Intro to Orthopedic Emergencies - RCSI Orthopaedic Emergencies - MK1

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Transcript of Intro to Orthopedic Emergencies - RCSI Orthopaedic Emergencies - MK1

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    Title Orthopaedic Emergencies

    Class Intermediate Cycle 3

    Course Musculoskeletal Education

    Title Orthopaedic Emergencies

    Lecturer  Dr Martin Kelly

    Date 06/01/016

    RCSI !oyal College o" #urgeons in Ireland Coláiste Ríoga na Máinleá inÉirinn

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    LEARNING OUTCOMES

    $  %t the end o" this lecture the student should &e a&le to'

    1( )nderstand the &asic approach to the *rauma patient

    ( )nderstand and &e a&le to recognise the main #pinalEmergencies

    3( )nderstand and &e a&le to recognise the lim&

    threatening Orthopaedic Emergencies

    +( )nderstand and appreciate ho, to diagnose and themanagement o" the main Orthopaedic pathologies

    ,hich present to the ED

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    TOICS

    1- .i"e threatening orthopaedics inuries ,ith re"erence to the %*.#  el2ic "ractures

    - #pinal Emergencies  #pinal *rauma %*.# &ased

      Cauda Euina #yndrome

    3- Musculoskeletal/.im& threatening components o" %*.#  Compartment syndrome

      Open "ractures

      *raumatic %mputation

    +- Common ED orthopaedic presentations ,ith emphasis on radiology  #eptic arthritis

      .arge oint dislocation

      4ractures

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    ATLS

    $ E2erything in clinical medicine

    resol2es around/&egins ,ith

     %5CDE

    $ #ometimes the per"ormance o"

    the primary sur2ey isnt o&2ious&ut its al,ays there  #aying hello on the ,ard

    round/OD/ED

    $ E2erything else can &e seen as

    a secondary sur2ey once li"e

    threatening emergencies ha2e&een managed

    $  % structured

    approach/a,areness are key

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    !"O TO CALL #

    $ 7ot all "ractures are

    orthopaedic

    $ May need help "rom'  8ascular surgeon  7eurosurgeon

      9eneral #urgeon

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    $% LI&E T"REATENING ORT"OAEDIC

    IN'URIES !IT" RE&ERENCE TO T"E

    ATLS

    75 el2ic "ractures

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    AIR!A( ) *REAT"ING

    Air+a,

    $ 4oreign &ody in mouth

    $ Ma:illo"acial trauma

    $ 7eck trauma$ .aryngeal trauma

    $ *racheo&ronchial tree

    inury

    $ #ternocla2icular oint

    *reathing

    $ *ension pneumothora:

    $ Open pneumothora:

    $ 4lail chest$ ulmonary contusion

    $ Massi2e haemothora:

    $ *raumatic diaphragmatic

    inury

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    CIRCULATION

    $ 5lood on the "loor 

    $ Chest

    $  %&domen

    $ !etroperitoneum

    $ el2is$ .ong&ones

     Think Blood on the foor and 5

    more

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    *LOOD ON T"E &LOOR

    $ Maor arterial haemorrhage

    $ !arely missed

    $ Can cause hypo2olaemic shock

    rapidly; especially in children

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    EL-IC TRAUMA

    $ el2ic "ractures are o" 2arying se2erity  atients can &leed to death i" the iliac 2essels are torn-

      #ome "ractures can destroy the hip oint-

      Others are little more serious than a &ad &ruise

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    EL-IC TRAUMA

    $ 4ractures and ligamentous disruption suggest maor

    "orce

    $Mechanism; usually car 2s pedestrian; motor 2ehicle andmotorcycle crashes-

    $ #igni"icant association ,ith inuries to intraperitoneal and

    retroperitoneal 2iscera and 2ascular structures-

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    SOURCES O& *LOOD LOSS

    $ atients ,ith haemorrhagic shock and anunsta&le pel2is ha2e + potential sources o"&lood loss1- 4ractured &one sur"aces- el2ic 2enous ple:us3- el2ic arterial inury+- E:tra pel2ic sources

    $ #igni"icant increase o" tears o" thoracic aorta in those

    ,ith pel2ic "ractures; esp % "ractures$ 5lood on the "loor and > more$ Intra=a&ominal sources must &e e:cluded or treated

    operati2ely

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    MEC"ANISM O& IN'UR(.CLASSI&ICATION

