ORTHOPAEDIC

EMERGENCIES
ANDRE TRIADI DESNANTYO

DEPARTEMENT OF ORTHOPAEDIC & TRAUMATOLOGY

FACULTY OF MEDICINE, AIRLANGGA UNIVERSITY
DR SOETOMO GENERAL HOSPITAL
SURABAYA
2015
 ORTHOPAEDIC EMERGENCY
overview
Definition
• A condition that is immediately life or limb threatening involving the musculoskeletal system
OBJECTIVE:
 Prioritize the emergent orthopaedic conditions into the ATLS protocol
 Describe the basic management of emerge orthopaedic conditions

FIRST ACTION!!

RESULT : PREVENTIVE-CURATIVE
from morbidity & mortality
 Emergencies condition

• Pelvic injury
• Open fracture
• Compartment syndrome
• Dislocation
• Spine injury
• Septic arthritis
• Neurovascular injury
 PELVIC INJURY
• High energy trauma
• Unstable pelvis
• Unstable hemodynamic
• Ex:
 Vertical shear
 Anteroposterior compression
 Lateral compression
Anatomy
 Risks of Pelvic Injury

• 15-30% association with hemodynamic instability

• 6-35% mortality rate
• Rarely isolated injuries
Clinical features
• Hypovolemic shock
• Scrotal hematoma, perianal laceration
• Multiple trauma
• Deformity rotation, discrepancy
Examination of Pelvic Instability

• Anteroposterior compression
• Lateral compression
• Vertical traction – counter traction
(cranio-caudo traction)
• Firmly with one shoot exam!!
Immediate respons by
General practioner
Definitive treatment
 Goals of Orthopaedic Treatment
• Reduce Stabilize
• Realign • Hemodynamic • Tamponade
• Retain • pelvic • Blood clot

Condition: • Refer to
• Unstable pelvic Orthopaedic
• Unstable surgeon +trauma
hemodynamic center
 OPEN FRACTURE OF LONG BONE
DEFINITION
• A open fracture of the shaft of a major appendicular bone (Femur, Tibia,
Humerus)

SPECTRUM OF INJURY
• Broken bone and surrounding tissue
• Contamination at fracture site
 Risk of infection

• open fractures are associated with a higher rate of infection, this

depends on many variables (severity of damage tissue)
• A bone infection can be difficult to eliminate (once osteomyelitis, forever
osteomyelitis)
• Amputating the infected limb is the only way to stop the infection
(several cases)
• Preventing infection is the focus of early treatment for open fractures
 Recognize

• Open or close wound?

• when there is any wound in the the same area as a fracture, it is assumed
to be an open fracture.
• Most open fractures are obvious because bone is visible - either
protruding through the skin or within a wound. Some open fractures are
more subtle.
 Classification
Gustilo-Anderson Classification
• Type I -< 1cm, clean, little soft tissue injury, simple fracture
configuration
• Type II –1-10 cm, moderate soft tissue injury, moderate fracture
configuration
• Type III –large wound with extensive soft tissue injury, high energy,
contaminated, comminutived fracture configuration
IIIA –able to close defect
IIIB –requires free flap for coverage, massive contamination
IIIC –any open fracture with vascular compromise
Grade 1 Grade 3
 What if..

Grade??
 START ACTION!!
• ATLS PRINCIPLE
• Antibiotic broadspectrum + anti tetanus
(ASAP <3 hours, debridement+ stabilization surgery <6 hours )
grade 1: Cephalosporin (gen.1)
2: Cephalosporin + Amynoglycoside
3: Cephalosp + Aminoglyc + Penicillin (if gross contamination)
• Analgetic
• RECOGNIZE
 hemodynamic state, Local state confirm (deformity, wound, neurovascular)
 irrigate with normal saline, compression dressing the wound w/o povidone
• REDUCE
 if gross contamination (++) & distal pulse is fine  just irrigate + dressing
 re-align (gently traction) , re-check distal pulse
• RETAIN
 temporary stabilization-splint
Splint-stabilization
 DISLOCATION
ANATOMY joint break:
• BONY stabilizer
Joint structure ball and socket
(ex: Hip joint)
• SOFTTISSUE stabilizer
dynamic  tendon/ muscle
static ligament, labrum/meniscus
 Clinical features

• PAIN
• DEFORMITY
• LOSS OF ROM (limitation)
• w/o NEUROVASCULAR INJURY
 START ACTION

• Maintain & stabilize the joint deformity  always evaluate

neurovascular
• Analgetic
• refer to orthopaedic surgeon with trauma center facility immediately
(must be reduce less than 6 hours)
 Risks and Complication
Late complications:
•Stiffness
Early Complications: •Heterotopic ossification
• Heterotopic ossification •Chronic instability
• Neurological injury (reversible or •Avascular necrosis
irreversible)
•Post traumatic
• Vascular injury
osteoarthritis
• Compartment syndrome
• Osteochondral fracture/injury
Dislocated more than 6 hours
 ischemic cartilage (no active
diffusion synovial fluid)
 COMPARTMENT SYNDROME
Definition:
• An increase in compartment pressure to the point where tissue
perfusion is impaired

Physiological Basis :
• Groups of muscles covered with fascia Lower leg, forearm classic areas
• Injury causes inflammatory response
Increased influx of fluid or blood
Fascia limits compartment expansion
Pressure therefore increases
 Causes
• Fracture (tibia, radius)
• Circumferential burns
• Tight dressings
• Crush injuries
• Bleeding (minor injury while anticoagulated)
• Reperfusion injury
Threshold pressure:
• 30 mm Hg (rigid)
• Less than 30 mm Hg difference between compartment pressure and diastolic pressure
(clinically relevant)
 DIAGNOSIS

• Tight, woody compartment

• Tender compartment
• Blister
 Diagnosis..
Early:
• Pain!!!
• Pain increase with stretching the involved compartment
 Dorsoflex passive stretching
• Presence of risk factor
• High index of suspicion
• Measurement of compartment pressure is high
 Diagnosis..

