بنام خداوند جان وخرد

1. بنام خداوند جان وخرد

2. ORTHOPAEDIC EMERGENCIES DR.HosseinSaremi Orthopaedic surgeon Hand&shoulder fellowship Hamedan University of medical sciences

3. Orthopaedic Emergencies A musculoskeletal injury or condition that, if missed, could result in additional complications, significant impairment, or death and needs immediate management

4. Definition “missed” = Lawsuit “additional complications” = Lawsuit “impairments” = Lawsuit Delaied management=Lawsuit “death” = Lawsuit

5. Emergent orthopaedic conditions Open FX Dislocation Compartementsyndrom Any FX with associated vascular injury

6. Open FX the skin overlying a fracture is broken, allowing communication between the fracture and the external environment Inside-out Outside-in

7. Open FX complications Soft tissue infection Osteomyelitis Gas gangrene Tetanus Crush syndrome Skin loss Non-union

8. Open Fx Management DOs: • Control the bleeding • Cover with sterile dressing • Splint • IV antibiotics • Tetanus prophylaxis DON’Ts: • Scream and pass out • Replace protruding bone • Explore wound • Clamp vessels

9. Debridement Conservative debridement

10. Debridement • Pasteur : It is the environment not the bacteria that determines whether a wound becomes infected

11. Open Joint Any open wound over or near a joint should be assumed to extend to the joint until proven otherwise

12. Dislocation Displacement of bones at a joint from their normal position May be associated with neurovascular injury Cartilage damage

13. Dislocation-Knee Anterior (31%) • Caused by hyperextension • Often ACL and PCL both torn • MCL and/or LCL usually injured • Popliteal artery- intimal tear Posterior (25%) • ACL and PCL torn • Possible tear of extensor mechanism • Avulsion or disruption of popliteal artery Lateral (13%) Medial (3%) Rotary (4%)- usually posterolateral

14. Dislocation-Knee

15. Dislocation-Hip Usually high-energy trauma More frequent in young patients Anterior- hip in external rotation Posterior- hip in internal rotation Central acetabular fracture dislocation May result in avascular necrosis Sciatic nerve injury in 10-35%

16. Reduction

17. Dislocation-Shoulder Most common major joint dislocation May be associated with: • Bankart lesion • Fracture dislocation • Hill sachs lesion • SLAP lesion • Rotator cuff tear • Nerve injury- axillary, posterior cord, musculocutaneous

18. Dislocation-Shoulder Anterior (95%) • Arm abducted and externally rotated Posterior (2-4%) • Arm adducted and internally rotated • Electrocution, seizure Inferior (1%) • Hyperabduction • Usually associated with significant trauma

20. Dislocation-shoulder • Reduction (ant disloc) • Stimson (hanging weight technique) • Scapular Manipulation • Leidelmeyer (external rotation) • Milch • Traction-Countertraction • Reduction (post disloc) • Traction on internally rotated and adducted arm with pressure on humeral head

21. Simple Reduction manuvere

22. Post-reduction neurovascular exam • Axillary nerve • Radial pulse • Post-reduction x-rays • Reduction • Fractures

23. Follow up

24. Dislocation-Elbow Second most common major joint dislocation Usually closed and posterior Fall on extended elbow Posterior, posterolateral, posteromedial, lateral, medial, or divergent Complex- dislocation with fracture (35-40%) • Radial head fracture most common Simple- dislocation without fracture • Rupture of capsule, rupture of MCL and lateral ligaments, rupture of flexor pronator mass, possible injury to brachialis muscle and rupture of brachial artery

26. Elbow DX

27. Dislocation-Elbow • Nerve inury • Neuropraxia involving median or ulnar nerve in 20% of elbow dislocations • Ulnar nerve palsies more common in pediatric • Most neuro deficits are transient

28. Dislocation-Elbow • Nerve inury • Neuropraxia involving median or ulnar nerve in 20% of elbow dislocations • Ulnar nerve palsies more common in pediatric • Most neuro deficits are transient

29. Dislocation-ankle

30. Dislocation-ankle Described by relationship of talus to tibia Usually associated with fracture Pre/post-reduction neurovascular exam and x-rays Adequate analgesia vs conscious sedation Reduction (even if open) Splint Ortho for washout if open

31. Fractures ,Examine vascular status

32. Compartementsyndrom Limb threatening Increased pressure in tight fascial compartment Muscle necrosis at > 30mm Hg Ischemic injury at 4 hrs Irreversible injury 4-8 hrs Signs: disproportionate pain, 5 P’s • Pain • Pallor • Paraesthesiae • Paralysis • Pulseless

33. 120 mm Hg Difference between diastolic pressure and compartment pressure (delta pressure)< 30mmHg is indication for immediate decompression Pulse Pressure 60 mm Hg Ischemia 30 mm Hg Elevated Pressure 10 mm Hg Normal 0 mm Hg

34. Causes of compartementsyndrom Fractures ~75% Crush injury Burns Extravasation Tourniquets, constrictive dressings/plasters Snake bites

37. Management Early recognition! Urgent fasciotomies

38. Compartementsyndrom Volkmanischaemic contractures Permanent nerve damage Limb ischaemia and amputation Rhabdomyolysis and renal failure