Orthopedic Emergencies
Dr. Alex, MD.
Introduction
Bone:
◦ composed of the hardest variety of connective tissue.
◦ Shape and support to the body.
◦ Protecting vital organs
◦ Attachment for the muscles of the limbs, and
movement.
Tendon:
◦ Structure connecting muscle to bone, cartilage, or
ligaments.
◦ Enable muscles to effect motion in the joint or body
area to which they are attached.
Joint:
◦ Two or more bones articulate with one another.
◦ Most joints of the extremities are synovial joints,
which allow the greatest amount of motion.
Ligament:
◦ bundle of connective tissue forming capsule
surrounding a joint and attached to it.
◦ Purpose is to stabilize the joint by confining its
movements to specific planes.
◦ Preventing movement beyond physiologic limits.
Fracture:
◦ A disruption of bone tissue.
◦ Caused by:
Application of force exceeding the strength of the bone
Repetitive stress
Invasive process that undermines the bone’s integrity.
Dislocation:
◦ Complete disruption of a joint.
Subluxation:
◦ Partial disruption of a joint.
Strain:
◦ A tearing injury to muscle fibers
◦ Due to excessive tension or overuse.
Sprain:
◦ tearing injury to one or more ligaments of a joint
◦ Occurs when the joint is forced beyond the limits of
its normal planes of motion.
Classification
Pathological classification
◦ “Common” Fractures
Most fractures are the result of significant external
forces
◦ Pathologic Fractures
◦ Stress Fractures
“fatigue” fracture by being subjected to repetitive
forces.
◦ Salter (Epiphyseal Plate) Fractures
Those involving the physis, cartilaginous epiphyseal
plate of the long bones of growing children.
Orientation of Fracture Line
◦ Transverse
◦ Oblique
◦ Spiral
◦ Comminuted
◦ Segmental
◦ Torus
◦ Greenstick
Open Vs Closed fracture:
◦ Open wound with exposure of bone to out side
enviroment.
Orthopedic Emergencies
I. Open Fracture
◦ classified by their severity, based on the
extent of overlying tissue disruption
lack of bone coverage
kinetic energy of the injuring force
evidence or likelihood of significant contamination.
◦ Irrespective of these factors, any open fracture
should be promptly and carefully treated.
◦ High risk for osteomyelitis and soft tissue
infection
II. Subluxation and Dislocation
◦ The neurovascular bundle passing close to the
affected joint may become “kinked” around the
dislocation.
◦ Result in neurologic or vascular deficit
◦ irreversible if treatment is delayed.
◦ Also Reduction difficulty due to muscle spasm.
Anterior Dislocation Presentation
Posterior Dislocation Presentation
Inferior Dislocation Presentation
III. Neuro-Vascular Injury
◦ Should be addressed as soon as possible.
◦ The longer such a deficit goes untreated, the longer
it is likely to persist and the greater the possibility
that it will be irreversible.
◦ reducing a deformity by means of longitudinal
traction is all that is necessary to restore circulation
or nerve function.
IV. Acute Compartment syndrome
V. Septic Arthritis
VI. Pelvic Fracture
Clinical Features
History
value of the history in cases of orthopedic trauma is often
underestimated.
Knowing the precise mechanism of injury may be the key
to diagnosis.
Some musculoskeletal injuries may not necessarily be
associated with a history of direct trauma. E.g.,
osteoporotic patients
History taking should not necessarily be limited to
orthopedic issues.
Physical Examination
Components
◦ Inspection for swelling, discoloration, or deformity
◦ Assessment of active and passive range of motion of
the joints proximal and distal to the injury
◦ palpation for tenderness or deformity
◦ assessment of neurovascular status.
The sooner circulatory compromise is identified and
addressed, the better the chance of avoiding tissue
ischemia or necrosis.
Diagnosis
Imaging
◦ joints above and below a fracture should be imaged
with long bone fractures
◦ X rays are the immediate modalities that should be
utilized in the ED.
◦ Images are usually taken AP, Lateral and oblique
◦ Some require special views or other modalities of
study.
