Orthopedic Emergencies Dr Fathy Khallaf Consultant Orthopedic Surgeon

1. Al-Jahra Hospital Orthopedic Emergencies Dr Fathy Khallaf Consultant Orthopedic Surgeon

2. Definition Orthopedic Emergency is a musculo-skeletal injury or disease that, if missed could result in significant complications or impairment which badly affect the activity of the patient and would leave an adverse residual effect.

3. Orthopedic Emergencies • Open fractures • Dislocations • Fracture or dislocation associated • with vascular injuries • Acute compartment syndrome • .

4. Exsanguinating Pelvic Trauma • Fracture neck of femur • Fracture neck of talus • Septic arthritis • Osteomyelitis

5. Open fractures An open fracture is one in which a break in the skin and soft tissue envelope allows for direct communication of the fracture site or fracture hematoma with the exterior.

6. Gustilo- Anderson Classification of open fractures Type I Type II Type III A Type III B Type IIIC

7. Open fractures management • Dos: • Cover the wound with sterile dressing • Control bleeding • Splint the fracture • IV antibiotics • Tetanus prophylaxis • Anti-Gas gangrene serum

8. DONTs: • - Replace the protruding bone • - Explore the wound in ED • - Close the wound in ED • - Clamp vessels in ED

9. Open fractures complications • - Soft tissue infection • - Compartment syndrome • - Skin gangrene with skin loss • - Delayed union • - Non-union • - Infected pseudo-arthrosis • - Gas gangrene • - Tetanus • - Amputation

10. Acute compartment syndrome • Etiology • Fractures • Direct blow or contusion • Crushing injuries • Hematoma • Prolonged pressure

11. After vascular reconstruction and revascularization in acute ischemia due to major arterial injury • Burns • Snake bites

12.  The most common fracture associated with ACS is tibial diaphyseal fractures which have been reported to be 3-11%. The second most common cause is soft tissue injury, but the second most common fracture to be complicated by ACS is distal radius fracture.

13. Acute compartment syndrome • Pathophysiology • An injury or a condition that causes • prolonged elevation of interstitial tissue • pressure • Increased pressure within enclosed • fascial compartment leads to impaired • tissue perfusion.

14.  Prolonged ischemia causes cell damage • which leads to increase vessels • permeability • Plasma leaks in the interstitium causing • further increase in compartment • pressure • Extensive muscles and nerve death if • this ischemia prolonged more than 8 h.

15. Acute compartment syndrome • Symptoms & Signs • Severe continuous pain out of • proportion of the original injury or • fracture disturbing the patient's sleep • Pain on passive stretch • Pain with active contraction • Tense swelling in the involved • compartment

16. Tight shiny skin • Late findings: Paraethesia • Paralysis • Pallor • Pulselessness

17. Investigations Measurements of intra-compartmental  pressure using the following methods: 1- Needle manometer 2-Wick catheter 3- Slit catheter 4- Pressure transducer

18.  Threshold for Decompression in ACS • Absolute measurement of intra- • compartmental • Pressure ≥ 30 mm Hg • Relative measurement of intra- • compartmental Pressure to diastolic • blood pressure DBP-ICP ≤ 30 mm Hg • Treatment • Emergency fasciotomy

19. Dislocations Definition: dislocation is the displacement of bones at a joint from their normal relation and position

20. Dislocation shoulder

21. Dislocation elbow

23. Dislocation hip

25. Dislocation knee

28. Exsanguinating Pelvic Trauma Tile classification of pelvic fractures The two pelvic fractures most commonly associated with significant hemorrhage are: 1- Antero-posterior external rotation injury B1 2- Rotationally and vertically unstable pelvic injury whether unilateral or bilateral or associated with acetabular fracture CI, C2, C3

29. Clinical presentation -Hemo-dynamically unstable and deteriorating -Destot's sign -Earle's sign -Roux's sign

30. X-ray and CT scan APC type BI • or VS type C 1, 2, 3 • -U/S and CT scan abdomen • revealed no intra-peritoneal • bleeding

35. Management • Resuscitation according to ATLS • guidelines • Reduction and immobilization of pelvic • fracture using an external fixator in APC • B I or pelvic C-clamp in VS C I,2,3 may • be required to stop the bleeding

36.   Laparotomy with abdominal or pelvic • packing • Angiography and??selective • embolization may also be required.

39. FRACTURE NECK OF FEMUR Not emergent but urgent

41. FRACTURE NECK OF TALUS Not emergent but urgent

43. Septic arthritis Children and immuno-compromised adults Staphylococcus aureus is most common organism Hip and knee are the most affected joints Presentation: fever- pain in the affected joint or limb- toxicity- swelling and effusion in superficial joints- complete restriction of active

44. or passive movements in the affected joint- exquisite pain and tenderness on palpating or moving the affected joint- x-ray is negative- bone scan and MRI can give positive data-leukocytosis-high ESR and CRP Treatment: start broad spectrum antibiotic – emergent joint arthrotomy incision& drainage

45. Osteomyelitis • Children and immuno-compromised • adults • Staphylococcus aureus is most common • organism • lower femoral and upper tibial Metaphysis • are the most common sites • Presentation: fever- toxicity- pain in • The affected part of the limb- swelling

46. And tenderness along the affected metaphysis- sympathetic effusion with painful but mildly limited range of movements- x -ray is negative-MRI and bone scan are positive- leukocytosis- high ESR and CRP Treatment: start broad spectrum antibiotic –incision& drainage with bone drilling and guttering.

47. Thank you