RCSI Royal College of Surgeons in Ireland Coliste Roga na Minle in

irinn

Title

Orthopaedic Emergencies

Class
Course
Title
Lecturer
Date

Intermediate Cycle 3
Musculoskeletal Education
Orthopaedic Emergencies
Dr Martin Kelly
06/01/2016

LEARNING OUTCOMES
At the end of this lecture the student should be able to:
1) Understand the basic approach to the Trauma patient
2) Understand and be able to recognise the main Spinal
Emergencies
3) Understand and be able to recognise the limb
threatening Orthopaedic Emergencies
4) Understand and appreciate how to diagnose and the
management of the main Orthopaedic pathologies
which present to the ED

TOPICS
1. Life threatening orthopaedics injuries with reference to the ATLS
Pelvic fractures

2. Spinal Emergencies
Spinal Trauma ATLS based
Cauda Equina Syndrome

3. Musculoskeletal/Limb threatening components of ATLS

Compartment syndrome
Open fractures
Traumatic Amputation

4. Common ED orthopaedic presentations with emphasis on radiology

Septic arthritis
Large joint dislocation
Fractures

ATLS
Everything in clinical medicine
resolves around/begins with
ABCDE
Sometimes the performance of
the primary survey isnt obvious
but its always there
Saying hello on the ward
round/OPD/ED

Everything else can be seen as

a secondary survey once life
threatening emergencies have
been managed
A structured
approach/awareness are key

WHO TO CALL ?
Not all fractures are
orthopaedic
May need help from:
Vascular surgeon
Neurosurgeon
General Surgeon

1. LIFE THREATENING ORTHOPAEDIC

INJURIES WITH REFERENCE TO THE
ATLS
NB Pelvic fractures

AIRWAY & BREATHING

Airway
Foreign body in mouth
Maxillofacial trauma
Neck trauma
Laryngeal trauma
Tracheobronchial tree
injury
Sternoclavicular joint

Breathing
Tension pneumothorax
Open pneumothorax
Flail chest
Pulmonary contusion
Massive haemothorax
Traumatic diaphragmatic
injury

CIRCULATION

Think Blood on the floor and 5

more
Blood on the floor
Chest
Abdomen
Retroperitoneum
Pelvis
Longbones

BLOOD ON THE FLOOR

Major arterial haemorrhage
Rarely missed
Can cause hypovolaemic shock
rapidly, especially in children

PELVIC TRAUMA
Pelvic fractures are of varying severity
Patients can bleed to death if the iliac vessels are torn.
Some fractures can destroy the hip joint.
Others are little more serious than a bad bruise (Simple pubic
ramus fractures)
They have a well deserved reputation for being missed

The pelvis is fractured in crushing injuries, and serious

fracture and unstable pelvis should be suspected
A pelvic x-ray is therefore mandatory in the assessment
of the acutely injured patient who has signs of
cardiovascular instability

PELVIC TRAUMA
Fractures and ligamentous disruption suggest major
force
Mechanism, usually car vs pedestrian, motor vehicle and
motorcycle crashes.
Significant association with injuries to intraperitoneal and
retroperitoneal viscera and vascular structures.

SOURCES OF BLOOD LOSS

Patients with haemorrhagic shock and an
unstable pelvis have 4 potential sources of
blood loss
1.
2.
3.
4.

Fractured bone surfaces

Pelvic venous plexus
Pelvic arterial injury
Extra pelvic sources

Significant increase of tears of thoracic aorta in those

with pelvic fractures, esp AP fractures
Blood on the floor and 5 more
Intra-abominal sources must be excluded or treated
operatively

MECHANISM OF INJURY/CLASSIFICATION
Patterns of force

AP compression 60-70%
Lateral compression 15-20%
Vertical shear 5-15%
Complex (or combination) pattern

ASSESSMENT
The flank, scrotum and perianal area should be
inspected quickly

blood at the urethral meatus

Laceration in the perineum, vagina, rectum or buttock which is
suggestive of an open pelvis fracture

Testing of mechanical instability is a controversial area, a

rapidly available x-ray may avoid the pain and potential
haemorrhage associated with manipulating the pelvis
First indication of mechanical instability is seen on
inspection for leg length discrepancy or rotational
deformity (usually external)

MANAGEMENT
ABC
Mechanical stabilization
Pelvic binder (or bed sheet!)

Internally rotates hip reduces pelvic volume

Surgery ORIF vs. external fixation

LONG BONE FRACTURES

Femoral fractures
High impact e.g. RTA
Up to 1500mls blood loss from shaft fracture
Thomas splint immobilisation

Humerus and tibia

Up to 750mls can be lost

CRUSH SYNDROME (TRAUMATIC

RHABDOMYOLYSIS)
Check renal function and creatinine kinase in patients
who have suffered crush injuries
Usually seen in patients trapped for long time periods
Needs ICU management with Renal physician consult

2. SPINAL EMERGENCIES

Spinal Trauma ATLS based

Cauda Equina Syndrome

DISABILITY-SPINAL TRAUMA
ABCDE
High Index of suspicion?
Examination
Awake vs Comatose

Imaging
Cervical
Thoraco lumbar

EXAMINATION CERVICAL SPINE NO PAIN

Awake
Alert
No neck pain or midline tenderness
Remove collar and palpate spine
Ask to move neck
When in doubt leave collar on!

