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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 • • • • “additional complications” = Lawsuit “impairments” = Lawsuit Delaied management=Lawsuit “death” = Lawsuit Emergent orthopaedic conditions • • • • 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 • • • • • • 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%) – – – – 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 • • • • • • • 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 • • • • • • 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 o o o o o 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 • • • • • • Fractures ~75% Crush injury Burns Extravasation Tourniquets, constrictive dressings/plasters Snake bites Management • Early recognition! • Urgent fasciotomies Compartement syndrom • • • • Volkman ischaemic contractures Permanent nerve damage Limb ischaemia and amputation Rhabdomyolysis and renal failure