You are on page 1of 112

WELCOME TO

2006 by : Andre Yanuar, Darmadji Ismono

One week internship in dept. of


orthopaedic & traumatology

Ward-Clinic-OR-Emg
Morning visits (Monday & Thursday) at 6
a.m
Morning report (Wednesday & Saturday)
at 7 a.m
Grand Round (Tuesday)

One week internship in dept. of


orthopaedic & traumatology
Journal reading & referat (Monday &
Thursday) at 7 a.m or 7.30 a.m
Apley reading (Tuesday & Friday) at 1.30
p.m
Pre assessment (Thursday) at 1.30 p.m
Assessment (Friday) at 7.00 a.m
CSS, BST, Mini CX

In Emergency Room

Assess all trauma patient for possibility of orthopaedic case!


If the patient need operation prepare as soon as possible!
1. Informed consent (resident do, co-ass ask for ps or fams signature)
2. Tell to fast at least 6 hours prior to op
3. Make IV line
4. Tetanus prophilactic
5. Antibiotic & analgetic
6. Blood check (SYSMEX for < 40 y.o, complete for > 40 y.o and < 14 y.o)
7. Urine check
8. Cross match & blood reservation in blood bank
9. EKG ( for > 40 y.o)
10. Chest X-Ray, with expertise for < 14 y.o
11. Complete the medical record ! (under resident supervision)
12. IPD or paediatric consultation ( for > 40 or < 14, sometimes no
need)
13. Anesthesiology consultation

Introduction
Orthopaedics is
concerned with bones,
joints, muscles, tendons
and nerves the
skeletal system and all
that makes it move

Introduction
Scope :

Congenital & developmental


abnormalities

Infection & inflammation

Arthritis & rheumatic


disorders

Metabolic & endocrine


disorders

Tumours

Sensory disturbance &


muscle weakness

Injury & mechanical


derangment

Subdivision :
Traumatology
Orthopaedi :
1. Adult Reconstruction
2. Oncology Orthopaedic
3. Pediatric Orthopaedic
4. Spine
5. Hand & Microsurgery

Introduction
Steps in orthopaedic diagnosis:
1. History taking
2. Physical Examination
* Posture
* Gait
1. Inspection
2. Palpation
3. Examination of movements
4. Conduction of special tests
3. Further investigations
1. Examination of radiographs
2. Examination of blood, sinovial fluid, etc

Inspection

Is there swelling?
Is there bruising?
Is there any discoloration, or edema?
Is there muscle wasting?
Is there any alteration in shape or posture,
or is there evidence of shortening?

Inspection

Palpation
Is the joint warm?
Is there tenderness?
How is the artery
pulse?

Movements

Active ROM
Passive ROM
Fixed deformities
Restriction of ROM
Movements in abnormal plane
Crepitus
Strength of muscle contraction
Gait

Movements

Conduction of Special Test


Integrity of certain
joint ligaments
Examination of
structures associated
with the joint
Appropriate
neurological
examination

Examination of Radiographs
Soft tissue
Bone : shape, size, contour
Alignment

Examination of Radiographs

Comparison films
Oblique projections
Localized views
Stress films

Arranging Further Investigations

ESR, CRP
Full blood count with differential
Estimation of RF
Serum calcium, phosphate & AP
Serum Uric Acid
Chest X-Ray

Equipment Requirements

A tape measure
A goniometer
A tendon hammer
A disposable sharp point

WHAT IS POLYTRAUMA ?

Emergency in Orthopaedic
Emergency : trauma cases
- Life threatening
- Limb treatening
85 % of blunt trauma affect
musculoskeletal system
Major musculosekeletal injuries
often indicate other injuries
Resuscitation priority is like
another trauma
Life saving before limb saving

Life before Limb

Assessment of the Polytrauma Patient


Primary Survey
A irway with cervical spine control
B reathing
C irculation with control of hemorrage
D isability (neurological state)
E xposure (take the patient clothes off)

Primary Survey & Resuscitation


Recognize and control hemorrhage
Direct pressure
Splint fractures
Fluid resuscitation
BE AWARE OF REPERFUSION
INJURY!

