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Ward-Clinic-OR-Emg
Morning visits (Monday & Thursday) at 6
a.m
Morning report everyday
Grand Round (Tuesday)
In Emergency Room
Introduction
Orthopaedics is
concerned with bones,
joints, muscles, tendons
and nerves the
skeletal system and all
that makes it move
Introduction
Scope :
Tumours
Subdivision :
Traumatology
Orthopaedi :
1. Adult Reconstruction
2. Oncology Orthopaedic
3. Pediatric Orthopaedic
4. Spine
5. Hand & Microsurgery
6. Sports Injury
Introduction
Steps in orthopaedic diagnosis:
1. History taking
2. Physical Examination
* Posture
* Gait
1. Inspection
2. Palpation
3. Examination of movements
4. Conduction of special tests
3. Further investigations
1. Examination of radiographs
2. Examination of blood, sinovial fluid, etc
Inspection
Is there swelling?
Is there bruising?
Is there any discoloration, or edema?
Is there muscle wasting?
Is there any alteration in shape or posture,
or is there evidence of shortening?
Inspection
Palpation
Is the joint warm?
Is there tenderness?
How is the artery
pulse?
Movements
Active ROM
Passive ROM
Fixed deformities
Restriction of ROM
Movements in abnormal plane
Crepitus
Strength of muscle contraction
Gait
Movements
Examination of Radiographs
Soft tissue
Bone : shape, size, contour
Alignment
Examination of Radiographs
Comparison films
Oblique projections
Localized views
Stress films
ESR, CRP
Full blood count with differential
Estimation of RF
Serum calcium, phosphate & AP
Serum Uric Acid
Chest X-Ray
Equipment Requirements
A tape measure
A goniometer
A tendon hammer
A disposable sharp point
WHAT IS POLYTRAUMA ?
Objectives
Establish the principles for assessing the
patient with musculoskeletal injuries.
Establish treatment priorities.
Identify the importance of musculoskeletal
injuries in the multiply injured patient.
Emergency in Orthopaedic
Emergency : trauma cases
- Life threatening
- Limb treatening
85 % of blunt trauma affect
musculoskeletal system
Life saving before limb
saving
Key Questions
How do musculoskeletal injuries
impact on the primary survey?
What are my priorities?
What are my management principles?
Secondary Survey
History
AMPLE
Secondary Survey
Look
Feel
Listen
For What?
For What?
Feel
Crepitus
Skin flaps
Neurologic
deficit
Pulses
Look
Deformity
Pain
Tenderness
Wound(s)
Listen
Doppler signals
Bruit
Life Threatening
Musculoskeletal Trauma
Pelvic Trauma with Massive Bleeding
Posterior pelvic structures disrupted
Pelvis open : vessels, nerves,rectum, skin
Mechanism of injury
Motorcycle
Pedestrian
Crush
Falls > 12 feet (3.6 meters)
Life Threatening
Musculoskeletal Trauma
Pelvic Trauma with Massive Bleeding
Life Threatening
Musculoskeletal Trauma
Pelvic Trauma with Massive Bleeding
Pelvic
Wrapping
Life Threatening
Musculoskeletal Trauma
Main Arterial Rupture
1.
2
3.
Trauma
- sharp, blunt
Examination
- Artery pulse, Doppler
- Ankle / brachial index
Management
- Pneumatic tourniquet
- Vascular clamp?
- Traction, Splint
Life Threatening
Musculoskeletal Trauma
Crush Syndrome
Myoglobinuria
Metabolic acidosis, K,
Ca and coagulopathy
Compartment syndrome
IV fluids, alkalization of
urine
Limb Threatening
Musculoskeletal Trauma
Open Fractures
Limb Threatening
Musculoskeletal Trauma
Open Fractures
Classifying the injury
Gustilos classification (Gustilo et al, 1990)
Open Fracture
grade 3C
Limb Threatening
Musculoskeletal Trauma
Open Fractures
Principles of treatment
Objectives :
- Prevention of infection
(sepsis/osteomyelitis)
- Promote bone healing
- Restoration of function
Limb Threatening
Musculoskeletal Trauma
Open
Fractures
Principles
of treatment
4 essentials are :
1. Wound irrigation & debridement
2. Antibiotic prophylaxis
3. Stabilization of the fractures
4. Early wound coverage
Open Fracture
Complicated
case
Not
proper initial management
Limb Threatening
Musculoskeletal Trauma
Vascular Trauma & Traumatic Amputation
Reduce fracture(s)
Splint fracture(s)
Assess by Doppler
Obtain consult (time
is critical)
Consider
angiography
Limb Threatening
Musculoskeletal Trauma
Compartement Syndrome
Limb Threatening
Musculoskeletal Trauma
Compartement Syndrome
Clinical features
Elbow, forearm bones, 1/3 prox.