    $ atterns o" "orce   % compression 60=?0@

      .ateral compression 1>=0@

      8ertical shear >=1>@

      Comple:

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    ASSESSMENT

    $ *he "lank; scrotum and perianal area should &einspected uickly  &lood at the urethral meatus  .aceration in the perineum; 2agina; rectum or &uttock ,hich is

    suggesti2e o" an open pel2is "racture

    $ *esting o" mechanical insta&ility is a contro2ersial area; arapidly a2aila&le :=ray may a2oid the pain and potentialhaemorrhage associated ,ith manipulating the pel2is

    $ 4irst indication o" mechanical insta&ility is seen oninspection "or leg length discrepancy or rotationalde"ormity

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    MANAGEMENT

    $  %5C$ Mechanical sta&iliAation$ el2ic &inder

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    LONG *ONE &RACTURES

    $ 4emoral "ractures  igh impact e-g- !*%

      )p to 1>00mls &lood loss "rom sha"t "racture

      *homas splint immo&ilisation

    $ umerus and ti&ia  )p to ?>0mls can &e lost

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    CRUS" S(NDROME /TRAUMATIC

    R"A*DOM(OL(SIS0

    $ Check renal "unction and creatinine kinase in patients

    ,ho ha2e su""ered crush inuries

    $ )sually seen in patients trapped "or long time periods

    $ 7eeds IC) management ,ith !enal physician consult

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    1% SINAL EMERGENCIES

    #pinal *rauma %*.# &ased

    Cauda Euina #yndrome

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    DISA*ILIT(2SINAL TRAUMA

    $  %5CDE

    $ igh Inde: o" suspicion

    $ E:amination   %,ake 2s Comatose

    $ Imaging

    $ Cer2ical

    $ *horaco lum&ar 

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    E3AMINATION CER-ICAL SINE 4 NO AIN

    $  %,ake

    $  %lert

    $ 7o neck pain or midline tenderness

    $ !emo2e collar and palpate spine$  %sk to mo2e neck

    $ hen in dou&t lea2e collar onB

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    E3AMINATION C SINE 4 AIN RESENT

    $ Must e:clude an inury

    $  %; .ateral and E9 < Open mouth ( 2ie,s

    $ F/= C* imaging

    $ Must see C1 to *1B

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    LATERAL C SINE 4 CONTOUR LINES

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    ASSESSING LATERAL &ILM

    $ Check the top o" *1 can &e seen

    $ *race the 3 contour lines

    $ Check 2erte&ral &odies

    $ Check inter2erte&ral disc spaces

    $ Check so"t tissues

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    LONG A -IE!

    $ Check spinous process

    alignment  4acet oint dislocation

    $ Check a&normal

    ,idening o"interspinous distance

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    C$ &RACTURE

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    C$ &RACTURES

    $ 5urst

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    ANATOM(

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    C1 &RACTURES

    $ edicle / angmans "racture

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    C1 &RACTURES

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    ODONTOID EG &RACTURE T(E 1

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    T"ORACO LUM*AR SINE

    $ Compression "ractures H edge; or anterior;  account "or >0 ?0 @ o" all *. "ractures

      9enerally sta&le

      One column usually a""ected$ 5urst "ractures

      appro:imately 1> @ o" all *. inuries

      )nsta&le

      1 column e""ected

    $ 4le:ion=distraction

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    T"ORACO2LUM*AR SINE 5 COLUMN

    T"EOR(

    $ Insta&ility i" out o" 3 disrupted

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    ANTERIOR !EDGE -S *URST &RACTURE

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    DON6T &ORGET T"IS 7

    $ #pinal haematoma

    $ Intradural or epidural

    $ Joung people trauma

    $ Elderly on ,ar"arin

    2ulnera&le a"ter mildtrauma

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    CAUDA E8UINA S(NDROME

    $ Compression o" some or all o" the ner2e roots o" the

    cauda euina; resulting in symptoms that include &o,el

    and &ladder dys"unction; saddle anesthesia; and 2arying

    degrees o" loss o" lo,er e:tremity sensory and motor

    "unction

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    RESENTATION

    S,mptoms

    $ lo, &ack pain

    $ groin and perineal pain

    $ &ilateral sciatica$ loss o" &o,el or &ladder

    "unction-

    $ #u&tle hesitancy

    $ E2entually o2er"lo,incontinence

    Signs

    $ lo,er e:tremity ,eakness

    $ ypo"le:ia or are"le:ia;

