Fractures 101

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Fractures 101

• Orthopaedic Emergenciesfor the Primary Care
  Physician

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Seth S. Leopold, MDAssociate ProfessorUniversit
y of Washington School of MedicineDepartment of
Orthopaedics and Sports MedicineHip Knee
Arthritis
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Introduction to the Non-Cognitive Specialties

• Orthopaedics and Trauma

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Ortho Broad Specialty

• gt50 of CPT codes
• 8 fellowship disciplines
• Numerous basic science angles

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Mercifully Few Emergencies

• Open Fractures and Dislocations
• with or without vascular injury
• with or without neurological impairment

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Mercifully Few Emergencies

• Compartment Syndrome
• Septic Arthritis
• Certain hand infections
• Abscess, Necrotizing Fasciitis

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Polytrauma

• Orthopaedic eval is part of the secondary survey
• ABCs of Trauma Care
• Life-threatening emergencies
• Then look for limb-threatening emergencies

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Not broken
but still a limb-threatening emergency!
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Which are Emergencies?

• Closed fracture, n.v. normal
• Closed dislocation, n.v. normal
• Open fracture
• Open dislocation

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What is the diagnosis? Which is an emergency?
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Joint Dislocations

• Must be reduced at once
• Risk to circulation and nerves
• Risk of Osteonecrosis (AVN)

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Fractures Diagnosis

• Indications for radiographs
• Pain
• Tenderness
• Swelling
• Deformity
• Orthogonal views
• Absolutely required
• Joint above, joint below
• X-ray or at least thorough exam

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Orthogonal Views
or
X-ray

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Lat
AP
Lat
Apparently Undisplaced
Truly Undisplaced
100 Displaced
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If Not Displaced Elective

• Splint
• Counsel
• Elevate, ice, comfort care
• Symptoms of tight dressing
• Coordinate timely referral

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If Displaced Urgent

• Needs prompt reduction
• Splint until that can be arranged
• Arrange for care ASAP (today)
• ER
• Urgent Care
• Orthopaedists office

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What is an Emergency?

• Not generally emergencies, unless
• Pulseless limb
• Open injury
• Associated with compartment syndrome
• Open Bone is, or has ever been, in contact
  with the outside world
• In-to-out
• Out-to-in
• What about road rash?

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Looks terrible
but not an emergency!
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Nothingbroken
But still an emergency!
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So what if its open?

• Surgical emergency
• What operation is indicated?
• Significant increase in risk of infection (up to
  25-50)
• Risk of eventual amputation

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Fracture with Pulselessness

• Why is the limb pulseless (most of the time?)
• What should you do?
• Panic?
• Angiogram then consult vascular?
• What, then?
• What if that doesnt work?

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What is Compartment Syndrome?

• When the pressure within a compartment exceeds
  the perfusion pressure of the capillaries within
  that compartment

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Compartment Syndrome

• Too many Ps
• Pain, paresthesias, paralysis, pallor,
  pulselessness, poikilothermia (cool limb)
• Horsefeathers!
• Think about the pathophysiology

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Compartment Syndrome

• Whats a compartment?
• What increases compartment pressure?
• So what if capillary perfusion pressure is
  exceeded?
• Which structures are you worried about?

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Common Causes

• Fracture
• Burns
• Crush (also, obtunded, found down)
• Re-perfusion

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History

• History of common mechanism
• Pain Out of proportion to injury
• Tough, because you need to know how much pain is
  appropriate
• Deep, unrelenting, throbbing, pressure
• Paresthesias Later on
• Ddx Neuropraxia from direct trauma

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Review those Ps

• Pain?
• Paresthesias?
• Paralysis?
• Pallor?
• Pulselessness?
• Poikilothermia?

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Physical Exam

• Pain with passive stretch
• Need to know some anatomy!
• Pressure or tense swelling
• Paresis? Very late!
• Pulses? Almost always INTACT!
• If absent, consider other disease process
• Emboli, direct arterial interruption

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Diagnostic Tests

• How would you test for this?
• When would you test for this?
• Consider sensitivity/specificity of test
• Indications for direct manometry
• Equivocal exam (what does that mean?)
• Obtunded or impaired patient
• Uncooperative patient (often peds)
• History of severe prior nerve injury

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Direct Manometry?

