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saves nine” It is a common medical myth that orthopedics has no real emergency. A limb & or life threatening condition is called emergency. HERE ARE SOME OF THEM to remember
Compartment Syndrome: A clinical syndrome characterized by elevated
compartment pressure within a tight osseo-fascial compartment. Pain out of proportion, pain on passive stretching & a tense limb. Key to management: Early clinical diagnosis, removal of all encircling bandages down to the skin, proactive, liberal & adequate fasciotomy, stabilize #, moderate limb elevation & monitoring. Note the various fasciotomy incisions for common sites of compartment syndrome --leg, foot hand and forearm. After an adequate fasciotomy the distal-most peripheral arteries should start pulsating.
Gas Gangrene: A rapidly progressive limb & life threatening infective
gangrene with anaerobic bacteria. (Clostridia)
Key to management: IV Antibiotics (penicillin or cephalosporin), AGGS (Optional), Aggressive debridement & removal of dead space or Amputation, Hyperbaric oxygen therapy (Optional)
Fat Embolism Syndrome: a subacute onset potentially life threatening condition of obscure origin mainly involving the CNS and the lungs that occurs after long bone fractures. Key to management: Early diagnosis with high index of suspicion, adequate oxygenation, ICU care, aggressive symptomatic management & immediate # stabilization.
Acute cervical Spine Injury: high cervical cord injury can cause instant
respiratory paralysis due to involvement of root values of both the phrenic nerves. Temporary Immobilization for transportation is essential, Key to management: Resuscitation with oxygen, IV Fluids, may need a Tracheostomy + Ventilatory support, Foley’s catheterization, Ryle’s tube to avoid aspiration, Radiological investigations, Skeletal Traction . High dose IV Methyl prednisolone (within 1ST 8 Hrs of injury) Symptomatic management, avoidance of bed sores through good nursing care, Input- output chart. Clinical diagnosis of type of neural deficits: complete Vs incomplete cord lesion depending on return of bulbocavernosus reflex after resolution of spinal shock, identification of type of cord syndrome, if incomplete Decompression & definitive # fixation.
Unstable Pelvic Fracture with Hypotension: Profound shock may
occur in major pelvic fractures and more than three litres of blood may be lost internally even without major arterial bleed. Key to management: ABCDE FGHI of Resuscitation, quick assessment of radiographs, Avoidance of patient movements, Priority surgery after resuscitation –supra pubic cystostomy, external fixator for #, control of major internal visceral bleeding through Laparotomy +/Internal fixation of the # at one sitting. Fracture hematoma & Venous bleed contribute to major # related Hypotension. . Arterial cause is rare cause of Hypotension in pelvic #s, contrary to common myth.
Cauda Equina Syndrome with Acute lumbar Disc Prolapse: A neurological emergency where disc lesion at any level below D10 causing compressive or ischemic damage to cauda equina can produce a painful sciatica, saddle-shaped anesthesia (S2 spinal segment), penile sensory loss in association with urinary retention with or without overflow incontinence & impotence as sympatheic outflow is also involved.
Key to management: These entire neural deficits may not recover if not treated urgently. Catherization of bladder, absolute bed rest, urgent MRI, IV steroid (optional), Urgent spinal decompression & discectomy should be done to avoid permanent neurological damage. Wide laminectomy may be required for adequate decompression. The disc may lay intra- dural.
Open fracture with major vascular injury (Grade III C #) any open fracture with major vascular injury. If not treated promptly gangrene will develop and amputation will become madatory to save the life particularly in lowert limb injuries Key to management : Thorough irrigation, systematic debridement, IV antibiotics, # Stabilization, angiography (Optional), vascular repair, fasciotomy (Optional), moderate limb elevation &monitoring
Acute Septic Arthritis of hip joint: This may be life as well as limb damaging/threatening in newborne infants particularly low birth weight babies who are the usual victim. Key to management : Aspiration & culture, IV Antibiotics, arthrotomy &drainage &immobilization
Acute Osteomyelitis Acute infective inflammation of bone & medullary cavity due to pyogenic bacteria. This may be life threatening in newborne infants particularly low birth weight babies who are the usual victim. Key to management : Early diagnosis, blood culture( in infants & young children in particular ) broad spectrum empirical IV antibiotics before formation of pus, rest to the part , I & D when pus is formed & patient not responding within 48 hours of IV-antibiotics , bacterial identification ,culture & sensitivity.Appropriate antibiotics based on culture sensitivity , serial falling CRP, TLC ,PMN leukocyte proportion should be achieved. TB Spine with rapid paraplegia.
