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Includes the Adobe Acrobat Reader for reading and printing publications.
Numerous illustrations and matrices.
Contains the following key public domain (not copyrighted) U.S. Government publication(s) on one CD-ROM in both Microsoft PowerPoint and Adobe Acrobat PDF file formats:
TITLE:
Orthopedic Emergencies and Urgencies, 59 pages (slides)
SLIDE TOPICS, SUBTOPICS and CONTENTS:
Orthopedic Emergencies and Urgencies Rodney S. Gonzalez MAJ, MC, USA Family Medicine/Sports Medicine Chief, Department of Warrior Care Martin ACH, Ft. Benning, GA Objectives Define orthopedic urgencies and emergencies Determine whether or not to evacuate Acute management issues Front-line treatment of orthopedic injuries Definition A musculoskeletal injury or condition that, if missed, could result in additional complications, significant impairment, or death Orthopedic Emergencies Open Fractures or Joints Neurovascular Injuries Dislocations Septic Joints Open Fractures An open (or compound) fracture occurs when the skin overlying a fracture is broken, allowing communication between the fracture and the external environment Open Fractures- Classifications Compound from within (inside-out): The broken end of the bone breaks through or pierces the skin Compound from without (outside-in): External violence causes laceration or tissue trauma Higher likelihood of contamination Open Fractures- Classifications Type I: Small wound (<1cm), usually clean; low energy Type II: Moderate wound (>1cm), minimal soft tissue damage or loss; low energy Type III: Severe skin wound, extensive soft tissue damage; high velocity
Open Fractures- Complications Soft tissue infection Osteomyelitis Gas gangrene Tetanus Crush syndrome Skin loss Non-union Open Fractures- Management DOs: Control the bleeding Cover with sterile dressing Splint IV antibiotics Tetanus prophylaxis Anti Gas Gangrene Serum (AGGS, Clostridium perfringes)
DON’Ts: Scream and pass out Replace protruding bone Explore wound Clamp vessels One more thing… Any open wound over or near a joint should be assumed to extend to the joint until proven otherwise
Neurovascular Injuries Vascular trauma Trauma to peripheral nerves Acute compartment syndrome Neurovascular- Etiology Fracture Humerus, femur Dislocation Elbow, knee Direct/penetrating trauma Embolism Direct Compression Cast, unconscious Nerves- Lower Extremity Nerves- Upper Extremity Acute Compartment Syndrome An injury or condition that causes prolonged elevation of interstitial tissue pressures Increased pressure within enclosed fascial compartment leads to impaired tissue perfusion Prolonged ischemia causes cell damage which leads to increased vessel permeability Plasma leaks into interstitium causing further increase in compartment pressure Extensive muscle and nerve death >8 hours ACS- Etiology Direct blow or contusion Crush injury Burns Snake bites Fractures Hematoma Prolonged pressure ACS- Findings 5 Ps Pain Paresthesias Paralysis Pulses Palpation Severe pain Pain with stretch Tense compartment Tight, shiny skin Late findings Paresthesias Paralysis Loss of pulses
ACS- Anatomy Upper Extremity Deltoid Brachium Anteroir Posterior Antebrachium Volar Dorsal Mobile wad Hand Thenar Hypothenar Adductor Interosseous Carpal canal Finger ACS- Anatomy Lower Extremity Gluteal Tensor fascia lata Gluteus medius and minimus Gluteus maximus Thigh Anterior Posterior Leg Anterior Lateral Superficial posterior Deep posterior Foot
Anterior Extensor hallucis longus Extensor digitorum longus Peroneus tertius Tibialis anterior Deep peroneal nerve Anterior tibial artery Lateral Peroneus longus Peroneus brevis Superficial peroneal nerve Superficial posterior Gastrocnemius Soleus Sural nerve Deep posterior Flexor digitorum longus Flexor hallucis longus Posterior tibialis Posterior tibial nerve Posterior tibial artery Peroneal artery ACS- Final Thought Always check neurovascular status after moving patient, manipulating injured limb, before and after applying cast or splint, and at frequent intervals if transfer is delayed.
