Common pitfalls in orthopedics

Common Orthopedic Pitfalls Common Orthopedic Pitfalls

for Emergency Specialistfor Emergency Specialist

The Emergency Specialist’s The Emergency Specialist’s

ApproachApproach

For Orthopaedic Patient

Why is consultation necessary?Why is consultation necessary?

“Call for help” in emergency

Admission

Equivocal diagnosis

Follow-up plan

Orthopedic Consultation in the Orthopedic Consultation in the Emergency DepartmentEmergency Department

"In many cases, such as fracture of the hip, the need for hospital admission and/or orthopedic consultation in the emergency department is obvious. In some situations, however, differences of opinion may exist among emergency physicians and among orthopedists as to whether the patient needs to be seen by an orthopedist in the emergency department, or whether the patient may be treated in preliminary fashion and referred for subsequent definitive orthopedic management. Even patients with injuries that ultimately may require surgical repair, such as an unstable ankle fracture, sometimes may be immobilized and discharged for prompt orthopedic follow-up.The physiology and potentially catastrophic consequences of compartment syndrome are described in Chap. 278. In cases of known or suspected compartment syndrome, orthopedic consultation should be obtained promptly. Emergency surgical intervention may be required to try to avert permanent tissue damage and muscle contracture...."

Orthopedic Consultation in the Orthopedic Consultation in the Emergency DepartmentEmergency Department

Sections: Compartment Syndrome, Irreducible

Dislocation, Circulatory Compromise, Open

Fracture, Injuries Requiring Surgical Repair.

Topics Discussed: blood circulation; compartment

syndrome; dislocations; fractures; fractures, open;

muscle injury; musculoskeletal system; orthopedics;

skeletal injury.

Tintinalli 6Tintinalli 6thth Edition Edition

1651 - 1805

Orthopaedic EmergencyOrthopaedic Emergency

Examples?

Orthopaedic emergencyOrthopaedic emergency

• Trauma

Non-trauma

- Osteomyelitis, Septic arthritis, Pyomyositis

- Gouty arthritis

- C1 - C2 subluxation

(Grisel’s syndrome, Rheumatoid arthritis)

- Acute disc syndrome

Management in Musculoskeletal InjManagement in Musculoskeletal Inj

uryury

R = Rest

I = Ice

C = Compression

E = Elevation

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ประคบด้�วิยน้ำ�าแข็�ง 15 – 20 น้ำาทำ� แล้�วิพั�ก 5 น้ำาทำ� สล้�บไปจน้ำไม่$บวิม่

เพั��ม่ข็&�น้ำ

Principles to approach severe Principles to approach severe musculoskeletal injurymusculoskeletal injury

A. First aids

B. Initial treatment of major fractures / dislocation

C. Standard radiographs of fractures / dislocation

D. Immediate definitive treatment of fracture /

dislocation

Principles to approach severe musculoskeletal injury

A. First aidsA. First aids

Bleeding control

Immobilization

Pain control

Antibiotic administration

Tetanus prophylaxis

Improve microcirculation


Technique of Immobilization Technique of Immobilization

1. Check distal neurovascular status; if no pulse:

equivocal to gentle traction until pulse return

2. Treat any wound โด้ยการป(ด้แผล้3. Pad bony prominence โด้ยการป ผ�าหร+อบ,ด้�วิย

สาล้�4. Apply adequate splint; 1 joint (bone) above 1

joint (bone) below in nearly normal position

5. Reassess distal neurovascular status

Methods of immobilizationMethods of immobilizationSplinting; wooden, commercialBrace or supportStrapSlab immobilizationCast immobilizationTractionExternal fixationOpen reduction and internal fixation

Purpose of immobilizationPurpose of immobilization

Temporary

Definite

Complication of immobilizationComplication of immobilization

Too fit

Too loose

Too long interval

Too short interval

; pressure sore, compartment syndrome

; inadequate immobilization (loss reduction, delayed, mal or nonunion)

; muscle atrophy, osteoporosis, joint stiffness, maceration of skin

; inadequate immobilization (loss reduction, delayed, mal or nonunion)

