orthopedic emergencies rachel steinhart ccrmc ed april 2010

Orthopedic EmergenciesOrthopedic

EmergenciesRachel SteinhartCCRMC EDApril 2010

ObjectivesObjectives

Review H&P for orthopedic emergencies

Review appropriate documentation Describe x-rays Recognize potential limb/function threatening conditions

Discuss some high-risk & some common injuries

Review management including emergent/urgent orthopedic consult

HistoryHistory Mechanism Past medical history Medications Dominant hand Occupation Previous injuries Last meal

Physical ExamPhysical Exam Inspect (deformity, swelling, skin)

Palpate (step-off, tenderness) Range of motion (active &

passive) Neurovascular exam

Physical Exam

Documentation

Physical Exam

Documentation Joint above -

Joint below Sensory Motor Vascular Skin Compartments

Neurovascular

Compromise

Neurovascular

Compromise Straight forward

Any sensory or motor deficit Any question of circulatory compromise Pallor or cold distal to injury Decreased capillary refill/pulse

Compartment Syndrome

Compartment Syndrome

Raised pressure in a closed fascial space

Reduced capillary perfusion below level needed

for tissue viability

Limb Compartment

Syndrome Causes

Limb Compartment

Syndrome Causes Orthopedic

Fractures: open or closed Fx management (e.g. tight casting)

Vascular/Iatrogenic Vascular puncture: esp. anticoagulated

Intra-arterial drug administration

Extravasation of IV fluids Soft-tissue injury

Crush (e.g. Police K9 bites) Burns

Hypotension: Always worsens perfusion in compartment sx

Each limb contains a number of compartments at risk for CS.

Upper arm: anterior(biceps-brachialis) and posterior(triceps).Forearm: volar(flexors) and dorsal(extensors)3 gluteal, 2 thigh, 4 in the lower leg.

Compartment

Syndrome Risk

Factors

Compartment

Syndrome Risk

Factors Tibial Fracture Incidence ranges 1.5 to 29%

Variable dx/tx thresholds Anterior compartment most common

Forearm Supracondylar Fracture Comminuted = increased risk Open = decreased risk (~50%)

Compartment Compartment Syndrome - Syndrome - Pressure Pressure ThresholdThreshold

Compartment Compartment Syndrome - Syndrome - Pressure Pressure ThresholdThreshold

Intracompartmental pressure:   Pressure as low as 30 mm H2O can

result in compartment syndrome when accompanied by periods of hypotension

Is it Compartment Syndrome?

Is it Compartment Syndrome?

Clinical – 6 P’s PainPain out of proportion - passive extension

INCREASING NARCOTIC REQUIREMENT Paralysis Paraesthesia Pulselessness Pallor Poikilothermia - Cold

Irreversible damage occurs 6 hours6 hours after ischemia begins

Monitor Extremity

Pulses

Monitor Extremity

Pulses Be sure to occlude the other major

artery (e.g. posterior tibial artery vs. dorsalis pedis) so that retrograde flow does not interfere with diagnosis

alternatively, apply a pulse oximetry monitor to the great toe, and sequentially occlude the posterior tibial and dorsalis pedis pulses

compare pulses to the opposite, non-injured limb

Measuring Compartme

nt Pressure

Measuring Compartme

nt Pressure Usually performed by

Orthopedist Is within Emergency scope of practice

At CCRMC, Stryker instrument is in Med Room - Sterile kit w/needle and syringe must be obtained by Nurse Supervisor

Describing Radiograph

s

Describing Radiograph

s Type of fracture

Transverse, oblique, spiral, segmental, comminuted

Pediatric: Salter-Harris, torus/buckle, greenstick

Location of fracture

Displacement Shortening, angulation, rotation

Associated dislocation

Fracture DescriptionFracture Description

Open Fracture

Open Fracture

Carefully examine skin If skin not intact, determine whether bone exposed Irrigate thoroughly - will require OR wash

Bandage IV antibiotics (Ancef or Ancef+Gent)

Tetanus Contact Ortho as soon as discovered

QuickTime™ and a decompressor

are needed to see this picture.

Pediatric

Fractures

Pediatric

FracturesFractures involving or near the

epiphyseal plate require urgent orthopedic consult

Salter-Harris

Classification

Salter-Harris

Classification

QuickTime™ and a decompressor

are needed to see this picture.

Joint Dislocation

Joint Dislocation

Complete separation of 2 articulating bony surfaces, often caused by a sudden impact to the joint Commonly dislocated joints include shoulder, finger, patella and elbow Dislocations are often associated with fractures

Shoulder Dislocation

Shoulder Dislocation

Vast majority are anterior Document axillary nerve fxn pre- and post-reduction Sensation over deltoid

Posterior associated with seizure activity, can be bilateral, often missed

Anterior

Posterior

Peri-lunate & Lunate

Dislocations

Peri-lunate & Lunate

Dislocations

Peri-lunate Lunate

Both with significant wrist instability Both associated with SCAPHOID fractures Usually require surgical intervention

Scapho-lunate Dissociation

Scapho-lunate Dissociation

Unstable ligamentous injury Generally requires surgical repair

“Terry Thomas Sign”Gap normally 1-2 mm

Scaphoid FractureScaphoid Fracture Can be difficult to see on

xray May require additional view May require delayed imaging If middle or proximal, risk osteonecrosis

Contact ortho while patient in ER

When in doubt, splint & refer Short arm, thumb spica

Hip Dislocatio

n

Hip Dislocatio

n Rapid reduction imperative: prolonged dislocation avascular necrosis

Hip Fracture

Hip Fracture

PotentialForAvascularNecrosis

>

Knee DislocationKnee Dislocation

Usually reduce spontaneously Often associated with tibial plateau fx Posterior highly associated with vascular injury - vascular study IMPERATIVE

Anterior Posterior Arteriogram

Patellar FracturePatellar Fracture

Transverse fracture -> inability to extend leg at the knee

Usually requires ORIF

Maisonneuve Fracture

Maisonneuve Fracture

Unstable fracture Often requires surgical repair

Ankle DislocationAnkle Dislocation

Easily reduced Associated with malleolar fractures and significant instability

Usually require surgical intervention

Lisfranc FractureLisfranc Fracture

Unstable fracture Often requires surgical repair

Jones Fracture

Jones Fracture

Unstable fracture Often requires surgical repair

Nursemaid’s Elbow

Nursemaid’s Elbow

Common Easily reduced

Supracondylar FractureSupracondylar Fracture

Common pediatric fracture Significant risk for compartment syndrome Volkmann’s Contracture Unreliable parents? ADMIT for observation

Often require surgical intervention

Initial Treatment of Orthopedic Injuries

Initial Treatment of Orthopedic Injuries

Remove jewelry Ice Elevate Control pain Irrigate, dress, reduce,

splint, dT, IV antibiotic NPO

Dislocation +/-

Fracture

Dislocation +/-

Fracture Increase time dislocated =

more difficult to reduce Reduction results in:

Relief of acute pain Removal of pressure from neurovascular structures

Restoration of circulation

Splint immediately post-reduction to avoid recurrent dislocation

Repeat physical exam and x-ray to confirm reduction & r/o addt’l injury

Early Orthopedic Consult Emergent or

Urgent

Early Orthopedic Consult Emergent or

Urgent Neurovascular compromise

Attribute to initial injury or Post reduction Possible compartment sx

Irreducible dislocation Fracture + dislocation Open fracture Risk of avascular necrosis (e.g. scaphoid, femoral neck)