EXAMINATION C SPINE PAIN PRESENT

Must exclude an injury
AP, Lateral and PEG ( Open mouth ) views
+/- CT imaging
Must see C1 to T1!

LATERAL C SPINE CONTOUR LINES

ASSESSING LATERAL FILM

Check the top of T1 can be seen

Trace the 3 contour lines

Check vertebral bodies

Check intervertebral disc spaces

Check soft tissues

LONG AP VIEW
Check spinous process
alignment
Facet joint dislocation

Check abnormal
widening of
interspinous distance

C1 FRACTURE

C1 FRACTURES
Burst (Jefferson)
Unstable
vertical compression force is transmitted through the occipital
condyles to lateral masses
Instability determined by transverse ligament involvement

Posterior arch
More stable
Potentially very dangerous

ANATOMY

C2 FRACTURES
Pedicle / Hangmans fracture (spinal canal is widened
and there is little risk for spinal cord injury)
Odontoid PEG fractures
Type 1 , 2 , 3

Anterior Wedge
Spinous process

C2 FRACTURES

ODONTOID PEG FRACTURE TYPE 2

THORACO LUMBAR SPINE

Compression fractures Wedge, or anterior,
account for 50 70 % of all TL fractures
Generally stable
One column usually affected

Burst fractures
approximately 15 % of all TL injuries
Unstable
>1 column effected

Flexion-distraction (lap belt) injuries

10 % of all TL spinal column injuries

THORACO-LUMBAR SPINE 3 COLUMN

THEORY
Instability if 2 out of 3 disrupted

ANTERIOR WEDGE VS BURST FRACTURE

DONT FORGET THIS !

Spinal haematoma
Intradural or epidural
Young people trauma
Elderly on warfarin
vulnerable after mild
trauma

CAUDA EQUINA SYNDROME

Compression of some or all of the nerve roots of the
cauda equina, resulting in symptoms that include bowel
and bladder dysfunction, saddle anesthesia, and varying
degrees of loss of lower extremity sensory and motor
function

PRESENTATION
Symptoms
low back pain
groin and perineal pain
bilateral sciatica
loss of bowel or bladder**
function.
Subtle hesitancy
Eventually overflow
incontinence

Signs
lower extremity weakness
Hypoflexia or areflexia,
Perineal hypoesthesia or
saddle anesthesia to
Pinprick

EMERGENCY !
MRI useful but dont delay
Early surgery to avoid
Bladder / Bowel incontinence
Lower limb weakness

Low threshold for admission

Counsel patients in back pain clinics

FURTHER READING CES

J Am Acad Orthop Surg. 2008 Aug
Cauda equina syndrome.Spector LR,

3. MUSCULOSKELETAL/LIMB
THREATENING COMPONENTS TO
ATLS
NB compartment syndrome

COMPARTMENT SYNDROME
Definition
Elevation of tissue pressure within a myofascial compartment
that exceeds capillary pressure and compromises its perfusion
and tissue function

Lower leg most common

Can occur in arm, forearm, hand, thigh, foot, gluteal
area.

CAUSES
Compartment
contents

Blood
Fracture or
soft tissue
Muscle
Ischaemic

External
compression

Constricting cast / dressing

Burns (Full thickness)

Sutures closing fascia

SIGNS

Paraesthesia / Numbness later

Pain on Passive movement of distal joints
Disproportional generalised pain in limb
Tense on palpation Not a sensitive sign
Pulse absent VERY LATE SIGN
Not the same as pain, pulseless, pale, paraesthesia

MANAGEMENT
Call help early if suspected
Remove cast / Dressing
Re examine

Keep patient NPO

Check CPK ( after above done )
Decompressive fasciotomy

OPEN FRACTURES & JOINT INJURIES

Communication between external environment & bone
Muscle and skin injured and bacterial contamination
Prone to
Infection
Poor healing
Poor function

OPEN FRACTURES & JOINT INJURIES

Fracture and open wound in same limb segment is an
open fracture until proven otherwise
Gustilo-Anderson classification
Paramedic documentation very important
If adequate no further inspection of wound
If inadequate wound inspected under as sterile conditions as
possible
Never probe the wound

Open wounds near a joint

Assume that this wound enters the joint
Urgent surgical consultation +/- surgical exploration

OPEN FRACTURES & JOINT INJURIES

Management
Make diagnosis promptly
Immobilise fracture
Describe wound accurately and associated soft
tissue injury
Neurovascular involvement

Prompt surgical consultation

Tetanus prophylaxis
Antibiotics based on mechanism , consult
microbiology (cephalosporin)
Operative debridement and fracture
stabilization

TRAUMATIC AMPUTATION
Severe form of open fracture that results in the loss of an
extremity
Tourniquet may be useful
Prolonged ischaemia, neurologic injury and muscle
damage may require amputation
Life over limb !

