Primary Care Office Orthopedic Emergencies/ Urgencies

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Collin Logan
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1 Primary Care Office Orthopedic Emergencies/ Urgencies Joshua Crum M.D. Hill Country Sports Medicine San Marcos, TX

3 Goals Define what constitutes and orthopedic emergency/urgency Know what conditions need immediate attention Talk about specific examples

4 Definition A Musculoskeletal Injury that potentially will lead to complications, future impairment, or loss of life or limb if not treated with appropriate expeditious care

5 Importance Missing, Ignoring, or not expediting care can result in disastrous consequences

6 Classifications Neurovascular Injuries Compartment Syndrome Open Fractures Open Joints Joint Dislocations Septic Joints

8 Compartment Syndrome A potentially devastating condition caused by increased interstitial pressure within an enclosed compartment Occurs when compartment pressure rises to a level that impedes vascular perfusion gradient across tissues capillary beds Prolonged ischemia causes cellular anoxia, muscle ischemia, and death

9 Compartment Syndrome Anatomy of leg: 4 compartments Anterior Lateral Superficial posterior Deep posterior

10 Compartment Syndrome Anatomy of forearm: 2 compartments Volar Dorsal

11 Compartment Syndrome Anatomy of thigh: 3 compartments Anterior Medial Posterior

12 Compartment Syndrome Anatomy of foot: Many Compartments

13 Compartment Syndrome Causes Fractures Closed and Open Contusions/Soft tissue Trauma Intercompartmental bleeding/bleeding disorders Vascular Injuries/Post ischemic Swelling Burns Snake Bites

14 Compartment Syndrome The 6 P s Pain Pressure Paralysis Paresthesias Pallor Pulselessness Severe pain Pain with Stretch Tense Compartment Tight shiny skin Late Findings Paralysis Loss of Pulses

reached when compartment pressure is elevated to

15 Compartment Syndrome Compartment Pressure Monitoring Ischemia threshold of normal muscle is reached when compartment pressure is elevated to 20 mmhg below the diastolic pressure, or 30 mmhg below MAP

16 Compartment Syndrome Clinical Exam A dramatically swollen/tense limb Dramatic pain with squeeze of compartment Paresthesias

$humerus fracture Delay in$ tense swelling several

17 Example 1 6 year old with a displaced supracondylar humerus fracture Delay in treatment Child develops tense swelling several hours after injury Unable to move fingers

18 Example 1 Develops muscle necrosis Results in Volkman s Ischemic Contracture

19 Example 2 15 year male Bike vs. Car Tib/Fib Fx Numbness in foot Extraordinary pain with passive flex/ext of toes Tight Compartments

20 Example 2 Initially leg swollen but compartments compressible. 6 hours after surgery started developing Increased pain and loss of sensation in foot. Re-exam: compartments firm, pain with passive stretch

21 Example 2 Taken emergently to OR for 4-compartment fasciotomy.

22 Definitive fixation with plate/screws Example 2

24 Neurovascular- Etiology Fracture or Dislocation Kinking or laceration of vessel Direct/Penetrating Trauma Knife wounds, Lacerations Direct Compression Tight casts, Ring Burns

25 Hand/Finger Lacerations Common Injury Digital Artery(s) Digital Nerve Flexor tendons Thorough Neurovascular exam Pallor/Capillary refill Sensory exam (pinprick or 2 point discrimination Tendon Exam

26 Ring Burns Circumferential Burn around finger Car batteries, Electrical systems Skin contracture can act as digital tourniquet Requires escarotomy if vascular compromise

28 Definitions An open fracture occurs when the skin overlying a fracture is broken, allowing communication between the fracture and the external environment Inside-Out: Bone breaks and breaks out through the skin Outside-In: External tissue trauma breaks through skin and communicates with the underlying fracture

29 Avoid the term Compound Definitions Open Communited

30 Classification Type I: Small wound (<1cm), usually clean; low energy Type II: Moderate wound (1-10cm), minimal soft tissue damage or loss; low energy Type III: Severe skin wound, extensive soft tissue damage; high velocity

31 Complications Soft tissue infection Osteomyelitis Tetanus Skin loss Non-union

32 Treatment DOs: Brief inspection of wound Cover with dressing Splint IV Abx Urgent I&D DON Ts: Repeatedly uncover wound to show people Replace protruding bone Explore wound Clamp Vessels

33 Treatment Antibiotics Simple grade I - Cephalosporin Grade III - Cephalasporin + Gentamycin Soil Contaminated - Cephalasporin + Penicillin G I & D Open phalanx fractures OK to do in clinic Everything else OR Obtaining Clean wound initially takes precedent over definitive fixation of fracture

