Triage and Emergency Orthopaedics PDF

Triage dan Kondisi Kegawatdaruratan Muskuloskeletal  TRIAGE Di UGD, sistem triase gawat darurat medis → pasien mana yang harus ditangani dahulu Konsep ≈ immediate, priority, non-urgent  Sistem triase ,kode warna 1. Merah: ≠ penanganan dengan cepat → meninggal, sy...

Triage dan Kondisi Kegawatdaruratan Muskuloskeletal  TRIAGE Di UGD, sistem triase gawat darurat medis → pasien mana yang harus ditangani dahulu Konsep ≈ immediate, priority, non-urgent  Sistem triase ,kode warna 1. Merah: ≠ penanganan dengan cepat → meninggal, syarat pasien tersebut masih memiliki kemungkinan untuk dapat hidup ( mis. pasien dengan gangguan pernapasan, trauma kepala dengan ukuran pupil anisokor,perdarahan hebat) 2. Kuning: perawatan segera ≈ ditunda (kondisi stabil). Pasien masih memerlukan perawatan di rumah sakit. (mis. pasien multiple fraktur, trauma kepala) 3. Hijau: perawatan masih dapat ditunda. Biasanya pasien cedera yang masih sadar dan bisa berjalan masuk. Ketika pasien lain yang dalam keadaan gawat sudah selesai ditangani, maka pasien kode hijau akan ditangani (mis. pasien fraktur ringan, luka bakar minimal, luka ringan 4. Putih : pasien cedera minimal, tidak perlu dokter 5. Hitam : pasien ≠ Tanda kehidupan, mengalami cedera amat parah, minimal hidup walau ditangani  Triase adalah tingkatan klasifikasi pasien berdasarkan : Penyakit Keparahan Prognosis Ketersediaan sumber daya E S I m e n e v d e r e g r x e i n t c y y Orthopaedic Emergencies  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), 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 Wound infection Osteomyelitis – staph aureus, pseudomona sp. Gas gangrene Tetanus Non-union/malunion  Acute Compartment Syndrome An injury or condition that causes prolonged elevation of interstitial tissue pressures Increased pressure within enclosed → leads to impaired tissue perfusion Prolonged ischemia causes cell damage which leads to oedema → further increase compartment pressure leading to a vicious cycle Extensive muscle and nerve death > 4 hours Nerve may regenerate but infarcted muscle is replaced by fibrous tissue (Volkmann’s ischaemic contracture) ACS- Etiology 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 sensation to injury) Pain with passive stretch Paresthesias Tense compartment Paralysis Tight, shiny skin Pulselessness Pallor Can confirm diagnosis by measuring intracompartmental pressures (Stryker STIC)  120 mm Hg Difference between diastolic pressure and compartment pressure (delta pressure)< Pulse Pressure 30mmHg is indication for immediate decompression 60 mm Hg Ischemia 30 mm Hg Elevated Pressure 10 mm Hg Normal 0 mm Hg  ACS - Management 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  Dislocations Displacement of bones at a joint from their normal position Do x rays 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 Injury to popliteal artery and vein is common Peroneal nerve injury in 20-40% of knee dislocations Associated with ligamentous injury Anterior (31%) Posterior (25%) Lateral (13%) Medial (3%)  Dislocation- Hip Usually high-energy trauma More frequent in young patients Posterior- hip in internal rotation, most common Anterior- hip in external rotation Central - acetabular fracture May result in avascular necrosis of femoral head Sciatic nerve injury in 10-35%  Neurovascular Injuries Fractures and dislocations can be associated with vascular and nerve damage Always check neurovascular status before and after reduction Neurovascular Injuries - Etiology 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. 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 Inflammation of a synovial membrane with purulent effusion into the joint capsule. Followed by articular cartilage erosion by bacterial and cellular enzymes. Usually monoarticular Usually bacterial Staph aureus Streptococcus Neisseria gonorrhoeae Septic Joint Arthritis- Etiology Direct invasion through penetrating wound, intra-articular injection, arthroscopy Direct spread from adjacent bone abcess Blood spread from distant site  Septic Joint- Location Knee- 40-50% Hip- 20-25%* *Hip is the most common in infants and very young children Wrist- 10% Shoulder, ankle, elbow- 10-15% Septic Joint- Risk Factors Prosthetic joint Joint surgery Rheumatoid arthritis Elderly Diabetes Mellitus IV drug use Immunosupression AIDS Septic Joint- Signs and Symptoms Rapid onset Joint pain Joint swelling Joint warmth Joint erythema Decreased range of motion Pain with active and passive ROM Fever, raised WCC/CRP, positive blood cultures  Septic Joint- Treatment 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  Cauda Equina Syndrome Compression of lumbosacral nerve roots below conus medullaris secondary (e.c. large central herniated disc/extrinsic mass/infection/trauma)  FEATURES OF CAUDA EQUINA SYNDROME Bladder and bowel incontinence Perineal numbness Bilateral sciatica Lower limb weakness Crossed straight-leg raising sign Note: Scan urgently and operate urgently if a large central disc is revealed.  Management Surgical emergency - requires urgent investigation and decompression (