Orthopedic Emergencies

and Urgencies
Scott Playford
LCDR, MC, USNR
Objectives
Define orthopedic emergencies/urgencies
Discuss relevance to our practice
Review specific categories and examples
Discuss initial management

Definition
A musculoskeletal injury or condition that, if missed, could result
in additional complications, significant impairment, or death
Implications/Importance
missed = Lawsuit
additional complications = Lawsuit
impairments = Lawsuit
death = Lawsuit
Orthopedic Emergencies
Open Fractures or Joints
Neurovascular Injuries
Dislocations
Septic Joints
Open Fractures
An open (or compound) fracture occurs when the skin
overlying a fracture is broken, allowing communication
between the fracture and the external environment
Open Fractures- Classifications
Compound from within (inside-out):
The broken end of the bone breaks through or pierces the skin
Compound from without (outside-in):
External violence causes laceration or tissue trauma
Higher likelihood of contamination
Open Fractures- Classifications
Type I:
Small wound (<1cm), usually clean; low energy
Type II:
Moderate wound (>1cm), minimal soft tissue damage or loss; low
energy
Type III:
Severe skin wound, extensive soft tissue damage; high velocity
Open Fractures- Complications
Soft tissue infection
Osteomyelitis
Gas gangrene
Tetanus
Crush syndrome
Skin loss
Non-union
Open Fractures- Management
DOs:
Control the bleeding
Cover with sterile dressing
Splint
IV antibiotics
Tetanus prophylaxis
Anti Gas Gangrene Serum (AGGS,
Clostridium perfringes)

DONTs:
Scream and pass out
Replace protruding bone
Explore wound
Clamp vessels
One more thing
Any open wound over or near a joint should be assumed to
extend to the joint until proven otherwise
Orthopedic Emergencies
Open Fractures or Joints
Neurovascular Injuries
Dislocations
Septic Joints
Neurovascular Injuries
Vascular trauma
Trauma to peripheral nerves
Acute compartment syndrome
Neurovascular- Etiology
Fracture
Humerus, femur
Dislocation
Elbow, knee
Direct/penetrating trauma
Embolism
Direct Compression
Cast, unconscious
Lower Extremity
Nerves- Lower Extremity
Nerve Motor Sensation Injury
Femoral Knee extension Anterior knee Pubic rami fracture
Obturator Hip adduction Medial thigh Obturator ring fracture
Posterior tibial Toe flexion Sole of foot Knee dislocation
Superficial peroneal Ankle eversion Lateral dorsum of foot
Fibular neck fracture, knee
dislocation
Deep peroneal Ankle/toe dorsiflexion Dorsal 1
st
to 2
nd
web space
Fibular neck fracture, compartment
syndrome
Sciatic nerve Plantar and dorsiflexion Foot Posterior hip dislocation
Superior gluteal Hip abduction Acetabular fracture
Inferior gluteal
Gluteus maximus hip
extension
Acetabular fracture
Upper Extremity
Nerves- Upper Extremity
Nerve Motor Sensation Injury
Ulnar
Index finger abduction
Little finger Elbow Injury
Median distal
Thenar contraction with
opposition
Index finger Wrist dislocation
Median, anterior
interosseous
Index tip flexion
Supracondylar fracture of humerus
(child)
Musculo-cutaneous Elbow flexion Lateral forearm Anterior shoulder dislocation
Radial
Thumb, finger, MCP
extension
1
st
dorsal web space Distal humeral shaft, anterior
shoulder dislocation
Axillary Deltoid Lateral shoulder
Anterior shoulder dislocation,
proximal humerus fracture
Acute Compartment Syndrome
An injury or condition that causes prolonged elevation of interstitial tissue
pressures
Increased pressure within enclosed fascial compartment leads to impaired
tissue perfusion
Prolonged ischemia causes cell damage which leads to increased vessel
permeability
Plasma leaks into interstitium causing further increase in compartment
pressure
Extensive muscle and nerve death >8 hours
ACS- Etiology
Direct blow or contusion
Crush injury
Burns
Snake bites
Fractures
Hematoma
Prolonged pressure
ACS- Findings
5 Ps
Pain
Paresthesias
Paralysis
Pulses
Palpation
Severe pain
Pain with stretch
Tense compartment
Tight, shiny skin
Late findings
Paresthesias
Paralysis
Loss of pulses

