emergency orthopaedics

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