$open fracture Remove Nail,$

34 The More Subtle Open Fractures Open distal phalanx fx with proximal nail avulsion Treat like an open fracture Remove Nail, I&D, Nail bed repair 5 days course of antibiotics

35 Fingertip Amputations Abx, tetanus, I&D Soft tissue coverage Shorten bone Various Flap coverage

36 Nail bed Lacerations Abx, tetanus, I&D Soft tissue coverage Shorten bone Various Flap coverage

38 Open Joints Occur with penetrating trauma to soft tissue over joint Outside-In Must violate skin, subcutaneous tissue and Joint Capsule

39 Open Joints Occur with penetrating trauma to soft tissue over joint Outside-In Must violate skin, subcutaneous tissue and Joint Capsule

40 Open Joints Occur with penetrating trauma to soft tissue over joint Outside-In Must violate skin, subcutaneous tissue and Joint Capsule If uncertain can do Methylene blue test Inject cc See if blue extravasates from wound

41 Open Joints- Treatment Arthrotomy and I & D of joint space IV Abx Careful Follow-up

42 Fight Bites Most Common over MP joints of fingers Essentially a human bite injury Should all be treated by I&D Arthrotomy if penetrate the extensor tendon or joint capsule Staph, Strep, Cornyebacterium, Eikenella Amoxicillin/Clavulanic acid

44 Joint Dislocations When a joint moves grossly out of position Shoulder Elbow PIP joint Sternoclavicular Can potentially cause Neurovascular injury

45 Shoulder Dislocations Most Common is Anterior Dislocation associated with trauma Second most common is posterior Often related to seizure

46 Shoulder Dislocations Prominence of Acromion Limited ROM Hard to tell on obese patients

$lesion Glenoid fracture Rotator Cuff tear Especially in the older$

47 Shoulder Dislocations Associated Injuries Bankart tear Hill Sach s lesion Glenoid fracture Rotator Cuff tear Especially in the older patient

48 Plain Films Diagnostic But must get adequate views! Radiology Standard Anterior Dislocation

49 Plain Films Diagnostic But must get adequate views! Radiology Posterior Dislocation

50 Plain Films Diagnostic But must get adequate views! Radiology

51 Reduction Maneuvers Important to get patient relaxed! Often can reduce without medications if caught early IV sedation Intra-articular lidocain injection

52 Reduction Maneuvers Traction/Countertraction

53 Reduction Maneuvers Stimson Technique

54 Reduction Maneuvers Kocher Method

55 Reduction Maneuvers Ram your foot into armpit and pull like hell aka Hippocratic Technique

56 Confirm Reduction with x-rays Regular Sling Gentle Codman s Follow-up with Orthopedist Aftercare

$Dislocation with fracture radial head most common,$

58 Elbow Dislocations 2 nd most common large joint dislocation Usually Closed and Posterior Fall on extended Elbow Simple: dislocation without Fracture Complex: Dislocation with fracture radial head most common, followed by coronoid

59 Elbow Dislocations Neuropraxia involving median or ulnar nerve in 20% of elbow dislocations Most Neuro Deficits are Transient

60 Treatment Prompt Reduction Posterior Splint and Sling Simple Dislocations are quite stable and do well Complex dislocations can re-displace and may require surgery

62 PIP Dislocations Most common Dorsal Hyperextension injury Volar plate always injured Simple Dislocations Prompt reduction Dorsal splint for 1 wk Early ROM

63 PIP Dislocations Fracture dislocations Usually involve avulsion fx of volar plate attachment If large may lead to persistent joint dislocation/subluxa tion

65 Sternoclavicular Dislocations Proper recognition important because some may be life threatening MVA s and athletic injuries 80% of SC dislocations Significant force required

66 Sternoclavicular Anatomy Strong capsular ligaments Medial Clavicular physis last to close- age 20-25

67 Sternoclavicular Dislocations Anterior dislocation far more common Posterior dislocation Compression of trachea, esophagus, great vessels Pneumothorax

68 Sternoclavicular Dislocations Clinical exam most important But can be difficult due to swelling X-rays difficult to interpret CT scan most useful

69 Sternoclavicular Dislocations- Treatment Anterior Dislocations Most do well with conservative tx Consider closed reduction if significantly displaced Posterior Dislocations

70 Thank You

Basic Care of Common Fractures Utku Kandemir, MD

Basic Care of Common Fractures Utku Kandemir, MD Assistant Clinical Professor Trauma & Sports Medicine Dept. of Orthopaedic Surgery UCSF / SFGH History Physical Exam Radiology Treatment History Acute trauma