ORTHOPEDIC EMERGENCIES James M.Steinberg, D.O. Garden City Hospital

1. ORTHOPEDIC EMERGENCIESJames M.Steinberg, D.O.Garden City Hospital

2. Types of Emergencies • Open Fractures • Dislocations • Compartment Syndrome • Cauda Equina Syndrome • Necrotizing Fasciitis

3. OPEN FRACTURES • Break in the skin and soft tissue leads directly to the fracture • Force causing the injury is dissipated by the soft tissue and osseous structures • Vacuum is created by the soft tissue shock wave which can pull material into the wound

4. Clinical Evaluation • ABC’s • Identify injuries to the extremities • Assess neurovascular status • Note skin and soft tissue damage • Identify bony injury

5. Radiographic Evaluation • AP and lateral of affected bone • Joint above and below the injury • Any other area that is painful • Angiography if there is a vascular injury

6. Gustilo Classification • Grade I: -clean skin opening of <1cm -usually from inside to outside -minimal muscle contusion -simple transverse or short oblique fractures

7. Gustilo Classification • Grade II: -laceration >1cm long -extensive soft tissue damage -minimal to moderate crushing component -simple transverse or short oblique fractures with minimal comminution

8. Gustilo Classification • Grade III: -extensive soft tissue damage -high energy injury with severe crushing component IIIA: -adequate bone coverage -minimal periosteal stripping IIIB: -periosteal stripping and bone exposure IIIC: -vascular injury requiring repair

9. Management • Saline soaked gauze on the wound with a sterile wrap • DO NOT irrigate or debride - this may further contaminate the wound • DO NOT remove bone or close the wound • DO NOT culture the wound • X-rays • Splint anatomically

10. Antibiotic Coverage • Begin IV antibiotics in the ER • Grades I & II: First generation cephalosporin • Grade III: Add an aminoglycoside • Farm injuries: Add penicillin and an aminoglycoside • Tetanus prophylaxis: toxoid 0.5ml IM and immune globulin for non-immunized

11. Treatment • Patient to the OR as soon as possible • Debridement less than eight hours after injury has a lower incidence of infection • Thorough debridement is crucial -Extend wound proximally and distally -Begin with the skin -Expose the fracture surfaces -Discard osseous fragments devoid of soft tissue

12. Treatment -Perform pulsatile irrigation with or without antibiotic solution -Intraoperative cultures…controversial -Do not close the traumatic wound -Close the surgically extended portion only -Cover the wound with a saline soaked dressing

13. Treatment -Repeat debridements every 24 to 48 hours until there is no evidence of necrotic tissue or bone • Fracture stabilization -Fractures with extensive soft tissue injury should be stabilized with internal or external fixation -Stabilization provides protection from additional soft tissue injury and access for wound management

14. DISLOCATIONS • A complete disruption of a joint so that the articular surfaces are no longer in contact • Features: -Pain -Loss of normal contour and relationship of bony points -Loss of motion -The position the limb is held is often diagnostic -Fractures and neurovascular injury

15. Assessment • Radiographic evaluation: AP, lateral, and special views appropirate for the joint involved • Neurovascular exam

16. Anterior Dislocations of the Glenohumeral Joint • Majority of shoulder dislocations • Types of anterior dislocations -Atraumatic usually due to congenital laxity -Traumatic major injury anterior/inferior labrum may be detatched -Acquired generally from repeated minor injuries

17. Radiographic Evaluation • X-rays: AP, scapular Y, axillary (most important) • Special views: Hill-Sachs, Hermodsson’s internal rotation and tangential views, and others • CT or MRI may be utilized to help identify Bankart lesions

18. Treatment • Neurovascular assessment: -Axillary nerve: check sensation over lateral shoulder -Musculocutaneous nerve: check sensation over anterolateral forearm • Closed reduction with appropriate muscle relaxants and analgesics

19. Treatment • Closed reduction techniques: -Traction-countertraction -Traction-lateral traction -Stimson technique -Milch technique -Kocher maneuver • Immobilization: duration is age dependent • Irreducible anterior dislocations are usually due to interposed soft tissue and requires open reduction

20. Posterior Dislocations of the Glenohumeral Joint • Approximately ten percent of shoulder dislocations • Often missed by ER staff • Mechanism of injury: -Direct force applied to anterior shoulder forcing humeral head posterior -Indirect force: more common, arm usually in adduction, flexion, and internal rotation

21. Radiographic Evaluation • AP: loss of normal elliptical overlap of humeral head on glenoid lost • Axillary view will confirm dislocation • Vacant glenoid sign: space between anterior rim and humeral head>6 mm • CT is valuable in assessing percentage of head impacted by glenoid

22. Treatment • Closed reduction: analgesia and full muscle relaxation required (pain greater than in anterior dislocations) • Traction to the adducted arm in the line of the deformity with gentle lifting of the head back into the glenoid • Do not force the arm into external rotation, this may fracture the humeral head • Immobilization: type depends on stability and duration depends on age

23. Hip Dislocations • Almost always due to high energy trauma • Anterior dislocations: -Limb is externally rotated and abducted -Inferior: abduction, external rotation, and hip flexion -Superior: abduction, external rotation, and hip extension