Irreducible Dislocation of Hip: A dislocation of hip, which fails to reduce even after adequate attempt at reduction under, appropriates anesthesia. Key to management: Open reduction, systematic examination of the cause/causes, post operative CT Scan
Total or Subtotal Amputation of Thumb / Multiple Digits
Key to management: Proper preservation at 4 degree C, avoidance of improper handling and undue treatment of amputed part with spirit/ formaldehyde, early prompt referral to higher centers.
Acute Injection Palsy of Major Nerve Key to management: Immediate surgical decompression and irrigation
Acute Infection in Palmer Spaces Key to management: -Aspiration & culture, Early IV antibiotics, urgent decompression, proper immobilization & Elevation of hand
Acute Dislocation of Knee Key to management: Closed reduction, limb Vascularity assessment, immobilization, angiography & vascular repair if needed
Acute Slipped Capital Femoral Epiphysis (SCFE) Key to management: -Gentle close reduction and internal fixation just like a fracture neck femur.
Acute Respiratory Obstruction in Cervical Spine TB Dyspnoea, Hoarseness & Dysphagia due to rapidly expanding tubercular retropharyngeal abscess causing acute cervical cord compression. Key to management: Emergency decompression/evacuation of TB abscess to relieve respiratory obstruction is warranted under ATT cover
Acute Hemophilic Arthritis with Haemarthrosis Key to management: factor replacement FFP, Pure factor replacement, tranexamic acid, EACA, Immobilization of joint, avoidance of invasive procedure or parenteral injections.
Poly Articular Rheumatoid Arthritis with Exacerbation Key to management: Rest, local heat, NSAIDs, look for significant extraarticular manifestation, short course IV steroids (after exclusion of infection), SAARDs (slow acting anti rheumatic drugs) with patient & family education.
Limb Fracture with Burn Key to management: –Resuscitation, Rehydration with crystalloid solution (Ringers solution), SSD application, External fixator application, early skin cover. Post Operative Early Infected Total Arthroplasty---Thorough debridement, culture, aggressive and appropriate IV Antibiotics
Acute Gout Key to management: Rest, NSAID, avoidance of allopurinol & high purin containing foods for example red meat & spinach, may add colchicin to prevent further attack .
Battered Baby Syndrome with fractures
Key to management: Protection, isolation & hospitalization followed by parent counseling.
ORTHOPAEDIC RADIOLOGY: THE GENERAL PRINCIPLES OF TAKING AN X-RAY FOR EVALUATION OF SKELETAL INJURY X-ray is like a shadowy first impression, reality may differ
In orthopedics the most commonly used method of investigation is plain X-ray. But an X-ray is just a shadow of a reality. Before we interpret a shadow we must know what produces these shadows HOW TO READ AN X-RAY: 1. Inspect the x-ray plate against bright light. 2. Confirm the name, age, date and number of the X-ray plate. 3. Confirm the right or left side of the part or limb. 4. Identify the type of X-ray taken, viz. plain or contrast, myelo, sinogram etc. 5. Identify the view of radiograph-AP, Lateral, oblique, axial, tangential etc. 6. Part exposed and extent of exposure. 7. Quality of radiograph and presence of artifacts, if any. 8. Now read the radiograph carefully and systematically as ABCD’S. A- Alignment: angulation, rotation, shanton’s line, neck shaft angle of femur etc. B- Bone: texture (normal, thickened, thinned.), cortico-medullary differentiation, Condition of growth plate in children, Examine systematically these in epiphyseal, Metaphyseal, and diaphyseal areas. C-Cartilage: Joint space, articular surface, any radio-opaque body or calcification in cartilage. D- Density: osteopenia, osteoporosis, osteosclerosis, osteoclastic areas etc. S- Soft tissue: density, fat lines, swelling if any, calcification etc. 9. Approximate age from radiological point of view in young patients can be made. Limitations: In Cx spine it is very crucial to include the cervico-dorsal junction to be visible in lateral view, this area is often not visualized in emergency dept due to patient’s shoulder superimposition & serious # or dislocation is missed. A shoulder pulled down view should be done to avoid this menace.