REPLANTATION
Possibility for replantation should be considered
Clean sharp amputations
of fingers
below knee or elbow

A patient with multiple injuries who requires

intensive resuscitation and emergency surgery is
not a candidate for replantation.

AMPUTATED PART

Wash in ringers lactate

Soak in aqueous penicillin
Wrap in moisted sterile towel
Placed in plastic bag
Placed in cooling chest with crushed ice
Transported with patient to replantation centre
Careful not to freeze

4. COMMON ED ORTHOPAEDIC
PRESENTATIONS
NB Septic arthritis
NB Large joint dislocation

SEPTIC ARTHRITIS
Usually refers to bacterial infection of a joint
Can be fungal , viral

Adult vs Paediatric

ADULT SEPTIC ARTHRITIS

Emergency with mortality of 10 - 15%
Predisposing factors

Intra-articular corticosteroid injection

Age > 80 years
Diabetes mellitus
Rheumatoid arthritis
Prosthetic joint / Recent joint surgery
Skin infection, cutaneous ulcers
IV drug abuse

MICROBIOLOGY
Staphylococcus aureus

Healthy adults, skin breakdown, previously damaged joint (eg,

rheumatoid arthritis), prosthetic joint

Streptococcal species

Healthy adults, splenic dysfunction

Neisseria gonorrhea

Healthy adults (particularly young, sexually active) negative

synovial fluid culture and gram stain

Gram negative bacteria , Mycobacteria, Fungal species

Immune compromised hosts

ADULT SEPTIC ARTHRITIS

Source of infection
Osteomyelitis
Direct infection from a penetrating wound
Haematogenous Bacteraemia / IVDU

It is more likely to localize in a joint with preexisting

arthritis.
Usually monoarticular but can be polyarticular especially
in Rheumatoid arthritis

PRESENTATION : ADULT SEPTIC

ARTHRITIS
Most common joint involved is knee
Also Hip, ankle, shoulder, wrist are common sites
Monoarticular arthritis
Remember Differential diagnosis
Hot swollen joint
Pain with passive and active movement
Diabetic patients can present atypically and they are at
increased risk of infection

An unexplained joint effusion in a diabetic should raise suspicion

of septic arthritis

DIFFERENTIAL MONOARTHRITIS
Infection
Crystal induced
Haemarthrosis
Trauma

Neoplastic
Inflammatory

INVESTIGATIONS
Joint aspiration and fluid analysis

US guidance if necessary
WCC & differential normal less 180/mm3
Gram stain and culture
Light microscopy for crystals in gout and pseudogout
Purulent fluid and/or positive gram stain indicates bacterial infection

Bloods
FBC, ESR, CRP, Blood Cultures

Xrays of infected joint

Not useful in diagnosis as only become abnormal when joint
destruction has occurred, useful as a baseline for later comparison

Swab
Of urethra, cervix and anorectum if gonococcal infection a possibility

TREATMENT

Antibiotics for 6/52, initially 2/52 i.v.

Treatment depends on organism concerned but a suitable

blind/empirical regime would be flucloxacillin 1-2g QDS iv.
(Erythromycin if penicillin allergic) +/- oral fusidic acid 500mg TDS

Modify based on C&S results

Local microbiology guidelines

It is widely accepted by orthopaedic surgeons that antibiotics

should be withheld until aspiration has been performed to
increase the odds of identifying an organism.

THERE IS A SIGNIFICANT HIGH FALSE

NEGATIVE RATE ASSOCIATED WITH KNEE
ASPIRATION WITH PRIOR ADMINISTRATION
OF ANTIBIOTIC THERAPY.

PAEDIATRIC SEPTIC ARTHRITIS

Consider in any child with
acute onset fever and
painful joint

PAEDIATRIC SEPTIC ARTHRITIS

Often presents as limp, refusal to weight bear
Evaluate with history and physical examination,
laboratory studies, including synovial fluid analysis, and
imaging studies as in adult
Kochers Criteria (score 1-4) Score 4 = 99% septic
arthritis

Non-weight-bearing on affected side

Erythrocyte sedimentation rate > 40
Fever > 38.5 C
White blood cell count > 12,000

SUFE: SLIPPED UPPER FEMORAL

EPIPHYSES
Characterised by:
- displacement of the capital femoral epiphysis from
the femoral neck through the physeal plate
Presenting Feature
- Hip Pain
- Gait Disturbance
- 15% present with isolated thigh/knee pain
Mean Age of Presentation:
- F:12yrs
M:13.5yrs

SUFE: SLIPPED UPPER FEMORAL

EPIPHYSES
Pathogenesis:
- occurs when shearing forces applied to the femoral
head exceed the strength of the capital femoral
physis
Predisposing Factors:
- Obesity
- Trauma
- Genetic Predisposition
- Normal periosteal thinning and widening of the physis
(Occurs during rapid growth)
- Endocrine & Metabolic disorders
(Hypothyroidism, Growth Hormone deficiency)

SUFE: SLIPPED UPPER FEMORAL

EPIPHYSES
Management:
- Referral to Orthopaedic Surgeons
- Non-Weightbearing
- Operative Stabilisation (single cannulated screw
placed in the centre of the epiphysis)

Questions?