Primary Survey & Resuscitation


Adjuncts : Fracture immobilization
Goals
Hemorrhage control
Pain relief
Prevent further soft tissue injury
Apply splint early, but avoid delay in
resuscitation.
Be careful in dislocation

Primary Survey & Resuscitation


Adjuncts : X-Rays

Determinited by patients condition

Obtain AP pelvis early if hemodynamically


abnormal and no obvious source of
bleeding

Secondary Survey

History

AMPLE

From Head to toe examination


Every orifice must be examined
Dont forget the back!

Secondary Survey
Goal: Identify life-and limb
-threatening, and occult injuries
Undress the patient
Component have to be examined :
1. Skin
2. Neuromuscular function
3. Circulatory state
4. Bone & ligament integrity

Secondary Survey
Physical Examination
Look
Feel
Move
X-Ray
Rule of 2

Life- Threatening Injuries

Major pelvic disruption with hemorrhage


Major arterial hemorrhage
Crush syndrome (rhabdomyolysis)

Life Threatening
Musculoskeletal Trauma
Pelvic Trauma with Massive Bleeding
Posterior pelvic structures disrupted
Pelvis open : vessels, nerves,rectum, skin
Mechanism of injury
Motorcycle
Pedestrian
Crush
Falls > 12 feet (3.6 meters)

Life Threatening
Musculoskeletal Trauma
Pelvic Trauma with Massive Bleeding

Life Threatening
Musculoskeletal Trauma
Pelvic Trauma with Massive Bleeding

Pelvic
Wrapping

Life Threatening
Musculoskeletal Trauma
Main Arterial Rupture
1.
2

3.

Trauma
- sharp, blunt
Examination
- Artery pulse, Doppler
- Ankle / brachial index
Management
- Pneumatic tourniquet
- Vascular clamp?
- Traction, Splint

Life Threatening
Musculoskeletal Trauma
Crush Syndrome

Myoglobinuria
Metabolic acidosis, K,
Ca and coagulopathy
Compartment syndrome
IV fluids, alkalization of
urine

Limb- Threatening Injuries

Open fracture and joint injuries


Vascular injuries
Compartment syndrome
Neurologic injury

Limb Threatening
Musculoskeletal Trauma
Open Fractures

Initial management
Multiple injuries & severe shock
Wound should be covered
Tetanus prophylaxis

Limb Threatening
Musculoskeletal Trauma
Open Fractures
Classifying the injury
Gustilos classification (Gustilo et al, 1990)

Open Fracture grade 1

Open Fracture grade 2

Open Fracture grade 3A

Open Fracture grade 3B

Open Fracture
grade 3C

Limb Threatening
Musculoskeletal Trauma
Open Fractures

Principles of treatment
Objectives :
- Prevention of infection
(sepsis/osteomyelitis)
- Promote bone healing
- Restoration of function

Limb Threatening
Musculoskeletal Trauma
Open
Fractures
Principles
of treatment
4 essentials are :
1. Wound irrigation & debridement
2. Antibiotic prophylaxis
3. Stabilization of the fractures
4. Early wound coverage

Open Fracture
Complicated
case
Not
proper initial management

Limb Threatening
Musculoskeletal Trauma
Vascular Trauma & Traumatic Amputation

Variable presentation : Assess


pulses
Associated with
fracture/dislocations
Realign
Check pulses after splinting
Immediate orthopaedic
consult

Limb Threatening Musculoskeletal Trauma


Vascular Trauma & Traumatic Amputation

Limb Threatening Musculoskeletal Trauma


Vascular Trauma & Traumatic Amputation
Management
Muscle necrosis : 6 h
Warm & Cold Ischemic
Reimplatantation &
Revascularization
Proper amputee
management!

