Orthopaedic Emergencies

Question 1

Define septic arthritis

Answer 1

A painful condition that occurs due to infection of a joint space and it’s synovium

Question 2

Aetiology of septic arthritis

Answer 2

Infants - S.aureus, group B strep and E.Coli
Children - S.aureus, S.Pyogenes and H.Influenza
Adults - S.aureus and S.Epidermidis

The bacteria reaches the knee through either the bloodstream (most common) or a direct penetrating injury to the knee

Question 3

Clinical features of septic arthritis

Answer 3

Erythematous 
Hot 
Swollen 
Extreme pain - doesn't allow passive movement 
History or trauma or infection 
Acute onset pyrexia 
Refusal to weight bear

Question 4

Differential diagnosis of septic arthritis

Answer 4

Osteoarthritis 
Reactive arthritis 
Rheumatoid arthritis 
Lyme disease 
Gout/Pseudogout 
Psoriatic arthritis 
Trauma 
Haemoarthrosis 
Bursitis 
Cellulitis

Question 5

Investigations required for septic arthritis

Answer 5

Plain X-Ray - often normal
USS - demonstrates effusion and guides aspiration
Aspiration
- immediate gram stain and microscopy (diagnosis)
- cultures (sensitivities)
- look for crystals
Bloods - FBC (WCC), CRP and ESR

Question 6

Management of septic arthritis

Answer 6

Drainage and washout of affected joint
Broad spectrum antibiotics - tailored after culture sensitivity result
- IV two weeks then 4 weeks oral

Question 7

Complications of septic arthritis

Answer 7

Osteoarthritis - bony erosions
Osetomyelitis
Sepsis

Question 8

What is the cauda equina?

Answer 8

Collection of nerve roots distal to the conus medullaris

Question 9

Causes of cauda equina syndrome

Answer 9

Large paracentral or central disc herniation at L4, L5 or S1
Spinal injury neoplasms 
Tumours
Infections - abscess or TB
Haematoma - iatrogenic

Question 10

Clinical features of cauda equina syndrome

Answer 10

Bladder/bowel dysfunction - incontinence or retention
Sexual dysfunction
Saddle/perianal anaesthesia
Lower back pain - possible radiation down one or both legs
Sensory changes in the lower limb
Weakness in lower limbs
Lower limb hyporeflexia

Question 11

Describe examination and investigations of suspected cauda equina syndrome

Answer 11

Full neurological examination of the lower limb
PR exam - anal tone
Urgent MRI

Question 12

Management of cauda equina syndrome

Answer 12

Neurological review for urgent decompression (<24 hours)
High dose steroids - reduce swelling
Immobilisation - if trauma the cause

Question 13

Complications of cauda equina syndrome

Answer 13

Permanent damage

• pain
• sexual dysfunction
• bladder/bowel dysfunction (incontinence or retention)
• paralysis
• hyporeflexia

Question 14

What is the primary survey in management of major trauma?

Answer 14

Airway and C-spine 
Breathing 
Circulation 
Disability 
Exposure

Question 15

Airway and C-spine management

Answer 15

Immobilise the C-spine immediately with manual in-line stabilisation - performed until C-spine injury excluded
Assess airway patency
- talking/snoring
Consider foreign body in airway and tracheal/facial fracture if unconscious
Manage compromised airway
- airway manoeuvres (head tilt-chin lift and jaw thrust)
- airway adjuncts (oro- and nasopharyngeal tubes)
Consider permanent airway

Question 16

Breathing management

Answer 16

Assess the breathing
- obs (RR, sats) 
- expansion and symmetry of breathing 
- wounds to chest wall
- percussion and auscultation 
Manage breathing 
- high flow oxygen via a trauma mask 
Investigations 
- CXR
- ABG
- chest drain

Question 17

Circulation management?

