Orthopaedic Emergencies

Orthopedic Emergencies
 Open Fractures
 Acute Compartment Syndrome
 Neurovascular injuries
 Dislocations
 Septic Joints
 Spinal cord injury
Open Fractures
 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- Gustilo-Anderson Classification:
 Type I:
 Small wound (<1cm), usually clean, no soft tissue damage and no
skin crushing (i.e. a low energy fracture)
 Type II:
 Moderate wound (>1cm), minimal soft tissue damage or loss,
may have comminution of fracture (i.e. a low-moderate energy
fracture)
 Type III:
 Severe skin wound, extensive soft tissue damage (i.e. high energy
fracture)
 Three grades: A – adequate soft tissue coverage, B – fracture
cover not possible without local/distant flaps, C – arterial injury
that needs to be repaired.
 Open Fractures- Management
 ABCDE – check neurovascular status (pulses, cap. refill, sensation,
motor) , fluid resuscitation, blood
 Antibiotics, tetanus prophylaxis – 48-72 hrs
 Surgical debridement – removal of de-vitalised tissue, irrigation
 Stabilization of fracture – internal/external, if closure delayed then
external prefered
 Early definitive wound cover – split skin grafts, local/distant flaps
(involve plastics)
Open Fractures- Complications

 Wound infection – 2% in Type I , >10% in Type III

 Osteomyelitis – staph aureus, pseudomona sp.
 Gas gangrene
 Tetanus
 Non-union/malunion
 Acute
Compartment
Syndrome
 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 oedema
 Oedema further increase compartment pressure leading to a
vicious cycle
 Extensive muscle and nerve death >4 hours
 Nerve may regenerate but infarcted muscle is replaced by fibrous
tissue (Volkmann’s ischaemic contracture)
ACS- Etiology

 Crush injury
 Circumferential burns
 Snake bites
 Fractures – 75%
 Tourniquets, constrictive
dressings/plasters
 Haematoma – pt with
coagulopathy at increased risk
ACS- Findings
 5 Ps of ischaemia  Severe pain, “bursting”
 Pain (out of proportion to sensation
injury)  Pain with passive stretch
 Paresthesias  Tense compartment
 Paralysis  Tight, shiny skin
 Pulselessness
 Pallor

 Can confirm diagnosis by

measuring
intracompartmental
pressures (Stryker STIC)
 120 mm Hg
Difference between
diastolic pressure and
compartment
pressure (delta
Pulse Pressure
pressure)< 30mmHg
is indication for
immediate
decompression
60 mm Hg

Ischemia

30 mm Hg
Elevated Pressure
10 mm Hg
Normal
0 mm Hg
ACS - Mangement
 Early recognition
 Muscle necrosis at delta
pressure < 30mm Hg
 Irreversible injury 4-6 hrs
 Remove cast, bandages and
dressings
 Arrange urgent fasciotomy
Fasciotomy
ACS- Complications
 Volkman ischaemic contractures
 Permanent nerve damage
 Limb ischaemia and amputation
 Rhabdomyolysis and renal failure
Dislocation
s
 Dislocations
 Displacement of bones at a joint from their
normal position
 Do xrays before and after reduction to look for
any associated fractures
Dislocation- Shoulder
 Most common major joint dislocation
 Anterior (95%) - Usually caused by fall on hand
 Posterior (2-4%) – Electrocution/seizure
 May be associated with:
 Fracture dislocation
 Rotator cuff tear
 Neurovascular injury
 Dislocation- Knee

 Injury to popliteal artery and vein is common

 Peroneal nerve injury in 20-40% of knee dislocations
 Associated with ligamentous injury
 Anterior (31%)
 Posterior (25%)
 Lateral (13%)
 Medial (3%)
 Dislocation- Hip

 Usually high-energy trauma

 More frequent in young patients
 Posterior- hip in internal rotation, most common
 Anterior- hip in external rotation
 Central - acetabular fracture
 May result in avascular necrosis of femoral head
 Sciatic nerve injury in 10-35%
Neurovascular
Injuries
 Neurovascular Injuries
 Fractures and dislocations can be associated with vascular and nerve
damage
 Always check neurovascular status before and after reduction
Neurovascular Injuries - Etiology