Limb Threatening
Musculoskeletal Trauma
Compartement Syndrome

Fractures of the arm or leg ischemia


Infarcted muscles fibrous tissue
(Volkmanns ischemic contracture)

Limb Threatening
Musculoskeletal Trauma
Compartement Syndrome
Clinical features
Elbow, forearm bones, 1/3 prox.
of tibiae, multiple fractures of
the foot or hand, crush injuries
& circumferential burns
Five Ps
The presence of a pulse does
not exclude the diagnosis
Be careful in unconscious
patient !

Limb Threatening
Musculoskeletal Trauma
Compartement Syndrome
Treatment
Decompression
Open fasciotomi

Limb Threatening
Musculoskeletal Trauma
Dislocations
Displacement of bone from normal joint
Location : hip, shoulder, elbow, finger, patella,
knee, ankle, acromioclavicular
Sign : loss of normal shape &
loss of movement

Posterior Hip Dislocation

Neurologic Injury

Due to fracture /dislocation


Posterior shoulder : Axillary nerve
Posterior hip : Sciatic nerve
Recognize injury and immobilize
Early orthopaedic consult
Careful reduction, if possible
reassess and splint

Limb Threatening
Musculoskeletal Trauma
Massive skin avulsion

Abdominal flap following


skin avulsion of the hand

Limb Threatening Musculoskeletal Trauma


Massive skin avulsion

Kelirumologi in Fracture
Management

Pitfalls

Occult injuries
Occult blood loss
Compartment syndrome

Case 1 : Male, 40 y.o

ICD 9-CM 79.63, 93.44

Question

Summary

Primary Survey : Identify life-threatening


Injuries
Secondary Survey : Identify limbthreatening injuries
Mechanism of Injuries : History important
Orthopaedic consult
Early immobilization

Spine and Spinal


Cord Trauma

Suspect Spinal Injury

High-Speed Crash
Unconscious patient
Multiple injuries
Neurologic deficit
Spinal pain / tenderness

Spinal Injury

5% of Patients worsen neurologically at


hospital
Protection priority
Detection secondary
Spinal evaluation complicated by brain
injury
Remove spine board as soon as possible

Cord injury Severity

Complete : No motor or sensory


function below injury level
Incomplete :
Any motor or sensory preservation
injury level
Sacral sparing may be only residual
function

Sensory Examination
Cervical
C-5 Deltoid
C-6 Thumb
C-7 Middle
finger
C-8 Little finger

Thoracic

Lumbosacral

T-4 Nipple
T-8 Xiphoid
T-10 Umbilicus
T-12
Symphysis

L-4 Medial Leg


L-5 1st/2nd toes
S-1 Lateral foot
S-4 Perianal

Motor Examination
Cervical / Thoracic
C-5
C-6
C-7
C-8
T-1

Shoulder abduction
Wrist Extension
Elbow extension
Middle finger flexion
Little finger
abduction

Lumbosacral
L-2
L-3
L-4
L-5
S-1

Hip flexion
Knee extension
Ankle dorsiflexion
Big toe extension
Big toe / ankle
plantar flexion

Neurologic Assessment
Neurogenic Shock

Hypotension associated with cervical /


high thoracic spine injury

Bradycardia

Treatment : Maintenance fluids,


atropine and occasionally vasopressors

Case : Male, 37 y.o


Cervical Fracture with Neurogenic Shock

Case : Male, 37 y.o


Cervical Fracture with Neurogenic Shock

Case : Male, 37 y.o


Cervical Fracture with Neurogenic Shock

Case : Male, 37 y.o


Cervical Fracture with Neurogenic Shock

Neurologic Assessment
Spinal Shock

Neurologic Not hemodynamic


phenomenon

Occurs shortly after cord injury

Flaccidity

Loss of reflexes

Bulbocavernosus reflex (-)

