
pressure) within 30 mmHg
from diastolic pressure
• Usually happen in leg, forearm, hand, foot
• Causes :
– Increased Volume - internal : hemorrhage,
fractures, swelling from traumatized tissue,
increased fluid secondary to burns, post-ischemic
swelling
– Decreased volume - external: tight casts, dressings
COMPARTMENT SYNDROME
• Patophysiology
– “vicious cycle”
– Muscle ischemia
• 4 hours - reversible
damage
• 8 hours - irreversible
changes
• 4-8 hours - variable
– Nerve ischemia
• 1 hour - normal
conduction
• 1- 4 hours - neuropraxic
damage - reversible
• 8 hours - axonotmesis irreversible
COMPARTMENT SYNDROME
• Diagnosis
– Clinical (5 P)
• Pain  early sign “pain on passive strech, out of
proportion, progressive, not relieved by immobilization”
• Paresthesia
• Paralysis
• Pallor
• Pulselessness
– ICP pressure measurement
COMPARTMENT SYNDROME
• Management
– Remove any restricting
bandages, cast
– Symptomatic treatment
– In doubt  monitoring
pressure every 4 hours,
in 24 hours
– Definite  fasciotomy
DISLOCATION
• Joint moves beyond normal range, loss of contact of
joint surface
• May be complete or partial
• Partial  subluxation
• Causes deformity, severe pain, rigidity, loss of function
• Neurovascular compromise
DISLOCATION
• Clinical sign :
– Look : deformity,
shortening, rotation
– Feel : pain, empty socket
(eg : empty shoulder in
shoulder dislocation),
assess distal
neurovascular
– Move : decrease ROM
• Imaging :
– X-ray : loss of joint
contact
DISLOCATION
• Management
– Primary survey
– Secondary survey
– Definitive
• Reduction under GA
– May be closed or open
– Must be done within 6 hours since injury
• Immobilization after reduction
VASCULAR INJURY
• Vascular injury often
follows fracture or
dislocation
• Important to always
check the distal
vascular status!
VASCULAR INJURY
• Mainly arteries
• Clinical signs :
– Hard signs
• Pulsating bleeding
• Direct view of anterial injury
– Soft signs
• Hematome
• Non pulsating
VASCULAR INJURY
• Management :
– Early :
• Primary & secondary survey
• Stop bleeding  apply external pressure
– Definitive
• Exploration
• Further management depends on the findings during
exploration :
– Rupture  repair, or vascular graft
– Trombosis  vascular graft
– Reduction & stabilization (if fracture or dislocation
present)
UNSTABLE PELVIC FRACTURE
• Pelvis
– 2 innominate bones +
1 sacrum
– Bond together by
strong ligamentous
complex  maintain
stability, vertically &
horizontally
– Major vessels close to
the bone
UNSTABLE PELVIC FRACTURE
• Pelvic fracture (pelvic ring fracture)
– Stable
• Configuration
• Hemodynamic
– Unstable
• Configuration
• Hemodynamic
• Mechanism of injury :
– High energy trauma
– Force direction (4) :
•
•
•
•
Lateral compression
Anterior Posterior compression
Vertical shear
Combined
• Pelvic fracture classification (Young & Burgess)
• Clinical evaluation :
– Perform primary survey
– Initiate resuscitation. Adress life threatening
injuries
– In suspicion of pelvic fracture, check :
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•
•
•
Leg length discrepancy
Pelvic instability test  can only be performed once
Hematoma in flank, around iliac crest, perineum
Urethral injury often accompanies pelvic fracture 
blood in MUE, butterfly hematoma, floating prostate
• Vaginal or rectal perforation by fracture fragments
• Pelvic AP X-ray  using portable X-ray
• FAST  Focused Assesment Sonography for Trauma
• Management :
– Problem : hemorrhage
– Primary survey & resuscitation
• 2 large bore IV cath
• IV fluids (crystalloids, blood)
• urine production monitor
– Other options :
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•
•
•
•
Pelvic binder
Pelvic sling
Pelvic clamp
External fixator
MAST / PSAG
Pelvic Sling & C-clamp
Pelvic External Fixator
Pneumatic Anti Shock Garments
SEPTIC ARTHRITIS
• Definition
– Acute joint infection due to bacterial agents
– Medical emergency
• Epidemiology
– Incidence:
•
•
•
•
40-68/100000/ yr in Prosthetic joint
28-38/ 100000/ yr in RA
5- 12/ 100000/ yr in Children
2-5/ 100000/ yr in GP
– In Adult: 75% with risk factor
SEPTIC ARTHRITIS
• Risk factors:
– Systemic:
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•
•
•
•
•
Old age (>80 Y)
RA
DM
Immunosuppressive
Hemodyalisis
Malignancy
– Local:
• RA
• OA
• Prosthetic joint
SEPTIC ARTHRITIS
• Etiology (microbiology)
– Microbial agent:
• Staphylococcus aureus: most common (7580%)
• Other organism in special patients:
– Sexually active woman: Neisseria gonorrheae
– Elderly, IV drug abuser, immunocompromised, UTI: Gram
negative (p. aeruginosa and E.coli)
– HIV: Pneumococci, Salmonella, H. influenzae
– Alcoholism, Humeral immunity abnormality,
Hemoglobinopathies: Pneumococcal infections
SEPTIC ARTHRITIS
• Root of infection:
– Blood stream
– Contiguous infection
– Direct inoculation:
• Injection: 0.0002
• Arthroscopic surgery: < 0.005
• Animal or human bite
SEPTIC ARTHRITIS
• Site of involvement:
– Mono (80-90%)
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•
•
•
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•
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Knee: 55%
Ankle: 10%
Wrist: 9%
Shoulder: 7%
Hip: 5%
Elbow: 5%
SC: 5%- IV drug abuser
SI: 2%- IV drug abuser
Foot joints: 2%
– Poly (more than 1 joint): RA
SEPTIC ARTHRITIS
• Clinical manifestations
– Fever (toxic)
– Look : swelling, redness
– Feel : warmth, pain, effussion
– Move : limited ROM
• Synovial fluid aspiration  pus
Acute Monoarthritis
Sepsis workup
Biochemist
Positive B/C :
50-70%
Leukocytosis
ESR & CRP
Synovial Fluid
Aspiration
Smear- Culture
Light microscope
Positive Gram stain:
75% in s. aureus
30-50% in gram (-)
Positive Fluid culture: 90%
PCR: partially treated or culture negative
SEPTIC ARTHRITIS
• Radiographic changes
– Early:
• Soft tissue swelling Joint space widening
– Late (2-3 w):
• Erosion
• Joint space narrowing
TREATMENT
Supportive
Bed rest
IV Fluids
Analgesics
Antipiretics
Antibiotic
Empiric (IV):
Smear
Age or Risk factors
Extra articular site
Definitive therapy;
based on culture
Joint Drainage
Closed needle
Aspiration
Arthrotomy:
Hip, Shoulder
Arthroscopic Drainage:
Symptom
S. fluid volume
S. fluid WBC
S. fluid smear & culture
Empirical antibiotic