Trauma/Fracture Management & Orthopaedic Emergencies (PDF)

TRAUMA/FRACTURE MANAGEMENT & ORTHOPAEDIC EMERGENCIES DR. EMILY CRILLY LEARNING OBJECTIVES 1. Basic principles of fracture management. 2. Explain the stages of fracture healing. 3. Describe how to examine a fracture and the appropriate radiology. 4. Understanding infect...

TRAUMA/FRACTURE MANAGEMENT & ORTHOPAEDIC EMERGENCIES DR. EMILY CRILLY LEARNING OBJECTIVES 1. Basic principles of fracture management. 2. Explain the stages of fracture healing. 3. Describe how to examine a fracture and the appropriate radiology. 4. Understanding infection in orthopaedics. 5. Outline of limb threatening conditions. 6. Outline of spine emergencies.  Types of Fractures BASICS OF FRACTURE MANAGEMENT 00 A fracture is a break or interruption in the continuity of a bone far Displaced v Undisplaced D Closed v Open (Compound) Simple v Comminuted E May be pathological - weakened by disease Greenstick Fracture - immature bone. Cortex bends rather than breaks Mostly in children bone bends and cracks on  one S BASICS OF FRACTURE MANAGEMENT AdvancedTrauma LifeSupport 0 0 Follow ATLS guidelines ABCD- Treat life threatening injuries first! Always check neurovascular status before and after interventions Management Fracture dislocations need to be reduced ASAP Open wounds will need cleaning and IV antibiotics 1 ABCD Open wounds will need a tetanus Neurosies Reduction promotes healing and reduces pain 3 Reduction woundTreatment 4 Provide Good Analgesia 5 Analgesia Unstable fractures/poorly reduced fractures nearly always require 6 surgery operative intervention v only when needed  Resititate PRINCIPLES OF FRACTURE TREATMENT nEii ation mW – ATLS, manage life threatening injuries first 1. Resusitate 2. Reduce – anatomical realignment of fracture 3. Immobilise – maintain reduction (cast/splints/surgery) 4. Rehabilitate – mobilise, exercise, etc. METHODS OF IMMOBILISATION  STAGES OF FRACTURE HEALING tart Ever Tissue destruction and haematoma formation (immediate) Inflammation and cellular proliferation (acute) Callus formation (few days to weeks) Consolidation (few weeks to months) E Remodelling (months up to more than 1 year) Ed FACTORS ADVERSELY AFFECTING FRACTURE HEALING I Degree of the local tramm Degree of local trauma Inadequate reduction and immobilization Infection 0 Location of fracture Disturbances of ossification Age, poor nutrition, smoking, drugs (especially NSAIDs), diabetes CLINICAL/EXAM FINDINGS Look, Feel, Move MSK examination Pain, tenderness Swelling Bruising Loss of function 11 Crepitus Signs of blood loss Injury to other structures DESCRIBING A FRACTURE ON X-RAY Identifying factors - Anatomical: Bone involved and the part of the bone involved - Direction of fracture line: Transverse, Oblique, Spiral o - Displaced v Undisplaced 0 - Simple v Comminuted - Angulation:back front dorsal, volar - Deformity: Varus, valgus 080 8500  RULE OF TWO’S O Two planes (AP and Lateral) x ray imaging Two joints (above and below) EE Two occasions Two limbs (compare with normal side) Two opinions DISLOCATION VS. SUBLUXATION Partial dislocation Dislocation Occurs when the joint surfaces become disengaged Subluxation 00 Is a partial or incomplete joint dislocation  ORTHOPAEDIC EMERGENCIES Function Poor infection mating OPEN FRACTURES & JOINT INJURIES Communication between external environment & bone Muscle and skin injured and bacterial contamination Prone to Infection B8 Poor healing Poor function Gust lo Andras n classification OPEN FRACTURES & JOINT INJURIES 00 0 Fracture and open wound in same limb segment is an open fracture until we otherwise e proven Gustilo-Anderson classification Paramedic documentation very important 8 – If adequate no further inspection of wound E – 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 _o – Urgent surgical consultation +/- surgical exploration OPEN FRACTURES & JOINT INJURIES Management O – Make diagnosis promptly O– Clinical photographs Describe wound accurately and associated soft tissue injury O– Immobilise fracture Neurovascular involvement O– Prompt surgical consultation O– Tetanus prophylaxis – Antibiotics based on mechanism , consult microbiology – Operative debridement and fracture stabilization SEPTIC ARTHRITIS Refers to infection in a joint Can be bacterial, fungal or viral Adult vs Paediatric  ADULT SEPTIC ARTHRITIS Emergency with mortality of 10 - 15% Common organisms: Staph. aureus, Predisposing factors Streptococcal species, Neisseria gonorrhea O Intra-articular corticosteroid injection Age > 80 years O Diabetes mellitus 8 O Rheumatoid arthritis O Prosthetic joint / recent joint surgery O Skin infection, cutaneous ulcers O IV drug abuse ADULT SEPTIC ARTHRITIS Source of infection Osteomyelitis E 8 Direct infection from a penetrating wound Haematogenous – Bacteraemia / IVDU o It is more likely to localize in a joint with pre-existing arthritis. o Usually monoarticular but can be polyarticular especially in rheumatoid arthritis PRESENTATION : ADULT SEPTIC ARTHRITIS 0008 Most common joint involved is knee Also Hip, ankle, shoulder, wrist are common sites Monoarticular arthritis Remember differential diagnosis – infection, crystal induced, inflammatory, neoplastic, hemarthrosis Hot swollen joint Pain with passive and active movement o 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 INVESTIGATIONS Joint aspiration and fluid analysis – US guidance if necessary F – 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 X-rays of infected joint – Not useful in diagnosis as only become abnormal when joint destruction has occurred, useful as a baseline for later comparison ADULT SEPTIC ARTHRITIS – TREATMENT Antibiotics for 6/52, initially 2/52 I.V. o Treatment depends on organism concerned Local microbiology guidelines o 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 COMPARTMENT SYNDROME Definition rise of tissue pressure within a myofascial compartment that exceeds capillary pressure and compromises its perfusion and tissue function May lead to irreversible muscle and nerve damage 000000 Lower leg most common but can occur in arm, forearm, hand, thigh, foot, gluteal area Etiology: fractures, crush injury, contusions, gunshot wounds, burns, extravasation of iv fluids Signs: Early: disproportional pain in limb, pain on passive movement of distal joints Late: paraesthesia, pulseless, pale, paralysis CAUSES Compartment contents O External compression O Constricting cast / dressing O Blood – Fracture or O Burns (Full thickness) soft tissue Sutures closing fascia Muscle – O Ischaemic O Tourniquet MANAGEMENT Call help early if suspected Remove or open the cast or dressing Re examine Measure intra-compartment pressure Check CK (creatinine kinase) Decompressive fasciotomy CAUDA EQUINA SYNDROME Compression of someEor all of the nerve roots of the cauda equina Symptoms include bowel and bladder so dysfunction, saddle anesthesia, and varying degrees of loss of lower extremity sensory and motor function  PRESENTATION Symptoms o Signs O Low back pain O Lower extremity weakness O Groin and perineal pain O Hypoflexia or areflexia, O Bilateral sciatica bothlegs 0 Perineal hypoesthesia or saddle Loss of bowel or bladder anesthesia to pinprick EE function. Subtle hesitancy Eventually overflow incontinence TREATMENT 0 MRI useful but don’t delay Early surgery to avoid: E Bladder / Bowel incontinence Lower limb weakness Low threshold for admission Counsel patients in back pain clinics THANK YOU