Orthopedic Emergencies
and Urgencies
Scott Playford
LCDR, MC, USNR
Objectives
• Define orthopedic emergencies/urgencies
• Discuss relevance to our practice
• Review specific categories and examples
• Discuss initial management
Definition
• A musculoskeletal injury or condition that, if
missed, could result in additional
complications, significant impairment, or
death
Implications/Importance
• “missed” = Lawsuit
• “additional complications” = Lawsuit
• “impairments” = Lawsuit
• “death” = Lawsuit
Orthopedic Emergencies
• Open Fractures or Joints
• Neurovascular Injuries
• Dislocations
• Septic Joints
Open Fractures
• An open (or compound) fracture occurs
when the skin overlying a fracture is broken,
allowing communication between the
fracture and the external environment
Open Fractures- Classifications
• Compound from within (inside-out):
– The broken end of the bone breaks through or pierces the
skin
• Compound from without (outside-in):
– External violence causes laceration or tissue trauma
– Higher likelihood of contamination
Open Fractures- Classifications
• Type I:
– Small wound (<1cm), usually clean; low energy
• Type II:
– Moderate wound (>1cm), minimal soft tissue
damage or loss; low energy
• Type III:
– Severe skin wound, extensive soft tissue damage;
high velocity
Quiz
Time
Open Fractures- Complications
• Soft tissue infection
• Osteomyelitis
• Gas gangrene
• Tetanus
• Crush syndrome
• Skin loss
• Non-union
Open Fractures- Management
DOs: DON’Ts:
• Control the bleeding • Scream and pass out
• Cover with sterile • Replace protruding bone
dressing • Explore wound
• Splint • Clamp vessels
• IV antibiotics
• Tetanus prophylaxis
• Anti Gas Gangrene Serum
(AGGS, Clostridium
perfringes)
One more thing…
Any open wound over or near a joint should
be assumed to extend to the joint until proven
otherwise
Orthopedic Emergencies
• Open Fractures or Joints
• Neurovascular Injuries
• Dislocations
• Septic Joints
Neurovascular Injuries
• Vascular trauma
• Trauma to peripheral nerves
• Acute compartment syndrome
Neurovascular- Etiology
• Fracture
– Humerus, femur
• Dislocation
– Elbow, knee
• Direct/penetrating trauma
• Embolism
• Direct Compression
– Cast, unconscious
Lower Extremity
Nerves- Lower Extremity
Nerve Motor Sensation Injury
Femoral Knee extension Anterior knee Pubic rami fracture
Obturator Hip adduction Medial thigh Obturator ring fracture
Posterior tibial Toe flexion Sole of foot Knee dislocation
Lateral dorsum of Fibular neck fracture, knee
Superficial peroneal Ankle eversion dislocation
foot
Ankle/toe Dorsal 1st to 2nd web Fibular neck fracture,
Deep peroneal compartment syndrome
dorsiflexion space
Plantar and Posterior hip
Sciatic nerve Foot
dorsiflexion dislocation
Superior gluteal Hip abduction Acetabular fracture
Gluteus maximus
Inferior gluteal Acetabular fracture
hip extension
Upper Extremity
Nerves- Upper Extremity
Nerve Motor Sensation Injury
Index finger
Ulnar Little finger Elbow Injury
abduction
Thenar contraction
Median distal with opposition Index finger Wrist dislocation
Supracondylar fracture of
Median, anterior humerus (child)
Index tip flexion
interosseous
Musculo- Anterior shoulder
Elbow flexion Lateral forearm dislocation
cutaneous
Thumb, finger, 1st dorsal web Distal humeral shaft,
Radial MCP extension space anterior shoulder
dislocation
Anterior shoulder
Axillary Deltoid Lateral shoulder dislocation, proximal
humerus fracture
Acute Compartment Syndrome
• An injury or condition that causes prolonged
elevation of interstitial tissue pressures
• Increased pressure within enclosed fascial
compartment leads to impaired tissue perfusion
• Prolonged ischemia causes cell damage which leads
to increased vessel permeability
• Plasma leaks into interstitium causing further
increase in compartment pressure
• Extensive muscle and nerve death >8 hours
ACS- Etiology
• Direct blow or contusion
• Crush injury
• Burns
• Snake bites
• Fractures
• Hematoma
• Prolonged pressure
ACS- Findings
• 5 Ps • Severe pain
– Pain • Pain with stretch
– Paresthesias • Tense compartment
– Paralysis • Tight, shiny skin
– Pulses
• Late findings
– Palpation
– Paresthesias
– Paralysis
– Loss of pulses
120 mm Hg
Pulse Pressure
60 mm Hg
Ischemia
30 mm Hg
Elevated Pressure
10 mm Hg
Normal
0 mm Hg
ACS- Anatomy
Upper Extremity
• Deltoid
• Brachium
– Anteroir
– Posterior
• Antebrachium
– Volar
– Dorsal
– Mobile wad
• Hand
– Thenar
– Hypothenar
– Adductor
– Interosseous
– Carpal canal
– Finger
ACS- Anatomy
Lower Extremity
• Gluteal
– Tensor fascia lata
– Gluteus medius and minimus
– Gluteus maximus
• Thigh
– Anterior
– Posterior
• Leg
– Anterior
– Lateral
– Superficial posterior
– Deep posterior
• Foot
Quiz Time
• Anterior
• Superficial posterior
– Gastrocnemius
– Extensor hallucis longus
– Soleus
– Extensor digitorum longus
– Sural nerve
– Peroneus tertius
– Tibialis anterior • Deep posterior
– Deep peroneal nerve – Flexor digitorum longus
– Anterior tibial artery – Flexor hallucis longus
– Posterior tibialis
• Lateral – Posterior tibial nerve
– Peroneus longus
– Posterior tibial artery
– Peroneus brevis – Peroneal artery
– Superficial peroneal nerve
ACS- Final Thought
Always check neurovascular status after moving
patient, manipulating injured limb, before and after
applying cast or splint, and at frequent intervals if
transfer is delayed.
