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. Common orthopaedic trauma emergencies . Common accompanying complications . Tips for management . Improve your care of the trauma patient Emergencies . Bleeding - Pelvic fracture - Arterial injury . Open fracture . Long bone fracture . Dislocation . Compartment syndrome . Deep vein thrombosis Remember Orthopedic emergencies come second . A irway . B reathing . C irculation Bleeding There are only so many places to bleed -chest - abdomen - pelvis - gi/gu tract - into a limb - externally Pelvic bleeding . Pelvis houses the blood vessels to the leg Pelvic fractures: vector of force vertical anterior-posterior lateral Pelvic disruption can lead to major hemorrhage Initial treatment: Diagnosis . 3 xrays are taken for all trauma patients - Lateral cervical spine -chest ap - PELVIS AP Initial management . Reduction - sheet - pelvic binder - external fixation - internal fixation . Manage bleeding - check Hgb - fluid bolus then blood transfusion - Embolization Manage the bleeding . Resuscitation: ATLS . Saline first . Blood transfusion . Frequent hemoglobin checks Embolization: arteriogram . Patient must be stable . Angiography must be available . Useful if bleeding continues despite bony stabilization External bleeding . Wounds should be examined and cleaned . Look for - Open fractures - Burns - Abrasions - Lacerations - Swelling - Bleeding Arterial injury . Pumping blood . Start with direct pressure on wounds . Check distal pulses . Consider tourniquet Arterial injury . No distal blood flow is an emergency . Pulseless limb must be treated within 2-4 hours . Longer ischemia time leads to muscle, nerve death . Compartment syndrome Pulseless limb . Check pulse . Check with doppler . Angiogram . Direct exploration . Arterial repair Pulseless limb . Must be determined immediately . Permanent dysfunction: muscle/nerve death in 6 hours . Compartment syndrome . Your exam may limit complications Open Fracture: Diagnosis . Some open fractures are more difficult to diagnose than others . If a wound does not stop bleeding . Persistant oozing Open fracture: Initial treatment . Examine extremity distally . Check pulses . Check for swelling . Check Hgb Open fracture: Initial treatment . Clean wound . Flush with saline . Wrap with a betadine soaked dressing . Splint extremity . IV antibiotic . Tetanus Open fracture: treatment . Operative . Washout out fracture . Remove all dead tissue . Fixation of fracture - internal - external Reasons to debride open fractures . Wound infections: residual debris in soft tissues . Osteomyelitis: debris in bones, bone infection Timing of debridement . 6 hour rule . Really depends on the injury Timing of debridement . Pediatric open fractures . Good evidence that debridement and fixation with in 24 hours gives excellent results Timing of debridement . Fractures with massive soft tissue injury should be treated expediently . Pulseless limbs . Compartment syndrome are priorities Long bone fractures . Fractures of the femur can result in 2 to 4 units of bleeding into the thigh . Multiple long bone fractures can lead to hypotension . follow ATLS guidelines Multiple long bone fractures . These patients will bleed significantly . You may have to wait for OR availability . Continue to check the hemaglobin every 1-2 hours . You can prevent hypotension, MI, death Long bone fractures . Treat first with splinting or traction . What other injuries does the patient have? Long bone fractures . Femur fractures . treated with intramedullary rodding . healing >95% . allows for weightbearing Long bone fractures . Tibia fractures . most treated with intramedullary rodding . allows for weightbearing Long bone fractures . Humerus . Forearm . most treated with plating Articular fractures/dislocation . Dislocations should be diagnosed . Should be reduced . Local/general anesthesia Articular fractures/dislocation . Examine for pulses . If no pulse first reduce fracture . Recheck pulse with doppler . If no pulse this is a vascular emergency Articular fractures/dislocation . Should be done as soon as possible . Blood supply may be hurt . May lead to osteonecrosis . May make articular cartilage damage worse Articular fractures/dislocation . Not all dislocations are reducable . Tendons or ligaments may get stuck preventing reduction Articular fractures/dislocation . Injury to the articular cartilage leads to: - malalignment of the joint - early arthritis Articular fractures/dislocation . Open reduction is required . Must see cartilage surface and fix . Often held with plates Articular fractures/dislocation . May require external fixation . Delayed open treatment to allow for reduction of swelling . Compartment syndrome . Muscles are contained within fascial compartments . A compartment can hold more than one muscle . Nerves and arteries also run through the compartment Compartment syndrome causes . Swelling of a muscle from - trauma - revascularization . Bleeding from - vessel damage - muscle tears . External cast or dressing too tight Compartment syndrome . Signs of compartment syndrome - Pain out of proportion to the injury - Swelling of the area . Late signs - decreased sensation - decreased strength Compartment syndrome . Beware: . Some patients cannot tell you about pain - overnarcotized - sedated - drug overdose - psychiatry problem - other distracting illness Compartment syndrome . Beware: . well leg compartment syndrome . during surgical procedure . lithotomy position Compartment syndrome . Patients to worry about - tibia fractures - tibial plateau fractures - patients casted after injury - polytrauma patients - drug overdose./ unconscious patients Compartment syndrome . How to detect . High level of suspicion . Pressure monitor Where is the monitor? . OR desk . ER . Floor . Make sure battery works . Needles come sterilely Compartment syndrome . If pressure is high . Fasciotomy . do not skimp on length . make sure all compartments are released Compartment syndrome . After fasciotomy . delayed closure . sometime skin grafting is required Missed compartment syndrome . leads to death of muscle . leads to death of nerves . contracture . paralysis . chronic pain . numbness Compartment syndrome . Awareness . Part of the injury . You can make a difference Deep vein thrombosis . All orthopedic patients are at risk . All trauma patients are at risk . Can lead to - fatal pulmonary embolus - post thrombotic syndrome Deep vein thrombosis . Evaluate all patients on admission . All should receive compression devices in hospital - SCD or foot pump - Only work when they are on!!! Deep vein thrombosis . Thromboprophlaxis should be thought about in all patients . Patient risk should be assessed - history of blood clots: self or family - fracture - imobilization - cancer - obesity Prevention in high risk patients . Low molecular weight heparin . Warfarin (INR 2.0-3.0) . Factor Xa inhibitor Diagnoses . High index of suspicion . Added awareness that this is part of the injury . Prevention DVT or PE: diagnosis . DVT: Limb swelling or pain . Ultrasound limb . PE: hypoxemia, taccycardia . Spiral CT scan Delirium . Associated with trauma . Especially the elderly patient . Avoid excess narcotic/anxiolytics . Reorientation Decubitus ulcers . Associated with trauma, starts in the ED . Can be the longest thing to heal . Check the ankles/sacrum . Appropriate beds/padding Conclusion: Awareness . Orthopaedic emergencies . Complications in trauma are associated with the condition . Know what can happen Conclusion: Bleeding . treat ABCs . check hemoglobin in bleeding patients . determine source of bleeding . diagnose open fractures Compartment syndrome . Part of the injury . Evaluation . Unaware patients!!!!! . Fasciotomy Conclusion: Deep Vein Thrombosis . Part of the injury . Prevention in trauma patients . Prophylaxis: mechanical, chemical |