• Make the diagnosis clinically whenever possible
• Use the test selectively
• Effect of false negatives, false positives
• If youre using manometer, go with result
• Pressure gt 30 mm hg, or gt diastolic pressure -
  20 mm, suggests compartment syndrome

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Treatment

• Emergency fasciotomy
• Decreases pressure by opening closed space
• Often, will leave skin open because of severe
  swelling of muscles
• Delayed primary closure or STSG

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Sequelae

• Irreversible damage within hours
• To which structures in the compartment?
• Contractures (Volkmanns)
• Paralysis
• Myoglobinuria and renal failure
• Limb loss

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Septic Arthritis

• Same as Pyarthrosis
• Bacterial infection of a joint
• How is this different from osteomyelitis?
• Which is a surgical emergency?

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Pathophysiology

• 3 common mechanisms
• Hematogenous
• Direct spread (contiguous osteomyelitis)
• Especially in children lt18 months old
• Trauma, including iatrogenic

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Pathophysiology

• Host factors
• Immunosuppression
• Circulation in children (shared metaph/epiph
  blood supply up to 18 mos
• Bug factors
• Virulence
• Resistance to abx

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Presentation

• Age?
• Joints?
• Single vs. Multiple Joints?

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History

• Classic pain, swelling, fevers
• Onset acute but not sudden
• Recent trauma, surgery, concurrent focus of
  infection

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Physical Exam

• Effusion (distinguish from edema)
• Single joint, acute inflammation
• Systemic illness? Sometimes
• 75 have fever at some point in course
• Chills, tachycardia very inconsistent

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Physical Exam

• Range of Motion
• Active vs. Passive
• Splinting and joint position
• To maximize capsular volume
• Pseudoparalysis
• Presentation in infants

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Tests

• Bloodwork
• CBC, ESR, CRP Together, gt90 sensitive
• X-rays
• Seldom helpful
• Exceptions Gas in joint (rare, severe!),
  osteomyelitis (late), subluxation (ped hips)
• Blood cultures
• Often taken, seldom helpful
• May give organism if aspirate false negative

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Lat. Edge of Acetabulum
Lat. Edge of Acetabulum
Subluxation
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Gold Standard Test

• What is it?
• What are criteria for diagnosis?
• What other diagnoses might it suggest?

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Always use sterile technique!
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Treatment Principles

• Remove bacteria and inflammation from joint ASAP
• How best to do this?
• Bactericidal antibiosis
• Prevent deformity
• Rehabilitate joint

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Emergency Medical or Surgical?

• Hard Joints Hip, shoulder
• Surgical treatment essential
• Arthrotomy, ID
• Easy Joints Knee, ankle
• Controversy Serial aspiration vs. surgery
• No debate If poor response to serial aspiration,
  need ID
• Arthroscopy has lowered threshold for surgical
  treatment of these joints

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Details

• Serial aspirations
• Need to stay ahead of fluid collection
• May be several times per day at first!
• Initial antibiotic choice
• Empirical
• Modify based on culture or gram stain
• Duration of abx controverial, few good data
• Prognosis
• Directly related to time before joint is clean

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Hand Emergencies

• Suppurative Flexor Tenosynovitis
• Human Bite
• Felon

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Flexor Tenosynovitis

• What part of the body are we talking about?
• Kanavels Cardinal Signs
• Fusiform swelling
• Posture in flexion
• Tenderness to passive extension
• Pain with palpation of tendon sheath

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Flexor Tenosynovitis

• Untreated Severe adhesions
• Stiff, painful, functionless digit
• Surgical Emergency
• Open drainage vs. closed sheath irrigation

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Other Hand Miseries

• Human Bite
• Fight bite Nearly always intra-articular
• High risk of joint sepsis
• Suspect if cut over metacarpal head
• Most common S. aureus worry about E. Corrodens
  (G-). Give Amox/Clav, and
• Surgical ID mandatory
• Felon
• SubQ abscess of distal pulp
• Can manage with ID in office or ER

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Misc Emergencies

• Soft-tissue abscess
• Pain, tenderness, fluctuant mass
• /- Systemic signs (may depend on host)
• Rx ID, IV abx
• Necrotizing Fasciitis
• Rapidly spreading fascial-plane infection
• Life- and limb-threatening
• Strep and clostridia most common
• Aggressive debridement emergently

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Thank You