Orthopedic Emergencies
• Open Fractures or Joints
• Neurovascular Injuries
• Dislocations
• Septic Joints
Dislocations
• Displacement of bones at a joint from their
normal position
• May be associated with neurovascular injury
Dislocation- Finger
Finger
Dislocation- Knee
• Anterior (31%)
– Caused by hyperextension
– Often ACL and PCL both torn
– MCL and/or LCL usually injured
– Popliteal artery- intimal tear
• Posterior (25%)
– ACL and PCL torn
– Possible tear of extensor mechanism
– Avulsion or disruption of popliteal artery
• Lateral (13%)
• Medial (3%)
• Rotary (4%)- usually posterolateral
Dislocation- Knee
• Injury to popliteal artery and vein is common
• Peroneal nerve injury in 20-40% of knee
dislocations
• With peroneal nerve injury, suspect vascular
injury
Dislocation- Elbow
• Second most common major joint dislocation
• Usually closed and posterior
• Fall on extended elbow
• Posterior, posterolateral, posteromedial, lateral,
medial, or divergent
• Complex- dislocation with fracture (35-40%)
– Radial head fracture most common
• Simple- dislocation without fracture
– Rupture of capsule, rupture of MCL and lateral ligaments,
rupture of flexor pronator mass, possible injury to
brachialis muscle and rupture of brachial artery
Dislocation- Elbow
• Nerve inury
– Neuropraxia involving median or ulnar nerve in
20% of elbow dislocations
– Ulnar nerve palsies more common in pediatric
– Most neuro deficits are transient
Dislocation- Sternoclavicular
• Anterior
– More common
– Traumatic or atraumatic
• Posterior
– Rare
– Soft tissue swelling may give false impression of
anterior dislocation
– Up to 25% complication rate
• Hemorrhage, tracheal or esophageal injuries,
pneumothorax
Dislocation- Hip
• Usually high-energy trauma
• More frequent in young patients
• Anterior- hip in external rotation
• Posterior- hip in internal rotation
• Central acetabular fracture dislocation
• May result in avascular necrosis
• Sciatic nerve injury in 10-35%
Dislocation- Shoulder
• Most common major joint dislocation
• May be associated with:
– Bankart lesion
– Fracture dislocation
– Hill sachs lesion
– SLAP lesion
– Rotator cuff tear
– Nerve injury- axillary, posterior cord,
musculocutaneous
Dislocation- Shoulder
• Anterior (95%)
– Arm abducted and externally rotated
• Posterior (2-4%)
– Arm adducted and internally rotated
– Electrocution, seizure
• Inferior (1%)
– Hyperabduction
– Usually associated with significant trauma
Orthopedic Emergencies
• Open Fractures or Joints
• Neurovascular Injuries
• Dislocations
• Septic Joints
Septic Joint/Septic Arthritis
• Inflammation of a synovial membrane with
purulent effusion into the joint capsule
• Usually monoarticular
• 2-10 cases per 100,000 in general population
• Gonococcal vs nongonococcal
• 80% are from gram-positive aerobes (S
aureus, beta-hemolytic streptococci, and
Streptococcus pneumoniae)
Septic Joint- Etiology
• Direct inoculation
• Trauma
• Iatrogenic
• Hematogenously
• Adjacent osteomyelitis
• Soft tissue infection
Septic Joint- 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%
Septic Joint- Risk Factors
• Prosthetic joint
• Skin infection
• Joint surgery
• Rheumatoid arthritis
• Elderly
• Diabetes Mellitus
• IV drug use
Septic Joint- Signs and Symptoms
• Rapid onset
• Joint pain
• Joint swelling
• Joint warmth
• Joint erythema
• Fever
• Decreased range of motion
• Pain with active and
passive ROM
Septic Joint- Treatment
• IV antibiotics
• Drainage
– Repeated aspirations
– Consider lavage
Septic Joint- Treatment
• Open surgical drainage indications
– Difficult joint aspiration
– Persistent fever and symptoms >24 hours
– Leukocytosis persists >48-72 hours
– Positive repeat blood or joint cultures >48 hours
– Infected joint prosthesis
Septic Joint- Complications
• Rapid destruction of joint with delayed
treatment (>24 hours)
• Degenerative joint disease
• Soft tissue injury
• Osteomyelitis
• Joint fibrosis
• Sepsis
• Death
Final Thought
• Open Fractures or Joints
• Neurovascular Injuries
• Dislocations
• Septic Joints
The End
