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Orthopedic EmergenciesOrthopedic
EmergenciesRachel SteinhartCCRMC EDApril 2010
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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
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HistoryHistory Mechanism Past medical history Medications Dominant hand Occupation Previous injuries Last meal
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Physical ExamPhysical Exam Inspect (deformity, swelling, skin)
Palpate (step-off, tenderness) Range of motion (active &
passive) Neurovascular exam
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Physical Exam
Documentation
Physical Exam
Documentation Joint above -
Joint below Sensory Motor Vascular Skin Compartments
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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
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Compartment Syndrome
Compartment Syndrome
Raised pressure in a closed fascial space
Reduced capillary perfusion below level needed
for tissue viability
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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
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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.
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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%)
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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
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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
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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
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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
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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
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Fracture DescriptionFracture Description
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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.
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Pediatric
Fractures
Pediatric
FracturesFractures involving or near the
epiphyseal plate require urgent orthopedic consult
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Salter-Harris
Classification
Salter-Harris
Classification
QuickTime™ and a decompressor
are needed to see this picture.
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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
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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
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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
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Scapho-lunate Dissociation
Scapho-lunate Dissociation
Unstable ligamentous injury Generally requires surgical repair
“Terry Thomas Sign”Gap normally 1-2 mm
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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
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Hip Dislocatio
n
Hip Dislocatio
n Rapid reduction imperative: prolonged dislocation avascular necrosis
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Hip Fracture
Hip Fracture
PotentialForAvascularNecrosis
>
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Knee DislocationKnee Dislocation
Usually reduce spontaneously Often associated with tibial plateau fx Posterior highly associated with vascular injury - vascular study IMPERATIVE
Anterior Posterior Arteriogram
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Patellar FracturePatellar Fracture
Transverse fracture -> inability to extend leg at the knee
Usually requires ORIF
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Maisonneuve Fracture
Maisonneuve Fracture
Unstable fracture Often requires surgical repair
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Ankle DislocationAnkle Dislocation
Easily reduced Associated with malleolar fractures and significant instability
Usually require surgical intervention
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Lisfranc FractureLisfranc Fracture
Unstable fracture Often requires surgical repair
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Jones Fracture
Jones Fracture
Unstable fracture Often requires surgical repair
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Nursemaid’s Elbow
Nursemaid’s Elbow
Common Easily reduced
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Supracondylar FractureSupracondylar Fracture
Common pediatric fracture Significant risk for compartment syndrome Volkmann’s Contracture Unreliable parents? ADMIT for observation
Often require surgical intervention
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Initial Treatment of Orthopedic Injuries
Initial Treatment of Orthopedic Injuries
Remove jewelry Ice Elevate Control pain Irrigate, dress, reduce,
splint, dT, IV antibiotic NPO
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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
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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)