24. Hip Dislocations • Posterior dislocations: -More common than anterior dislocations -Blow to the flexed knee with the hip varying degrees of flexion -Limb is typically held flexed, adducted, and in internal rotation

25. COMPARTMENT SYNDROME • First described by Richard von Volkmann in 1881 -Post Traumatic muscle contracture with paralysis due to what he described as isechmic changes of the muscles • Jepson was the first to prove that paralysis and contracture could be prevented by prompt decompression in 1926

26. Definition • An acute increase in tissue pressure within a muscle compartment resulting in: -Increased local venous pressure -Decrease in the arteriovenous gradient -Decrease in arterial inflow • Majority of cases caused by severe trauma • Other causes include prolonged increase in exercise intensity, tight dressings, vascular injury, and surgery

27. Signs and Symptoms • Pain: -The earliest and most reliable indicator -Passive stretch of the muscles in the compartment often elicits pain out of proportion to the injury -Typically described as deep, unremitting, and poorly localized

28. Signs and Symptoms • Pallor: -May or may not be present -The extremity may appear cyanotic or mottled -Cyanosis is present early whereas marked pallor occurs late after arterial occlusion has occurred -Pallor or cyanosis should not be considered a sign that is necessary for the diagnosis

29. Signs and Symptoms • Paresthesia -In the cutaneous distribution of the peripheral nerve is usually a sign of impending but still reversible compartment syndrome -Fixed hypoesthesia or anesthesia is typically a late finding

30. Signs and Symptoms • Paralysis: -Ischemia has usually been well established for some time and permanent damage may occur -Motor function is the first nerve function to be lost when a limb is rendered ischemic -Irreversible muscle fiber changes may occur as early as six hours after the onset of tissue ischemia

31. Signs and Symptoms • Pulselessness: -Typically occurs late in the course of compartment syndrome -Distal pulses can remain long after muscle and nerve ischemia and damage are irreversible

32. Signs and Symptoms • Compartment pressures: -Pressures >30 mm Hg or within 10-30 mm Hg of the diastolic blood pressure are highly suggestive of the diagnosis -Pressures may be measured using a variety of techniques including needle manometer, wick catheter, slit catheter, and microcapillary infusion

33. Treatment • Fasciotomy within four hours of onset usually prevents muscle necrosis • Generous skin incisions should be utilized • Muscle debridement is necessary for any ischemic muscle • The wounds are left open and delayed primary closure is anticipated in seven to ten days

34. CAUDA EQUINA SYNDROME • A large midline disc herniation that may compress several roots of the cauda equina • Occurs in two percent of patients with a herniated disc • Herniation at the L4-L5 disc is the most common • Onset may be rapid or slowly progressing

35. Clinical Presentation • Low back pain • Bilateral sciatica • Saddle anesthesia • Motor weakness in the lower extremities • Bowel and bladder dysfunction - usually urinary retention • In men, a recent history of impotence

36. Diagnosis • Digital rectal examination • Evaluation of perianal sensation • Anal and bulbocavernosus reflexes • Immediate MRI/Myelography • Myelography shows a complete block with large disc herniations

37. Treatment • Surgical decompression: -Should be done as soon as possible to allow maximum recovery and minimize scar formation • Prognosis has been linked to the extent of sensory deficit in the perineal or saddle area

38. NECROTIZING FACIITIS • An uncommon severe infection involving the subcutaneous soft tissues, particullarly the superficial and often deep fascia • Usually is an acute process • Commonly affects the extremities, especially the legs • Entry is usually at a sight of trauma • Predisposing factors: cirrhosis, peripheral vascular disease, corticosteroid therapy, diabetes mellitus, alcoholism, and parenteral drug abuse

39. Bacteriologic Entities • Type I: an anaerobic species (most commonly Bacteroides and Peptostreptococcus) is isolated with a facultative anaerobic species such as streptococci • Type II (hemolytic streptococcal gangrene): group A streptococci is typically isolated with Staphylococcus aureus

40. Presentation • Evidence of soft tissue infection: localized swelling, erythema, and marked tenderness • Fever, tachycardia, hypotension, confusion, and multi organ failure • Leukocytosis, thrombocytopenia, azotemia, and increased levels of CPK • Sequential skin color changes from red-purple to blue-gray

41. Diagnosis • Prompt diagnosis is imperative • Mortality rates range from 20 to 47 percent • Systemic toxicity out of proportion to local findings should alert the physician • Gram stain and C&S of exudate • Frozen biopsy specimens including the fascia and underlying muscle has been found to be helpful for early diagnosis

42. Treatment • Surgical debridement is essential • Extensive incisions should be made through the skin and subcutaneous tissues until normal fascia is found • Necrotic fat and fascia should be excised • The wound should be left open • A second look is frequently necessary 24 hours later to ensure adequate initial debridement

43. Treatment-Antibiotics • Prior to obtaining the results of cultures and sensitivity combinations of ampicillin, gentamicin, and clindamycin are typically used • Other combinations include: ampicillin, gentamicin, and metronidazole or ampicillin-sulbactam and gentamicin