Injuries that require special views.
◦ acromioclavicular
separation
◦ fracture of the scaphoid
◦ posterior shoulder dislocation
◦ sternoclavicular dislocation
Children with trauma at or near a joint need
comparison studies of the opposite extremity.
Particularly true of the pediatric elbow, which
typically exhibits six ossification centers
sequentially as the child grows.
First Negative radiologic report does not exclude
significant injury.
◦ Fracture of the radial head,
◦ Scaphoid
◦ Lunate
◦ Hamate
◦ Metatarsal shaft
Describing radiological findings
◦ Closed vs Open
◦ Location: midshaft, proximal, distal or anatomic
reference points such as condylar, trochanteric and
such.
◦ Orientation of fracture lines
◦ Displacement : amount and direction
◦ Separation: distance and percentage
◦ Shortening
◦ Angulation: degree and direction
◦ Rotational deformity
◦ Involvement of articular surface
Salter Harris classifications
◦ Classifies fractures involving the epiphyseal plate at
the end of the long bone of a growing child.
◦ There are five classification based on the
involvement of epiphysis and metaphysis.
Salter Type Whats broken off?
I Entire Epiphysis
II Entire Epiphysis with portion of
metaphysis
III Portion of epiphysis
IV Portion of epiphysis with
metaphysis
V Compression Injury
Pearls of Imaging
◦ The pain of a fracture or a dislocation may be
referred to another area.
◦ Imaging decisions should be based on the findings
of components of physical exam.
◦ Some injuries might not be radiographically
apparent on the first day, regardless of what views
are taken.
Management
Control pain and swelling
◦ the application of cold and elevation are often quite
effective
◦ Jewelry, watches, or rings that may cause
compression or constriction as an extremity swells
should be removed.
◦ Give analgesics as necessary
Reduce Fracture Deformity
◦ short-term benefits to reducing deformity
early:
alleviating pain
relieving the tension on nerves or vessels
eliminating or significantly minimizing converting a closed fracture to
an open one when the skin is tented by a sharp bony fragment
restoring circulation to a pulseless distal extremity.
◦ After appropriately sedateding, deformity at or near
the midshaft of a long bone is usually reduced with gradual,
steady, longitudinal traction.
◦ Any rotational deformity should be corrected only after the
angular component has been addressed and should be
performed while traction is maintained.
Reduce Dislocations
◦ prereduction radiographs are advisable when there
has been significant trauma and circulation is not
threatened.
◦ postreduction radiographs are valuable
for confirming the success of the procedure
Initial management of open fracture
◦ tetanus prophylaxis
◦ Irrigation and debridement
◦ Antibiotics
Choices of antibiotics
◦ 1st generation cephalosporin plus aminoglycoside if
wound >10cm and loss of bone coverage
◦ Add penicillin or metronidazole when there are soil
and other contaminants
Orthopedic consultations in the ED
◦ Compartment syndrome
◦ Irreducible Dislocations
◦ Circulatory compromise
◦ Open fractures
◦ Injuries requiring surgical intervention or open
reduction.
Principles of splinting
◦ Plaster of Paris (calcium sulfate) is commonly used
◦ Chemical reaction when in contact with water sets the plaster
◦ Its exothermic reaction and the higher the water temperature the
faster it hardens.
◦ To avoid irritation and pressure sore several layer of padding should
be over the skin.
◦ splint should be long enough to provide the leverage needed to
immobilize the injured joint.
◦ If the fracture is along the midportion of a distal extremity (i.e., the
forearm or the lower leg) the splint should be long enough to
immobilize the joint above and the joint below the fracture.
Types of immobilization dressings
Complications
Early
◦ Neurologic injury
◦ Vascular injury
◦ Compartment syndrome
Delayed
◦ Pulmonary Fat Embolus (few days)
◦ Fracture nonunion, malunion and joint stiffness
◦ Avascular necrosis
◦ osteomyelitis
◦ DVT and PTE
References
Tintinallis Emergency Medicine a
comprehensive study guide 8th edn.
Tintinallis EM just the facts
Up-to-date 21.1
