Orthopedic Emergencies Flashcards
Acronym for ortho emergencies
VON CHOP
Vascular compromise Open fracture Neurological compromise/cauda equina syndrome Compartment syndrom Hip dislocation Osteomyelitis/septic arthritis Unstable Pelvic fracture
Initial management of open fractures
- A first-generation cephalosporin (or clindamycin) should be administered upon arrival. In general, 24 h of antibiotics after each debridement is sufficient to reduce infection rates.
- Although cultures are taken from delayed (>24 h) or infected injuries, it may not be necessary to routinely take post-debridement cultures in open fractures.
- Open fractures should be debrided as soon as possible, although the “6-h rule” is not generally valid.
- Wounds should be closed within 7 d once soft tissue has stabilized and all non-viable tissue removed.
- Negative pressure wound therapy (NPWT) has been shown to decrease infection rates in open fractures.
Symptoms of fat embolism syndrome
SOB, hypoxemia, petechial rash, thrombocytopenia, and neurological symptoms
Open fractures immediate management
- ABCs, primary survey, and resuscitation as needed
- removal of obvious foreign material
- irrigate with normal saline if grossly contaminated
- cover wound with sterile dressings
- immediate IV antibiotics
- tetanus toxoid or immunoglobulin as needed
- reduce and splint fracture
• NPO and prepare for OR (blood work, consent, ECG, CXR)
■ operative irrigation and debridement within 6-8 h to decrease risk of infection
■ traumatic wound often left open to drain but vacuum-assisted closure dressing may be used
■ re-examine with repeat irrigation and debridement in 48 h
Gustilo classification of open fractures and antibiotic regiment for each
Grade 1
Length of open wound <1cm
Minimal contamination and soft tissue injury, simple or minimally comminuted fracture
ABX- First generation cephalosporin (cefazolin) for 3 d
If allergy use floroquinolone
If MRSA positive use vancomycin
Grade II
Length 1-10 cm
Moderate contamination Moderate soft tissue injury
Abx as per grade 1
Grade III
>10 cm
IIIA: Extensive soft tissue injury with adequate ability of soft tissue to cover wound
IIIB: Extensive soft tissue injury with periosteal stripping and bone exposure; inadequate soft tissue to cover wound
IIIC: Vascular injury/compromise
First generation cephalosporin (cefazolin) for 3 d plus Gram-negative coverage (gentamicin) for at least 3 d For soil contamination, penicillin is added for clostridial coverage
*Any high energy, comminuted fracture, shot gun, farmyard/soil/water contamination exposure to oral flora, or fracture >8 h old is immediately classified as Grade II
Compartment syndrome description and prognosis
- increased interstitial pressure in an anatomical compartment (forearm, calf) where muscle and tissue are bounded by fascia and bone (fibro-osseous compartment), with little room for expansion
- interstitial pressure exceeds capillary perfusion pressure, leading to muscle necrosis (in 4-6 h) and eventually nerve necrosis
Compartment syndrome etiology
• intracompartmental
■ fracture (particularly tibial shaft or paediatric supracondylar and forearm fractures)
■ reperfusion injury, crush injury, or ischemia
• extracompartmental: constrictive dressing (circumferential cast), poor position during surgery, circumferential burn
Compartment syndrome pathophysiology
Increased pressure from blood and intracompartmental swelling –>
Decreased venous and lymphatic drainage –>
Intracompartmental pressure greater than perfusion pressure –>
Muscle and nerve anoxia –>
Acidosis and muscle and nerve necrosis –>
Necrosis causes leaky basement membranes –>
Transudation into tissue surrounding compartment –>
Inc pressure from blood and intracompartmental swelling
Compartment syndrome clinical features
- pain out of proportion to injury (typically first symptom)
- pain with active contraction of compartment
- pain with passive stretch (most sensitive)
- swollen, tense compartment
- suspicious history
• 5 Ps: late sign – do not wait for these to develop to make the diagnosis!
