Pitfalls in

Orthopaedic

Lt Col S K RAICapt Pramod Mahender

opps

Case Study

• A case was tried where a 10-month-old girl suffered anoxic brain injury after “being deprived of oxygen for 40 minutes, forgot the keys to an onboard medicine cabinet and later falsified records related to the rescue”

Medicolegal Outcome

• The girl, now 5, is a spastic quadriplegic with severe brain damage

• State health officials heard of the case only after a story appeared in the state Lawyers Weekly

• The $10.2 million(50 crores) settlement included a confidentiality agreement that kept secret the identities of the family, the hospital and the EMS technicians

Errors

• Not all errors result in harm to the patient, and many react only to errors that are considered to have an adverse effect on a patient (injury or death)

Orthopaedic Emergency

Examples?

Orthopaedic emergency

• Non-trauma

- Osteomyelitis, Septic arthritis, Pyomyositis

- Gouty arthritis

- C1 - C2 subluxation

( Rheumatoid arthritis)

- Acute disc syndrome

• Trauma

Assume the cervical spine to be unstable until proven otherwise

• up to 50% of patients sustaining C-spine trauma develop neurologic abnormalities (nerve root compression and weakness to quadri- plegia and death).

• 10% are initially neurologically intact, but develop deficits during emergency care

• risks of airway management

C-spine evaluation

• bone and soft tissue• X-ray exam: „one view is no view”, AP-lateral open mouth view -atlanto-occipital and

atlanto-axial joints, the odontoid process, oblique – intervert. foramina

• CT• lateral cervical spine - sensitivity of about

85% 92% in a three view series 100% when selective CT scanning is

employed

The primary survey –life threatening conditions are identified and management is

begun simultaneously!

• A - Airway maintenance with cervical spine control

• B - Breathing and ventilation • C - Circulation with hemorrhage control • D - Disability: neurological status • E - Exposure: completely undress the patient

CirculationDoes patient have radial pulse?

– Absent radial = systolic BP < 80

Does patient have carotid pulse?– Absent carotid = systolic BP < 60

CirculationNo carotid pulse?

– intubate– CPR– Pneumatic Antishock Garment

Survival rate from cardiac arrest secondary to blunt trauma is < 1%

CirculationSerious external bleeding?

– Direct pressure – Tourniquet as last resort

All bleeding stops eventually!

Circulation Is patient in shock?

– Cool, pale, moist skin = shock, until proven otherwise

– Capillary refill > 2 sec = shock until proven otherwise

– Restlessness, anxiety = shock until proven otherwise

CirculationIf possible internal

hemorrhage, QUICKLY expose, palpate:–Abdomen–Pelvis–Thighs

Circulation

• BP• HR Alghevar scheme - quantification of shock: SBP / HR

>1 no or minor clinical symptoms <1 major shock• Pulses• Indirect signs: UO, skin, tachypnoe,

altered consciousness, empty” periferal veins

Large bore IV lines

Circulation

• warmed intravenous infusionsControl: • external hemorrhage• internal hemorrhage:MAST suitPelvic binders

Surgery stabilisation secondary survey

Disability (CNS Function)

Level of Consciousness = Best brain perfusion indicator

Check pupils– The eyes are the window of the CNS

Disability (CNS Function)

Decreased LOC in trauma = Head injury until proven otherwise

B. Initial treatment of major

fractures• Shock in orthopaedic patient

- Hypovolemic shock

- Neurogenic shock

• Major fracture

- Pelvis

- Spine (cervical)

- Femur

- Multiple fractures

- Hip

(shock)

(shock)

(shock)(shock)

Associated injury

• Fracture pelvis ; Urethral injury

• Fracture scapula ; Shoulder, chest

• Fracture calcaneus ; Spine

(thoracolumbar region)

Which are Emergencies?

• Closed fracture, n.v. normal

• Closed dislocation, n.v. normal

• Open fracture

• Open dislocation

Mercifully Few Emergencies

• Open Fractures and Dislocations

– with or without vascular injury

– with or without neurological impairment

Not “broken”…

…but still a limb-threateningemergency!

Joint Dislocations

• Must be reduced at once

• Risk to circulation and nerves

• Risk of Osteonecrosis (AVN)

Management in Musculoskeletal Injury

R = Rest

I = Ice

C = Compression

E = Elevation

Principles to approach severe musculoskeletal injury

A. First aids

B. Initial treatment of major fractures /

dislocation

C. Standard radiographs of fractures / dislocation

D. Immediate definitive treatment of fracture /

dislocation

A. First aids

• Bleeding control

• Immobilization

• Pain control

• Antibiotic administration

• Tetanus prophylaxis

• Improve microcirculation

Methods of immobilization

• Splinting; wooden, commercial

• Brace or support

• Strap

• Slab immobilization

• Cast immobilization

• Traction

• External fixation

• Open reduction and internal fixation

Purpose of immobilization

• Temporary

• Definite

Complication of immobilization

• Too fit

• Too loose

• Too long interval

• Too short interval

; pressure sore, compartment syndrome

; inadequate immobilization (loss reduction, delayed, mal or nonunion)

; muscle atrophy, osteoporosis, joint stiffness, maceration of skin

; inadequate immobilization (loss reduction, delayed, mal or nonunion)

Complications of castingPressure sores

Cast sores

Velpeau’s strap

Injury of shoulder region

Slab immobilization

• U or Sugar tong slab for humerus fracture

• Short or long arm slab with or without

thumb spica

Below or above knee slab

• Cylindrical slab

Advice to give patients before casting

• Objectives and advantages of

casting

• Duration of casting

• Activities to do and not to do

during casting

• Good co-operation is needed

Skeletal traction

1 lbs of traction for every 7 lbs of body weight(usually uncomfort if > 35 lbs)

Disadvantages

• Costly in terms of hospital stay• Hazards of prolonged bed rest

– Thromboembolism– Decubiti– Pneumonia

• Requires meticulous nursing care• Can develop contractures

Skull traction

Gardner-Wells tong

Crutchfield tongs

Skull traction

Orthopaedic patients : Antibiotics

• Cefazolin

• Cloxacillin

• Gentamicin

• Amikacin

• Metronidazole

• Clindamycin

• Ofloxacin

• Cotrimoxazole

Pitfalls in paediatrics

Different point of musculoskeletal injury between children and adult

• More incidence of fracture in children

• More stronger and more rapid growth of periosteum

• More difficult to diagnose

• More ability of remodeling

• Difference in treatment or complication

• Less incidence of ligamentous injury or dislocation

• Less tolerability to blood loss

Prognosis of epiphyseal plate

injury• Type of injury

• Age of patient

• Blood supply of the epiphysis

• Method of reduction

• Open or closed injury

Fracture of Necessity

• Galeazzi’s fracture• Monteggiae’s fracture• Lateral condylar fracture• Supracondylar fracture

Common Pitfalls

• Tunnel vision

“Premature closure of hypothesis generation”

• Just the opposite

“Inability to see the forest for the trees”

• Failure to attend to the patient

“Fail to social interaction with patient and

family”

How to approach patients

• Bio

• Psycho

• Social

• Spirit

TAKE HOME

• In emergency medicine, the central task

is not diagnosis, but management

• Alghevar scheme BP>HR

THANK YOU