sss orthopedicemergencies 2012 final samuel-wong

8/12/2019 Sss Orthopedicemergencies 2012 Final Samuel-wong

1/38

Dr. Samuel WongRMH Intern

2012

Orthopaedic Emergencies


2/38

Orthopedic EmergenciesOpen FracturesAcute Compartment SyndromeNeurovascular injuries

DislocationsSeptic JointsCauda Equina Syndrome


3/38

Open Fractures

An open (or compound) fracture occurs when the skin overlying afracture is broken, allowing communication between the fracture andthe external environment


4/38

Open Fractures- Gustilo-Anderson Classification:

Type I :Small wound (1cm), minimal soft tissue damage or loss,may have comminution of fracture (i.e. a low-moderate energyfracture)

Type III :Severe skin wound, extensive soft tissue damage (i.e. high energy

fracture)Three grades: A adequate soft tissue coverage, B fracturecover not possible without local/distant flaps, C arterial injurythat needs to be repaired.


5/38


6/38

Open Fractures- Management

ABCDE check neurovascular status (pulses, cap. refill, sensation,motor) , fluid resuscitation, blood

Antibiotics, tetanus prophylaxis 48-72 hrs

Surgical debridement removal of de-vitalised tissue, irrigation

Stabilization of fracture internal/external, if closure delayed thenexternal prefered

Early definitive wound cover split skin grafts, local/distant flaps(involve plastics)


7/38


8/38

Open Fractures- Complications

Wound infection 2% in Type I , >10% in Type III

Osteomyelitis staph aureus, pseudomona sp.

Gas gangrene

Tetanus

Non-union/malunion


9/38

Acute Compartment Syndrome

An injury or condition that causes prolonged elevation ofinterstitial tissue pressures

Increased pressure within enclosed fascial compartment leads toimpaired tissue perfusion

Prolonged ischemia causes cell damage which leads to oedema

Oedema further increase compartment pressure leading to avicious cycle

Extensive muscle and nerve death >4 hours

Nerve may regenerate but infarcted muscle is replaced by fibroustissue (Volkmanns ischaemic contracture)


10/38

ACS- Etiology

Crush injury

Circumferential burns

Snake bites

Fractures 75%Tourniquets, constrictivedressings/plasters

Haematoma pt with

coagulopathy at increased risk


11/38

ACS- Findings

5 Ps of ischaemiaPain (out of proportion toinjury)ParesthesiasParalysisPulselessnessPallor

Severe pain, burstingsensation

Pain with passive stretch

Tense compartment

Tight, shiny skin

Can confirm diagnosis bymeasuringintracompartmentalpressures (Stryker STIC)


12/38

0 mm Hg

10 mm Hg

30 mm Hg

60 mm Hg

120 mm Hg

Pulse Pressure

Ischemia

Elevated Pressure

Normal

Difference betweendiastolic pressure andcompartment

pressure (deltapressure)< 30mmHgis indication forimmediatedecompression


13/38

ACS - Mangement

Early recognitionMuscle necrosis at deltapressure < 30mm HgIrreversible injury 4-6 hrs

Remove cast, bandages anddressings

Arrange urgent fasciotomy


14/38

Fasciotomy


15/38

ACS- Complications

Volkman ischaemic contractures

Permanent nerve damage

Limb ischaemia and amputation

Rhabdomyolysis and renal failure


16/38

Dislocations

Displacement of bones at a joint from their normal positionDo xrays before and after reduction to look for any associated fractures


17/38

Dislocation- Shoulder

Most common major joint dislocationAnterior (95%) - Usually caused by fall on handPosterior (2-4%) Electrocution/seizureMay be associated with:

Fracture dislocationRotator cuff tearNeurovascular injury


18/38

Dislocation- Knee

Injury to popliteal artery and vein is common

Peroneal nerve injury in 20-40% of knee dislocations

Associated with ligamentous injury

Anterior (31%)Posterior (25%)

Lateral (13%)

Medial (3%)


19/38

Dislocation- Hip

Usually high-energy traumaMore frequent in young patientsPosterior- hip in internal rotation, most commonAnterior- hip in external rotationCentral - acetabular fractureMay result in avascular necrosis of femoral headSciatic nerve injury in 10-35%