 Fracture
 Humerus, femur
 Dislocation
 Elbow, knee
 Direct/penetrating trauma
 Thrombus
 Direct Compression/
Acute Compartment Syndrome
 Cast, unconscious
Common vascular injuries
Injury Vessel
1st rib fracture Subclavian artery/vein
Shoulder dislocation Axillary artery
Humeral supracondylar fracture Brachial artery
Elbow Dislocation Brachial artery
Pelvic fracture Presacral and internal iliac
Femoral supracondylar fracture Femoral artery
Knee dislocation Popliteal artery/vein
Proximal tibial Popliteal artery/vein
Clinical Features & Mx
 Paraesthesia/numbness
 Injured limb cold, cyanosed, pulse weak/absent
 Call for help!
 Remove all bandages and splints
 Reduce the fracture/ dislocation and reassess circulation
 If no improvement then vessels must be explored by operation
 If vascular injury suspected angiogram should be performed
immediately
Common nerve injuries
Injury Nerve
Shoulder dislocation Axillary
Humeral shaft fracture Radial
Humeral supracondylar fracture Radial or median
Elbow medial condyle Ulnar
Monteggia fracture-dislocation Posterior-interosseous
Hip dislocation Sciatic
Knee dislocation Peroneal
Clinical Features & Mx
 Paraesthesia and weakness to supplied area
 Closed injuries: nerve seldom severed, 90% recovery in 4 months.
If not do nerve conduction studies +/- repair
 Open injuries: Nerve injury likely complete. Should be explored at
time of debridement/repair
 Indications for early exploration:
 Nerve injury associated with open fracture
 Nerve injury in fracture that needs internal fixation
 Presence of concomitant vascular injury
 Nerve damage diagnosed after manipulation of fracture
 Septic Joint
Septic Arthritis
 Septic Joint/Septic Arthritis

 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
Septic Joint- Etiology

 Direct invasion through penetrating

wound, intra-articular injection,
arthroscopy
 Direct spread from adjacent bone abcess
 Blood spread from distant site
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
 Joint surgery
 Rheumatoid arthritis
 Elderly
 Diabetes Mellitus
 IV drug use
 Immunosupression
 AIDS
Septic Joint- Signs and Symptoms
 Rapid onset
 Joint pain
 Joint swelling
 Joint warmth
 Joint erythema
 Decreased range of motion
 Pain with active and passive ROM
 Fever, raised WCC/CRP, positive
blood cultures
 Septic Joint- Treatment

 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
Septic Joint- Complications
 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
Spinal cord
injury
Outline
 Goal of spine trauma care
 Pre-hospital management
 Clinical and neurologic assessment
 Acute spinal cord injury
 Term, type and clinical characteristic
 Common cervical spine fracture and dislocation
Goal of spine trauma care
 Protect further injury during evaluation and
management

 Identify spine injury or document absence of spine

injury

 Optimize conditions for maximal neurologic recovery

Goal of spine trauma care
 Maintain or restore spinal alignment

 Minimize loss of spinal mobility

 Obtain healed & stable spine

 Facilitate rehabilitation
Suspected Spinal Injury
 High speed crash
 Unconscious
 Multiple injuries
 Neurological deficit
 Spinal pain/tenderness
Pre-hospital management
 Protect spine at all times during the management of
patients with multiple injuries

 Up to 15% of spinal injuries have a second (possibly

non adjacent) fracture elsewhere in the spine

 Ideally, whole spine should be immobilized in neutral

position on a firm surface
 PROTECTION  PRIORITY
 Detection  Secondary

“Log-rolling”
Pre-hospital management
 Cervical spine immobilization

 Transportation of spinal cord-injured patients

Cervical spine immobilization
 “Safe assumptions”
 Head injury and unconscious
 Multiple trauma
 Fall
 Severely injured worker
 Unstable spinal column

 Hard backboard, rigid cervical collar and lateral support

(sand bag)

 Neutral position
Philadelphia hard collar
Transportation of spinal cord-injured patients
 Emergency Medical Systems (EMS)
 Paramedical staff
 Primary trauma center
 Spinal injury center
Clinical assessment
 Advance Trauma Life Support (ATLS) guidelines
 Primary and secondary surveys
 Adequate airway and ventilation are the most
important factors
 Supplemental oxygenation
 Early intubation is critical to limit secondary injury
from hypoxia
Physical examination
 Information
 Mechanism
 energy, energy
 Direction of Impact
 Associated Injuries
 Is the patient awake or
“unexaminable”?
 What’s the difference ?
 Awake
 ask/answer question OW!
 pain/tenderness
 motor/sensory exam

