20 Orthopedic Emergencies

ORTHOPEDIC EMERGENCIESORTHOPEDIC EMERGENCIES

JOE BEIRNE DO FACOEPANTHONY JENNINGS DO FACOEP

Orthopedic EmergenciesOrthopedic 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

HistoryHistory

Obtaining a thorough history of the mechanism of injury (MOI) may help identify the orthopedic injury

Past medical historyMedicationsDocument dominant hand (if applicable)Previous injuriesLast Meal?

Physical ExamPhysical ExamPhysical examination of orthopedic injuries in the

ED is based on a simple four step processPalpation of the injury for deformity and

tendernessAssess 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 Treatment

Sprains and Minor Injuries May Require:Ace wraps, splints, immobilizersCrutches, walkers, or wheelchairs Ice packsElevationPain control

TreatmentTreatmentInjuries less than 24 hours old should have ice packs or

cold packs applied prior to splint applicationCold therapy stiffens collagen and reduces the tendency

for ligaments and tendons to deformAlso 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 EvaluationED Evaluation

Appropriate radiographs based on H & PTreatment Consultation if neededDescribing radiographs to consultants

Open vs. Closed?Angulation?Impaction?

Describing RadiographsDescribing Radiographs

Type of fracture– Transverse, oblique, spiral, segmental,

comminutedPediatric: Salter-Harris, torus/buckle,

greenstickLocation of fractureDisplacement

– Shortening, angulation, rotation

Long Bone FracturesLong Bone Fractures

Divided into thirds– Proximal– Middle– Distal

Proximal- MiddleJunction

Middle-Distal Junction

Fracture DescriptionFracture Description

ComminutedObliqueTransverse Spiral Segmental

Describing FracturesDescribing Fractures

Displacement Angulation

Orthopedic EmergenciesOrthopedic EmergenciesPediatric FracturesPediatric 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 FracturesPediatric FracturesDamage 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 boneThe earlier a Salter-Harris fracture occurs, the more likely the

chance of a deformity will occurApproximately 15% of growth plate fractures will have long term

bone growth disturbanceFracture pattern is also a significant factor in the development of

deformity

SalterSalter--Harris ClassificationHarris Classification

Initial Treatment Initial Treatment -- SplintingSplinting

Control pain and swellingReduce deformity/dislocationsImmobilization of fracture, sprain, or injury

Splinting & ImmobilizationSplinting & Immobilization

Goals– Relieve pain– Augment healing – Stabilize fracture– Prevent further injury

SplintingSplinting

Splinting and immobilization of fractures is the mainstay of emergency orthopedics

Most fractures can be immobilized with a simple splintFracture type will dictate the splint required to immobilize itMost 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

SplintingSplinting

Immobilization facilitates the healing process by decreasing pain and protecting the extremity from further injury

Splinting maintains bony alignmentSplinting also reduces motion; by limiting early mobility, edema

can be reducedSplints 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 Splinting Advantages Over CastingOver Casting

Ease of applicationShort-term immobilization Allows continued swelling to prevent

complicationsPatient removal

Splinting IndicationsSplinting Indications

FracturesDeep laceration/large abrasions Tendon lacerationsInflammatory disorders (gout,

tenosynovitis)Deep space infections (hand, feet, joints)Multiple trauma

SplintingSplinting

Which type of splint do you use?Most upper extremity injuries can be managed using a long arm

posterior splintSugar tong, ulnar gutter and thumb spica are also usedFinger injuries can be managed with foam finger splints or hard

plastic splintsShoulder injuries can be managed with a sling/swathe, or

shoulder immobilizerLower 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 SplintingPrinciples 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 techniqueDocument and dress open wounds

Principles of Splinting (cont’d)Principles of Splinting (cont’d)

Remove all clothing and constrictive devices from extremity (jewelry, rings)

