Download - Common pitfalls in orthopedics
Common Orthopedic Pitfalls Common Orthopedic Pitfalls
for Emergency Specialistfor Emergency Specialist
The Emergency Specialist’s The Emergency Specialist’s
ApproachApproach
For Orthopaedic Patient
Why is consultation necessary?Why is consultation necessary?
“Call for help” in emergency
Admission
Equivocal diagnosis
Follow-up plan
Orthopedic Consultation in the Orthopedic Consultation in the Emergency DepartmentEmergency Department
"In many cases, such as fracture of the hip, the need for hospital admission and/or orthopedic consultation in the emergency department is obvious. In some situations, however, differences of opinion may exist among emergency physicians and among orthopedists as to whether the patient needs to be seen by an orthopedist in the emergency department, or whether the patient may be treated in preliminary fashion and referred for subsequent definitive orthopedic management. Even patients with injuries that ultimately may require surgical repair, such as an unstable ankle fracture, sometimes may be immobilized and discharged for prompt orthopedic follow-up.The physiology and potentially catastrophic consequences of compartment syndrome are described in Chap. 278. In cases of known or suspected compartment syndrome, orthopedic consultation should be obtained promptly. Emergency surgical intervention may be required to try to avert permanent tissue damage and muscle contracture...."
Orthopedic Consultation in the Orthopedic Consultation in the Emergency DepartmentEmergency Department
Sections: Compartment Syndrome, Irreducible
Dislocation, Circulatory Compromise, Open
Fracture, Injuries Requiring Surgical Repair.
Topics Discussed: blood circulation; compartment
syndrome; dislocations; fractures; fractures, open;
muscle injury; musculoskeletal system; orthopedics;
skeletal injury.
Tintinalli 6Tintinalli 6thth Edition Edition
1651 - 1805
Orthopaedic EmergencyOrthopaedic Emergency
Examples?
Orthopaedic emergencyOrthopaedic emergency
• Trauma
Non-trauma
- Osteomyelitis, Septic arthritis, Pyomyositis
- Gouty arthritis
- C1 - C2 subluxation
(Grisel’s syndrome, Rheumatoid arthritis)
- Acute disc syndrome
Management in Musculoskeletal InjManagement in Musculoskeletal Inj
uryury
R = Rest
I = Ice
C = Compression
E = Elevation
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ประคบด้�วิยน้ำ�าแข็�ง 15 – 20 น้ำาทำ� แล้�วิพั�ก 5 น้ำาทำ� สล้�บไปจน้ำไม่$บวิม่
เพั��ม่ข็&�น้ำ
Principles to approach severe Principles to approach severe musculoskeletal injurymusculoskeletal injury
A. First aids
B. Initial treatment of major fractures / dislocation
C. Standard radiographs of fractures / dislocation
D. Immediate definitive treatment of fracture /
dislocation
Principles to approach severe musculoskeletal injury
A. First aidsA. First aids
Bleeding control
Immobilization
Pain control
Antibiotic administration
Tetanus prophylaxis
Improve microcirculation
Principles to approach severe musculoskeletal injury
Technique of Immobilization Technique of Immobilization
1. Check distal neurovascular status; if no pulse:
equivocal to gentle traction until pulse return
2. Treat any wound โด้ยการป(ด้แผล้3. Pad bony prominence โด้ยการป ผ�าหร+อบ,ด้�วิย
สาล้�4. Apply adequate splint; 1 joint (bone) above 1
joint (bone) below in nearly normal position
5. Reassess distal neurovascular status
Methods of immobilizationMethods of immobilizationSplinting; wooden, commercialBrace or supportStrapSlab immobilizationCast immobilizationTractionExternal fixationOpen reduction and internal fixation
Purpose of immobilizationPurpose of immobilization
Temporary
Definite
Complication of immobilizationComplication of immobilization
Too fit
Too loose
Too long interval
Too short interval
; pressure sore, compartment syndrome
; inadequate immobilization (loss reduction, delayed, mal or nonunion)
; muscle atrophy, osteoporosis, joint stiffness, maceration of skin
; inadequate immobilization (loss reduction, delayed, mal or nonunion)
A. Taylor brace
B. Chairback
brace
C. Jewett hyperextension brace
D. Lumbosacral support
Strap immobilizationStrap immobilization