 Not awake
 you can ask (but they won’t answer)
 can’t assess tenderness
 no motor/sensory exam

------
“Unexaminable”

≠
“No exam”
Physical examination
 Inspection and palpation
 Occiput to Coccyx
 Soft tissue swelling and bruising
 Point of spinal tenderness
 Gap or Step-off
 Spasm of associated muscles

 Neurological assessment
 Motor, sensation and reflexes
 PR

 Do not forget the cranial nerve (C0-C1 injury)

 Neurogenic Shock
 Temporary loss of autonomic function of the cord at the
level of injury
 results from cervical or high thoracic injury

 Presentation
 Flaccid paralysis distal to injury site
 Loss of autonomic function
 hypotension
 vasodilatation
 loss of bladder and bowel control
 loss of thermoregulation
 warm, pink, dry below injury site
 bradycardia
Comparison of neurogenic and hypovolemic shock

Neurogenic Hypovolemic

Etiology Loss of sympathetic Loss of blood volume

outflow
Blood Hypotension Hypotension
pressure
Heart rate Bradycardia Tachycardia

Skin Warm Cold

temperature

Urine Normal Low

output 57
Definitions of terms
 Neurologic level
 Most caudal segment with normal sensory and motor
function both sides
 Skeletal level
 Radiographic level of greatest vertebral damage
 Complete injury
 Absence of sensory and motor function in the lowest
sacral segment
 Incomplete injury
 Partial preservation of sensory and/or motor function
below the neurologic level
Neurologic assessment
 Spinal shock
 Bulbocavernosus reflex

 Complete VS incomplete cord injury

 ต ้องพ้นภาวะ spinal shock ไปก่อน
 Sacral sparing
 Voluntary anal sphincter control
 Toe flexor
 Perianal sensation
 Anal wink reflex
Neurologic assessment
 American Spinal Injury Association grade
 Grade A – E

 American Spinal Injury Association score

 Motor score (total = 100 points)
 Key muscles : 10 muscles
 Sensory score (total = 112 points)
 Key sensory points : 28 dermatomes
Incomplete cord injury
 Anterior cord syndrome
 Brown-Sequard syndrome
 Central cord syndrome
Anterior cord syndrome

 Loss of motor, pain and

temperature

 Preserved
propioception and deep
touch
Brown-Sequard syndrome

 Loss of ipsilateral motor

and propioception

 Loss of contralateral
pain and temperature
Central cord syndrome

 Weakness :
 upper > lower

 Variable sensory loss

 Sacral sparing
Radiographic imaging
 Who needs an x- ray of the spine ?

 NEXUS -The National Emergency X- Radiograph Utilization

Study
 Prospective study to validate a rule for the decision to obtain
cervical spine x- ray in trauma patients
 Hoffman, N Engl J Med 2000; 343:94-99
 Canadian C-Spine rules
 Prospective study whereby patients were evaluated for 20
standardized clinical findings as a basis for formulating a decision as
to the need for subsequent cervical spine radiography
 Stiell I. JAMA. 2001; 286:1841-1846
 NEXUS
 NEXUS Criteria:
1. Absence of tenderness in the posterior midline
2. Absence of a neurological deficit
3. Normal level of alertness (GCS score = 15)
4. No evidence of intoxication (drugs or alcohol)
5. No distracting injury/pain
 NEXUS
 Patient who fulfilled all 5 of the criteria were
considered low risk for C-spine injury
 No need C-spine X-ray

 For patients who had any of the 5 criteria

 radiographic imaging was indicated
( AP, lateral and open mouth views)
The Canadian C-spine Rule for alert and stable trauma patients where cervical spine injury is a
concern.

 Any high-risk factor that mandates radiography?

 Age>65yrs or
 Dangerous mechanism or
 Paresthesia in extremities
NO
Any low-risk factor that allows safe
YES
assessment of range of motion?
• Simple rear-end MVC, or NO
• Sitting position in ER, or Radiography
• Ambulatory at any time, or
• Delayed onset of neck pain, or
• Absence of midline C-spine tenderness

YES
Able to actively rotate neck? UNABLE
• 45 degrees left and right
ABLE
No Radiography
 National Emergency X
Radiography Utilization Study
(NEXUS)

&
The Canadian C-spine rule

Both have:
 Excellent negative predictive value for excluding patients
identified as low risk
 Clearance of Cervical Spine Injury in
Conscious, Symptomatic Patients

