ORTHOPEDIC EMERGENCIES

JOE BEIRNE DO FACOEP

ANTHONY JENNINGS DO FACOEP
 Orthopedic Emergencies

Common presenting complaint -- 20% of visits

Basic knowledge of orthopedic injuries, fracture
patterns, dislocations, reduction techniques,
and splinting techniques are required to
manage injuries
Understanding of radiology –ordering and
interpreting films is required
Practical knowledge of fracture physiology
 History
Obtaining a thorough history of the
mechanism of injury (MOI) may help
identify the orthopedic injury
Past medical history
Medications
Document dominant hand (if applicable)
Previous injuries
Last Meal?
 Physical Exam
Physical examination of orthopedic injuries in the
ED is based on a simple four step process
Palpation of the injury for deformity and
tenderness
Assess range of motion (both active and passive)
of the affected bone, as well as consideration of
the joints above and below the injured bone
Inspection (deformity, swelling, discoloration)
Neurovascular exam
 Treatment
Sprains and Minor Injuries May Require:
Ace wraps, splints, immobilizers
Crutches, walkers, or wheelchairs
Ice packs
Elevation
Pain control
 Treatment
Injuries less than 24 hours old should have ice packs or
cold packs applied prior to splint application
Cold therapy stiffens collagen and reduces the tendency
for ligaments and tendons to deform
Also decreases muscle spasm, blood flow (limiting
hemorrhage and edema), increases pain threshold and
decreases inflammation
Cold packs should be applied for 30 minutes at a time
(avoid frostbite injury)
Cold packs should be limited to the first 24-48 hours;
after this, cold can interfere with long-term healing
 ED Evaluation
Appropriate radiographs based on H & P
Treatment
Consultation if needed
Describing radiographs to consultants
Open vs. Closed?
Angulation?
Impaction?
 Describing Radiographs
Type of fracture
– Transverse, oblique, spiral, segmental,
comminuted
Pediatric: Salter-Harris, torus/buckle,
greenstick
Location of fracture
Displacement
– Shortening, angulation, rotation
 Long Bone Fractures
Divided into thirds
– Proximal
– Middle
– Distal
Proximal- Middle
Junction
Middle-Distal Junction
 Fracture Description