Figure of eight strap
Gibney’s strap
Velpeau’s strap
; A band or slip used in attaching parts to each others
Gibney’s strapGibney’s strap
Ankle sprain
Nondisplaced fracture of ankle
Velpeau’s strapVelpeau’s strap
Injury of shoulder region
Slab immobilizationSlab immobilization
U or Sugar tong slab for humerus fracture
U slab for fracture of forearms
Short or long arm slab with or without thumb spica
Short or long leg slab
Mid-leg mid-thigh slab
Sugar tong slabSugar tong slab
Fracture of humeralshaft
U slab for fracture of forearmsU slab for fracture of forearms
Fracture of forearm
Fracture of distal radius or ulna
Short arm slabShort arm slab
Long arm slabLong arm slab
Thumb spica slabThumb spica slab
Short leg slabShort leg slab
Long leg slabLong leg slab
CastingCasting
How to get success in treating fracture by casting
1. Good soft tissue hinge
2. Potential for three-point fixation
3. Proper immobilization
- Degree of deformity
- Fracture type (simple, oblique, spiral)
Three point fixationThree point fixation
Produce tension in the intact soft tissueProduce compression across the fracture sites to immobilize
the fracture
* This principle is used in nearly all immobilization technique for fractures
* A straight cast will usually contain a crooked bone, but a curved cast will generally contain a well-aligned bone
Advice to give patients before Advice to give patients before castingcasting
Objectives and advantages of casting
Duration of casting
Activities to do and not to do during casting
Good co-operation is needed
Complications of castingComplications of casting
Pressure sores
Cast sores
Measured time from the point which the plaster is wetted to
the point at which the cast has become firm
A period during setting time when the plaster became dry or
sticky like rubber and color changed. At this point, the
plaster should keep still without any movement or molding
Setting time
Critical setting time
Duration for completely dry of plaster of Duration for completely dry of plaster of ParisParis
Wettness of plaster
Number of plaster
Humidity of environment
Ventilation
Depend on
Normally 48 – 72 hours
Well-molded, one solid piece Laminated layer
Casting Casting Short or long arm cast with or without spica
Hanging cast
Short or long leg cast
Cylinder cast
Functional cast ; patellar tendon bearing
castBoot cast
Bolero cast
Shoulder spica cast
Hip spica cast
Minerva cast
Body jacket
Casting (cont.)Casting (cont.)
Short arm Short arm thumb thumb
spica castspica cast
Long arm castLong arm cast
Hanging Hanging castcast
Long leg castLong leg cast
Sarmiento or Functional castSarmiento or Functional cast
Bolero castBolero cast
Shoulder spica castShoulder spica cast
Hip spica castHip spica cast
Adult hip spica Adult hip spica castcast
Minerva castMinerva cast
Body jacketBody jacket
TractionTraction
Skin traction
Skeletal traction
Skull traction
Skin tractionSkin tractionBuck’s traction
1861 by Gurdon Buck
Full extension
Modified Buck’s tractionModified Buck’s traction
Bryant’s traction
The treatment of choic
e for fracture shaft of f
emur (esp. subtrochant
eric fracture) in infant
young children
Skin tractionSkin traction
Skeletal tractionSkeletal traction
1 lbs of traction for every 7 lbs of body weight(usually uncomfort if > 35 lbs)
Skeletal traction in Skeletal traction in upper extremitiesupper extremities
Dunlop traction for supracondylar fractureIn children
Overhead olecranon pin traction
Skull tractionSkull traction
Gardner-Wells tong
Crutchfield tongs
Skull tractionSkull traction
Halo Vest
Exception for non-immobilizationException for non-immobilization
Surgical neck fracture of humerus in elderly
Stable fracture of radial head and neck
Minimal displaced fracture calcaneus
Early, protected, gentle active motion
Principles to approach severe Principles to approach severe musculoskeletal injurymusculoskeletal injury
A. First aids
B. Initial treatment of major fractures / dislocation
C. Standard radiographs of fractures / dislocation
D. Immediate definitive treatment of fracture /
dislocation
Principles to approach severe musculoskeletal injury