Precautions and pitfalls of X-ray studies RULE OF 2—“one view is no view”
2 views (don’t miss the #), 2 joints (don’t miss a # dislocation), two sides (don’t miss an Epiphyseal injury in young child), and two occasions (don’t miss hairline #in an important bone –e.g. Fracture neck of Femur, # waist of scaphoid). AP, Lateral (in all injuries), Oblique (in Scaphoid, Spine, Sacroiliac joints), Axial (Calcaneum)
ALWAYS TAKE 2 VIEWS 2 SIDES TAKE 2 JOINTS Special views: better but difficult, avoided due to lack of exposure. Example of IN PAEDITRIC INJURY RULE OF 2 IS MUST
underutilization of special view is axially lateral view in suspected shoulder dislocation. Relatively rare posterior dislocation of shoulder is commonly missed in the casualty department due to lack of an axially lateral view. Radiation involved: TAKE CARE in Pregnant, children, serial X-ray examinations. USG (ultrasosnography) is better (Plus Points are Cheap, widely available, portable) ROLE OF ADVANCE INVESTIGATIONS IN FRACTURES
CT-Important additional information can be obtained in injuries of Spine, complex intra-articular #s, #-Dislocations (shoulder, hip, spine), # pelvis &acetabulum, assessment of # union; especially when # was reduced accurately with implants, consolidation of spinal fusion MRI-It is very useful in evaluation of Spinal injury with neural deficits, acute knee injury, Shoulder injury, epiphyseal injury in young children & diagnosis of chondral damage &AVN. BONE SCAN –It can confirm a doubtful # line, stress #, pathological #, vascularity assessment in small bone fragment ULTRASOUND---- It can assess #union –callus is seen earlier than in conventional x-ray by expert radiologists.
Interpretation of Radiograph of Spine
As said before a radiographic image is just a shadow; like the 1 ST impression, careful close observation might change your view for better. Before any interpretation it is important to assess the quality of the radiograph. In Cx spine it is very crucial to include the cervico-dorsal junction to be visible in lateral view, this area is often not visualized in emergency dept due to patient’s shoulder superimposition & serious # or dislocation is missed. A shoulder pulled down view should be done to avoid this menace.In dorsolumbar & lumbar spine intestinal gas shadow may jeopardize any fruitful interpretation .If any doubt exists bowel preparation should be done with a laxative and charcoal tablet and a repeat x-ray taken to rule out any fracture. It is possible that the cervico-dorsal & lumbo-sacral junctions are not adequately visualized for any meaningful interpretation with plain X-rays; a CT scan is the logical second option if advised by expert.
WHAT TO LOOK FOR IN LATERAL & OBLIQUE VIEW? 1. Alignment—Cx lordosis, dorsal kyphosis, lumber lordosis, dislocation/subluxation 2. Bones -------vertebrae (height, shape, bony texture, erosion), paradiscal /end plates, spinous processes, inter-spinous distance, pedicles, pars interarticularis, sagittal diameter of spinal canal, neural foramina 3. Cartilage ---I.V. Disc spaces (normal, decreased or increased) , calcification of discs ,facet joints 4. Density----- osteoporosis, osteopenia, osteosclerosis, osteolysis 5. Soft tissues – ligament calcification WHAT TO LOOK FOR IN AP VIEW? 1. Alignment---scoliosis 2. Bone --------interpedicular distance, transverse processes, pedicle destruction, sup. & Inf. Articular Processes, Cx rib if any, spina bifida, sacralization of lumbar vertebra, ribs 3. Cartilages---facet joints 4. Density --- osteopenia,porosis, sclerosis 5. Soft tissue --any Para-vertebral soft tissue shadow, ligament calcification, psoas shadow. Any other calcified mass in abdomen e.g.—renal calculus etc RULE OF THUMB IN IMAGING OF SPINAL TRAUMA 1. Clinical examination is must before ordering an x-ray 2. Plain x-ray is very important screening method for evaluation, but they don’t provide meaningful information in every patient 3. When radiography is not adequate more extensive evaluation is required while Cx spine is being immobilized. 4. CT is the second line of investigation choice for evaluation of bony elements especially in casualty dept. 5. MRI is the investigation of choice for evaluating spine & cord in conscious cooperative patients with neural deficits
GENERAL PRINCIPLES OF FRACTURE MANAGEMENT