20/38

Neurovascular Injuries

Fractures and dislocations can be associated with vascular and nervedamage

Always check neurovascular status before and after reduction


21/38

Neurovascular Injuries - Etiology

FractureHumerus, femur

Dislocation

Elbow, kneeDirect/penetrating trauma

Thrombus

Direct Compression/

Acute Compartment SyndromeCast, unconscious


22/38

Common vascular injuries

Injury Vessel1st rib fracture Subclavian artery/vein

Shoulder dislocation Axillary artery

Humeral supracondylar fracture Brachial artery

Elbow Dislocation Brachial artery

Pelvic fracture Presacral and internal iliac

Femoral supracondylar fracture Femoral artery

Knee dislocation Popliteal artery/vein

Proximal tibial Popliteal artery/vein


23/38

Clinical Features & Mx

Paraesthesia/numbness

Injured limb cold, cyanosed, pulse weak/absent

Call for help!Remove all bandages and splints

Reduce the fracture/ dislocation and reassess circulationIf no improvement then vessels must be explored by operation

If vascular injury suspected angiogram should be performedimmediately


24/38


25/38

Common nerve injuries

Injury NerveShoulder dislocation Axillary

Humeral shaft fracture Radial

Humeral supracondylar fracture Radial or median

Elbow medial condyle Ulnar

Monteggia fracture-dislocation Posterior-interosseous

Hip dislocation Sciatic

Knee dislocation Peroneal


26/38

Clinical Features & Mx

Paraesthesia and weakness to supplied areaClosed injuries: nerve seldom severed, 90% recovery in 4 months.If not do nerve conduction studies +/- repair

Open injuries: Nerve injury likely complete. Should be explored attime of debridement/repair

Indications for early exploration:Nerve injury associated with open fractureNerve injury in fracture that needs internal fixationPresence of concomitant vascular injury

Nerve damage diagnosed after manipulation of fracture


27/38


28/38

Septic Joint/Septic Arthritis

Inflammation of a synovial membrane with purulent effusion intothe joint capsule. Followed by articular cartilage erosion bybacterial and cellular enzymes.Usually monoarticular

Usually bacterialStaph aureusStreptococcusNeisseria gonorrhoeae


29/38

Septic Joint- Etiology

Direct invasion through penetratingwound, intra-articular injection,arthroscopy

Direct spread from adjacent bone abcessBlood spread from distant site


30/38

Septic Joint- Location

Knee- 40-50%

Hip- 20-25%**Hip is the most common in infants and very young children

Wrist- 10%

Shoulder, ankle, elbow- 10-15%


31/38

Septic Joint- Risk Factors

Prosthetic joint

Joint surgery

Rheumatoid arthritis

Elderly

Diabetes MellitusIV drug use

Immunosupression

AIDS


32/38

Septic Joint- Signs and Symptoms

Rapid onset

Joint pain

Joint swelling

Joint warmth

Joint erythemaDecreased range of motion

Pain with active and passive ROM

Fever, raised WCC/CRP, positive

blood cultures


33/38

Septic Joint- Treatment

Diagnosis by aspirationGram stain, microscopy, cultureLeucocytes >50 000/ml highly

suggestive of sepsisJoint washout in theatre

IV Abx 4-7 days then orally for another 3 weeks

Analgesia

Splintage


34/38

Septic Joint- Complications

Rapid destruction of joint with delayed treatment (>24 hours)

Growth retardation, deformity of joint (children)

Degenerative joint disease

Osteomyelitis

Joint fibrosis and ankylosingSepsis

Death


35/38

Cauda Equina Syndrome

Compression of lumbosacral nerve roots below conus medullarissecondary to large central herniated disc/extrinsicmass/infection/trauma


36/38

Clinical Features

motor (LMN signs)-weakness/paraparesis in multiple root distribution-reduced deep tendon reflexes (knee and ankle)-sphincter disturbance (urinary retention and fecalincontinence due to loss of anal sphincter tone)

sensory-saddle anesthesia (most common sensory deficit)-pain in back radiating to legs, crossed straight leg test-bilateral sensory loss or pain: involving multipledermatomes


37/38

Management

Surgical emergency - requires urgent investigation anddecompression (


38/38

The End

sss orthopedicemergencies 2012 final samuel-wong

Documents