B. Initial treatment of major fracturesB. Initial treatment of major fractures Shock in orthopaedic patient
- Hypovolemic shock
- Neurogenic shock Major fracture
- Pelvis
- Spine (cervical)
- Femur
- Multiple fractures
- Hip
Principles to approach severe musculoskeletal injury
(shock)
(shock)
(shock)
(shock)
Associated injuryAssociated injury
Fracture pelvis ; Urethral injury
Fracture scapula ; Shoulder, chest
Fracture calcaneus ; Spine (thoracolumbar
region)
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Clinical stable
Waiting time α Stability of condition
C. Standard radiographs of C. Standard radiographs of fractures / dislocationfractures / dislocation
Principles to approach severe musculoskeletal injury
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x-ray x-ray อะไรบ�างอะไรบ�างChest
Cervical spine (lateral cross table, including
C1 - C7)
Pelvis
D. Immediate definitive treatment D. Immediate definitive treatment
of fractureof fractureกระด้ กห�กทำ��ไม่$จาเป/น้ำต้�องผ$าต้�ด้ สาม่ารถูด้&ง reduce
ทำ�� ER ได้�; intrahematoma block
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กระด้ กห�กทำ��พัยายาม่ด้&งให�เข็�าทำ��ทำ��ห�องฉุ,กเฉุ�น้ำแล้�วิแต้$
ไม่$สาเร�จPrinciples to approach severe musculoskeletal injury
Objective of treatment in Objective of treatment in
orthopaedic patient orthopaedic patient
1. Good function
2. Prevent further degenerative changes
3. Acceptable clinical appearance
Management of Common Management of Common
Fractures and DislocationsFractures and Dislocations
DefinitionDefinition
Fracture
: Structural break in continuity of bony cortex
Dislocation
: Displacement of a partSubluxation
: Incomplete or partial dislocation
Stability of jointStability of joint
depend onReciprocal contours of the opposing joint
surfacesIntegrity of the fibrous capsule and
ligamentsProtective power of muscles that move the
joint
Special types of fracturesSpecial types of fractures
Stress fractures
Pathological fracture
Epiphyseal plate injury
Birth fracture
Stress fractureStress fracture
Common at
Metatarsal bone 2nd, 3rd and 4th (March
fracture)
Distal fibula (runner)
Proximal tibia (jumper and ballet dancer)
Birth fractureBirth fracture
Clavicle
Humerus
Femur
Spine
Diagnosis of joint injuriesDiagnosis of joint injuries
Joint swelling
Deformity ; angulation, rotation, loss of nor
mal contour, shortening
Abnormal movement
Local tenderness
Abnormal finding on X-ray
Common affected part related to Common affected part related to age of patientage of patient
Epiphyseal plateLigament, tendon, or muscleBone
Suspected fracture or dislocationSuspected fracture or dislocation
First pass evaluation
Focused evaluation
Physical examination
Analgesia
Studies
Suspected fracture or dislocationSuspected fracture or dislocationFirst pass evaluation
- Remove all rings and jewelry
- Keep the suspected fracture immobilized
- Patient NPO while awaiting x-rays or ortho consult
Focused evaluation
- Determine the history whether the injury is acute or chronic or due to trauma overuse
Suspected fracture or dislocationSuspected fracture or dislocation
Physical examination esp distal to suspected injry
- Circulation; pulse, capillary refill, or Doppler
- Sensation; light touch, 2-point discrimination
- Palpation; bony deformity or tenderness
- Motor; motor and nerve function
- Entire extremity; examine including the joint above and below the injury
Analgesia
Suspected fracture or dislocationSuspected fracture or dislocation
Studies
- Obtaining x-ray when obvious deformity, any bone tenderness, severe decreased range of motion, or significant swelling
- If a fracture is seen always look for a second fracture (the most commonly missed) and consider x-ray of the joint above and below the injury
Suspected fracture or dislocationSuspected fracture or dislocation
Studies- Acute injury to the foot and ankle; using Ottawa Ankle Rules to order x-ray
1. Ankle films; For pain near the ankle and inability to bear weight (4 steps) both immediately after injury and in ED or bony tenderness at the posterior edge or inferior tip of either malleolus2. Foot films; For midfoot pain and inability to bear weight both immediately after injury and in the ED or bony tenderness in navicular area or base of 5th metatarsal