Do the 4 R’s in fractures–Resuscitation, Reduction, Retention of reduction, Rehabilitation
1) RESUSCITAION: According to principle of ABCDE (save the patient) 2) REDUCTION By Traction, Counter-traction & Manipulation (save the limb integrity/stability) 3) RETENTION OF REDUCTION: Achieved stability of the fracture (save the reduction
achieved) through one of the following:
PLASTERS – CAST, POP, A/E, A/K, B/E, B/K, CYLINDER, SLAB: can avoid the danger of cast SPICA, plaster Jacket Special techniques: Pin & plaster technique PTB cast, cast braces Braces 4) REHABILITATION: This is usually started early once the general condition of the patient is
stabilized. Allowing movements of joints, Physiotherapy, Exercise and occupation therapy to attempt to bring back the patient to the pre-injury status. (Save the person as a whole)
Signs of fracture: look for it ESPECIALLY in polytrauma/unconscious patients: Swelling, deformity with or without shortening, crepitus, abnormal painful mobility & loss of function/disability.
Plaster of Paris (POP): cast and slab
BASICS OF A PLASTER APPLICATION
Protect bony prominences The cast should not be too tight or too loose Avoid cast when gross swelling is present Always elevate the limb Active toe/finger movements are to continue 5 Ps of compartment Syndrome to remember/Remind
► BENEFITS OF CAST: Immediate immobilization, pain control, physiological benefits ► DANGERS OF CAST: tight plaster leading to compartment syndrome and missed arterial injury, nerve palsy, plaster sore etc
SKIN TRACTION: when less force is needed, <6.8 kg. SKELETAL TRACTION: when >7kgs are needed as traction,
When skin is not normal SKULL TRACTION: Commonly used in Cx spine injury in adults Formula for WEIGHT to attach for Cx traction:
2.5kg + Cx spine number + 1.5 kg,
Note that heavier the skull more is the weight required according to age.
BENEFITS OF TRACTION
Pain relief, correct shortening /angulation/shift/joint friction and reduce muscle spasms etc
DANGERS OF TRACTION
Skin damage, infection, nerve palsy, vascular damage, ligament damage (knee), spinal cord damage (skull traction in unstable spine injury)
Fractures that don’t need a plaster
# Ribs Stable pelvic #: rami # Clavicle #Fibula except in lower 1/3 rd near the ankle joint (Lateral malleolus)
ROLE OF EXTERNAL FIXATORS EXIST IN FOLLOWING CONDITIONS: external fixator has revolutionized the treatment of crush injury, open fractures and polytrauma patients.
►In Open # ► # associated with major vascular injury (open grade IIIC #) ►Along with /Before Vascular Repair ►# With Poor skin & soft tissue condition / burn ►# with Infection: infected fracture or nonunion ►Large wounds especially over a joint ►# with Bone loss ►# with Compartment syndrome needing fasciotomy ►For ligamentotaxis to maintain reduction in comminuted intra-articular # ►# Femur in restless adolescent
Polytrauma: orthopaedic injury management in Polytrauma
A-B-C-D-E OF RESUSCITATION FIRST A-----Airway Clearance B-----Breathing C-----Circulation D-----Disability Assessment (Paralysis for example) E----- Exposure (Over or Under-exposure i.e. environment/Hypothermia/ missed injuries) A-B-C-D-E-F-G-H-I-S OF RESUSCITATION A-----Airway Clearance B-----Breathing C-----Circulation D-----Disability Assessment (Neurovascular in particular) E----- Exposure F----- Fracture (Look for it or else you will miss it) G-----Go Back (Secondary survey) H-----Help (Team involvement) I------Investigations (trauma series) S-----Surgery (if needed urgently) HEAD TO TOE EXAMINATION IN POLYTRAUMA Go for a systematic inspection, palpation (especially abdominal) and compression
► To rule out life-threatening injuries.(chest compression/ pelvic compression) ► Check length of the limb (measurement), movements of toes and fingers to rule out
disability e.g. spinal injury with paraplegia, nerve injury and arterial injury. ► Skull, eyes, oral cavity, ears, Face, Cx spine, ► Clavicles, Shoulders, arms, elbows, forearms, wrists & hand ► Chest compression, Abdomen, Pelvic compression, ► Dorsal & dorso-lumbar & lumbar spine, ► Hips, thighs, knees, legs, ankle & feet in that order
CLASSICAL SIGNS OF FRACTURE
►Tenderness, Swelling, Deformity with or without Shortening, Crepitus, abnormal
Mobility & loss of function/disability (inability to move/bear weight). ►Look for these ESPECIALLY in polytrauma/unconscious patients so that you don’t miss them!!
