Orthopedic Emergencies

Ted Parks, MD
Compartment Syndrome

Neurovascular Injuries

Open Fractures

Dislocations

Septic Arthritis

Extremity Amputation


Compartment Syndrome

Anatomy of a Compartment

Compartment Syndrome



Compartment Syndrome
Signs and Symptoms:

Pain out of proportion to injury

Hx of blunt, closed trauma

Firm, swollen, tense extremity

Pain with passive motion of distal parts
The 4 Ps
Pain

Pallor

Paresthesias

Pulselessness

Measuring compartment pressures


Measuring compartment pressures

Pressure Measurements
<15mmHg = normal, resting
<30mmHg = normal, injured
>45mmHg = compartment syndrome
30 45mmHg: borderline
Watch and re-measure frequently
Consider other clues
Compartment Syndrome



Treatment
Treatment = Fasciotomy


Neurovascular Injuries

Colles Fracture

Neurovascular Injuries



Nerve Injuries

Neurological (sensory) deficits
Document grade and extent
For example:
subjective sensory deficit to light touch, median
nerve distribution
or
complete loss of sensation, dorsum all 5 fingers

If you dont document nerve injuries, you
may be held responsible for them
Neurological (sensory) deficits
Reduce the fracture, OR

Start immediately to find someone who can

Once the fracture is reduced, repeat the sensory
exam and document any improvement (or lack
thereof)

If the sensory exam does not improve
Neurological (sensory) deficits
Do nothing! Over 90% of fracture
associated nerve injuries are either
neuropraxias or axonotmeses and they will
resolve with time once the fracture is
reduced.
Neuropraxisa
Neuropraxisa


No structural damage

Nerve function returns in minutes once
local microcirculation is reestablished
Axonotmesis

Axonotmesis
Axons are damaged and deteriorate
(Wallerian degeneration), but all other
structural elements remain intact

Axon begins to regenerate after a few
weeks, growing at about 1mm/day

Motor endplates disappear without
stimulation

Neurotmesis

Neurotmesis
Essentially no chance for return of function
without repair
Once repaired, expect slow return of
function (as with axonotmesis)
Neurological injuries that dont
resolve after fracture reduction

Observe

Get EMG/NCS studies at 6 weeks

Repeat EMG/NCS studies at 12 weeks,
if no sign of improvement, explore and repair the
nerve. Nerve repair results not significantly
worse 3 months out.
Why are these emergencies?
Vascular Injuries

Vascular Injuries

Poor pulses (doppler?)

Cold, pale skin

Poor capillary refill
Vascular Injuries
1. Document exam
2. Reduce fracture (or call somebody who
will)
3. Repeat exam
4. If no change on exam, order STAT
arteriogram
5. Repair/thrombectomy


Open Fractures

Open Fractures
Problem = Infection
Open Fractures
Start broad spectrum IV anitbiotics
(example=Zosin 3.375gm)
Debride wound of obvious foreign material

Apply an occlusive dressing

Splint extremity

Formal I&D in the OR ASAP


Open Fractures
Start broad spectrum IV anitbiotics
(example=Zosin 3.375gm)
Debride wound of obvious foreign material

Apply an occlusive dressing

Splint extremity

Formal I&D in the OR ASAP

Open Fractures
Risk of osteomyelitis decreases
dramatically if I&D is done before
4-6 hours*




*R.M. Gustilo The Journal of Bone and Joint Surg.
2002, 84:682

Dislocations
Dislocations
Compromise blood
flow to tissues

Injure cartilage
surfaces

Cause ischemia of
cartilage

Dislocations
Compromise blood
flow to tissues

Injure cartilage
surfaces

Cause ischemia of
cartilage

Dislocations
Compromise blood
flow to tissues

Injure cartilage
surfaces

Cause ischemia of
cartilage

Dislocations
Document neurovascular exam

Reduce the joint, or call somebody who
can

Immobilize the extremity

Document the reduction with an xray
Septic Arthritis
Septic Arthritis
Any joint that is red, hot, swollen with no
history of trauma is infected until proven
otherwise

Fever, WBC, ESR, CRP all helpful, but not
diagnostic

Definitive test = aspiration
Knee Joint Aspiration Technique
Pt supine on table
Knee extended
Muscles relaxed
Lateral approach
Sub-patellar



Septic Arthritis
Aspiration:
1. Cultures


Septic Arthritis
Aspiration:
1. Cultures
2. Gram stain


Septic Arthritis
Aspiration:
1. Cultures
2. Grams stain
3. Crystals


Septic Arthritis
Aspiration:
1. Cultures
2. Grams stain
3. Crystals
4. Cell count:
Presume infection if >50,000 WBC per
high powered field

Septic Joint
Start broad spectrum antibiotics as soon
as you have finished the aspiration
(ie: Zosin IV, Augmentin PO)

If gram stain and cell count are negative,
D/C abx and await cultures

If Gram stain or cell count are positive,
proceed with surgical I&D ASAP
Exceptions

Traumatic Amputations
Start abx ASAP
Give one aspirin PR
Place amputated part
in a small bag of
sterile saline, place that
bag in a bag of ice
Xray stump and part
Clean stump by irregating with sterile
saline
Thank You!

Ted Parks, MD
(303) 321-1333