Transcript Orthopedic Emergencies

Orthopedic
Emergencies
Rachel Steinhart
CCRMC ED
April 2010
Objectives
 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
History
 Mechanism
 Past medical history
 Medications
 Dominant hand
 Occupation
 Previous injuries
 Last meal
Physical Exam
 Inspect (deformity, swelling, skin)
 Palpate (step-off, tenderness)
 Range of motion (active & passive)
 Neurovascular exam
Physical Exam
Documentation
 Joint above - Joint below
 Sensory
 Motor
 Vascular
 Skin
 Compartments
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
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Raised pressure in a
closed fascial space
Reduced capillary
perfusion below
level needed for
tissue viability
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(bicepsbrachialis) and posterior(triceps).
Forearm: volar(flexors) and
dorsal(extensors)
3 gluteal, 2 thigh, 4 in the lower leg.
Compartment
Syndrome
Risk Factors
 Tibial Fracture
 Incidence ranges 1.5 to 29%
Variable dx/tx thresholds
 Anterior compartment most common
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Forearm
Supracondylar Fracture
Comminuted = increased risk
Open = decreased risk (~50%)
Compartment Syndrome
- Pressure Threshold
 Intracompartmental pressure:
 Pressure as low as 30 mm H2O can
result in compartment syndrome when
accompanied by periods of hypotension
Is it Compartment
Syndrome?
 Clinical – 6 P’s
 Pain out of proportion - passive extension
 INCREASING NARCOTIC REQUIREMENT
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Paralysis
Paraesthesia
Pulselessness
Pallor
Poikilothermia - Cold
 Irreversible damage occurs 6 hours
after ischemia begins
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, noninjured limb
Measuring
Compartment
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
Radiographs
 Type of fracture
 Transverse, oblique, spiral,
segmental, comminuted
 Pediatric: Salter-Harris,
torus/buckle, greenstick
 Location of fracture
 Displacement
 Shortening, angulation,
rotation
 Associated dislocation
Fracture Description
Open Fracture
 Carefully examine skin
 If skin not intact, determine whether
bone exposed
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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
Fractures involving or near the
epiphyseal plate require urgent
orthopedic consult
Salter-Harris
Classification
QuickTime™ and a
decompressor
are needed to see this picture.
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
 Vast majority are anterior
 Document axillary nerve fxn preand post-reduction
 Sensation over deltoid
 Posterior associated with seizure
activity, can be bilateral, often
missed
Anterior
Posterior
Peri-lunate & Lunate
Dislocations
Peri-lunate
Lunate
 Both with significant wrist instability
 Both associated with SCAPHOID fractures
 Usually require surgical intervention
Scapho-lunate
Dissociation
“Terry Thomas Sign”
Gap normally 1-2 mm
 Unstable ligamentous injury
 Generally requires surgical repair
Scaphoid Fracture
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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 Dislocation
 Rapid reduction imperative:
prolonged dislocation
avascular necrosis
Hip Fracture
Potential
For
Avascular
Necrosis
>
Knee Dislocation
Anterior
Posterior
Arteriogram
 Usually reduce spontaneously
 Often associated with tibial plateau fx
 Posterior highly associated with vascular
injury - vascular study IMPERATIVE
Patellar Fracture
 Transverse fracture -> inability to extend
leg at the knee
 Usually requires ORIF
Maisonneuve Fracture
 Unstable fracture
 Often requires surgical repair
Ankle Dislocation
 Easily reduced
 Associated with malleolar fractures and
significant instability
 Usually require surgical intervention
Lisfranc Fracture
 Unstable fracture
 Often requires surgical repair
Jones Fracture
 Unstable fracture
 Often requires surgical repair
Nursemaid’s Elbow
 Common
 Easily reduced
Supracondylar 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
 Remove jewelry
 Ice
 Elevate
 Control pain
 Irrigate, dress, reduce,
splint, dT, IV antibiotic
 NPO
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
 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)