Suspected fracture or dislocationSuspected fracture or dislocationHow to present to orthopedic surgeon
- Open or closed fracture
- Exact anatomic location
- Simple versus comminuted
- Position; displacement, angulation
- Complete versus incomplete
- Articular (joint) involvement
Suspected fracture or dislocationSuspected fracture or dislocation- Position; displacement, angulation
1. Displacement: 50% displacement means the distal fragment has shifted sideways toward the dorsal surface of the extremity a distance of about 50% the thickness of the fractured bone
2. Angulation: the sharp angle and its direction (dorsal, volar) is your angulation
* As displacement and angulation increases, the risk of nonunion and compartment syndrome, and thus the need for operative management
How to describeHow to describe
Site
Extent
Configuration
Relation between fragment
Relation to external environment
Complications
SiteSite
Diaphyseal
Metaphyseal
Epiphyseal
Intraarticular
ExtentExtent
Complete
Incomplete
- Hairline
- Plastic deformation
- Buckle
- Greenstick
ConfigurationConfiguration
Transverse
Oblique
Spiral
Comminuted
Relation between fragmentRelation between fragment
Nondisplace
Displace
Relation to external environmentRelation to external environment
Closed
Open
ComplicationsComplications
Uncomplicated
Complicated
Duration for bone healingDuration for bone healing
Age
Location and configuration of fracture (more
muscle, more cancellous and oblique or spiral)
Degree of displacement
Blood supply at fracture site (femoral neck,
scaphoid and talus)
Complication of fracturesComplication of fractures
Early
Late
Goal of treatmentGoal of treatment
Pain free or less
Good healing
Good alignment
Good function
Acceptable alignment
Methods of treatment for Methods of treatment for
closed fractureclosed fracture
Protection alone
External splinting
Closed reduction and immobilization
Closed reduction by continuous traction and
immobilization
Methods of treatment for Methods of treatment for
closed fractureclosed fracture
Closed reduction and skeletal traction
Open reduction and Internal fixation
Excised of the fracture fragment and
prosthetic replacement
Methods of treatment for Methods of treatment for
open fractureopen fractureCleansing of the wound
Debridement
Treatment of the fracture
Closure of the wound
Antibiotics
Prevention of tetanus
Different point of musculoskeletal Different point of musculoskeletal injury between children and adultinjury between children and adult
More incidence of fracture in childrenMore stronger and more rapid growth of periosteum More difficult to diagnoseMore ability of remodelingDifference in treatment or complicationLess incidence of ligamentous injury or dislocationLess tolerability to blood loss
Prognosis of epiphyseal plate injuryPrognosis of epiphyseal plate injury
Type of injury
Age of patient
Blood supply of the epiphysis
Method of reduction
Open or closed injury
Before any treatmentBefore any treatment
Firstly Do No Harm
Acceptable AlignmentAcceptable Alignment
Indication form SurgeryIndication form Surgery
Proper TreatmentProper Treatment
Open FractureOpen Fracture
1
2
3
4
5
6
1
2
3
4
5
6
Open fractureOpen fracture
The fracture in which a break in the skin and
underlying soft tissues leads directly into or
communicates with it and its hematoma
DiagnosisDiagnosis
Small puncture wounds and deep abrasions on extremities with f
ractures
The presence of crepitance (subcutaneous emphysema from trap
ped air due to open wounds or gas gangrene)
Fluctuance from soft tissue stripping and internal degloving are s
igns of extensive soft tissue damage. (even a small puncture wou
nd or laceration that appears remote from the fracture may indee
d communicate with the fracture)
Air can be sucked into the soft tissues of an extremity
as a result of penetrating or blunt trauma because of the
occurrence of a temporary vacuum phenomenon, as
energy is dissipated throughout the soft tissues.
