ORTHOPAEDIC

EMERGENCIES
Introduction
• Emergency  A situation which poses an immediate risk and which requires
urgent attention
• Emergency in Orthopaedic  - Life threatening
- Limb threatening
• Orthopaedic Emergencies  1. Open fracture
2. Compartment syndrome
3. Dislocation
4. Fat Embolism Syndrome
5. Septic arthritis
6. Cauda Equina Syndrome
OPEN FRACTURE
OPEN FRACTURE
• An open fracture is an injury where the
fractured bone and/or fracture hematoma are
exposed to the external environment via a
traumatic violation of the soft tissue and skin.

• The skin wound may lie at a site distant to the

fracture and not directly over it.
GUSTILO ANDERSON CLASSIFICATION
TREAMENT
All open fractures,  assumed to be contaminated;
Important to try to prevent them from becoming infected.
The four essentials are:
1. antibiotic prophylaxis
2. urgent wound and fracture debridement
3. early definitive wound cover
4. stabilization of the fracture.
ACS (ACUTE COMPARTMENT
SYNDROME)
ACUTE COMPARTMENT SYNDROME

Compartment syndrome is an
elevation of the interstitial
pressure in a closed osteofascial
compartment that results in
microvascular compromise

Acute compartment syndrome is a medical emergency

Fractures are the most common cause of ACS

PATHOPHYSIOLOGY
CLINICAL PRESENTATION
INTRACOMPARTMENTAL PRESSURE
MEASUREMENT
Confirmation of the diagnosis can be
made by measuring the
intracompartmental pressures.

A differential pressure (ΔP) < 30

mmHg is an indication for immediate
compartment decompression
 TREATMENT
Initial : Removing cast or dressing 
observe and limb maintained at heart
level

If clinical condition does not improve,

fasciotomy is indicated as an emergency
procedure to decompress the
compartments

Irreversible ischaemia occurs in 6 hours. 

DISLOCATION
GLENOHUMERAL DISLOCATION
Most common dislocation
CLINICAL PRESENTATION
Trauma/fall, pain, inability to move arm
“Flattened” shoulder, no ROM, test axillary nerve function
Anatomic (based on location of humeral head):
• Anterior (90%)

• Posterior (often missed)

• Inferior (luxatio erecta: abducted arm

cannot be lowered [rare])

Reduction Technique
TREATMENT
Acute: reduce dislocation
• Methods (with sedation):

Hippocratic/traction
Stimson
Milch
Kocher
Traction Countertraction
• Immobilize: sling for 3 week
• Physical therapy
Milch Kocher
Traction and Countertraction
 HIP DISLOCATION
High-energy trauma (esp. MVA, dashboard injury) or significant fall

Clinical presentation
Trauma history. Severe pain, cannot
move thigh/hip

Thigh position
• Posterior : Flexed, adducted, IR
• Anterior : Flexed, abducted, ER
 CLASSIFICATION

Posterior: Thompson and (Epstein)

I: No or minor post. wall fx
II: Large posterior wall fx
III: Comminuted acetabular fx
IV: Acetabular floor fx

V: Femoral head fx (Pipkin classification)

CLASSIFICATION

Anterior: Epstein
I (A, B, C): Superior
II (A, B, C): Inferior
A: No associated fx
B: Femoral head fx
C: Acetabular fx
 TREATMENT
TREATMENT

Early reduction essential (6 hr), then repeat XR & neuro exam

 Posttraumatic osteonecrosis (AVN) (reduced risk with early reduction);

post-reduction  CT-Scan  Immobilization for 3 weeks

Posterior:
I: Closed reduction and abduction pillow
II-V:
1. Closed reduction (open if irreducible)
2. ORIF (fracture or excise fragment/LB)

Anterior: Closed reduction, ORIF if necessary

Stimson gravity method
 Bigelow

Orthopaedic emergency; risk of femoral head AVN increases with late/delayed reduction (should < 6 hours)
FES (FAT EMBOLISM SYNDROME)
 Fat embolism syndrome (FES)
FE syndrome (FES) caused by
an inflammatory response to embolized fat
globules

Frequently, FE occurs after trauma and

during orthopaedic procedures
CLINICAL PRESENTATION

• characterized by
• hypoxia
• CNS depression
• pulmonary edema
• petechial rash

Clinical images of axillary petechiae (A) and subconjunctival hemorrhage (B).

(Reproduced with permission from Maghrebi S, Cheikhrouhou H, Triki Z, Karoui
A: Transthoracic Echocardiography in Fat Embolism: A Real-Time Diagnostic
Tool. J Cardiothorac Vasc Anesth 2017;31[3]:e47-e48.)
Gurd Criteria
• 1 major + 4 minor
LABORATORY AND IMAGING FINDING
TREATMENT

Treatment is primarily supportive care

Given the lack of direct treatment

options, an important goal is prevention.
Early fixation of fractures within 12 hours
of injury could prevent the development
of fat embolism syndrome because this
case fatal in up to 15% of patients
SEPTIC ARHTRITIS
SEPTIC ARTHRITIS
Acute pyogenic infection of the knee
is an acute emergency and requires
prompt treatment to prevent
systemic spread of the infection and
to prevent local damage to the knee.

The organism  Staphylococcus

aureus, but in adults gonococcal
infection can occur
CLINICAL PRESENTATION
The joint is swollen, painful and inflamed.

The patient reports extreme pain on

movement of the joint, which can be
confirmed during careful examination.
KOCHER’S CRITERIA
SYNOVIAL FLUID EXAM
 TREATMENT
Systemic antibiotics and drainage of the joint –
ideally by arthroscopy, with irrigation and
complete synovectomy;

If fluid reaccumulates, it can be aspirated through

a wide-bore needle.

Failure to initiate appropriate antibiotic

therapy within the first 24 to 48 hours of
onset can cause subchondral bone loss
and permanent joint dysfunction
CES (CAUDA EQUINA SYNDROME)
CAUDA EQUINA SYNDROME
Cauda equina syndrome is a rare but
emergent condition associated with
back pain and other symptoms
resulting from compression of the
cauda equine
 CLINICAL PRESENTATION

The gold standard for diagnosis is magnetic resonance imaging (MRI)

TREATMENT
Treatment involves immediate neurosurgical
consultation for operative management.

Surgery should be performed < 48 h of

symptoms with abrupt onset (delays beyond
48 h are associated with a greater risk of
permanent dysfunction)

Those with rapid onset should undergo

surgery within 24 h of presentation.
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