A. Taylor brace

B. Chairback

brace

C. Jewett hyperextension brace

D. Lumbosacral support

Strap immobilizationStrap immobilization

Figure of eight strap

Gibney’s strap

Velpeau’s strap

; A band or slip used in attaching parts to each others

Gibney’s strapGibney’s strap

Ankle sprain

Nondisplaced fracture of ankle

Velpeau’s strapVelpeau’s strap

Injury of shoulder region

Slab immobilizationSlab immobilization

U or Sugar tong slab for humerus fracture

U slab for fracture of forearms

Short or long arm slab with or without thumb spica

Short or long leg slab

Mid-leg mid-thigh slab

Sugar tong slabSugar tong slab

Fracture of humeralshaft

U slab for fracture of forearmsU slab for fracture of forearms

Fracture of forearm

Fracture of distal radius or ulna

Short arm slabShort arm slab

Long arm slabLong arm slab

Thumb spica slabThumb spica slab

Short leg slabShort leg slab

Long leg slabLong leg slab

CastingCasting

How to get success in treating fracture by casting

1. Good soft tissue hinge

2. Potential for three-point fixation

3. Proper immobilization

- Degree of deformity

- Fracture type (simple, oblique, spiral)

Three point fixationThree point fixation

Produce tension in the intact soft tissueProduce compression across the fracture sites to immobilize

the fracture

* This principle is used in nearly all immobilization technique for fractures

* A straight cast will usually contain a crooked bone, but a curved cast will generally contain a well-aligned bone

Advice to give patients before Advice to give patients before castingcasting

Objectives and advantages of casting

Duration of casting

Activities to do and not to do during casting

Good co-operation is needed

Complications of castingComplications of casting

Pressure sores

Cast sores

Measured time from the point which the plaster is wetted to

the point at which the cast has become firm

A period during setting time when the plaster became dry or

sticky like rubber and color changed. At this point, the

plaster should keep still without any movement or molding

Setting time

Critical setting time

Duration for completely dry of plaster of Duration for completely dry of plaster of ParisParis

Wettness of plaster

Number of plaster

Humidity of environment

Ventilation

Depend on

Normally 48 – 72 hours

Well-molded, one solid piece Laminated layer

Casting Casting Short or long arm cast with or without spica

Hanging cast

Short or long leg cast

Cylinder cast

Functional cast ; patellar tendon bearing

castBoot cast

Bolero cast

Shoulder spica cast

Hip spica cast

Minerva cast

Body jacket

Casting (cont.)Casting (cont.)

Short arm Short arm thumb thumb

spica castspica cast

Long arm castLong arm cast

Hanging Hanging castcast

Long leg castLong leg cast

Sarmiento or Functional castSarmiento or Functional cast

Bolero castBolero cast

Shoulder spica castShoulder spica cast

Hip spica castHip spica cast

Adult hip spica Adult hip spica castcast

Minerva castMinerva cast

Body jacketBody jacket

TractionTraction

Skin traction

Skeletal traction

Skull traction

Skin tractionSkin tractionBuck’s traction

1861 by Gurdon Buck

Full extension

Modified Buck’s tractionModified Buck’s traction

Bryant’s traction

The treatment of choic

e for fracture shaft of f

emur (esp. subtrochant

eric fracture) in infant

young children

Skin tractionSkin traction

Skeletal tractionSkeletal traction

1 lbs of traction for every 7 lbs of body weight(usually uncomfort if > 35 lbs)

Skeletal traction in Skeletal traction in upper extremitiesupper extremities

Dunlop traction for supracondylar fractureIn children

Overhead olecranon pin traction

Skull tractionSkull traction

Gardner-Wells tong

Crutchfield tongs

Skull tractionSkull traction

Halo Vest

Exception for non-immobilizationException for non-immobilization

Surgical neck fracture of humerus in elderly

Stable fracture of radial head and neck

Minimal displaced fracture calcaneus

Early, protected, gentle active motion

Principles to approach severe Principles to approach severe musculoskeletal injurymusculoskeletal injury