    $ erineal hypoesthesia orsaddle anesthesia to

    inprick

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    EMERGENC( 7

    $ M!I use"ul &ut dont delay

    $ Early surgery to a2oid  5ladder / 5o,el incontinence

      .o,er lim& ,eakness

    $ .o, threshold "or admission

    $ Counsel patients in &ack pain clinics

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    &URT"ER READING CES

    $ G %m %cad Orthop #urg- 00L %ug  Cauda euina syndrome-#pector .!;

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    5% MUSCULOS9ELETAL.LIM*

    T"REATENING COMONENTS TO

    ATLS

    75 compartment syndrome

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    COMARTMENT S(NDROME

    $ De"inition  Ele2ation o" tissue pressure ,ithin a myo"ascial compartment

    that e:ceeds capillary pressure and compromises its per"usion

    and tissue "unction

    $ .o,er leg most common$ Can occur in arm; "orearm; hand; thigh; "oot; gluteal

    area-

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    CAUSES

    $ Compartment

    contents

    $ E:ternal

    compression

    $ Constricting cast / dressing

    $ 5urns

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    SIGNS

    $ araesthesia / 7um&ness later 

    $ ain on assi;e mo;ement o< distal =oints

    $ Disproportional generalised pain in lim&

    $*ense on palpation 7ot a sensiti2e sign$ ulse a&sent 8E!J .%*E #I97

    $ Not the same as pain, pulseless, pale, paraesthesia

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    MANAGEMENT

    $ Call help early i" suspected

    $ !emo2e cast / Dressing   !e e:amine

    $ Keep patient 7O

    $ Check CK < a"ter a&o2e done (

    $ Decompressi2e "asciotomy

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    OEN &RACTURES ) 'OINT IN'URIES

    $ Communication &et,een e:ternal en2ironment &one

    $ Muscle and skin inured and &acterial contamination

    $ rone to  In"ection

      oor healing

      oor "unction

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    OEN &RACTURES ) 'OINT IN'URIES

    $ 4racture and open ,ound in same lim& segment is an

    open "racture until pro2en other,ise$ Gustilo2Anderson classi

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    OEN &RACTURES ) 'OINT IN'URIES

    $ Management  Make diagnosis promptly

      Immo&ilise "racture

    $ Descri&e ,ound accurately and associated so"t

    tissue inury$ 7euro2ascular in2ol2ement

      rompt surgical consultation

      *etanus prophyla:is

       %nti&iotics &ased on mechanism ; consult

    micro&iology

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    TRAUMATIC AMUTATION

    $ #e2ere "orm o" open "racture that results in the loss o" an

    e:tremity

    $ *ourniuet may &e use"ul

    $ rolonged ischaemia; neurologic inury and muscle

    damage may reuire amputation

    $ .i"e o2er lim& B

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    RELANTATION

    $ ossi&ility "or replantation should &e considered

    $ Clean sharp amputations  o" "ingers

      &elo, knee or el&o,

    $ A patient +ith multiple in=uries +ho re>uiresintensi;e resuscitation and emergenc, surger, is

    not a candidate

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    AMUTATED ART

    $ ash in ringers lactate

    $ #oak in aueous penicillin

    $ rap in moisted sterile to,el

    $ laced in plastic &ag

    $ laced in cooling chest ,ith crushed ice$ *ransported ,ith patient to replantation centre

    $ Care"ul not to "reeAe

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    ?% COMMON ED ORT"OAEDIC

    RESENTATIONS

    75 #eptic arthritis

    75 .arge oint dislocation

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    SETIC ART"RITIS

    $ )sually re"ers to &acterial in"ection o" a oint  Can &e "ungal ; 2iral

    $  Adult vs Paediatric

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    ADULT SETIC ART"RITIS

    $ Emergency ,ith mortality o" 10 = 1>@

    $ redisposing "actors  Intra=articular corticosteroid inection

       %ge L0 years

      Dia&etes mellitus  !heumatoid arthritis

      rosthetic oint / !ecent oint surgery

      #kin in"ection; cutaneous ulcers

      I8 drug a&use

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    MICRO*IOLOG(

    $ #taphylococcus aureus  ealthy adults; skin &reakdo,n; pre2iously damaged oint

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    ADULT SETIC ART"RITIS

    $ #ource o" in"ection  Osteomyelitis

      Direct in"ection "rom a penetrating ,ound

      aematogenous 5acteraemia / I8D)

