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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
Orthopedic EmergenciesOrthopedic Emergencies
SalterSalter--Harris ClassificationHarris Classification
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
Fracture Fracture PathophysiologyPathophysiology
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
Fracture Fracture PathophysiologyPathophysiology
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
Fracture Fracture PathophysiologyPathophysiology
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
Orthopedic EmergenciesOrthopedic Emergencies
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!
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