A. First aids

B. Initial treatment of major fractures / dislocation

C. Standard radiographs of fractures / dislocation

D. Immediate definitive treatment of fracture /

dislocation


B. Initial treatment of major fracturesB. Initial treatment of major fractures Shock in orthopaedic patient

- Hypovolemic shock

- Neurogenic shock Major fracture

- Pelvis

- Spine (cervical)

- Femur

- Multiple fractures

- Hip


(shock)

(shock)

(shock)

(shock)

Associated injuryAssociated injury

Fracture pelvis ; Urethral injury

Fracture scapula ; Shoulder, chest

Fracture calcaneus ; Spine (thoracolumbar

region)

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Clinical stable

Waiting time α Stability of condition

C. Standard radiographs of C. Standard radiographs of fractures / dislocationfractures / dislocation


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x-ray x-ray อะไรบ�างอะไรบ�างChest

Cervical spine (lateral cross table, including

C1 - C7)

Pelvis

D. Immediate definitive treatment D. Immediate definitive treatment

of fractureof fractureกระด้ กห�กทำ��ไม่$จาเป/น้ำต้�องผ$าต้�ด้ สาม่ารถูด้&ง reduce

ทำ�� ER ได้�; intrahematoma block

กระด้ กห�กทำ��ต้�องใช้�การด้ม่ยาสล้บช้$วิยใน้ำการด้&ง

กระด้ กห�กทำ��พัยายาม่ด้&งให�เข็�าทำ��ทำ��ห�องฉุ,กเฉุ�น้ำแล้�วิแต้$

ไม่$สาเร�จPrinciples to approach severe musculoskeletal injury

Objective of treatment in Objective of treatment in

orthopaedic patient orthopaedic patient

1. Good function

2. Prevent further degenerative changes

3. Acceptable clinical appearance

Management of Common Management of Common

Fractures and DislocationsFractures and Dislocations

DefinitionDefinition

Fracture

: Structural break in continuity of bony cortex

Dislocation

: Displacement of a partSubluxation

: Incomplete or partial dislocation

Stability of jointStability of joint

depend onReciprocal contours of the opposing joint

surfacesIntegrity of the fibrous capsule and

ligamentsProtective power of muscles that move the

joint

Special types of fracturesSpecial types of fractures

Stress fractures

Pathological fracture

Epiphyseal plate injury

Birth fracture

Stress fractureStress fracture

Common at

Metatarsal bone 2nd, 3rd and 4th (March

fracture)

Distal fibula (runner)

Proximal tibia (jumper and ballet dancer)

Birth fractureBirth fracture

Clavicle

Humerus

Femur

Spine

Diagnosis of joint injuriesDiagnosis of joint injuries

Joint swelling

Deformity ; angulation, rotation, loss of nor

mal contour, shortening

Abnormal movement

Local tenderness

Abnormal finding on X-ray

Common affected part related to Common affected part related to age of patientage of patient

Epiphyseal plateLigament, tendon, or muscleBone

Suspected fracture or dislocationSuspected fracture or dislocation

First pass evaluation

Focused evaluation

Physical examination

Analgesia

Studies

Suspected fracture or dislocationSuspected fracture or dislocationFirst pass evaluation

- Remove all rings and jewelry

- Keep the suspected fracture immobilized

- Patient NPO while awaiting x-rays or ortho consult

Focused evaluation

- Determine the history whether the injury is acute or chronic or due to trauma overuse


Physical examination esp distal to suspected injry

- Circulation; pulse, capillary refill, or Doppler

- Sensation; light touch, 2-point discrimination

- Palpation; bony deformity or tenderness

- Motor; motor and nerve function

- Entire extremity; examine including the joint above and below the injury

Analgesia


Studies

- Obtaining x-ray when obvious deformity, any bone tenderness, severe decreased range of motion, or significant swelling

- If a fracture is seen always look for a second fracture (the most commonly missed) and consider x-ray of the joint above and below the injury