Dislocations Displacement of bones at a joint from their normal position May be associated with neurovascular injury Dislocation- Shoulder Most common major joint dislocation May be associated with: Bankart lesion Fracture dislocation Hill sachs lesion SLAP lesion Rotator cuff tear Nerve injury- axillary, posterior cord, musculocutaneous Dislocation- Shoulder Anterior (95%) Arm abducted and externally rotated Posterior (2-4%) Arm adducted and internally rotated Electrocution, seizure Inferior (1%) Hyperabduction Usually associated with significant trauma Dislocation- Knee Anterior (31%) Caused by hyperextension Often ACL and PCL both torn MCL and/or LCL usually injured Popliteal artery- intimal tear Posterior (25%) ACL and PCL torn Possible tear of extensor mechanism Avulsion or disruption of popliteal artery Lateral (13%) Medial (3%) Rotary (4%)- usually posterolateral Dislocation- Knee Injury to popliteal artery and vein is common Peroneal nerve injury in 20-40% of knee dislocations With peroneal nerve injury, suspect vascular injury Dislocation- Elbow Second most common major joint dislocation Usually closed and posterior Fall on extended elbow Posterior, posterolateral, posteromedial, lateral, medial, or divergent
Complex- dislocation with fracture (35-40%) Radial head fracture most common Simple- dislocation without fracture Rupture of capsule, rupture of MCL and lateral ligaments, rupture of flexor pronator mass, possible injury to brachialis muscle and rupture of brachial artery Dislocation- Elbow Nerve inury Neuropraxia involving median or ulnar nerve in 20% of elbow dislocations Ulnar nerve palsies more common in pediatric Most neuro deficits are transient Dislocation- Sternoclavicular Anterior More common Traumatic or atraumatic Posterior Rare Soft tissue swelling may give false impression of anterior dislocation Up to 25% complication rate Hemorrhage, tracheal or esophageal injuries, pneumothorax Dislocation- Hip Usually high-energy trauma More frequent in young patients Anterior- hip in external rotation Posterior- hip in internal rotation Central acetabular fracture dislocation May result in avascular necrosis Sciatic nerve injury in 10-35%
Septic Joint/Septic Arthritis Inflammation of a synovial membrane with purulent effusion into the joint capsule Usually monoarticular 2-10 cases per 100,000 in general population Gonococcal vs nongonococcal 80% are from gram-positive aerobes (S aureus, beta-hemolytic streptococci, and Streptococcus pneumoniae) Septic Joint- Etiology
Direct inoculation Trauma Iatrogenic Hematogenously Adjacent osteomyelitis Soft tissue infection 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% Septic Joint- Risk Factors Prosthetic joint Skin infection Joint surgery Rheumatoid arthritis Elderly Diabetes Mellitus IV drug use Septic Joint- Signs and Symptoms Rapid onset Joint pain Joint swelling Joint warmth Joint erythema Fever Decreased range of motion Pain with active and passive ROM Septic Joint- Treatment IV antibiotics Drainage Repeated aspirations Consider lavage Septic Joint- Treatment Open surgical drainage indications Difficult joint aspiration Persistent fever and symptoms >24 hours Leukocytosis persists >48-72 hours Positive repeat blood or joint cultures >48 hours Infected joint prosthesis
Septic Joint- Complications Rapid destruction of joint with delayed treatment (>24 hours) Degenerative joint disease Soft tissue injury Osteomyelitis Joint fibrosis Sepsis Death Be Careful You may get a “finger” Jersey Finger Rupture of FDP tendon Inability to flex tip of finger Splint in position Repair within 7 days Complications if Missed Retraction into palm of hand Loss of flexion of tip Impaired work ability Difficult surgery PIP Injuries Tear of the central slip of the extensor tendon Treatment Splint in extension for 6 to 8 weeks. Pain relief Watch for complications Complications if Missed Loss of function Persistent pain Boutonniere deformity Lawsuit Objectives Define orthopedic urgencies and emergencies Determine whether or not to evacuate Acute management issues Front-line treatment of orthopedic injuries Injections Subacromial AC Joint Elbow Finger Trochanteric Bursa Knee Foot Subacromial Injections Rotator Cuff Syndrome (Impingement) When NSAIDs and PT fail Posterior Approach Contents: 4 cc 1% Lidocaine 4 cc Marcaine 1 cc Kenalog 40 (or Celestone 6) Needle: 1 ½ in (21 – 25G) AC Joint Injections AC Arthritis When NSAIDs and PT fail Direct Superior Approach Contents: ½ cc 1% Lidocaine ½ cc Marcaine ½ cc Kenalog 40 (or Celestone 6) (May not be able to inject full 1 ½ cc due to joint space) Needle: ½ in (25 – 27G) Elbow Injections Tennis Elbow (Lateral Epicondylosis) Golfer’s Elbow (Medial Epicondylosis) When NSAIDs, elbow strap, and PT fail Approx 1cm distal to lateral or medial epicondyle Contents: 1cc 1% Lidocaine 1cc Marcaine 1cc Kenalog 40 (or Celestone 6) Needle: 1 ½ in (25 – 27G) Finger Injections Trigger Finger Flexor Tendon Sheath palmar aspect at the MCP joint Contents: ½ cc 1% Lidocaine ½ cc Marcaine ½ cc Kenalog 40 (or Celestone 6) Needle: 1 in (25 – 27G) Trochanteric Bursa Injections Trochanteric Bursitis When NSAIDs fail (or on initial presentation) Direct Approach (cogwheel) Contents: 4 cc 1% Lidocaine 4 cc Marcaine 1 cc Kenalog 40 (or Celestone 6) Needle: 1 ½ in (25 – 27G) Knee Injections Knee Arthritis (possible PFPS) When NSAIDs and PT fail Anterior Lateral Approach (with knee flexed) or Superior Lateral Approach (with straight knee) Contents: 4 cc 1% Lidocaine 4 cc Marcaine 1 cc Kenalog 40 (or Celestone 6) – may want to consider avoiding the steroid in some Needle: 1 ½ in (21 – 25G) Foot Injections Plantar Fasciitis When NSAIDs, Inserts, and PT fail Medial approach Contents: 1 cc 1% Lidocaine 1 cc Marcaine 1 cc Kenalog 40 (or Celestone 6) Needle: 1 ½ in (25 – 27G) Questions
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