Neurologic Assessment
Effect on Other Organ Systems

Inadequate ventilation

Abdominal evaluation compromised

Occult compartment syndrome

Classifications of injury
Levels of injury

Clinical exam
Most caudal
Normal bilaterally
Motor / sensory function

Bony : Site of vertebral column damage

Classification of Injury
Incomplete

Any sensation

Position sense

Voluntary
movement in
lower extremity

Sacral sparing

Complete

No motor /
sensory function

No sacral sparing

May have
reflexes

Classifications of Injury
Spinal Cord Syndromes

Central cord

Anterior cord

Brown Sequard

Posterior cord

Conus medullaris

Cauda equina

Classification of Injury
Morphology

Fracture or fracture / dislocation

Spinal cord injury without radiographic


abnormality (SCIWORA)

Penetrating

Classification of Injury
Morphology

Consider unstable if :
X-ray evidence of injury
Neurologic deficit
Severe pain on spine movement or
palpation

X-ray Guidelines

Adequacy
Alignment
Bony abnormality
Base of skull
Cartilage , Contours
Disc space
Soft tissue

C-spine x-rays

Cross table lateral film excludes 85% of


fracture
Additional 2 views excludes most fractures
Also may require
Swimmers view
CT scan for bony detail
MRI/CT myelogram
Open mouth view

C Spine X-rays

10% of patients with a C-spine fracture


have a 2nd, associated noncontiguous
vertebral column fracture
Identify one abnormality ?
Look for another!
Radiographic screening of entire spine
required in this instance

Screening for Spinal Injury


Conscious Patient
Presence of
paraplegia/quadriplegia
Presume spinal instability

Identify bony
fracture subluxation

Early
orthopaedic consult

Screening for spinal injury


Alert,sober, neurologically normal
patient :
1. If no neck or spine
pain or tenderness to
palpation or voluntary
movement
2. If no painful
3. If still no pain or tenderness
with voluntary movement
distracting injury

No further spine
evaluation or c-spine
x-ray necessary
Remove C-colar

Screening for Spinal Injury


Alert, sober, neurologically normal patient :

Neck or spine pain


or tenderness to
palpation or
voluntary
movement ?
After removal of ccollar ?

If yes to any
question
Protect c-spine
Obtain
necessary
x-ray exams

Screening for Spinal Injury


Altered LOC

Radiographic visualization of entire spine

Plain films

CT scan of suspicious areas

Screening for Spinal Injury

Radiographic : Normal x-rays


Clinical :
Normal Neurologic exam and
Absence of spinal pain/tenderness

Drugs,alcohol
distracting
injuries may mask an
injury

Management
Immobilization

Entire Patient

Proper padding

Maintain until spine


injury excluded

Avoid prolonged
use of backboard!

Medical Management

Ensure adequate ventilation especially for


high level (C-4) quadriplegic
Maintain blood pressure
Atropine as needed for bradycardia
Methylprednisolone

Medical Management
Intravenous Fluids

Treat hypovolemia first

Consider neurogenic shock

Insert urinary catheter

Medical Management
Steroids
IV Methylprednisolone
Proven spinal cord injury
Start within 1st 8 hours from injury only
30 mg/kg over 15 minutes
5.4 mg/kg over next 23 hours (if < 3 h)
5.4 mg/kg over next 47 hours (if 3-8 h)
Proven in blunt trauma only

Medical Management
Transfer

Unstable fractures

Neurologic deficit
Avoid delay

Properly Immobilized

Respiratory support as needed

Male, 27 y.o

MVA victim
Referred to RSHS from Cikampek
Hospital without cervical
protection.
He was unable to move his lower
leg & upper extremity

Questions

Is This Cervical X Ray Normal?

Summary

Treat life threatening injuries first


Immobilize
Appropriate spine films
Document examination
Orthopaedic consult
Transfer unstable fracture /cord injury