of tibiae, multiple fractures of
the foot or hand, crush injuries
& circumferential burns
Five Ps
The presence of a pulse does
not exclude the diagnosis
Be careful in unconscious
patient !
Limb Threatening
Musculoskeletal Trauma
Compartement Syndrome
Treatment
Decompression
Open fasciotomi
Limb Threatening
Musculoskeletal Trauma
Dislocations
Displacement of bone from normal joint
Location : hip, shoulder, elbow, finger, patella,
knee, ankle, acromioclavicular
Sign : loss of normal shape &
loss of movement
Neurologic Injury
Limb Threatening
Musculoskeletal Trauma
Massive skin avulsion
Kelirumologi in Fracture
Management
Pitfalls
Occult injuries
Occult blood loss
Compartment syndrome
Question
Summary
Objectives
Evaluate for suspected spinal injury.
Appropriately manage spinal injury.
Determine appropriate patient disposition.
High-Speed Crash
Unconscious patient
Multiple injuries
Neurologic deficit
Spinal pain / tenderness
Spinal Injury
Sensory Examination
Cervical
C-5 Deltoid
C-6 Thumb
C-7 Middle
finger
C-8 Little finger
Thoracic
Lumbosacral
T-4 Nipple
T-8 Xiphoid
T-10 Umbilicus
T-12
Symphysis
Motor Examination
Cervical / Thoracic
C-5
C-6
C-7
C-8
T-1
Shoulder abduction
Wrist Extension
Elbow extension
Middle finger flexion
Little finger
abduction
Lumbosacral
L-2
L-3
L-4
L-5
S-1
Hip flexion
Knee extension
Ankle dorsiflexion
Big toe extension
Big toe / ankle
plantar flexion
Neurologic Assessment
Neurogenic Shock
Bradycardia
Neurologic Assessment
Spinal Shock
Flaccidity
Loss of reflexes
Neurologic Assessment
Effect on Other Organ Systems
Inadequate ventilation
Classifications of injury
Levels of injury
Clinical exam
Most caudal
Normal bilaterally
Motor / sensory function
Classification of Injury
Incomplete
Any sensation
Position sense
Voluntary
movement in
lower extremity
Sacral sparing
Complete
No motor /
sensory function
No sacral sparing
May have
reflexes
Classifications of Injury
Spinal Cord Syndromes
Central cord
Anterior cord
Brown Sequard
Posterior cord
Conus medullaris
Cauda equina
Classification of Injury
Morphology
Penetrating
Classification of Injury
Morphology
Consider unstable if :
X-ray evidence of injury
Neurologic deficit
Severe pain on spine movement or
palpation
X-ray Guidelines
Adequacy
Alignment
Bony abnormality
Base of skull
Cartilage , Contours
Disc space
Soft tissue
C-spine x-rays
C Spine X-rays
Identify bony
fracture subluxation
Early
orthopaedic consult
No further spine
evaluation or c-spine
x-ray necessary
Remove C-colar
If yes to any
question
Protect c-spine
Obtain
necessary
x-ray exams
Plain films
Drugs,alcohol
distracting
injuries may mask an
injury
Management
Immobilization
Entire Patient
Proper padding
Avoid prolonged
use of backboard!
Medical Management
Medical Management
Intravenous Fluids
Medical Management
Steroids
IV Methylprednisolone
Proven spinal cord injury
Start within 1st 8 hours from injury only
30 mg/kg over 15 minutes
5.4 mg/kg over next 23 hours (if < 3 h)
5.4 mg/kg over next 47 hours (if 3-8 h)
Proven in blunt trauma only
Medical Management
Transfer
Unstable fractures
Neurologic deficit
Avoid delay
Properly Immobilized
Male, 27 y.o
MVA victim
Referred to RSHS from Cikampek
Hospital without cervical
protection.
He was unable to move his lower
leg & upper extremity
Questions
Summary