Studies- Acute injury to the foot and ankle; using Ottawa Ankle Rules to order x-ray

1. Ankle films; For pain near the ankle and inability to bear weight (4 steps) both immediately after injury and in ED or bony tenderness at the posterior edge or inferior tip of either malleolus2. Foot films; For midfoot pain and inability to bear weight both immediately after injury and in the ED or bony tenderness in navicular area or base of 5th metatarsal

Suspected fracture or dislocationSuspected fracture or dislocationHow to present to orthopedic surgeon

- Open or closed fracture

- Exact anatomic location

- Simple versus comminuted

- Position; displacement, angulation

- Complete versus incomplete

- Articular (joint) involvement

Suspected fracture or dislocationSuspected fracture or dislocation- Position; displacement, angulation

1. Displacement: 50% displacement means the distal fragment has shifted sideways toward the dorsal surface of the extremity a distance of about 50% the thickness of the fractured bone

2. Angulation: the sharp angle and its direction (dorsal, volar) is your angulation

* As displacement and angulation increases, the risk of nonunion and compartment syndrome, and thus the need for operative management

How to describeHow to describe

Site

Extent

Configuration

Relation between fragment

Relation to external environment

Complications

SiteSite

Diaphyseal

Metaphyseal

Epiphyseal

Intraarticular

ExtentExtent

Complete

Incomplete

- Hairline

- Plastic deformation

- Buckle

- Greenstick

ConfigurationConfiguration

Transverse

Oblique

Spiral

Comminuted

Relation between fragmentRelation between fragment

Nondisplace

Displace

Relation to external environmentRelation to external environment

Closed

Open

ComplicationsComplications

Uncomplicated

Complicated

Duration for bone healingDuration for bone healing

Age

Location and configuration of fracture (more

muscle, more cancellous and oblique or spiral)

Degree of displacement

Blood supply at fracture site (femoral neck,

scaphoid and talus)

Complication of fracturesComplication of fractures

Early

Late

Goal of treatmentGoal of treatment

Pain free or less

Good healing

Good alignment

Good function

Acceptable alignment

Methods of treatment for Methods of treatment for

closed fractureclosed fracture

Protection alone

External splinting

Closed reduction and immobilization

Closed reduction by continuous traction and

immobilization


closed fractureclosed fracture

Closed reduction and skeletal traction

Open reduction and Internal fixation

Excised of the fracture fragment and

prosthetic replacement


open fractureopen fractureCleansing of the wound

Debridement

Treatment of the fracture

Closure of the wound

Antibiotics

Prevention of tetanus

Different point of musculoskeletal Different point of musculoskeletal injury between children and adultinjury between children and adult

More incidence of fracture in childrenMore stronger and more rapid growth of periosteum More difficult to diagnoseMore ability of remodelingDifference in treatment or complicationLess incidence of ligamentous injury or dislocationLess tolerability to blood loss

Prognosis of epiphyseal plate injuryPrognosis of epiphyseal plate injury

Type of injury

Age of patient

Blood supply of the epiphysis

Method of reduction

Open or closed injury

Before any treatmentBefore any treatment

Firstly Do No Harm

Acceptable AlignmentAcceptable Alignment

Indication form SurgeryIndication form Surgery

Proper TreatmentProper Treatment

Open FractureOpen Fracture

1

2

3

4

5

6

Open fractureOpen fracture

The fracture in which a break in the skin and

underlying soft tissues leads directly into or

communicates with it and its hematoma

DiagnosisDiagnosis

Small puncture wounds and deep abrasions on extremities with f

ractures

The presence of crepitance (subcutaneous emphysema from trap

ped air due to open wounds or gas gangrene)

Fluctuance from soft tissue stripping and internal degloving are s

igns of extensive soft tissue damage. (even a small puncture wou

nd or laceration that appears remote from the fracture may indee

d communicate with the fracture)

Air can be sucked into the soft tissues of an extremity

as a result of penetrating or blunt trauma because of the

occurrence of a temporary vacuum phenomenon, as

energy is dissipated throughout the soft tissues.