Gas can also be produced by Clostridium perfringens
and enteropathogens such as Escherichia coli.
The presence of air or gas in the soft tissues on initial
radiographs in the presence of a fracture strongly suggests
an open fracture.
Injecting sterile saline or methylene blue to
distend the joint capsule and watching for fl
uid extravasation from the open wound
(not 100% sensitive)
Open fractureOpen fracture
Classification
What to do at ER
- Irrigation ด้�วิย NSS เพั+�อกาจ�ด้แล้ะเจ+อจางส��งแปล้กปล้อม่แล้ะ ป(ด้ด้�วิย sterile dressing ห�าม่explore แผล้ - Tetanus prophylaxis
- Start antibiotic IV หร+ออย$างช้�าก$อน้ำ start debridement
ให�เหม่าะสม่ (S. Aureus, or Gram negative)
Infection rateInfection rate
Type I ; 0 – 2 %
Type II ; 2 – 7 %
Type III ; 10 – 50 % (26 – 41%)
IIIA : 10 %
IIIB : 10 – 50 %
IIIC : 25 – 50 % (amputation rate > 50 %)
Recommendations for acute Recommendations for acute management of open fracturesmanagement of open fractures
1. Airway management and urgent resuscitation (ABC)
2. Immobilize the injured extremity and apply sterile dress
ing to the wound.
3. Administer early intravenous antibiotics.
4. Perform urgent operative wound debridement and irriga
tion, leave the wound open, and stabilize unstable skelet
al injuries.
5. Perform repeated debridements, as needed.
6. Delay wound closure/coverage.
Examination of the wound and Examination of the wound and initial emergency initial emergency
managementmanagementForeign bodies or obvious debris such as
leaves, stones, or grass found in open
wounds should be manually removed with
sterile forceps.
If the patient will be going to surgery within 1 or 2 hours
of injury, the wound can be covered with a sterile
bandage and the patient transported to the operating
room for definitive irrigation and debridement.
If the patient will not get to the operating room for
several hours, we prefer to irrigate the wound with 1 to 2
L of saline fluid before placing the sterile dressing
Povidone interferes with osteoblast function
Predebridement culture from the wound in the
emergency department before administration
of antibiotics or any antiseptics is not useful
Orthopaedic patients : AntibioticOrthopaedic patients : Antibioticss
Cefazolin
Cloxacillin
Gentamicin
Amikacin
Metronidazole
Clindamycin
Ofloxacin
Cotrimoxazole
May result from 1. Internal cause; inflammation and edema in a closed compartment, fracture, significant soft tissue injury, arterial injury leading to ischemia, necrosis, burns2. External cause; prolonged external compression
Calculate the perfusion by measuring the disastolic pressure in the involved extremity; then subtract the measured compartment pressure. A perfusion pressure of < 30 mm Hg in a symptomatic patient is an indication for fasciotomy
Compartment SyndromeCompartment Syndrome
Compartment SyndromeCompartment SyndromeWhen treated case of multiple fractures or
with significant fractures (long bones, large degree of displacement or angulation), the following complications should always be kept in mind1. ARDS (due to fat embolism or pulmonay contusion)2. Thrombo-embolic disease3. Atelectasis4. Compartment syndrome
ทำ$าน้ำจะทำาอย$างไร?
Traumatic amputationTraumatic amputation
Appropriate technique to keep the amputated part
1. Keep moist by gauze with NSS or RLS and put
in a plastic bag or cup
2. Soak in RLS in a plastic bag or sterile cup, then
keep cold by ice (not dry ice)
* Safety time for inappropriate technique for warm
ischemia ; 6 hr
* Safety time for inappropriate technique for cold
ischemia ; 12 hr (fingers ; 30 hr, but less in major
limb according to more muscles involvement)
* The amputated part should be sent for X-ray
Traumatic amputation
Traumatic amputationTraumatic amputationIndication for replantation
1. Thumb
2. Multiple digits
3. Metacarpal (palm)
4. Almost any part in a child
5. Wrist or forearm
6. Elbow or proximal arm (sharp, moderate severe
avulsion in a young patient)
7. Individual digit distal to FDS insertion
Traumatic amputationTraumatic amputationContraindication for replantation
1. Severely crushed or mangled part
2. Multiple levels
3. Serious co-injury or diseases
4. Arteriosclerosis
5. Mentally unstable
6. Individual digit proximal to FDS insertion
7. Prolonged warm ischemia
Mangled Extremity Severity Mangled Extremity Severity
Score (MESS)Score (MESS)
A. Skeletal / soft tissue injury
B. Limb ischemia
C. Shock
D. Age
* If the total score is < 7, the limb is nearly almost compatible with salvageable limb.
