Common Orthopedic Emergency Conditions and Their Management

Common Orthopedic Emergency Conditions and Their Management
Overview
 Definition:
o Branch of surgery which deals with the problems of the musculoskeletal system
 Orthos = straight ; pedis = child
Orthopedic trauma
 Fracture
o A break in the structural continuity of bone (but we have to remember that there is always some
degree of soft tissue injury with a fracture)
 Better definition: Soft tissue injury complicated by a break in the bone
How fractures happen

1. A single traumatic incident
2. Repetitive physical stress
3. Abnormal weakening of the bone (pathological fracture)
Types of Fracture...cont.
Open fracture :
 When the bony fragments are exposed to external environment by means of wound
Closed fracture :
 The fracture fragments are not exposed to outside
Goal of fracture treatment

 Prevent fracture and soft tissue complications
 Get fracture to heal and in satisfactory position for optimal functional recovery
 Intra-articular fracture needs accurate reduction & rigid fixation but non articular fracture of bone
require anatomical reduction & stable fixation.
 Rehabilitate as early as possible by active & passive exercises.
 Restore patient to optimal functional state
Radiographs
 Understand radiology
o -ordering and interpreting films
 Get appropriate radiographs
o At least 2 views
o Describe fracture to residents/ consultants
o complete?
o displaced?
o fracture type/ pattern?
o what bone? What part of the bone
o Left or right?
Soft Tissue Injury

 Soft Tissue Injury
 Sprain - ligaments • Strain Muscles, musculotendinous injuries
Torn ligaments
 TA
 ACL
Open fractures classification
 Gustilo classification
o Type 1 Low energy, wound <1cm (usually penetrating injury by bony fragments from inside )
o Type 2 Wound >1cm with moderate soft tissue damage
o Type 3 high energy wound >1cm with extensive soft tissue damage
 Type 3A - Adequate soft tissue cover
 Type 3B - extensive soft tissue injury with external or internal degloving injury which needs
flap coverage.
 Type 3C - any open fracture associated with neuro vascular injury.
Treatment principles of fracture

 Reduction
 Maintain reduction (+ hold until union)
 Rehabilitate - restore function by movement of the joint & patient itself.
 Prevent or treat complications
Management of orthopedic trauma patients

 Don't treat the X-rays of the fracture, but treat the patient !
 Life saving measures
- Diagnose and treat life threatening injuries (head injuries, Chest & abdominal injuries)
- Emergency orthopaedic involvement
• Life saving
• Complication saving
 Emergency orthopaedic management (day 1)
 Monitoring of fracture (days to weeks)
 Rehabilitation and treatment of complications (weeks to months)
Open compound fracture management

 While contacting orthopaedic team for definitive surgical treatment
 Irrigate wound with N.saline, if not available with tap water. Cover wound with sterile moist dressing
 Immobilise limb preferable with external fixator if not possible, by pos. cast(including joint above & below)
 Remove obvious contaminants with meticulous effort
 Take photos
 IV antibiotics (e.g. cefuroxime +/- metronidazole or gentamicin)
 Tetanus prophylaxis. • Check distal neurovascular status
 Re-assess
Reduction
If necessary, what reduction technique?
1) Closed reduction
o Need anaesthesialsedation, analgesia, x- ray facilities, equipment, knowledge
o Used for minimally displaced fractures and most fractures of children
o Distal part of limb pulled in line of bone
o Alignment adjusted in each plane
2) Open reduction
- Above + OR staff + additional equipment
- Risks
Cryotherapy
 Injuries < 24 hours ice packs prior to splint application
 decreases inflammation
 Limited to the first 24-48 hours; after this, cold can interfere with long-term healing
Case 1
 25/M tripped while playing basketball
 Came in the ER ambulatory
 » Pain/ tenderness/ swelling on L ankle
 What will you do next?
Answer
 A. Advise RICE method
 B. Get an xray
 C. Give NSAID/ pain reliever
 D. Call resident/consultant on duty
 E. A and C only
 F. A, B and C
Although most patients with ankle sprains who present to emergency departments undergo xrays, less than 15%
have a fracture
Ottawa Ankle Rules

 A series of ankle x ray films is required only if there is any pain in malleolar zone and any of these findings •
Bone tenderness at A • Bone tenderness at B • Inability to bear weight both immediately and in emergency
department
 A series of ankle x ray films is required only if there is any pain in mid-loot zone and any of these findings: •
Bone tenderness at C • Bone tenderness at D • Inability to bear weight both immediately and in emergency
department
Splinting
 Control pain and swelling
 Reduce deformity/ dislocations
 Immobilization of fracture, sprain, or injury
 Prevent further injury
 mainstay of emergency orthopedics
 Most fractures can be immobilized with a simple splint
 Fracture type will dictate splint required to immobilize it
 Remove all clothing and constrictive devices from extremity
 Align severely angulated fracture
 protect bony prominence
 Assess NV status immediately before and after splinting
 If periodic wound care is required, consider a removable splint
Discharge instructions
 Elevation
 Ice bags/ cold packs
 Allow setting of splint
 Avoid getting splint wet
 Clear follow-up instructions
 Check for signs of vascular insufficiency
Risk management issues

