Orthopaedic Emergencies Flashcards
What are dislocations, their investigation and management?
Dislocation- displacement of bones at a joint from their normal position resulting in complete loss of congruity
(subluxation- partial displacement)
History- trauma, previous dislocations
Examination- pain, LOF, check neurovascular status and XRAY
management-urgent reduction of joint using anaesthetics/ sedation
(document neuro status before and after reduction)
what are the two types of open fractures?
Compound from within (inside-out): high energy
• The broken end of the bone breaks through or pierces the
skin
Compound from without (outside-in): machete
• External violence causes laceration or tissue trauma
• Higher likelihood of contamination
what are the Gustillo-Anderson classification of open fractures and complications
classified during surgery
Type I: < 1 cm
Type II: 1-10cm
Type III: > 10 cm or high energy*
• A - adequate tissue for coverage
• B - extensive periosteal stripping and requires flap (plastic surgery)
• C - vascular injury requiring vascular repair
Complications:
- Soft tissue infection
- Osteomyelitis
- Tetanus
- Crush syndrome
- Skin loss
- Non-union
- Amputation
What is the initial management of open fractures in the ED
• Control the bleeding and wash it out
• Cover with sterile dressing (take a picture)
• Splint
• IV antibiotics
• Tetanus prophylaxis
What is septic arthritis and aetiology?
Singular, hot swollen joint
usually gram positive aerobes (staph aureus etc)
Aetiology:
- Direct inoculation
- Trauma
- Iatrogenic
- Hematogenously
- Adjacent osteomyelitis
- Soft tissue infection
- immunosuppression (Drug users, diabetics, HIV)
What are the clinical features and differential diagnosis of septic arthritis
Clinical features: rapid onset
- joint pain, swelling, erythema, warmth
- fever
- decreased ROM
- pain with active and passive movement
DDx:
- crystal induced (gout or pseudogout)
- reactive arthritis
- rheumatoid arthritis
- Vascultic conditions
What is the management and complications of Septic Arthritis?
Management:
• Aspiration of Joint
• IV antibiotics
May require several months of treatment
• Washout of joint
Arthroscopic or open
Complications:
• Rapid destruction of joint with delayed treatment (>24
hours)
• Degenerative joint disease
• Soft tissue injury
• Osteomyelitis
• Joint fibrosis
• Sepsis
• Death
What is compartment syndrome and its clinical features
A condition where the intra-compartmental pressure in a fascial compartment becomes elevated beyond the capillary perfusion pressure => muscle + nerve death => limb death
Clinical features:
- Pain (out of proportion to what is expected so extreme pain/doesn’t settle with analgesia)
- Paraesthesia
- Pallor
- Pulselessness
- Paralysis
- Pressure
pain is worse on passive movement rather than active movement
What is the investigation and management of compartment syndrome
Investigation: usually a clinical diagnosis
- Measure Compartment pressure w/ needle manometry
intercompartmental pressure > 30mmHG = compartment syndrome
Management:
Initial: Escalating to the orthopaedic senior
Removing any external dressings or bandages
Elevating the leg to heart level
Maintaining good blood pressure (avoiding hypotension)
Definitive: Emergency fasciotomy
(preferably within 6 hours)
What is necrotising fasciitis and management
Necrositing fasciitis:
Life threatening bacterial infection of subcutaneous fascia (group A strep most common)
Management: Surgical debridement and High dose broad spectrum antibiotics
Describe the anatomy of the lumbosacral spine and its relation to cauda equina
Begins at T12 and ends at S1
The low back vertebral bodies are larger, thicker block-like structures
A group of nerve roots that travel down from the spinal cord is called the cauda equina. The cauda equina contains nerve roots from L2 in the lumbar spine to Co1 in the coccygeal (tail bone end) spine.
A space occupying lesion like a herniated disc within the lumbosacral canal puts pressure on the
nerves of the cauda equina –> cauda equina syndrome
Other causes: metastasis, infection, trauma
What are the clinical features of CES
Saddle anaesthesia
Loss of sensation in the bladder and rectum
Urinary retention or incontinence
Faecal incontinence
Bilateral sciatica
Bilateral or severe motor weakness in the legs
Reduced anal tone on PR examination
Severe lower back pain
What are the investigation and management of CES
Investigations:
Clinical Examination
- inspection (muscle wasting in extreme cases)
- palpation (palpate bladder for retention)
- NV examination (LMN signs)
- Rectal exam (reduced anal tone, reduced/absent pin prick sensation in S2-S4)
- Pre and post voiding bladder scan (looking for retention)
- Emergency MRI scan
Treatment
- Emergency hospital admission
- Urgent surgical lumbar decompression (within 24 hrs)
- If due to malignancy- oncology discussion for possible radiotherapy
What are the complications associated with CES
– Urinary/bowel dysfunction
– Sexual dysfunction
– Chronic pain
– Persistent leg weakness/altered sensation
what is acute compartment syndrome associated with?
associated with an acute injury, where bleeding or tissue swelling (oedema) associated with the injury increases the pressure within the compartment –> bone fractures or crush injury
usually affects the legs
e.g. monteggia and galleazi fractures