Oblique Comminuted
Transverse Spiral Segmental
Describing Fractures
Displacement Angulation
 Orthopedic Emergencies
Pediatric Fractures
Salter-Harris fractures involve the epiphysis, or cartilaginous
epiphyseal growth plate, near the ends of the long bones in
children
Named after the two physicians who devised the classification
system for naming these fractures
New bone material needed for elongation of bones during growth
is provided by specialized cells within the physis
When growth is complete, transformation of the physis into bone
occurs, ultimately fusing with the surrounding bone
Salter-Harris fractures cannot occur in adults
 Pediatric Fractures
Damage to the epiphyseal plate during bone growth can destroy
all or part of its ability to produce new bone
This may result in an aborted or deformed bone growth of bone
The earlier a Salter-Harris fracture occurs, the more likely the
chance of a deformity will occur
Approximately 15% of growth plate fractures will have long term
bone growth disturbance
Fracture pattern is also a significant factor in the development of
deformity
Orthopedic Emergencies
Salter-Harris Classification
Salter-Harris Classification
 Initial Treatment - Splinting
Control pain and swelling
Reduce deformity/dislocations
Immobilization of fracture, sprain, or injury
 Splinting & Immobilization
Goals
– Relieve pain
– Augment healing
– Stabilize fracture
– Prevent further injury
 Splinting
Splinting and immobilization of fractures is the mainstay of
emergency orthopedics
Most fractures can be immobilized with a simple splint
Fracture type will dictate the splint required to immobilize it
Most splints used in the emergency department are either OCLTM
or Ortho-GlassTM
The goal of fracture immobilization is to protect the damaged
bone, while keeping it in anatomic position; this will facilitate
healing with no anatomic defect
There are numerous types of splints; however, one can modify a
splint to immobilize almost any fracture
 Splinting
Immobilization facilitates the healing process by decreasing pain
and protecting the extremity from further injury
Splinting maintains bony alignment
Splinting also reduces motion; by limiting early mobility, edema
can be reduced
Splints can be either plaster of Paris or fiberglass (OrthoGlassTM)
Plaster of Paris is the most widely used material for splinting in
the ED; however, the fiberglass splints are becoming
extremely popular, as they are easy to apply and less messy
 Splinting Advantages
Over Casting
Ease of application
Short-term immobilization
Allows continued swelling to prevent
complications
Patient removal
 Splinting Indications
Fractures
Deep laceration/large abrasions
Tendon lacerations
Inflammatory disorders (gout,
tenosynovitis)
Deep space infections (hand, feet, joints)
Multiple trauma
 Splinting
Which type of splint do you use?
Most upper extremity injuries can be managed using a long arm
posterior splint
Sugar tong, ulnar gutter and thumb spica are also used
Finger injuries can be managed with foam finger splints or hard
plastic splints
Shoulder injuries can be managed with a sling/swathe, or
shoulder immobilizer
Lower extremity injuries can be managed with a knee
immobilizer or posterior mold splint; ankle injuries can be
managed with preformed splints or posterior mold splint
 Principles of Splinting
Assess ABC's and treat life-threatening
situations first
Identify/assess neurovascular structures at
risk
Early orthopedic consultation for open
fractures or fracture-dislocations
Select appropriate immobilization technique
Document and dress open wounds
 Principles of Splinting (cont’d)
Remove all clothing and constrictive devices
from extremity (jewelry, rings)
Align severely angulated fracture
Protect bony prominence
Assess neurovascular status immediately
before and after splinting
If periodic wound care is required, consider
a removable splint
 Complications
Ischemia
Plaster burn
Pressure sores
Infection
Dermatitis
Joint stiffness
 Discharge Instructions
Elevation
Ice bags/cold packs
Allow setting of splint
Avoid getting splint wet
Clear follow-up instructions
Check for signs of vascular insufficiency
 Risk Management Issues
Always document neurovascular status before and
after splint application
Always document neurovascular status before
and after any fracture or joint reduction
Remove all rings on hands/toes before splint
application
Clearly document follow-up instructions:
– with whom
– when to see orthopedic physician
– when to return to the emergency department
 Fracture Pathophysiology

Fracture healing has 3 distinct phases:

1) Inflammatory
2) Reparative
3) Remodeling
 Fracture Pathophysiology

Inflammatory Phase
After the initial fracture, microvessels that cross the fracture line
are transected; this results in ischemia to the damaged bone
ends
Damaged bone ends necrose, which triggers an inflammatory
response
Inflammatory phase is brief, but creates the tissue environment
for the reparative phase
 Fracture Pathophysiology
Reparative Phase
The reparative phase begins with granulation tissue infiltrating
the fracture area
Granulation tissue contains cells that secrete and form collagen,
cartilage and bone; these form the callus, which eventually
surrounds the fractured ends of the bone
Callus is responsible for stabilizing the fractured bone ends
As the fracture heals, the callus becomes mineralized and very
dense
The necrotic edges of the fracture fragments are attacked by
osteoclasts, which resorb bone
 Fracture Pathophysiology

Remodeling Phase
Remodeling is the final phase of bone healing
The bone gradually regains its original shape, contour and
strength
Remodeling often lasts years
Callus is resorbed, new bone laid down by osteoblasts
The trabeculae, linear densities easily seen on normal bone, are
the end result of the physiologic process that remodels bone
and provides maximum strength in relation to the amount of
bone used
 Orthopedic Emergencies

Success of bone remodeling depends of several factors

Young children have greater capacity for remodeling compared
to adults
Magnitude and direction of unreduced angulation, and fracture
location on the bone
Youth
Proximity of fracture to end of bone
Direction of angulation when compared to the plane of natural
joint motion
Decisions regarding fracture reduction require knowledge of the
physiology of bone healing and its relation to patient age
 Joint Dislocations

Joint dislocation is defined as the displacement of the articular

surfaces of bones that normally meet at the joint
Joint subluxation, by comparison, is when the articular surfaces
are noncontiguous, to any degree. Dislocation is the most
extreme form of subluxation
Urgency of reducing dislocations is dependent of several criteria
Neurologic or circulatory compromise is the most important, as
the neurovascular bundle that lies in close proximity to the
affected joint may be compressed around the dislocation
 Joint Dislocations