Late:
• Paresthesia
• Paralysis
• Pallor

Severely high pressure:

• Pulselessness (too late!!)
 Start Action!
Initial Management
• Remove all circumferential dressings/casts
• Ensure leg is at level of the heart
• Remove any traction
• Re-evaluate vascular status
 prepare for refer

Definitive management by orthopaedic surgeon

• Compartment fasciotomy
• 2 incisions, to decompress the compartment pressure
 Spine Injury
Common Mechanisms
• Compression
• Flexion
• Extension
• Rotation
• Lateral bending
• Distraction
• Penetration
 Diagnosis of spinal injuries:

Clinical evaluation
Inspection and palpation: Occiput to Coccyx
• Tenderness
• Gap or Step
• Edema and bruising
• Spasm of associated muscles
 Diagnosis of spinal injuries:
clinical evaluation

Neurological assessment
• Sensation
• Motor function
• Reflexes
• Rectal examination
 Neurological assessment: Motor
• L2: Hip flexors
Grading Scale: 0-5
• L3: Knee extensors
• 0: total paralysis
• L4: Ankle dorsiflexors
• 1: palpable or visible contraction
• L5: Long toe extensors
• 2: active movement; gravity
• S1: Ankle plantar flexors eliminated
• C5: Deltoids/biceps • 3: active movement: against gravity
• C6: Wrist extensors • 4: active movement: against some
resistance
• C7: Elbow extensors
• 5: active movement: against full
• C8: Finger flexors resistance
• T1: Finger Abductors
 Neurological assessment:
Sensory

Grading scale: 0-2

0: absent
1: impaired
2: normal
 Spinal Cord Injury Grading

Frankel grading system

• A: complete loss of motor-sensory function below level
of lesion
• B: complete motor paralyses with some sensory
preservation (including sacral sparing)
• C: retained motor function but useless
• D: retained useful motor function
• E: recovery (free of neurological symptoms)
 Suspect spinal injury with...

• Sudden decelerations (MVCs, falls)

• Compression injuries (diving, falls onto feet/buttocks)
• Significant blunt trauma (football, hockey, snowboarding, jet skis)
• Very violent mechanisms (explosions, cave-ins, lightning strike)
• Unconscious patient
• Neurological deficit
• Spinal tenderness
 Spinal Stabilization & Management

• spinal column injury must therefore be

presumed until it is excluded
• Protect spine at all times during the management of
patients with multiple injuries, include to
assess the back with logroll
• Whole spine should be immobilized in neutral
position on a firm surface.
• Can be done manually or with a combination of
semi-rigid cervical collar, side head supports, long
spine board and strapping.
• If neck is not in the neutral position, attempt should be
made to achieve alignment.
 Management Principle of Spine Injury

• PROTECTION => PRIORITY

• DETECTION => SECONDARY
 Septic Arthritis
Definition
• Inflammation of a synovial membrane with purulent
effusion into the joint capsule. Followed by articular
cartilage erosion by bacterial and cellular enzymes.
• Usually monoarticular
• Usually bacterial
• Staph aureus
• Streptococcus
• Neisseria gonorrhoeae
 Etiology

• Direct invasion through penetrating wound

• Direct spread from adjacent bone abcess
• Blood spread from distant site
 Location

• Knee- 40-50%
• Hip- 20-25%*
Hip is the most common in
infants and very young children
• Wrist- 10%
• Shoulder, ankle, elbow- 10-15%
 Risk Factors
• Prosthetic joint
• Joint surgery
• Rheumatoid arthritis
• Elderly
• Diabetes Mellitus
• IV drug use
• Immunosupression
• AIDS
 Sign and Symptoms
• Rapid onset
• Joint pain
• Joint swelling
• Joint warmth
• Joint erythema
• Decreased range of motion
• Pain with active and passive ROM
• Fever, raised WBC/CRP, positive blood cultures
 START ACTION!!

• Joint immobilization
• Analgetic
• Broadspectrum antibiotic
• Improving general condition
• Refer immediately to orthopaedic surgeon
 Management of treatment by
Orthopaedic surgeon
• Diagnosis by aspiration
• Gram stain, microscopy, culture
• Leucocytes >50 000/ml highly
suggestive of sepsis
• Joint washout in theatre
• IV Abx 4-7 days then orally for another 3 weeks
• Analgesia
• Splintage
 COMPLICATION
• Rapid destruction of joint with delayed treatment (>24 hours)
• Growth retardation, deformity of joint (children)
• Degenerative joint disease
• Osteomyelitis
• Joint fibrosis and ankylosing
• Sepsis
• Death
THANK YOU