0 mm Hg
10 mm Hg
30 mm Hg
60 mm Hg
120 mm Hg
Pulse Pressure
Ischemia
Elevated Pressure
Normal
ACS- Anatomy
Upper Extremity
Deltoid
Brachium
Anteroir
Posterior
Antebrachium
Volar
Dorsal
Mobile wad
Hand
Thenar
Hypothenar
Adductor
Interosseous
Carpal canal
Finger
ACS- Anatomy
Lower Extremity
Gluteal
Tensor fascia lata
Gluteus medius and minimus
Gluteus maximus
Thigh
Anterior
Posterior
Leg
Anterior
Lateral
Superficial posterior
Deep posterior
Foot
Anterior
Extensor hallucis longus
Extensor digitorum longus
Peroneus tertius
Tibialis anterior
Deep peroneal nerve
Anterior tibial artery
Lateral
Peroneus longus
Peroneus brevis
Superficial peroneal nerve
Superficial posterior
Gastrocnemius
Soleus
Sural nerve
Deep posterior
Flexor digitorum longus
Flexor hallucis longus
Posterior tibialis
Posterior tibial nerve
Posterior tibial artery
Peroneal artery
ACS- Final Thought
Always check neurovascular status after moving patient, manipulating
injured limb, before and after applying cast or splint, and at frequent
intervals if transfer is delayed.
Orthopedic Emergencies
Open Fractures or Joints
Neurovascular Injuries
Dislocations
Septic Joints
Dislocations
Displacement of bones at a joint from their normal position
May be associated with neurovascular injury
Dislocation- Finger
Dislocation- Knee
Anterior (31%)
Caused by hyperextension
Often ACL and PCL both torn
MCL and/or LCL usually injured
Popliteal artery- intimal tear
Posterior (25%)
ACL and PCL torn
Possible tear of extensor mechanism
Avulsion or disruption of popliteal artery
Lateral (13%)
Medial (3%)
Rotary (4%)- usually posterolateral
Dislocation- Knee
Injury to popliteal artery and vein is common
Peroneal nerve injury in 20-40% of knee dislocations
With peroneal nerve injury, suspect vascular injury
Dislocation- Elbow
Second most common major joint dislocation
Usually closed and posterior
Fall on extended elbow
Posterior, posterolateral, posteromedial, lateral, medial, or divergent
Complex- dislocation with fracture (35-40%)
Radial head fracture most common
Simple- dislocation without fracture
Rupture of capsule, rupture of MCL and lateral ligaments, rupture of flexor
pronator mass, possible injury to brachialis muscle and rupture of brachial artery
Dislocation- Elbow
Nerve inury
Neuropraxia involving median or ulnar nerve in 20% of elbow
dislocations
Ulnar nerve palsies more common in pediatric
Most neuro deficits are transient
Dislocation- Sternoclavicular
Anterior
More common
Traumatic or atraumatic
Posterior
Rare
Soft tissue swelling may give false impression of anterior dislocation
Up to 25% complication rate
Hemorrhage, tracheal or esophageal injuries, pneumothorax
Dislocation- Hip
Usually high-energy trauma
More frequent in young patients
Anterior- hip in external rotation
Posterior- hip in internal rotation
Central acetabular fracture dislocation
May result in avascular necrosis
Sciatic nerve injury in 10-35%
Dislocation- Shoulder
Most common major joint dislocation
May be associated with:
Bankart lesion
Fracture dislocation
Hill sachs lesion
SLAP lesion
Rotator cuff tear
Nerve injury- axillary, posterior cord, musculocutaneous
Dislocation- Shoulder
Anterior (95%)
Arm abducted and externally rotated
Posterior (2-4%)
Arm adducted and internally rotated
Electrocution, seizure
Inferior (1%)
Hyperabduction
Usually associated with significant trauma
Orthopedic Emergencies
Open Fractures or Joints
Neurovascular Injuries
Dislocations
Septic Joints
Septic Joint/Septic Arthritis
Inflammation of a synovial membrane with purulent effusion
into the joint capsule
Usually monoarticular
2-10 cases per 100,000 in general population
Gonococcal vs nongonococcal
80% are from gram-positive aerobes (S aureus, beta-hemolytic
streptococci, and Streptococcus pneumoniae)
Septic Joint- Etiology

Direct inoculation
Trauma
Iatrogenic
Hematogenously
Adjacent osteomyelitis
Soft tissue infection
Septic Joint- Location
Knee- 40-50%
Hip- 20-25%*
*Hip is the most common in infants and very young children
Wrist- 10%
Shoulder, ankle, elbow- 10-15%
Septic Joint- Risk Factors
Prosthetic joint
Skin infection
Joint surgery
Rheumatoid arthritis
Elderly
Diabetes Mellitus
IV drug use
Septic Joint- Signs and Symptoms
Rapid onset
Joint pain
Joint swelling
Joint warmth
Joint erythema
Fever
Decreased range of motion
Pain with active and passive ROM
Septic Joint- Treatment
IV antibiotics
Drainage
Repeated aspirations
Consider lavage
Septic Joint- Treatment
Open surgical drainage indications
Difficult joint aspiration
Persistent fever and symptoms >24 hours
Leukocytosis persists >48-72 hours
Positive repeat blood or joint cultures >48 hours
Infected joint prosthesis

Septic Joint- Complications
Rapid destruction of joint with delayed treatment (>24 hours)
Degenerative joint disease
Soft tissue injury
Osteomyelitis
Joint fibrosis
Sepsis
Death
Final Thought
Open Fractures or Joints
Neurovascular Injuries
Dislocations
Septic Joints