Duration of dislocation is another consideration. It is generally

considered an axiom that “the longer a joint is dislocated, the
more difficult the reduction will be”
This is due to the tremendous amount of edema, muscle spasm
and soft tissue injuries that occur with the dislocation
The most urgent dislocation you will deal with in the ED is hip
dislocation. Prolonged dislocation of the femoral head puts the
patient at high-risk of developing avascular necrosis, or AVN,
of the femoral head
The blood supply to the femoral head is via vessels that emerge
from the acetabulum; when hip dislocation occurs, circulation
to the femoral head is disrupted
 Fracture Reduction/Joint Reduction
Remove jewelry, watches, rings, etc. when an extremity is
fractured. As swelling continues after the fracture, delayed
removal of these objects becomes almost impossible
Any patient who may be a candidate for surgery must be kept
NPO!
Fracture reduction/joint reduction can be performed in the
emergency department, after adequate control of pain and
swelling
Long-term goal is to restore normal anatomic position and
function
Reduction also alleviates acute pain, relieves blood vessel and
nerve tension, and may restore circulation to a pulseless
extremity
 Fracture Reduction/Joint Reduction

Fracture reduction/Joint reduction is a simple process

Once the patient’s pain has been controlled, consider adding a
sedative hypnotic prior to the reduction
Fracture reduction is performed by applying gentle but steady,
longitudinal traction to the shaft of the bone
Joint dislocation reductions are also performed in the emergency
department
Adequate pain control is essential prior to the procedure
Use of a rapid-acting sedative/hypnotic, such as Etomidate, will
produce a relaxed state and facilitate successful reduction
 Open Fractures

Open fracture is associated with communication between the

bone and external surface of the body
Can be as simple as a puncture wound that extends to the bone or
a large area of bone exposure
Grading system exists (Gustillo & Anderson grades I through III)
Osteomyelitis is the most feared complication of open fracture
Can produce long-term morbidity, chronic pain, deformity,
antibiotic therapy, and often amputation despite all medical
interventions
All open fractures require prompt treatment and orthopedic
consultation in the emergency department
 Open Fracture

Require admission (for most open fractures)

Surgical consultation
Tetanus prophylaxis
Pain Control
Clean/Irrigate wound
Antibiotics - IV
Keep NPO-Need operative irrigation and repair
Consider fracture reduction if delay in going to
operating room
Splint
 Compartment Syndromes
Pathophysiology
Increased tissue pressure in closed fascial,
non-expansile space compromises
circulation to muscles and nerves within
the space
Excessive pressure and edema leads to
ischemia, necrosis, and cellular death
Injuries which result may be permanent and
in extreme cases may necessitate
amputation
 Compartment Syndromes
Common Causes
Fractures
Circumferential casting
Soft tissue trauma
--contusions
-- crush injuries
-- prolonged compression injuries
Burns
Snake bites
Arterial occlusion or re-perfusion
 Compartment Syndromes

Disproportionate pain
Weakness
Pain with passive stretching of compartment
muscles
Hypesthesia or paresthesias of nerves
within the compartment
Normal pulses and capillary refill
 Compartment Syndromes
Findings (the 6 P’s)
Pain Parasthesias

Pallor Paralysis

Pulselessness Poikilothermic
 Compartment Syndromes
Diagnosis
Elevated compartment pressures
– Normal 0-8 mmHg
– Damage begins with pressures of 30-45
mmHg
– Measured with a catheter inserted into
the individual compartment in question
Compartment Syndrome Treatment

Surgical consultation and fasciotomy

Time is of the essence
—elevated compartmental pressures left
untreated for more than 8 hours result in a
permanent injury
 Orthopedic Emergency Pearls
Take a thorough history to help diagnose injury
Do a complete physical exam (1 joint above injury
and 1 joint below)
Reject poor quality x-rays
Only one x-ray view may miss a fracture
When doubt exists as to whether a fracture is
present—splint/immobilize, inform the patient of
the possibility of a fracture, and arrange a follow-
up examination
 Original Contribution

Theodore Gaeta DO FACOEP

David Lang DO FACOEP

THANK YOU!