 Always document NV status before and after splint application
 Always document NV status before and after any fracture or joint reduction
 Remove all rings on hands/ toes before splint application
 when to see orthopedic physician
 when to return to the emergency department
 Not uncommon, especially for multiply injured patients
 Medico-legal concerns
Case 2
 72/M fell in the kitchen
 Painful R hip
 Known hypertensive but controlled
 How will you manage this patient?
Ans- cross table
Common Orthopedic Elective Cases and Their Management

Non-emergancy Orthopedic Cases
 Osteoarthritis
 ACL tear
 Carpal Tunnel Syndrome
 Tenosynovitis
 Plantar fascitis
 Lumbar strain
 Scoliosis
 Bone and Soft tissue tumors
Osteoarthritis of the Knee
 degenerative in nature
 wear and tear
 Initial conservative
 management:
o NSAIDs
o cortisone shots
o hyaluronic acid injections glucosamine/ chondroitin
o Stem cells??
• In order for joint replacements to be done, we need THREE THINGS

1. Joint replacement implants
2. Medical/ covid clearance
3. Prepare for blood products for possible OR use
Post-op, patients are referred to Rehab Medicine for physical therapy
Anterior Cruciate Ligament (ACL) Tear

 ACL provides 85% of the total restraining force to anterior translation of the tibia
 An ACL tear -a common injury that occurs in all types of sports,
 usually occurs during a sudden cut o deceleration
 The patient states. "I planted. twisted, and then heard a pop.”
LABORATORY STUDIES
 Lab studies are not indicated in the evaluation and diagnosis of anterior cruciate ligament injuries
IMAGING STUDIES
 Magnetic resonance imaging (MRI)
 MRI of the knee usually is recommended prior to surgery for evaluation of the other ligaments and the
menisci. because findings can influence the treatment plan
 MRI helps the surgeon to have the correct equipment at hand prior to beginning the surgery
Carpal Tunnel Syndrome
Initial non-surgical management

 NSAIDs
 physical therapy
 cortisone shot injection into the carpal tunnel
 Surgical decompression of the carpal tunnel when non surgical management fails
Tenosynovitis
 painful condition in which the sheath that holds a tendon becomes inflamed
 Conservative management includes NSAIDs finger and wrist exercises, physical therapy, cortisone injections
 open or endoscopic release surgery for severe cases
Back Pains Secondary to Muscle Spasms

 muscular in nature
 improper posture
 prolonged position
 lack of back exercises
Back pains
 Initial management: Avoid prolonged position
 Proper posture
 Back Strengthening and conditioning exercises
 Warm compress
 NSAIDS and muscle relaxant
Evaluation of musculoskeletal tumor

 PE
o Check for soft tissue masses (note depth, size) Overlying skin changes Palpate regional lymph nodes
 Radiography
o 2 planes
o Chest xrays if malignancy suspected
o Technetium bone scan, skeletal survey, MRI
 Laboratory studies
 Biopsy
o After complete evaluation of patients
Diagnostic Evaluation of Musculoskeletal Tumors
Differential diagnosis
1.AGE - certain diseases common in particular age groups
2 Number of bone lesions
3. Anatomic Location within bone
4. Effect of Lesion on Bone
5. Response of bone to lesion
6. Matrix characteristics
Management
o Chemotherapy
o Radiotherapy
o Surgical management - goal is to remove the tumor
o Targeted therapy
o Nursing Management

Common Orthopedic Emergency Conditions and Their Management

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Common Orthopedic Emergency Conditions and Their Management

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Common Orthopedic Emergency Conditions and Their Management

How fractures happen

Goal of fracture treatment

Soft Tissue Injury

Treatment principles of fracture

Management of orthopedic trauma patients

Open compound fracture management

Ottawa Ankle Rules

Risk management issues

Ans- cross table

Common Orthopedic Elective Cases and Their Management

• In order for joint replacements to be done, we need THREE THINGS

Anterior Cruciate Ligament (ACL) Tear

Carpal Tunnel Syndrome

Initial non-surgical management

Back Pains Secondary to Muscle Spasms

Evaluation of musculoskeletal tumor

Diagnostic Evaluation of Musculoskeletal Tumors

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