emergency orthopaedics
TRANSCRIPT
Orthopedic Emergencies
Ted Parks, MD
• Compartment Syndrome
• Neurovascular Injuries
• Open Fractures
• Dislocations
• Septic Arthritis
• Extremity Amputation
Compartment Syndrome
Anatomy of a Compartment
Compartment Syndrome
Compartment Syndrome
Signs and Symptoms:
• Pain out of proportion to injury
• Hx of blunt, closed trauma
• Firm, swollen, tense extremity
• Pain with passive motion of distal parts
The “4 Ps”
• Pain
• Pallor
• Paresthesias
• Pulselessness
Measuring compartment pressures
Measuring compartment pressures
Pressure Measurements
• <15mmHg = normal, resting
• <30mmHg = normal, injured
• >45mmHg = compartment syndrome
• 30 – 45mmHg: borderline Watch and re-measure frequently
Consider other clues
Compartment Syndrome
Treatment
Treatment = Fasciotomy
Neurovascular Injuries
Colles Fracture
Neurovascular Injuries
Nerve Injuries
Neurological (sensory) deficits
• Document grade and extent
For example:
“subjective sensory deficit to light touch, median
nerve distribution”
or
“complete loss of sensation, dorsum all 5 fingers”
• If you don’t document nerve injuries, you
may be held responsible for them
Neurological (sensory) deficits
• Reduce the fracture, OR
• Start immediately to find someone who can
• Once the fracture is reduced, repeat the sensory
exam and document any improvement (or lack
thereof)
• If the sensory exam does not improve…
Neurological (sensory) deficits
Do nothing! Over 90% of fracture
associated nerve injuries are either
neuropraxias or axonotmeses and they will
resolve with time once the fracture is
reduced.
Neuropraxisa
Neuropraxisa
• No structural damage
• Nerve function returns in minutes once
local microcirculation is reestablished
Axonotmesis
Axonotmesis
• Axons are damaged and deteriorate (Wallerian degeneration), but all other structural elements remain intact
• Axon begins to regenerate after a few weeks, growing at about 1mm/day
• Motor endplates disappear without stimulation
Neurotmesis
Neurotmesis
• Essentially no chance for return of function
without repair
• Once repaired, expect slow return of
function (as with axonotmesis)
Neurological injuries that don’t
resolve after fracture reduction
• Observe
• Get EMG/NCS studies at 6 weeks
• Repeat EMG/NCS studies at 12 weeks,
if no sign of improvement, explore and repair the
nerve. Nerve repair results not significantly
worse 3 months out.
Why are these emergencies?
Vascular Injuries
Vascular Injuries
• Poor pulses (doppler?)
• Cold, pale skin
• Poor capillary refill
Vascular Injuries
1. Document exam
2. Reduce fracture (or call somebody who
will)
3. Repeat exam
4. If no change on exam, order STAT
arteriogram
5. Repair/thrombectomy
Open Fractures
Open Fractures
Problem = Infection
Open Fractures
• Start broad spectrum IV anitbiotics
(example=Zosin 3.375gm)
• Debride wound of obvious foreign material
• Apply an occlusive dressing
• Splint extremity
• Formal I&D in the OR ASAP
Open Fractures
• Start broad spectrum IV anitbiotics
(example=Zosin 3.375gm)
• Debride wound of obvious foreign material
• Apply an occlusive dressing
• Splint extremity
• Formal I&D in the OR ASAP
Open Fractures
Risk of osteomyelitis decreases
dramatically if I&D is done before
4-6 hours*
*R.M. Gustilo The Journal of Bone and Joint Surg.
2002, 84:682
Dislocations
Dislocations
• Compromise blood
flow to tissues
• Injure cartilage
surfaces
• Cause ischemia of
cartilage
Dislocations
• Compromise blood
flow to tissues
• Injure cartilage
surfaces
• Cause ischemia of
cartilage
Dislocations
• Compromise blood
flow to tissues
• Injure cartilage
surfaces
• Cause ischemia of
cartilage
Dislocations
• Document neurovascular exam
• Reduce the joint, or call somebody who can
• Immobilize the extremity
• Document the reduction with an xray
Septic Arthritis
Septic Arthritis
• Any joint that is red, hot, swollen with no
history of trauma is infected until proven
otherwise
• Fever, WBC, ESR, CRP all helpful, but not
diagnostic
• Definitive test = aspiration
Knee Joint Aspiration Technique
• Pt supine on table
• Knee extended
• Muscles relaxed
• Lateral approach
• Sub-patellar
Septic Arthritis
Aspiration:
1. Cultures
Septic Arthritis
Aspiration:
1. Cultures
2. Gram stain
Septic Arthritis
Aspiration:
1. Cultures
2. Gram’s stain
3. Crystals
Septic Arthritis
Aspiration:
1. Cultures
2. Gram’s stain
3. Crystals
4. Cell count:
Presume infection if >50,000 WBC per
high powered field
Septic Joint
• Start broad spectrum antibiotics as soon as you have finished the aspiration
(ie: Zosin IV, Augmentin PO)
• If gram stain and cell count are negative, D/C abx and await cultures
• If Gram stain or cell count are positive, proceed with surgical I&D ASAP
Exceptions…
Traumatic Amputations
• Start abx ASAP
• Give one aspirin PR
• Place amputated part
in a small bag of
sterile saline, place that
bag in a bag of ice
• Xray stump and part
• Clean stump by irregating with sterile
saline
Thank You!
Ted Parks, MD
(303) 321-1333