Answer 17

Assessment 
- obs (temperature, heart rate, CR, BP)
- examine peripheries, JVP, pulses and check for oedema 
- auscultation for new murmurs 
Investigations 
- ECG 
Management 
- IV access and fluids (if low BP) 
- consider O-ve blood 
- surgical control of haemorrhage

Question 18

Disability management

Answer 18

Assessment 
- rapid neuro evaluation- AVPU or GCS 
- pupils 
- BM
Investigations 
- CT head (if decreased consciousness not due to hypoxia or blood loss)

Question 19

Exposure management

Answer 19

Expose the patient for a through examination
- rashes, DVT, catheter output, presence of wounds or drains
Take cultures and swabs as appropriate
Keep patient warm with blankets and warmed fluids

Question 20

Secondary survey

Answer 20

Begin after completion of primary surgery and resuscitation if continuing successfully 
History - AMPLE 
Head-to-toe physical examination 
Reassess vital signs 
Perform specialist diagnostic tests

Question 21

What does AMPLE stand for?

Answer 21

Allergy 
Medication 
Past medical history 
Last meal
Events of incident

Question 22

Initial management of an open fracture

Answer 22

Suitable resuscitation and stabilisation of patient - control haemorrhage
Urgent realignment and splinting
- constant reassessment of the neurovascular status
Broad spectrum antibiotics and tetanus vaccine
Photographic wound to minimise repeated uncovering of wound for inspection
Remove gross debris (not bone fragments)
Saline soaked dressing

Question 23

Assessment of an open fracture

Answer 23

Assess any soft tissue damage
Assess neurovascular compromise
- ABPI if concern of vascular (<0.9 is cause for a vascular consult and possible angiogram)

Question 24

Gustilo types of open fracture

Answer 24

Type 1 - wound <1cm with minimal contamination or muscle damage
Type 2 - wound 1-10cm and moderate soft tissue injury
Type 3A
- high energy with extensive soft tissue damage and contamination
- adequate tissue for flap coverage
- as a minimum for all farm injuries
Type 3B
- periosteal stripping and wound requires soft tissue coverage
Type 3C
- vascular repair is required (regardless of severity of soft tissue injury)
- requires flap coverage

Question 25

Name and describe the three classes of nerve damage.

Answer 25

Neurapraxia - temporary loss of motor and sensory function in a peripheral nerve (physiological due to blocked conduction)
Axonomesis - damage to axons and myelin sheath of peripheral nerves (preservation of connective tissue framework)
Neurotmesis - total severance or disruption of an entire peripheral nerve fibre

Question 26

Aetiology of compartment syndrome

Answer 26

Trauma - fractures (common), crush injuries, contusions, gunshot wounds 
Tight casts/external wrapping 
Extravasation of IV fluids 
Burns 
Post ischaemia swelling 
Bleeding disorders 
Arterial injury

Question 27

Pathophysiology of compartment syndrome

Answer 27

Increased intracompartmental pressure (variety of causes)
Local trauma and soft tissue destruction
Bleeding and oedema
Increased interstitial pressure
Vascular occlusion
Myoneural ischaemia

Question 28

Clinical features of compartment syndrome

Answer 28

Pain out of proportion with clinical situation 
- absent if nerve damage 
Pain with passive stretch
Paraesthesia and hypoaesthesia 
Paralysis 
Peripheral pulses absent

Question 29

Investigations for compartment syndrome

Answer 29

X-Ray to rule out fracture
Compartment pressure measurement - if unsure
- diagnosis if pressure is within 30mmHg of diastolic blood pressure (delta p)

Question 30

Management of compartment syndrome

Answer 30

Non-operative (uncommon)
- loosen tight dressings
- hyperbaric oxygen therapy
Operative
- emergency fasciotomy of all compartments
- physiotherapy and occupational therapy required post-op

Question 31

Complications of compartment syndrome

Answer 31

Irreversible tissue ischaemia 
- permanent muscle and nerve damage 
- chronic pain 
Peroneal nerve palsy 
Hyperaesthesia 
Painful dysaresthesia