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Title Orthopaedic Emergencies
Class Intermediate Cycle 3
Course Musculoskeletal Education
Title Orthopaedic Emergencies
Lecturer Dr Martin Kelly
Date 06/01/016
RCSI !oyal College o" #urgeons in Ireland Coláiste Ríoga na Máinleá inÉirinn
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LEARNING OUTCOMES
$ %t the end o" this lecture the student should &e a&le to'
1( )nderstand the &asic approach to the *rauma patient
( )nderstand and &e a&le to recognise the main #pinalEmergencies
3( )nderstand and &e a&le to recognise the lim&
threatening Orthopaedic Emergencies
+( )nderstand and appreciate ho, to diagnose and themanagement o" the main Orthopaedic pathologies
,hich present to the ED
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TOICS
1- .i"e threatening orthopaedics inuries ,ith re"erence to the %*.# el2ic "ractures
- #pinal Emergencies #pinal *rauma %*.# &ased
Cauda Euina #yndrome
3- Musculoskeletal/.im& threatening components o" %*.# Compartment syndrome
Open "ractures
*raumatic %mputation
+- Common ED orthopaedic presentations ,ith emphasis on radiology #eptic arthritis
.arge oint dislocation
4ractures
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ATLS
$ E2erything in clinical medicine
resol2es around/&egins ,ith
%5CDE
$ #ometimes the per"ormance o"
the primary sur2ey isnt o&2ious&ut its al,ays there #aying hello on the ,ard
round/OD/ED
$ E2erything else can &e seen as
a secondary sur2ey once li"e
threatening emergencies ha2e&een managed
$ % structured
approach/a,areness are key
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!"O TO CALL #
$ 7ot all "ractures are
orthopaedic
$ May need help "rom' 8ascular surgeon 7eurosurgeon
9eneral #urgeon
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$% LI&E T"REATENING ORT"OAEDIC
IN'URIES !IT" RE&ERENCE TO T"E
ATLS
75 el2ic "ractures
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AIR!A( ) *REAT"ING
Air+a,
$ 4oreign &ody in mouth
$ Ma:illo"acial trauma
$ 7eck trauma$ .aryngeal trauma
$ *racheo&ronchial tree
inury
$ #ternocla2icular oint
*reathing
$ *ension pneumothora:
$ Open pneumothora:
$ 4lail chest$ ulmonary contusion
$ Massi2e haemothora:
$ *raumatic diaphragmatic
inury
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CIRCULATION
$ 5lood on the "loor
$ Chest
$ %&domen
$ !etroperitoneum
$ el2is$ .ong&ones
Think Blood on the foor and 5
more
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*LOOD ON T"E &LOOR
$ Maor arterial haemorrhage
$ !arely missed
$ Can cause hypo2olaemic shock
rapidly; especially in children
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EL-IC TRAUMA
$ el2ic "ractures are o" 2arying se2erity atients can &leed to death i" the iliac 2essels are torn-
#ome "ractures can destroy the hip oint-
Others are little more serious than a &ad &ruise
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EL-IC TRAUMA
$ 4ractures and ligamentous disruption suggest maor
"orce
$Mechanism; usually car 2s pedestrian; motor 2ehicle andmotorcycle crashes-
$ #igni"icant association ,ith inuries to intraperitoneal and
retroperitoneal 2iscera and 2ascular structures-
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SOURCES O& *LOOD LOSS
$ atients ,ith haemorrhagic shock and anunsta&le pel2is ha2e + potential sources o"&lood loss1- 4ractured &one sur"aces- el2ic 2enous ple:us3- el2ic arterial inury+- E:tra pel2ic sources
$ #igni"icant increase o" tears o" thoracic aorta in those
,ith pel2ic "ractures; esp % "ractures$ 5lood on the "loor and > more$ Intra=a&ominal sources must &e e:cluded or treated
operati2ely
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MEC"ANISM O& IN'UR(.CLASSI&ICATION
$ atterns o" "orce % compression 60=?0@
.ateral compression 1>=0@
8ertical shear >=1>@
Comple:
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ASSESSMENT
$ *he "lank; scrotum and perianal area should &einspected uickly &lood at the urethral meatus .aceration in the perineum; 2agina; rectum or &uttock ,hich is
suggesti2e o" an open pel2is "racture
$ *esting o" mechanical insta&ility is a contro2ersial area; arapidly a2aila&le :=ray may a2oid the pain and potentialhaemorrhage associated ,ith manipulating the pel2is
$ 4irst indication o" mechanical insta&ility is seen oninspection "or leg length discrepancy or rotationalde"ormity
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MANAGEMENT
$ %5C$ Mechanical sta&iliAation$ el2ic &inder
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LONG *ONE &RACTURES
$ 4emoral "ractures igh impact e-g- !*%
)p to 1>00mls &lood loss "rom sha"t "racture
*homas splint immo&ilisation
$ umerus and ti&ia )p to ?>0mls can &e lost
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CRUS" S(NDROME /TRAUMATIC
R"A*DOM(OL(SIS0
$ Check renal "unction and creatinine kinase in patients
,ho ha2e su""ered crush inuries
$ )sually seen in patients trapped "or long time periods
$ 7eeds IC) management ,ith !enal physician consult
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1% SINAL EMERGENCIES
#pinal *rauma %*.# &ased
Cauda Euina #yndrome
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DISA*ILIT(2SINAL TRAUMA
$ %5CDE
$ igh Inde: o" suspicion
$ E:amination %,ake 2s Comatose
$ Imaging
$ Cer2ical
$ *horaco lum&ar
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E3AMINATION CER-ICAL SINE 4 NO AIN
$ %,ake
$ %lert
$ 7o neck pain or midline tenderness
$ !emo2e collar and palpate spine$ %sk to mo2e neck
$ hen in dou&t lea2e collar onB
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E3AMINATION C SINE 4 AIN RESENT
$ Must e:clude an inury
$ %; .ateral and E9 < Open mouth ( 2ie,s
$ F/= C* imaging
$ Must see C1 to *1B
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LATERAL C SINE 4 CONTOUR LINES
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ASSESSING LATERAL &ILM
$ Check the top o" *1 can &e seen
$ *race the 3 contour lines
$ Check 2erte&ral &odies
$ Check inter2erte&ral disc spaces
$ Check so"t tissues
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LONG A -IE!
$ Check spinous process
alignment 4acet oint dislocation
$ Check a&normal
,idening o"interspinous distance
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C$ &RACTURE
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C$ &RACTURES
$ 5urst
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ANATOM(
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C1 &RACTURES
$ edicle / angmans "racture
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C1 &RACTURES
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ODONTOID EG &RACTURE T(E 1
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T"ORACO LUM*AR SINE
$ Compression "ractures H edge; or anterior; account "or >0 ?0 @ o" all *. "ractures
9enerally sta&le
One column usually a""ected$ 5urst "ractures
appro:imately 1> @ o" all *. inuries
)nsta&le
1 column e""ected
$ 4le:ion=distraction
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T"ORACO2LUM*AR SINE 5 COLUMN
T"EOR(
$ Insta&ility i" out o" 3 disrupted
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ANTERIOR !EDGE -S *URST &RACTURE
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DON6T &ORGET T"IS 7
$ #pinal haematoma
$ Intradural or epidural
$ Joung people trauma
$ Elderly on ,ar"arin
2ulnera&le a"ter mildtrauma
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CAUDA E8UINA S(NDROME
$ Compression o" some or all o" the ner2e roots o" the
cauda euina; resulting in symptoms that include &o,el
and &ladder dys"unction; saddle anesthesia; and 2arying
degrees o" loss o" lo,er e:tremity sensory and motor
"unction
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RESENTATION
