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Chapter: Orthopaedics

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Orthopaedic Emergencies

1. Trauma Patient Work-Up 2. Open Fractures 3. Septic Joint 4. Osteomyelitis 5. Compartment Syndrome 6. Cauda Equina Syndrome 7. Hip Dislocation

Orthopaedic Emergencies

 

Trauma Patient Work-Up

 

 

Etiology

·                 high energy trauma e.g. motor vehicle accidents, fall from height

·                 may be 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 involvement of alcohol or other substances

 

Investigations

·                 trauma survey (see Emergency Medicine. Initial Patient Assessment/Management, ER2)

·                 x-rays: !at cervical spine, AP chest, abdo x-ray, AP pelvis, AP and lateral of all long bones suspected to be injured

·                 other views of 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

·                 hemorrhage -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 sacro-iliac joint pain

·                 persistent pain/stiffness/limp/weakness in affected extremities

·                 post-traumatic arthritis ofjoints with intra-articular fractures

·                 sepsis if missed open fracture

 

Open Fractures

 

Definition

 • 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 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

 

Teble 3. Gustilo Classification of Open Fractures


 

 

Septic Joint

 

Etiology

·                 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

·                 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 knee, hip, or shoulder: urgent decompression and surgical drainage

 

Osteomyelitis

 

Etiology

·                 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 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) ifMRI suggests an abscess or if 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

 

Etiology

 • 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 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 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 risk of AVN of the femoral head

·                 hip precautions (No extreme hlp flexion, adduction, internal or external rotation) for 6 weeks post-reduction

·                 also see Hip Dislocation after THA

 

ANTERIOR HIP DISLOCATION

·                 mechaniam: posteriorly directed blow to knee with hlp 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

·                 most frequent type of hip dislocation

·                 mechanism: severe force to knee with hip flexed and adducted

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

 

CENTRAL HIP DISLOCATION (rare)

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

 

COMPUCAT10NS FOR ALL HIP DISLOCAT10NS

·                 post-traumatic arthritis

·                 AVN

·                 fracture of femoral head. neck. or shaft

·                 sciatic nerve palsy in 25% (10% permanent)

·                 heterotopic osslfication (HO)

·                 thromboembolism- DVT/PE

 

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