Gas can also be produced by Clostridium perfringens

and enteropathogens such as Escherichia coli.

The presence of air or gas in the soft tissues on initial

radiographs in the presence of a fracture strongly suggests

an open fracture.

Injecting sterile saline or methylene blue to

distend the joint capsule and watching for fl

uid extravasation from the open wound

(not 100% sensitive)

Open fractureOpen fracture

Classification

What to do at ER

- Irrigation ด้�วิย NSS เพั+�อกาจ�ด้แล้ะเจ+อจางส��งแปล้กปล้อม่แล้ะ ป(ด้ด้�วิย sterile dressing ห�าม่explore แผล้ - Tetanus prophylaxis

- Start antibiotic IV หร+ออย$างช้�าก$อน้ำ start debridement

ให�เหม่าะสม่ (S. Aureus, or Gram negative)

Infection rateInfection rate

Type I ; 0 – 2 %

Type II ; 2 – 7 %

Type III ; 10 – 50 % (26 – 41%)

IIIA : 10 %

IIIB : 10 – 50 %

IIIC : 25 – 50 % (amputation rate > 50 %)

Recommendations for acute Recommendations for acute management of open fracturesmanagement of open fractures

1. Airway management and urgent resuscitation (ABC)

2. Immobilize the injured extremity and apply sterile dress

ing to the wound.

3. Administer early intravenous antibiotics.

4. Perform urgent operative wound debridement and irriga

tion, leave the wound open, and stabilize unstable skelet

al injuries.

5. Perform repeated debridements, as needed.

6. Delay wound closure/coverage.

Examination of the wound and Examination of the wound and initial emergency initial emergency

managementmanagementForeign bodies or obvious debris such as

leaves, stones, or grass found in open

wounds should be manually removed with

sterile forceps.

If the patient will be going to surgery within 1 or 2 hours

of injury, the wound can be covered with a sterile

bandage and the patient transported to the operating

room for definitive irrigation and debridement.

If the patient will not get to the operating room for

several hours, we prefer to irrigate the wound with 1 to 2

L of saline fluid before placing the sterile dressing

Povidone interferes with osteoblast function

Predebridement culture from the wound in the

emergency department before administration

of antibiotics or any antiseptics is not useful

Orthopaedic patients : AntibioticOrthopaedic patients : Antibioticss

Cefazolin

Cloxacillin

Gentamicin

Amikacin

Metronidazole

Clindamycin

Ofloxacin

Cotrimoxazole

May result from 1. Internal cause; inflammation and edema in a closed compartment, fracture, significant soft tissue injury, arterial injury leading to ischemia, necrosis, burns2. External cause; prolonged external compression

Calculate the perfusion by measuring the disastolic pressure in the involved extremity; then subtract the measured compartment pressure. A perfusion pressure of < 30 mm Hg in a symptomatic patient is an indication for fasciotomy

Compartment SyndromeCompartment Syndrome

Compartment SyndromeCompartment SyndromeWhen treated case of multiple fractures or

with significant fractures (long bones, large degree of displacement or angulation), the following complications should always be kept in mind1. ARDS (due to fat embolism or pulmonay contusion)2. Thrombo-embolic disease3. Atelectasis4. Compartment syndrome

ทำ$าน้ำจะทำาอย$างไร?

Traumatic amputationTraumatic amputation

Appropriate technique to keep the amputated part

1. Keep moist by gauze with NSS or RLS and put

in a plastic bag or cup

2. Soak in RLS in a plastic bag or sterile cup, then

keep cold by ice (not dry ice)

* Safety time for inappropriate technique for warm

ischemia ; 6 hr

* Safety time for inappropriate technique for cold

ischemia ; 12 hr (fingers ; 30 hr, but less in major

limb according to more muscles involvement)

* The amputated part should be sent for X-ray

Traumatic amputation

Traumatic amputationTraumatic amputationIndication for replantation

1. Thumb

2. Multiple digits

3. Metacarpal (palm)

4. Almost any part in a child

5. Wrist or forearm

6. Elbow or proximal arm (sharp, moderate severe

avulsion in a young patient)