Align severely angulated fractureProtect bony prominenceAssess neurovascular status immediately

before and after splintingIf periodic wound care is required, consider

a removable splint

ComplicationsComplications

IschemiaPlaster burnPressure soresInfectionDermatitisJoint stiffness

Discharge InstructionsDischarge Instructions

ElevationIce bags/cold packsAllow setting of splintAvoid getting splint wetClear follow-up instructionsCheck for signs of vascular insufficiency

Risk Management IssuesRisk 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 Fracture PathophysiologyPathophysiology

Fracture healing has 3 distinct phases:1) Inflammatory2) Reparative3) Remodeling


Inflammatory PhaseAfter 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


Reparative PhaseThe reparative phase begins with granulation tissue infiltrating

the fracture areaGranulation 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 endsAs the fracture heals, the callus becomes mineralized and very

denseThe necrotic edges of the fracture fragments are attacked by

osteoclasts, which resorb bone


Remodeling PhaseRemodeling is the final phase of bone healingThe bone gradually regains its original shape, contour and

strengthRemodeling often lasts yearsCallus is resorbed, new bone laid down by osteoblastsThe 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


Success of bone remodeling depends of several factorsYoung children have greater capacity for remodeling compared

to adultsMagnitude and direction of unreduced angulation, and fracture

location on the boneYouthProximity of fracture to end of boneDirection of angulation when compared to the plane of natural

joint motionDecisions regarding fracture reduction require knowledge of the

physiology of bone healing and its relation to patient age

Joint DislocationsJoint 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 surfacesare noncontiguous, to any degree. Dislocation is the most extreme form of subluxation

Urgency of reducing dislocations is dependent of several criteriaNeurologic 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 DislocationsJoint 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 ReductionFracture 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 pulselessextremity

Fracture Reduction/Joint ReductionFracture Reduction/Joint Reduction

Fracture reduction/Joint reduction is a simple processOnce the patient’s pain has been controlled, consider adding a

sedative hypnotic prior to the reductionFracture reduction is performed by applying gentle but steady,

longitudinal traction to the shaft of the boneJoint dislocation reductions are also performed in the emergency

departmentAdequate pain control is essential prior to the procedureUse of a rapid-acting sedative/hypnotic, such as Etomidate, will

produce a relaxed state and facilitate successful reduction

Open FracturesOpen 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 ora large area of bone exposure

Grading system exists (Gustillo & Anderson grades I through III)Osteomyelitis is the most feared complication of open fractureCan 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 FractureOpen Fracture

Require admission (for most open fractures)Surgical consultationTetanus prophylaxisPain ControlClean/Irrigate woundAntibiotics - IVKeep NPO-Need operative irrigation and repair Consider fracture reduction if delay in going to

operating roomSplint

Compartment SyndromesCompartment SyndromesPathophysiologyPathophysiology

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 SyndromesCompartment SyndromesCommon CausesCommon Causes

FracturesCircumferential castingSoft tissue trauma

--contusions -- crush injuries-- prolonged compression injuries

BurnsSnake bitesArterial occlusion or re-perfusion

Compartment SyndromesCompartment Syndromes

Disproportionate painWeaknessPain with passive stretching of compartment

musclesHypesthesia or paresthesias of nerves

within the compartmentNormal pulses and capillary refill

Compartment SyndromesCompartment SyndromesFindings (the 6 P’s)Findings (the 6 P’s)

Pain

Pallor

Pulselessness

Parasthesias

Paralysis

Poikilothermic

Compartment SyndromesCompartment SyndromesDiagnosisDiagnosis

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 TreatmentCompartment Syndrome Treatment

Surgical consultation and fasciotomyTime is of the essence

—elevated compartmental pressures left untreated for more than 8 hours result in a permanent injury

Orthopedic Emergency PearlsOrthopedic Emergency Pearls

Take a thorough history to help diagnose injuryDo a complete physical exam (1 joint above injury

and 1 joint below)Reject poor quality x-raysOnly one x-ray view may miss a fractureWhen 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 ContributionOriginal Contribution

Theodore Gaeta DO FACOEPDavid Lang DO FACOEP

THANK YOU!

20 Orthopedic Emergencies

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