Previously called Compound # Gustilo-Anderson’s classification for severity of compounding GRADE-I—small clean wound <1cm, no significant injury to muscle or periosteal stripping GRADE-II—larger wound >1cm, but no significant soft tissue damage, flaps or avulsion GRADE III---large wound, extensive injury to skin, muscle, periosteum & bone. e.g. Gunshot injury, crush injury etc
SUBCLASSIFICATION OF GRADE III OPEN FRACTURES ► A-extensive contamination /injury to underlying soft tissues but viable soft tissue
cover is possible without a muscle cover ► B – Usually massive contamination is present; muscle transfer is required to cover bone & neurovascular structure ► C—any size of wound with major vascular injury requiring vascular repair to save the limb ► “D”----traumatic amputations (Not named under Gustilo-Anderson’s classification)
Save the life, then save the limb, then save the function of the limb as a whole.
► RESUSCITATION ► COPIOUS IRRIGATION: Pulsatile lavage may be used for optimum results—upto 8 liters of saline should be used for irrigation ► SERIAL DEBRIDEMENT: Rule of 4Cs in debridement: 4 C’s---- Color, Consistency, Contraction & Circulation of muscle must be noted to ascertain the viability of the muscle Assess the zone of tissue injury—as a rule, more than expected damage is present Assess vascularity- palpate distal peripheral pulses & check nail-bed circulation. Assess nerve injury-sensation, active movements of toes or fingers. ► TETANUS PROPHYLAXIS: Depends on the previous immune status
PROPHYLACTIC ANTIBIOTICS: Antibiotics are given for 48-72 hrs
► Gr.I---------------1St-gen Cephalosporin: e.g. Cefazolin ► Gr. II---- --------1ST gen. Cephalosporin ► Gr. III A----------1ST GEN. Cephalosporin + Aminoglycosides ► Gr. IIIB & C---1ST Gen. Cephalosporin + aminoglycosides + Penicillin
3RD Gen. Cephalosporin in marine related injuries OPTIONS OF FIXATION AFTER RESUSCITATION
► EXTERNAL FIXATORS: for sever open fractures grade iii/ some grade ii, late
presentation, polytrauma with open fractures. ► O.R.I.F.: Grade I & II and Some Clean Grade II Fractures ► SLAB/ CAST WITH WINDOW: For Wound inspection/ Dressing ADDRESSING THE SOFT TISSUE PROBLEMS
► Split Skin Grafting ► Local Rotation Flap ► Muscle Pedicle: Gastrocnemius (leg), Gracillis (thigh), Latissimus dorsi flap
► Free tissue transfers by Plastic surgery procedures
Flaps: to know the exact blood supply is important for microvascular anastomosis. e.g. Medial gastrocnemius: medial sural vessels Lateral gastrocnemius: lateral sural vessels ADDRESSING THE PROBLEM OF BONE LOSS
► Distraction osteogenesis: Ilizarov frame ► Attempt union by ORIF or ext. fixator accepting the shortening ► Reconstruction with bone allograft ► Fibular graft: either free or vascularized (Plastic surgery) ► Tibialization of fibula/ tibia-pro fibula surgery ► Composite graft: osseo-fascio-cuteneous plastic surgery ► Sliding bone graft ► Boyd’s bypass bone graft ► Amputation.
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