Download Management of the mangled hand

‫بنام خداوند جان وخرد‬
ORTHOPAEDIC
EMERGENCIES
DR.Hossein Saremi
Orthopaedic surgeon
Hand&shoulder fellowship
Hamedan University of medical
sciences
Orthopaedic Emergencies
A musculoskeletal injury or condition that,
if missed, could result in additional
complications, significant impairment, or
death and needs immediate
management
Definition
• “missed” = Lawsuit
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“additional complications” = Lawsuit
“impairments” = Lawsuit
Delaied management=Lawsuit
“death” = Lawsuit
Emergent orthopaedic
conditions
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Open FX
Dislocation
Compartement syndrom
Any FX with associated vascular injury
Open FX
• the skin overlying a fracture is broken,
allowing communication between the
fracture and the external environment
• Inside-out
• Outside-in
Open FX complications
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Soft tissue infection
Osteomyelitis
Gas gangrene
Tetanus
Crush syndrome
Skin loss
Open Fx Management
DOs:
• Control the bleeding
• Cover with sterile
dressing
• Splint
• IV antibiotics
• Tetanus prophylaxis
DON’Ts:
• Scream and pass out
• Replace protruding
bone
• Explore wound
• Clamp vessels
Debridement
Conservative
debridement
Debridement
• Pasteur : It is the environment not the
bacteria that determines whether a wound
becomes infected
Open Joint
• Any open wound over or near a joint should
be assumed to extend to the joint until
proven otherwise
Dislocation
• Displacement of bones at a joint from their normal
position
• May be associated with neurovascular
injury
• Cartilage damage
Dislocation-Knee
• Anterior (31%)
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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
Dislocation-Hip
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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%
Reduction
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
Dislocation-shoulder
•Reduction (ant disloc)
•Stimson (hanging weight technique)
•Scapular Manipulation
•Leidelmeyer (external rotation)
•Milch
•Traction-Countertraction
•Reduction (post disloc)
•Traction on internally rotated and
adducted arm with pressure on
humeral head
Simple Reduction manuvere
•Post-reduction x-rays
•Reduction
•Fractures
 Post-reduction
neurovascular exam
 Axillary nerve
 Radial pulse
Follow up
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
Elbow DX
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-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-ankle
Dislocation-ankle
• Described by relationship of talus to tibia
• Usually associated with fracture
• Pre/post-reduction neurovascular exam and xrays
• Adequate analgesia vs conscious sedation
• Reduction (even if open)
• Splint
• Ortho for washout if open
Fractures ,Examine vascular
status
Compartement syndrom
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Limb threatening
Increased pressure in tight fascial compartment
Muscle necrosis at > 30mm Hg
Ischemic injury at 4 hrs
Irreversible injury 4-8 hrs
Signs: disproportionate pain, 5 P’s
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Pain
Pallor
Paraesthesiae
Paralysis
Pulseless
•120 mm Hg
•Difference between
diastolic pressure and
compartment
pressure (delta
pressure)< 30mmHg
is indication for
immediate
decompression
•Pulse
Pressure
•60 mm Hg
•Ischemia
•30 mm Hg
•Elevated Pres
•10 mm Hg
•Normal
•0 mm Hg
Causes of compartement
syndrom
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Fractures ~75%
Crush injury
Burns
Extravasation
Tourniquets, constrictive dressings/plasters
Snake bites
Management
• Early recognition!
• Urgent fasciotomies
Compartement syndrom
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Volkman ischaemic contractures
Permanent nerve damage
Limb ischaemia and amputation
Rhabdomyolysis and renal failure