S,mptoms
$ lo, &ack pain
$ groin and perineal pain
$ &ilateral sciatica$ loss o" &o,el or &ladder
"unction-
$ #u&tle hesitancy
$ E2entually o2er"lo,incontinence
Signs
$ lo,er e:tremity ,eakness
$ ypo"le:ia or are"le:ia;
$ erineal hypoesthesia orsaddle anesthesia to
inprick
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EMERGENC( 7
$ M!I use"ul &ut dont delay
$ Early surgery to a2oid 5ladder / 5o,el incontinence
.o,er lim& ,eakness
$ .o, threshold "or admission
$ Counsel patients in &ack pain clinics
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&URT"ER READING CES
$ G %m %cad Orthop #urg- 00L %ug Cauda euina syndrome-#pector .!;
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5% MUSCULOS9ELETAL.LIM*
T"REATENING COMONENTS TO
ATLS
75 compartment syndrome
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COMARTMENT S(NDROME
$ De"inition Ele2ation o" tissue pressure ,ithin a myo"ascial compartment
that e:ceeds capillary pressure and compromises its per"usion
and tissue "unction
$ .o,er leg most common$ Can occur in arm; "orearm; hand; thigh; "oot; gluteal
area-
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CAUSES
$ Compartment
contents
$ E:ternal
compression
$ Constricting cast / dressing
$ 5urns
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SIGNS
$ araesthesia / 7um&ness later
$ ain on assi;e mo;ement o< distal =oints
$ Disproportional generalised pain in lim&
$*ense on palpation 7ot a sensiti2e sign$ ulse a&sent 8E!J .%*E #I97
$ Not the same as pain, pulseless, pale, paraesthesia
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MANAGEMENT
$ Call help early i" suspected
$ !emo2e cast / Dressing !e e:amine
$ Keep patient 7O
$ Check CK < a"ter a&o2e done (
$ Decompressi2e "asciotomy
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OEN &RACTURES ) 'OINT IN'URIES
$ Communication &et,een e:ternal en2ironment &one
$ Muscle and skin inured and &acterial contamination
$ rone to In"ection
oor healing
oor "unction
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OEN &RACTURES ) 'OINT IN'URIES
$ 4racture and open ,ound in same lim& segment is an
open "racture until pro2en other,ise$ Gustilo2Anderson classi
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OEN &RACTURES ) 'OINT IN'URIES
$ Management Make diagnosis promptly
Immo&ilise "racture
$ Descri&e ,ound accurately and associated so"t
tissue inury$ 7euro2ascular in2ol2ement
rompt surgical consultation
*etanus prophyla:is
%nti&iotics &ased on mechanism ; consult
micro&iology
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TRAUMATIC AMUTATION
$ #e2ere "orm o" open "racture that results in the loss o" an
e:tremity
$ *ourniuet may &e use"ul
$ rolonged ischaemia; neurologic inury and muscle
damage may reuire amputation
$ .i"e o2er lim& B
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RELANTATION
$ ossi&ility "or replantation should &e considered
$ Clean sharp amputations o" "ingers
&elo, knee or el&o,
$ A patient +ith multiple in=uries +ho re>uiresintensi;e resuscitation and emergenc, surger, is
not a candidate
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AMUTATED ART
$ ash in ringers lactate
$ #oak in aueous penicillin
$ rap in moisted sterile to,el
$ laced in plastic &ag
$ laced in cooling chest ,ith crushed ice$ *ransported ,ith patient to replantation centre
$ Care"ul not to "reeAe
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?% COMMON ED ORT"OAEDIC
RESENTATIONS
75 #eptic arthritis
75 .arge oint dislocation
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SETIC ART"RITIS
$ )sually re"ers to &acterial in"ection o" a oint Can &e "ungal ; 2iral
$ Adult vs Paediatric
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ADULT SETIC ART"RITIS
$ Emergency ,ith mortality o" 10 = 1>@
$ redisposing "actors Intra=articular corticosteroid inection
