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Documenti di Professioni
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Orthopedic Emergencies
Open Fractures
Acute Compartment Syndrome
Neurovascular injuries
Dislocations
Septic Joints
Spinal cord injury
Open Fractures
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- Gustilo-Anderson Classification:
Type I:
Small wound (<1cm), usually clean, no soft tissue damage and no
skin crushing (i.e. a low energy fracture)
Type II:
Moderate wound (>1cm), minimal soft tissue damage or loss,
may have comminution of fracture (i.e. a low-moderate energy
fracture)
Type III:
Severe skin wound, extensive soft tissue damage (i.e. high energy
fracture)
Three grades: A – adequate soft tissue coverage, B – fracture
cover not possible without local/distant flaps, C – arterial injury
that needs to be repaired.
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 then
external prefered
Early definitive wound cover – split skin grafts, local/distant flaps
(involve plastics)
Open Fractures- Complications
Crush injury
Circumferential burns
Snake bites
Fractures – 75%
Tourniquets, constrictive
dressings/plasters
Haematoma – pt with
coagulopathy at increased risk
ACS- Findings
5 Ps of ischaemia Severe pain, “bursting”
Pain (out of proportion to sensation
injury) Pain with passive stretch
Paresthesias Tense compartment
Paralysis Tight, shiny skin
Pulselessness
Pallor
Ischemia
30 mm Hg
Elevated Pressure
10 mm Hg
Normal
0 mm Hg
ACS - Mangement
Early recognition
Muscle necrosis at delta
pressure < 30mm Hg
Irreversible injury 4-6 hrs
Remove cast, bandages and
dressings
Arrange urgent fasciotomy
Fasciotomy
ACS- Complications
Volkman ischaemic contractures
Permanent nerve damage
Limb ischaemia and amputation
Rhabdomyolysis and renal failure
Dislocation
s
Dislocations
Displacement of bones at a joint from their
normal position
Do xrays before and after reduction to look for
any associated fractures
Dislocation- Shoulder
Most common major joint dislocation
Anterior (95%) - Usually caused by fall on hand
Posterior (2-4%) – Electrocution/seizure
May be associated with:
Fracture dislocation
Rotator cuff tear
Neurovascular injury
Dislocation- Knee
Fracture
Humerus, femur
Dislocation
Elbow, knee
Direct/penetrating trauma
Thrombus
Direct Compression/
Acute Compartment Syndrome
Cast, unconscious
Common vascular injuries
Injury Vessel
1st 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
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 circulation
If no improvement then vessels must be explored by operation
If vascular injury suspected angiogram should be performed
immediately
Common nerve injuries
Injury Nerve
Shoulder 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
Clinical Features & Mx
Paraesthesia and weakness to supplied area
Closed 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 at
time of debridement/repair
Indications for early exploration:
Nerve injury associated with open fracture
Nerve injury in fracture that needs internal fixation
Presence of concomitant vascular injury
Nerve damage diagnosed after manipulation of fracture
Septic Joint
Septic Arthritis
Septic Joint/Septic Arthritis
Diagnosis by aspiration
Gram stain, microscopy, culture
Leucocytes >50 000/ml highly
suggestive of sepsis
Joint washout in theatre
IV Abx 4-7 days then orally for another 3 weeks
Analgesia
Splintage
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 ankylosing
Sepsis
Death
Spinal cord
injury
Outline
Goal of spine trauma care
Pre-hospital management
Clinical and neurologic assessment
Acute spinal cord injury
Term, type and clinical characteristic
Common cervical spine fracture and dislocation
Goal of spine trauma care
Protect further injury during evaluation and
management
Facilitate rehabilitation
Suspected Spinal Injury
High speed crash
Unconscious
Multiple injuries
Neurological deficit
Spinal pain/tenderness
Pre-hospital management
Protect spine at all times during the management of
patients with multiple injuries
“Log-rolling”
Pre-hospital management
Cervical spine immobilization
Neutral position
Philadelphia hard collar
Transportation of spinal cord-injured patients
Emergency Medical Systems (EMS)
Paramedical staff
Primary trauma center
Spinal injury center
Clinical assessment
Advance Trauma Life Support (ATLS) guidelines
Primary and secondary surveys
Adequate airway and ventilation are the most
important factors
Supplemental oxygenation
Early intubation is critical to limit secondary injury
from hypoxia
Physical examination
Information
Mechanism
energy, energy
Direction of Impact
Associated Injuries
Is the patient awake or
“unexaminable”?
What’s the difference ?
Awake
ask/answer question OW!
pain/tenderness
motor/sensory exam
Not awake
you can ask (but they won’t answer)
can’t assess tenderness
no motor/sensory exam
------
“Unexaminable”
≠
“No exam”
Physical examination
Inspection and palpation
Occiput to Coccyx
Soft tissue swelling and bruising
Point of spinal tenderness
Gap or Step-off
Spasm of associated muscles
Neurological assessment
Motor, sensation and reflexes
PR
Presentation
Flaccid paralysis distal to injury site
Loss of autonomic function
hypotension
vasodilatation
loss of bladder and bowel control
loss of thermoregulation
warm, pink, dry below injury site
bradycardia
Comparison of neurogenic and hypovolemic shock
Neurogenic Hypovolemic
Preserved
propioception and deep
touch
Brown-Sequard syndrome
Loss of contralateral
pain and temperature
Central cord syndrome
Weakness :
upper > lower
Sacral sparing
Radiographic imaging
Who needs an x- ray of the spine ?
YES
Able to actively rotate neck? UNABLE
• 45 degrees left and right
ABLE
No Radiography
National Emergency X
Radiography Utilization Study
(NEXUS)
&
The Canadian C-spine rule
Both have:
Excellent negative predictive value for excluding patients
identified as low risk
Clearance of Cervical Spine Injury in
Conscious, Symptomatic Patients
Plain films
AP, lateral and open mouth view
Optional: Oblique and Swimmer’s
CT
Better for occult fractures
MRI
Very good for spinal cord, soft tissue and ligamentous injuries
Adequacy, Alignment
Bone abnormality, Base of skull
Cartilage
Disc space
Soft tissue
Adequacy
• Malalignment of the
posterior vertebral bodies is
more significant than that
anteriorly, which may be
due to rotation
• A step-off of >3.5mm is
significant anywhere
Lateral Cervical Spine X-Ray
Disc Spaces
Should be uniform
Assess spaces between
the spinous processes
Soft tissue
Nasopharyngeal space (C1)
10 mm (adult)
Neurological status
neurological deficit decompression
Cauda Equina Syndrome
Compression of lumbosacral nerve roots below conus medullaris
secondary to large central herniated disc/extrinsic
mass/infection/trauma
Clinical Features