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. Common orthopaedic trauma emergencies
. Common accompanying complications
. Tips for management
. Improve your care of the trauma patient

Emergencies

. Bleeding
- Pelvic fracture
- Arterial injury
. Open fracture
. Long bone fracture
. Dislocation
. Compartment syndrome
. Deep vein thrombosis

Remember
Orthopedic emergencies come second

. A irway
. B reathing
. C irculation

Bleeding

There are only so many places to bleed
-chest
- abdomen
- pelvis
- gi/gu tract
- into a limb
- externally

Pelvic bleeding

. Pelvis houses the blood vessels to the leg

Pelvic fractures: vector of force
vertical anterior-posterior lateral

Pelvic disruption can lead to

major hemorrhage

Initial treatment: Diagnosis

. 3 xrays are taken for all trauma patients
- Lateral cervical spine
-chest ap
- PELVIS AP

Initial management

. Reduction
- sheet
- pelvic binder
- external fixation
- internal fixation

. Manage bleeding
- check Hgb
- fluid bolus then blood transfusion
- Embolization

Manage the bleeding

. Resuscitation: ATLS

. Saline first
. Blood transfusion
. Frequent hemoglobin checks

Embolization: arteriogram

. Patient must be stable
. Angiography must be
available
. Useful if bleeding
continues despite bony
stabilization

External bleeding

. Wounds should be examined and cleaned . Look for

- Open fractures
- Burns
- Abrasions
- Lacerations
- Swelling
- Bleeding

Arterial injury

. Pumping blood
. Start with direct
pressure on wounds
. Check distal pulses
. Consider tourniquet

Arterial injury

. No distal blood flow is an emergency
. Pulseless limb must be treated within 2-4 hours . Longer ischemia time leads to muscle,

nerve death

. Compartment syndrome

Pulseless limb
. Check pulse
. Check with doppler
. Angiogram
. Direct exploration
. Arterial repair

Pulseless limb

. Must be determined immediately
. Permanent dysfunction: muscle/nerve death
in 6 hours

. Compartment syndrome

. Your exam may limit complications

Open Fracture: Diagnosis

. Some open fractures
are more difficult to diagnose than others . If a wound does not stop bleeding
. Persistant oozing

Open fracture: Initial treatment

. Examine extremity distally
. Check pulses
. Check for swelling
. Check Hgb

Open fracture: Initial treatment

. Clean wound
. Flush with saline
. Wrap with a betadine soaked dressing
. Splint extremity
. IV antibiotic
. Tetanus


Open fracture: treatment

. Operative
. Washout out fracture
. Remove all dead tissue
. Fixation of fracture
- internal
- external

Reasons to debride open fractures

. Wound infections: residual debris in soft tissues

. Osteomyelitis: debris in bones, bone infection

Timing of debridement . 6 hour rule

. Really depends on the injury

Timing of debridement

. Pediatric open fractures

. Good evidence that debridement and fixation with in 24 hours gives excellent results

Timing of debridement

. Fractures with massive soft tissue injury should be treated expediently

. Pulseless limbs

. Compartment syndrome are priorities

Long bone fractures

. Fractures of the femur can result in 2 to 4 units of bleeding into the thigh . Multiple long bone fractures can lead to hypotension
. follow ATLS guidelines

Multiple long bone fractures

. These patients will bleed significantly . You may have to wait for OR availability . Continue to check the hemaglobin every 1-2 hours . You can prevent hypotension, MI, death

Long bone fractures

. Treat first with splinting or traction

. What other injuries does the patient have?