%ge L0 years
Dia&etes mellitus !heumatoid arthritis
rosthetic oint / !ecent oint surgery
#kin in"ection; cutaneous ulcers
I8 drug a&use
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MICRO*IOLOG(
$ #taphylococcus aureus ealthy adults; skin &reakdo,n; pre2iously damaged oint
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ADULT SETIC ART"RITIS
$ #ource o" in"ection Osteomyelitis
Direct in"ection "rom a penetrating ,ound
aematogenous 5acteraemia / I8D)
$ It is more likely to localiAe in a oint ,ith pree:isting
arthritis-
$ )sually monoarticular &ut can &e polyarticular especiallyin !heumatoid arthritis
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RESENTATION @ ADULT SETIC
ART"RITIS
$ Most common oint in2ol2ed is knee %lso ip; ankle; shoulder; ,rist are common sites
$ Monoarticular arthritis
!emem&er Di""erential diagnosis
$ ot s,ollen oint
$ Pain with passive and active movement
$ Dia&etic patients can present atypically and they are atincreased risk o" in"ection %n une:plained oint e""usion in a dia&etic should raise suspicion
o" septic arthritis
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DI&&ERENTIAL MONOART"RITIS
$ In"ection
$ Crystal induced
$ aemarthrosis *rauma
$7eoplastic
$ In"lammatory
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IN-ESTIGATIONS
$ Goint aspiration and "luid analysis )# guidance i" necessary
CC di""erential normal less 1L0/mm3
9ram stain and culture
.ight microscopy "or crystals in gout and pseudogout
urulent "luid and/or positi2e gram stain indicates &acterial in"ection
$ 5loods 45C; E#!; CR; 5lood Cultures
$ Nrays o" in"ected oint
7ot use"ul in diagnosis as only &ecome a&normal ,hen ointdestruction has occurred; use"ul as a &aseline "or later comparison
$ #,a& O" urethra; cer2i: and anorectum i" gonococcal in"ection a possi&ility
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TREATMENT
$ %nti&iotics "or 6/>; initially /> i-2-
$ *reatment depends on organism concerned &ut a suita&le&lind/empirical regime ,ould &e "luclo:acillin 1=g D# i2-00mg *D#
$ Modi"y &ased on C# results
$ .ocal micro&iology guidelines
$ It is +idel, accepted , orthopaedic surgeons that antiiotics
should e +ithheld until aspiration has een per
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T"ERE IS A SIGNI&ICANT "IG" &ALSE
NEGATI-E RATE ASSOCIATED !IT" 9NEEASIRATION !IT" RIOR ADMINISTRATION
O& ANTI*IOTIC T"ERA(%
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AEDIATRIC SETIC ART"RITIS
$ Consider in any child ,ith
acute onset "e2er and
pain"ul oint
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AEDIATRIC SETIC ART"RITIS
$ O"ten presents as limp; re"usal to ,eight &ear
$ E2aluate ,ith history and physical e:amination;
la&oratory studies; including syno2ial "luid analysis; and
imaging studies as in adult
$ Kochers Criteria RC hite &lood cell count 1;000
SU&E SLIED UER &EMORAL
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SU&E@ SLIED UER &EMORAL
EI"(SES
Characterised &y'
= displacement o" the capital "emoral epiphysis "rom
the "emoral neck through the physeal plate
resenting 4eature
= ip ain
= 9ait Distur&ance
= 1>@ present ,ith isolated thigh/knee pain
Mean %ge o" resentation' = 4'1yrs M'13->yrs
SU&E SLIED UER &EMORAL
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SU&E@ SLIED UER &EMORAL
EI"(SES
athogenesis@ = occurs ,hen shearing "orces applied to the "emoral
head e:ceed the strength o" the capital "emoral
physis
redisposing &actors@ = O&esity
= *rauma
= 9enetic redisposition
= 7ormal periosteal thinning and ,idening o" the physis
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SU&E@ SLIED UER &EMORAL
EI"(SES
$ Management'
= !e"erral to Orthopaedic #urgeons
= 7on=eight&earing
= Operati2e #ta&ilisation
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uestions