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Dr. Samuel WongRMH Intern
2012
Orthopaedic Emergencies
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Orthopedic EmergenciesOpen FracturesAcute Compartment SyndromeNeurovascular injuries
DislocationsSeptic JointsCauda Equina Syndrome
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Open Fractures
An open (or compound) fracture occurs when the skin overlying afracture is broken, allowing communication between the fracture andthe external environment
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Open Fractures- Gustilo-Anderson Classification:
Type I :Small wound (1cm), minimal soft tissue damage or loss,may have comminution of fracture (i.e. a low-moderate energyfracture)
Type III :Severe skin wound, extensive soft tissue damage (i.e. high energy
fracture)Three grades: A adequate soft tissue coverage, B fracturecover not possible without local/distant flaps, C arterial injurythat needs to be repaired.
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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 thenexternal prefered
Early definitive wound cover split skin grafts, local/distant flaps(involve plastics)
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Open Fractures- Complications
Wound infection 2% in Type I , >10% in Type III
Osteomyelitis staph aureus, pseudomona sp.
Gas gangrene
Tetanus
Non-union/malunion
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Acute Compartment Syndrome
An injury or condition that causes prolonged elevation ofinterstitial tissue pressures
Increased pressure within enclosed fascial compartment leads toimpaired tissue perfusion
Prolonged ischemia causes cell damage which leads to oedema
Oedema further increase compartment pressure leading to avicious cycle
Extensive muscle and nerve death >4 hours
Nerve may regenerate but infarcted muscle is replaced by fibroustissue (Volkmanns ischaemic contracture)
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ACS- Etiology
Crush injury
Circumferential burns
Snake bites
Fractures 75%Tourniquets, constrictivedressings/plasters
Haematoma pt with
coagulopathy at increased risk
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ACS- Findings
5 Ps of ischaemiaPain (out of proportion toinjury)ParesthesiasParalysisPulselessnessPallor
Severe pain, burstingsensation
Pain with passive stretch
Tense compartment
Tight, shiny skin
Can confirm diagnosis bymeasuringintracompartmentalpressures (Stryker STIC)
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0 mm Hg
10 mm Hg
30 mm Hg
60 mm Hg
120 mm Hg
Pulse Pressure
Ischemia
Elevated Pressure
Normal
Difference betweendiastolic pressure andcompartment
pressure (deltapressure)< 30mmHgis indication forimmediatedecompression
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ACS - Mangement
Early recognitionMuscle necrosis at deltapressure < 30mm HgIrreversible injury 4-6 hrs
Remove cast, bandages anddressings
Arrange urgent fasciotomy
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Fasciotomy
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ACS- Complications
Volkman ischaemic contractures
Permanent nerve damage
Limb ischaemia and amputation
Rhabdomyolysis and renal failure
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Dislocations
Displacement of bones at a joint from their normal positionDo xrays before and after reduction to look for any associated fractures
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Dislocation- Shoulder
Most common major joint dislocationAnterior (95%) - Usually caused by fall on handPosterior (2-4%) Electrocution/seizureMay be associated with:
Fracture dislocationRotator cuff tearNeurovascular injury
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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%)
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Dislocation- Hip
Usually high-energy traumaMore frequent in young patientsPosterior- hip in internal rotation, most commonAnterior- hip in external rotationCentral - acetabular fractureMay result in avascular necrosis of femoral headSciatic nerve injury in 10-35%
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Neurovascular Injuries
Fractures and dislocations can be associated with vascular and nervedamage
Always check neurovascular status before and after reduction
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Neurovascular Injuries - Etiology
FractureHumerus, femur
Dislocation
Elbow, kneeDirect/penetrating trauma
Thrombus
Direct Compression/
Acute Compartment SyndromeCast, unconscious
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Common vascular injuries
Injury Vessel1st 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
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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 circulationIf no improvement then vessels must be explored by operation
If vascular injury suspected angiogram should be performedimmediately
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Common nerve injuries
Injury NerveShoulder 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
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Clinical Features & Mx
Paraesthesia and weakness to supplied areaClosed 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 attime of debridement/repair
Indications for early exploration:Nerve injury associated with open fractureNerve injury in fracture that needs internal fixationPresence of concomitant vascular injury
Nerve damage diagnosed after manipulation of fracture
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Septic Joint/Septic Arthritis
Inflammation of a synovial membrane with purulent effusion intothe joint capsule. Followed by articular cartilage erosion bybacterial and cellular enzymes.Usually monoarticular
Usually bacterialStaph aureusStreptococcusNeisseria gonorrhoeae
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Septic Joint- Etiology
Direct invasion through penetratingwound, intra-articular injection,arthroscopy
Direct spread from adjacent bone abcessBlood spread from distant site
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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%
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Septic Joint- Risk Factors
Prosthetic joint
Joint surgery
Rheumatoid arthritis
Elderly
Diabetes MellitusIV drug use
Immunosupression
AIDS
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Septic Joint- Signs and Symptoms
Rapid onset
Joint pain
Joint swelling
Joint warmth
Joint erythemaDecreased range of motion
Pain with active and passive ROM
Fever, raised WCC/CRP, positive
blood cultures
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Septic Joint- Treatment
Diagnosis by aspirationGram stain, microscopy, cultureLeucocytes >50 000/ml highly
suggestive of sepsisJoint washout in theatre
IV Abx 4-7 days then orally for another 3 weeks
Analgesia
Splintage
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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 ankylosingSepsis
Death
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Cauda Equina Syndrome
Compression of lumbosacral nerve roots below conus medullarissecondary to large central herniated disc/extrinsicmass/infection/trauma
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Clinical Features
motor (LMN signs)-weakness/paraparesis in multiple root distribution-reduced deep tendon reflexes (knee and ankle)-sphincter disturbance (urinary retention and fecalincontinence 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 multipledermatomes
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Management
Surgical emergency - requires urgent investigation anddecompression (
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The End
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