Orthopaedic Emergencies Flashcards
Define septic arthritis
A painful condition that occurs due to infection of a joint space and it’s synovium
Aetiology of septic arthritis
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
Clinical features of septic arthritis
Erythematous Hot Swollen Extreme pain - doesn't allow passive movement History or trauma or infection Acute onset pyrexia Refusal to weight bear
Differential diagnosis of septic arthritis
Osteoarthritis Reactive arthritis Rheumatoid arthritis Lyme disease Gout/Pseudogout Psoriatic arthritis Trauma Haemoarthrosis Bursitis Cellulitis
Investigations required for septic arthritis
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
Management of septic arthritis
Drainage and washout of affected joint
Broad spectrum antibiotics - tailored after culture sensitivity result
- IV two weeks then 4 weeks oral
Complications of septic arthritis
Osteoarthritis - bony erosions
Osetomyelitis
Sepsis
What is the cauda equina?
Collection of nerve roots distal to the conus medullaris
Causes of cauda equina syndrome
Large paracentral or central disc herniation at L4, L5 or S1 Spinal injury neoplasms Tumours Infections - abscess or TB Haematoma - iatrogenic
Clinical features of cauda equina syndrome
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
Describe examination and investigations of suspected cauda equina syndrome
Full neurological examination of the lower limb
PR exam - anal tone
Urgent MRI
Management of cauda equina syndrome
Neurological review for urgent decompression (<24 hours)
High dose steroids - reduce swelling
Immobilisation - if trauma the cause
Complications of cauda equina syndrome
Permanent damage
- pain
- sexual dysfunction
- bladder/bowel dysfunction (incontinence or retention)
- paralysis
- hyporeflexia
What is the primary survey in management of major trauma?
Airway and C-spine Breathing Circulation Disability Exposure
Airway and C-spine management
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
Breathing management
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
Circulation management?
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
Disability management
Assessment - rapid neuro evaluation- AVPU or GCS - pupils - BM Investigations - CT head (if decreased consciousness not due to hypoxia or blood loss)
Exposure management
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
Secondary survey
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
What does AMPLE stand for?
Allergy Medication Past medical history Last meal Events of incident
Initial management of an open fracture
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
Assessment of an open fracture
Assess any soft tissue damage
Assess neurovascular compromise
- ABPI if concern of vascular (<0.9 is cause for a vascular consult and possible angiogram)
Gustilo types of open fracture
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