Pain: out of proportion for injury and not relieved by analgesics
• Increased pain with passive stretch of compartment muscles
Pallor: late finding
Paresthesia
Paralysis: late finding
Pulselessness: late finding
Compartment syndrome investigations
- usually not necessary, as compartment syndrome is a clinical diagnosis
- in children or unconscious patients where clinical exam is unreliable, compartment pressure monitoring with catheter AFTER clinical diagnosis is made (normal = 0 mmHg; elevated ≥30 mmHg or [measured pressure – dBP] ≤30 mmHg)
Compartment syndrome tx
• non-operative
■ remove constrictive dressings (casts, splints), elevate limb at the level of the heart
• operative
■ urgent fasciotomy
■ 48-72 h post-operative: wound closure ± necrotic tissue debridement
Compartment syndrome complications
- Volkmann’s ischemic contracture: ischemic necrosis of muscle, followed by secondary fibrosis, and finally calcification; especially following supracondylar fracture of humerus
- rhabdomyolysis, renal failure secondary to myoglobinuria
Osteomyelitis definition
bone infection with progressive inflammatory destruction
Osteomyelitis etiology
- most commonly caused by S. aureus
- mechanism of spread: hematogenous (most common) vs. direct inoculation vs. contiguous focus
- risk factors recent trauma/surgery, immunocompromised patients, DM, IV drug use, poor vascular supply, peripheral neuropathy
Osteomyelitis clinical features
- symptoms: pain and fever
* on exam: erythema, tenderness, edema common ± abscess/draining sinus tract; impaired function/WB
Osteomyelitis diagnosis
Imaging
• workup includes: WBC and differential, ESR, CRP, blood culture, aspirate culture/bone biopsy
Osteomyelitis treatment
Acute -
IV abx 4-6 weeks
Started empirically and adjusted after obtaining blood and aspirate cultures
+/- surgery (I&D) for abscess or significant involvement
+/- hardware removal (if present)
Chronic osteomyelitis
Surgical debridement
Abx - both local (ex. abx beads) and systemic (IV)
Osteomyelitis plain film findings
- Soft tissue swelling
- Lytic bone destruction*
- Periosteal reaction (formation of new bone, especially in response to #)*
*Generally not seen on plain films until 10-12 d after onset of infection
Septic joint most commonly affected joints in descending order
Knee
hip
elbow
ankle
sternoclavicular joint
Plain film findings in a septic joint
- Early (0-3 d): usually normal; may show soft-tissue swelling or joint space widening from localized edema
- Late (4-6 d): joint space narrowing and destruction of cartilage
Septic joint etiology
- most commonly caused by S. aureus in adults
- consider coagulase-negative Staphylococcus in patients with prior joint replacement
- consider Neisseria gonorrhoeae in sexually active adults and newborns
- most common route of infection is hematogenous
- risk factors: young/elderly (age >80 yr), RA, prosthetic joint, recent joint surgery, skin infection/ulcer, IV drug use, previous intra-articular corticosteroid injection, immune compromise (cancer, DM, alcoholism)
Septic joint clinical features
• inability/refusal to bear weight, localized joint pain, erythema, warmth, swelling, pain on active and passive ROM, ± fever
Septic joint investigations
- x-ray (to rule out fracture, tumour, metabolic bone disease), ESR, CRP, WBC, blood cultures
- joint aspirate: cloudy yellow fluid, WBC >50,000 with >90% neutrophils, protein level >4.4 mg/dL, joint glucose level <60% blood glucose level, no crystals, positive Gram stain results
- listen for heart murmur (to reduce suspicion of infective endocarditis, use Duke Criteria)
Septic joint treatment
• IV antibiotics, empiric therapy (based on age and risk factors), adjust following joint aspirate C&S results
• non-operative
■ therapeutic joint aspiration, serially if necessary (if early diagnosis and joint superficial)
• operative
■ arthroscopic/open irrigation and irrigation and drainage ± decompression
Septic joint how to monitor response to therapy
serial CRP