    $ It is more likely to localiAe in a oint ,ith pree:isting

    arthritis-

    $ )sually monoarticular &ut can &e polyarticular especiallyin !heumatoid arthritis

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    RESENTATION @ ADULT SETIC

    ART"RITIS

    $ Most common oint in2ol2ed is knee  %lso ip; ankle; shoulder; ,rist are common sites

    $ Monoarticular arthritis

      !emem&er Di""erential diagnosis

    $ ot s,ollen oint

    $ Pain with passive and active movement 

    $ Dia&etic patients can present atypically and they are atincreased risk o" in"ection   %n une:plained oint e""usion in a dia&etic should raise suspicion

    o" septic arthritis

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    DI&&ERENTIAL MONOART"RITIS

    $ In"ection

    $ Crystal induced

    $ aemarthrosis  *rauma

    $7eoplastic

    $ In"lammatory

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    IN-ESTIGATIONS

    $ Goint aspiration and "luid analysis  )# guidance i" necessary

      CC di""erential normal less 1L0/mm3

      9ram stain and culture

      .ight microscopy "or crystals in gout and pseudogout

      urulent "luid and/or positi2e gram stain indicates &acterial in"ection

    $ 5loods  45C; E#!; CR; 5lood Cultures

    $ Nrays o" in"ected oint

      7ot use"ul in diagnosis as only &ecome a&normal ,hen ointdestruction has occurred; use"ul as a &aseline "or later comparison

    $ #,a&  O" urethra; cer2i: and anorectum i" gonococcal in"ection a possi&ility

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    TREATMENT

    $  %nti&iotics "or 6/>; initially /> i-2-

    $ *reatment depends on organism concerned &ut a suita&le&lind/empirical regime ,ould &e "luclo:acillin 1=g D# i2-00mg *D#

    $ Modi"y &ased on C# results

    $ .ocal micro&iology guidelines

    $ It is +idel, accepted , orthopaedic surgeons that antiiotics

    should e +ithheld until aspiration has een per

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    T"ERE IS A SIGNI&ICANT "IG" &ALSE

    NEGATI-E RATE ASSOCIATED !IT" 9NEEASIRATION !IT" RIOR ADMINISTRATION

    O& ANTI*IOTIC T"ERA(%

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    AEDIATRIC SETIC ART"RITIS

    $ Consider in any child ,ith

    acute onset "e2er and

    pain"ul oint

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    AEDIATRIC SETIC ART"RITIS

    $ O"ten presents as limp; re"usal to ,eight &ear 

    $ E2aluate ,ith history and physical e:amination;

    la&oratory studies; including syno2ial "luid analysis; and

    imaging studies as in adult

    $ Kochers Criteria RC  hite &lood cell count 1;000

    SU&E SLIED UER &EMORAL

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    SU&E@ SLIED UER &EMORAL

    EI"(SES

    Characterised &y'

      = displacement o" the capital "emoral epiphysis "rom

    the "emoral neck through the physeal plate

    resenting 4eature

      = ip ain

      = 9ait Distur&ance

      = 1>@ present ,ith isolated thigh/knee pain

    Mean %ge o" resentation'  = 4'1yrs M'13->yrs

    SU&E SLIED UER &EMORAL

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    SU&E@ SLIED UER &EMORAL

    EI"(SES

    athogenesis@  = occurs ,hen shearing "orces applied to the "emoral

      head e:ceed the strength o" the capital "emoral

    physis

    redisposing &actors@  = O&esity

      = *rauma

      = 9enetic redisposition

      = 7ormal periosteal thinning and ,idening o" the physis

     

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    SU&E@ SLIED UER &EMORAL

    EI"(SES

    $ Management'

    = !e"erral to Orthopaedic #urgeons

      = 7on=eight&earing

      = Operati2e #ta&ilisation

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    uestions