A score of less than 7 points suggests that salvage should be attempted. Conversely, amputation should be considered if the score is more than 20 points.
Open Knee InjuryOpen Knee Injury
Pitfalls of Pitfalls of
Musculoskeletal Problem Musculoskeletal Problem
in Childrenin Children
Staging of fracture in young childrenStaging of fracture in young children
Incomplete Fracture1. Plastic deformation
2. Greenstick fracture
3. Buckle fracture
4. Torus fracture
Complete Fracture
Do you know these?Do you know these?
Fracture of Necessities (Fracture of medial or
lateral condyle fracture, supracondylar
fracture)
Triplane Fracture
Tillaux’s Fracture
Three Part FractureThree Part FractureTwo Part FractureTwo Part Fracture
Common Musculoskeletal ProblemsCommon Musculoskeletal Problems
Fracture distal end of radius
Fracture neck of femur
Shoulder dislocation
Fracture of Distal RadiusFracture of Distal Radius
Indication for surgery
1. Intra-articular step-off > 2 mm
2. Die-punch fracture
3. Significant dorsal comminution involving > 1/3 of AP diameter of radius
4. Lost reduction within the 1st week after injury
Fracture of distal radiusFracture of distal radiusGoal of treatment
1. Rapid restoration of function
2. Prevention of chronic disability
Diagnosis,
Appropriate intervention, and
Postintervention rehabilitation
Fracture of NecessityFracture of Necessity
Galeazzi’s fractureMonteggiae’s fractureLateral condylar fractureSupracondylar fracture
ImperturbabilityImperturbability
Remaining calm and unworried in spite of
problems or difficulties
The physician who shows that he is flustered
and hurried in ordinary emergencies, loses
rapidly the confidence of his patients
Five factorsFive factors
The pressure of time and volume
The variety of conditions faced
The paucity of information
The limitation of therapeutic options
The constraint of disposition
““Treat First and Ask Questions Later”Treat First and Ask Questions Later”
Most practicesMost practices
On average only 10 to 15 minutes per patient
for the evaluation, testing, treatment,
disposition, and documentation
The way of approachThe way of approach
First question to be asked and answered
in the first few seconds
Do I need to resuscitate this patient?
How great is the threat?
How soon must I act?
Management, Not DiagnosisManagement, Not Diagnosis
In emergency medicine, the central task is not
diagnosis, but management
If one can be made, it is extremely helpful, but
if not, decisions must still be made and actions
must still be taken
Decision ThresholdsDecision Thresholds
“Index of Suspicion”“Index of Suspicion”
Only one disease under consideration and
there are only two possible actions
To Treat or Not Treat
If the patient is almost certainly non-diseased
(probability is near zero), then the correct
decision is Not Treat, because treatment
entails costs and risks of its own
Very low probabilities of disease, it is better
not to test and not to treat
Decision ThresholdsDecision Thresholds
“Index of Suspicion”“Index of Suspicion”
Very high probabilities, it is better not to test,
but to treat
Intermediate probabilities, testing and treating
only those with a positive test will produce the
best overall outcome
Decision ThresholdsDecision Thresholds
“Index of Suspicion”“Index of Suspicion”
Common PitfallsCommon Pitfalls
Tunnel vision
“Premature closure of hypothesis generation”
Just the opposite
“Inability to see the forest for the trees”
Failure to attend to the patient
“Fail to social interaction with patient and family”
How to approach patientsHow to approach patients
Bio
Psycho
Social
Spirit