Orthopedic Emergencies Rachel Steinhart CCRMC ED April 2010

Objectives  Review H&P for orthopedic emergencies  Review appropriate documentation  Describe x-rays  Recognize potential limb/function threatening conditions  Discuss some high-risk & some common injuries  Review management including emergent/urgent orthopedic consult

History  Mechanism  Past medical history  Medications  Dominant hand  Occupation  Previous injuries  Last meal

Physical Exam  Inspect (deformity, swelling, skin)  Palpate (step-off, tenderness)  Range of motion (active & passive)  Neurovascular exam

Physical Exam Documentation  Joint above - Joint below  Sensory  Motor  Vascular  Skin  Compartments

Neurovascular Compromise  Straight forward  Any sensory or motor deficit  Any question of circulatory compromise  Pallor or cold distal to injury  Decreased capillary refill/pulse

Compartment Syndrome  Raised pressure in a closed fascial space  Reduced capillary perfusion below level needed for tissue viability

Limb Compartment Syndrome Causes  Orthopedic  Fractures: open or closed  Fx management (e.g. tight casting)  Vascular/Iatrogenic  Vascular puncture: esp. anticoagulated  Intra-arterial drug administration  Extravasation of IV fluids  Soft-tissue injury  Crush (e.g. Police K9 bites)  Burns  Hypotension: Always worsens perfusion in compartment sx

 Each limb contains a number of compartments at risk for CS.  Upper arm: anterior(biceps- brachialis) and posterior(triceps).  Forearm: volar(flexors) and dorsal(extensors)  3 gluteal, 2 thigh, 4 in the lower leg.

Compartment Syndrome Risk Factors  Tibial Fracture  Incidence ranges 1.5 to 29% Variable dx/tx thresholds  Anterior compartment most common  Forearm  Supracondylar Fracture  Comminuted = increased risk  Open = decreased risk(~50%)

Compartment Syndrome - Pressure Threshold  Intracompartmental pressure: Intracompartmental pressure:  Pressure as low as 30 mm H2O can result in compartment syndrome when accompanied by periods of hypotension

Is it Compartment Syndrome?  Clinical – 6 P’s  Pain  Pain out of proportion - passive extension  INCREASING NARCOTIC REQUIREMENT  Paralysis  Paraesthesia  Pulselessness  Pallor  Poikilothermia - Cold 6 hours  Irreversible damage occurs 6 hours after ischemia begins

Monitor Extremity Pulses  Be sure to occlude the other major artery (e.g. posterior tibial artery vs. dorsalis pedis) so that retrograde flow does not interfere with diagnosis  alternatively, apply a pulse oximetry monitor to the great toe, and sequentially occlude the posterior tibial and dorsalis pedis pulses  compare pulses to the opposite, non- injured limb

Measuring Compartment Pressure  Usually performed by Orthopedist  Is within Emergency scope of practice  At CCRMC, Stryker instrument is in Med Room - Sterile kit w/needle and syringe must be obtained by Nurse Supervisor

Describing Radiographs  Type of fracture  Transverse, oblique, spiral, segmental, comminuted  Pediatric: Salter-Harris, torus/buckle, greenstick  Location of fracture  Displacement  Shortening, angulation, rotation  Associated dislocation

Fracture Description

Open Fracture  Carefully examine skin  If skin not intact, determine whether bone exposed  Irrigate thoroughly - will require OR wash  Bandage  IV antibiotics (Ancef or Ancef+Gent)  Tetanus  Contact Ortho as soon as discovered

Pediatric Fractures Fractures involving or near the epiphyseal plate require urgent orthopedic consult

Salter-Harris Classification

Joint Dislocation  Complete separation of 2 articulating bony surfaces, often caused by a sudden impact to the joint  Commonly dislocated joints include shoulder, finger, patella and elbow  Dislocations are often associated with fractures

Shoulder Dislocation  Vast majority are anterior  Document axillary nerve fxn pre- and post-reduction  Sensation over deltoid  Posterior associated with seizure activity, can be bilateral, often missed AnteriorPosterior

Peri-lunate & Lunate Dislocations Peri-lunateLunate  Both with significant wrist instability  Both associated with SCAPHOID fractures  Usually require surgical intervention

Scapho-lunate Dissociation  Unstable ligamentous injury  Generally requires surgical repair “Terry Thomas Sign” Gap normally 1-2 mm

Scaphoid Fracture  Can be difficult to see on xray  May require additional view  May require delayed imaging  If middle or proximal, risk osteonecrosis  Contact ortho while patient in ER  When in doubt, splint & refer  Short arm, thumb spica

Hip Dislocation  Rapid reduction imperative: prolonged dislocation  avascular necrosis

Hip Fracture Potential For Avascular Necrosis >

Knee Dislocation  Usually reduce spontaneously  Often associated with tibial plateau fx  Posterior highly associated with vascular injury - vascular study IMPERATIVE AnteriorPosteriorArteriogram

Patellar Fracture  Transverse fracture -> inability to extend leg at the knee  Usually requires ORIF

Maisonneuve Fracture  Unstable fracture  Often requires surgical repair

Ankle Dislocation  Easily reduced  Associated with malleolar fractures and significant instability  Usually require surgical intervention

Lisfranc Fracture  Unstable fracture  Often requires surgical repair

Jones Fracture  Unstable fracture  Often requires surgical repair

Nursemaid’s Elbow  Common  Easily reduced

Supracondylar Fracture  Common pediatric fracture  Significant risk for compartment syndrome  Volkmann’s Contracture  Unreliable parents? ADMIT for observation  Often require surgical intervention

Initial Treatment of Orthopedic Injuries  Remove jewelry  Ice  Elevate  Control pain  Irrigate, dress, reduce, splint, dT, IV antibiotic  NPO

Dislocation +/- Fracture  Increase time dislocated = more difficult to reduce  Reduction results in:  Relief of acute pain  Removal of pressure from neurovascular structures  Restoration of circulation  Splint immediately post-reduction to avoid recurrent dislocation  Repeat physical exam and x-ray to confirm reduction & r/o addt’l injury

Early Orthopedic Consult Emergent or Urgent  Neurovascular compromise  Attribute to initial injury or  Post reduction  Possible compartment sx  Irreducible dislocation  Fracture + dislocation  Open fracture  Risk of avascular necrosis (e.g. scaphoid, femoral neck)