7. Individual digit distal to FDS insertion

Traumatic amputationTraumatic amputationContraindication for replantation

1. Severely crushed or mangled part

2. Multiple levels

3. Serious co-injury or diseases

4. Arteriosclerosis

5. Mentally unstable

6. Individual digit proximal to FDS insertion

7. Prolonged warm ischemia

Mangled Extremity Severity Mangled Extremity Severity

Score (MESS)Score (MESS)

A. Skeletal / soft tissue injury

B. Limb ischemia

C. Shock

D. Age

* If the total score is < 7, the limb is nearly almost compatible with salvageable limb.

A score of less than 7 points suggests that salvage should be attempted. Conversely, amputation should be considered if the score is more than 20 points.

Open Knee InjuryOpen Knee Injury

Pitfalls of Pitfalls of

Musculoskeletal Problem Musculoskeletal Problem

in Childrenin Children

Staging of fracture in young childrenStaging of fracture in young children

Incomplete Fracture1. Plastic deformation

2. Greenstick fracture

3. Buckle fracture

4. Torus fracture

Complete Fracture

Do you know these?Do you know these?

Fracture of Necessities (Fracture of medial or

lateral condyle fracture, supracondylar

fracture)

Triplane Fracture

Tillaux’s Fracture

Three Part FractureThree Part FractureTwo Part FractureTwo Part Fracture

Common Musculoskeletal ProblemsCommon Musculoskeletal Problems

Fracture distal end of radius

Fracture neck of femur

Shoulder dislocation

Fracture of Distal RadiusFracture of Distal Radius

Indication for surgery

1. Intra-articular step-off > 2 mm

2. Die-punch fracture

3. Significant dorsal comminution involving > 1/3 of AP diameter of radius

4. Lost reduction within the 1st week after injury

Fracture of distal radiusFracture of distal radiusGoal of treatment

1. Rapid restoration of function

2. Prevention of chronic disability

Diagnosis,

Appropriate intervention, and

Postintervention rehabilitation

Fracture of NecessityFracture of Necessity

Galeazzi’s fractureMonteggiae’s fractureLateral condylar fractureSupracondylar fracture

ImperturbabilityImperturbability

Remaining calm and unworried in spite of

problems or difficulties

The physician who shows that he is flustered

and hurried in ordinary emergencies, loses

rapidly the confidence of his patients

Five factorsFive factors

The pressure of time and volume

The variety of conditions faced

The paucity of information

The limitation of therapeutic options

The constraint of disposition

““Treat First and Ask Questions Later”Treat First and Ask Questions Later”

Most practicesMost practices

On average only 10 to 15 minutes per patient

for the evaluation, testing, treatment,

disposition, and documentation

The way of approachThe way of approach

First question to be asked and answered

in the first few seconds

Do I need to resuscitate this patient?

How great is the threat?

How soon must I act?

Management, Not DiagnosisManagement, Not Diagnosis

In emergency medicine, the central task is not

diagnosis, but management

If one can be made, it is extremely helpful, but

if not, decisions must still be made and actions

must still be taken

Decision ThresholdsDecision Thresholds

“Index of Suspicion”“Index of Suspicion”

Only one disease under consideration and

there are only two possible actions

To Treat or Not Treat

If the patient is almost certainly non-diseased

(probability is near zero), then the correct

decision is Not Treat, because treatment

entails costs and risks of its own

Very low probabilities of disease, it is better

not to test and not to treat



Very high probabilities, it is better not to test,

but to treat

Intermediate probabilities, testing and treating

only those with a positive test will produce the

best overall outcome



Common PitfallsCommon Pitfalls

Tunnel vision

“Premature closure of hypothesis generation”

Just the opposite

“Inability to see the forest for the trees”

Failure to attend to the patient

“Fail to social interaction with patient and family”

How to approach patientsHow to approach patients

Bio

Psycho

Social

Spirit

Common pitfalls in orthopedics

Health & Medicine

Transcript of Common pitfalls in orthopedics