1. Radiological evaluation of the cervical spine is indicated

for all patients who do not meet the criteria for clinical
clearance as described above

2. Imaging studies should be technically adequate and

interpreted by experienced clinicians
Cervical Spine Imaging Options

 Plain films
 AP, lateral and open mouth view
 Optional: Oblique and Swimmer’s

 CT
 Better for occult fractures

 MRI
 Very good for spinal cord, soft tissue and ligamentous injuries

 Flexion-Extension Plain Films

 to determine stability
Radiolographic evaluation
X-ray Guidelines (cervical)
AABBCDS

 Adequacy, Alignment
 Bone abnormality, Base of skull
 Cartilage
 Disc space
 Soft tissue
 Adequacy

 Must visualize entire C-spine

 A film that does not show the upper
border of T1 is inadequate
 Caudal traction on the arms may
help
 If can not, get swimmer’s view or CT
Swimmer’s view
Alignment
• The anterior vertebral line,
posterior vertebral line, and
spinolaminar line should
have a smooth curve with
no steps or discontinuities

• Malalignment of the
posterior vertebral bodies is
more significant than that
anteriorly, which may be
due to rotation

• A step-off of >3.5mm is
significant anywhere
 Lateral Cervical Spine X-Ray

 Anterior subluxation of one vertebra

on another indicates facet dislocation
 < 50% of the width of a vertebral body
 unilateral facet dislocation
 > 50%  bilateral facet dislocation
Bones
Disc

 Disc Spaces
 Should be uniform
 Assess spaces between
the spinous processes
Soft tissue
 Nasopharyngeal space (C1)
 10 mm (adult)

 Retropharyngeal space (C2-

C4)
 5-7 mm

 Retrotracheal space (C5-C7)

 14 mm (children)
 22 mm (adults)
AP C-spine Films

 Spinous processes should

line up
 Disc space should be
uniform
 Vertebral body height
should be uniform. Check
for oblique fractures.
Open mouth view

 Adequacy: all of the

dens and lateral
borders of C1 & C2
 Alignment: lateral
masses of C1 and C2
 Bone: Inspect dens for
lucent fracture lines
 CT Scan
 Thin cut CT scan should be
used to evaluate abnormal,
suspicious or poorly visualized
areas on plain film

 The combination of plain film

and directed CT scan provides
a false negative rate of less
than 0.1%
 MRI
 Ideally all patients with
abnormal neurological
examination should be
evaluated with MRI scan
 Management of SCI
 Primary Goal
 Prevent secondary injury

 Immobilization of the spine begins in the initial

assessment
 Treat the spine as a long bone
 Secure joint above and below
 Caution with “partial” spine splinting
 Management of SCI
 Spinal motion restriction: immobilization devices
 ABCs
 Increase FiO2
 Assist ventilations as needed with c-spine control
 Indications for intubation :
 Acute respiratory failure
 GCS <9
 Increased RR with hypoxia
 PCO2 > 50
 VC < 10 mL/kg
 IV Access & fluids titrated to BP ~ 90-100 mmHg
 Management of SCI
 Look for other injuries: “Life over Limb”
 Transport to appropriate SCI center once stabilized
 Consider high dose methylprednisolone
 Controversial as recent evidence questions benefit
 Must be started < 8 hours of injury
 Do not use for penetrating trauma
 30 mg/kg bolus over 15 minute
 After bolus: infusion 5.4mg/kg IV for 23 hours
Principle of treatment
 Spinal alignment
 deformity/subluxation/dislocation reduction

 Spinal column stability

 unstable  stabilization

 Neurological status
 neurological deficit  decompression
 Cauda Equina Syndrome
 Compression of lumbosacral nerve roots below conus medullaris
secondary to large central herniated disc/extrinsic
mass/infection/trauma
 Clinical Features

 motor (LMN signs)

-weakness/paraparesis in multiple root distribution
-reduced deep tendon reflexes (knee and ankle)
-sphincter disturbance (urinary retention and fecal
incontinence due to loss of anal sphincter tone)
 sensory
-saddle anesthesia (most common sensory deficit)
-pain in back radiating to legs, crossed straight leg test
-bilateral sensory loss or pain: involving multiple
dermatomes
Management
 Surgical emergency - requires urgent investigation and
decompression (<48 hrs) to preserve bowel and bladder function
The End
 Thank you
for your attention