Long bone fractures

. Femur fractures

. treated with intramedullary rodding
. healing >95%
. allows for weightbearing

Long bone fractures

. Tibia fractures

. most treated with intramedullary rodding . allows for weightbearing

Long bone fractures

. Humerus
. Forearm
. most treated with plating

Articular fractures/dislocation

. Dislocations should be diagnosed . Should be reduced

. Local/general anesthesia

Articular fractures/dislocation

. Examine for pulses

. If no pulse first reduce fracture

. Recheck pulse with doppler

. If no pulse this is a vascular emergency

Articular fractures/dislocation

. Should be done as soon as possible . Blood supply may be hurt . May lead to osteonecrosis . May make articular cartilage damage worse

Articular fractures/dislocation

. Not all dislocations are reducable

. Tendons or ligaments may get stuck preventing reduction

Articular fractures/dislocation

. Injury to the articular cartilage leads to:
- malalignment of the joint
- early arthritis


Articular fractures/dislocation

. Open reduction is required
. Must see cartilage surface and fix . Often held with plates

Articular fractures/dislocation

. May require external fixation
. Delayed open treatment to allow for reduction of swelling

. Compartment syndrome

. Muscles are contained within fascial compartments
. A compartment can hold more than one muscle . Nerves and arteries also run through the compartment

Compartment syndrome causes

. Swelling of a muscle from
- trauma
- revascularization

. Bleeding from
- vessel damage
- muscle tears

. External cast or dressing too tight

Compartment syndrome

. Signs of compartment syndrome
- Pain out of proportion to the injury
- Swelling of the area

. Late signs
- decreased sensation
- decreased strength

Compartment syndrome

. Beware:
. Some patients cannot tell you about pain
- overnarcotized
- sedated
- drug overdose
- psychiatry problem
- other distracting illness

Compartment syndrome

. Beware:
. well leg compartment syndrome
. during surgical procedure
. lithotomy position

Compartment syndrome

. Patients to worry about
- tibia fractures
- tibial plateau fractures
- patients casted after injury
- polytrauma patients
- drug overdose./ unconscious
patients

Compartment syndrome

. How to detect
. High level of suspicion
. Pressure monitor

Where is the monitor?
. OR desk
. ER
. Floor
. Make sure battery works
. Needles come sterilely

Compartment syndrome

. If pressure is high
. Fasciotomy
. do not skimp on length . make sure all compartments are released

Compartment syndrome

. After fasciotomy . delayed closure . sometime skin grafting is required

Missed compartment syndrome

. leads to death of muscle
. leads to death of nerves
. contracture
. paralysis
. chronic pain
. numbness

Compartment syndrome

. Awareness
. Part of the injury
. You can make a difference

Deep vein thrombosis

. All orthopedic patients are at risk
. All trauma patients are at risk
. Can lead to
- fatal pulmonary embolus
- post thrombotic syndrome

Deep vein thrombosis

. Evaluate all patients on admission
. All should receive compression devices in hospital
- SCD or foot pump
- Only work when they are on!!!

Deep vein thrombosis

. Thromboprophlaxis should be thought about in all patients

. Patient risk should be assessed
- history of blood clots: self or family
- fracture
- imobilization
- cancer
- obesity

Prevention in high risk patients
. Low molecular weight heparin
. Warfarin (INR 2.0-3.0)
. Factor Xa inhibitor

Diagnoses

. High index of suspicion
. Added awareness that this is part of the injury
. Prevention
DVT or PE: diagnosis
. DVT: Limb swelling or pain
. Ultrasound limb
. PE: hypoxemia, taccycardia
. Spiral CT scan

Delirium

. Associated with trauma
. Especially the elderly patient
. Avoid excess narcotic/anxiolytics
. Reorientation

Decubitus ulcers

. Associated with trauma, starts in the ED
. Can be the longest thing to heal
. Check the ankles/sacrum
. Appropriate beds/padding

Conclusion: Awareness

. Orthopaedic emergencies
. Complications in trauma are associated with the condition
. Know what can happen

Conclusion: Bleeding
. treat ABCs
. check hemoglobin in bleeding patients
. determine source of bleeding
. diagnose open fractures

Compartment syndrome

. Part of the injury
. Evaluation
. Unaware patients!!!!!
. Fasciotomy

Conclusion:

Deep Vein Thrombosis
. Part of the injury
. Prevention in trauma patients
. Prophylaxis: mechanical, chemical