“Emergency Orthopedics”

Suci Purnamaza
M. Aiman
 Emergency Orthopedic
Orthopedics is a branch of surgery departement that deals with the maintenance and restoration
of the functions of the musculoskeletal system, joints, and related structures. While orthopedic
surgery is a surgical procedure to restore the condition of musculoskeletal dysfunction.

Emergency is a situation which poses an immediate risk and which requires urgentattention.
Emergency orthopedics case is commonly finding nowdays. Base on characteristic of emergency
orthopedic is devided into two,

Life-threatening and Limb-threatening.

Treatment for emergency orthopedics improved so quickly, many medical technology
contributed to support emergency orthopedics treatment. Medical personnel must had
knowledge and skills to treat emergency orthopedic patient in emergency room.

Starting with a comprehensive assessment, planning appropriate interventions,

implementing actions, evaluating the results found during treatment and systematic
documentation of results.
 Life-Threatening Injuries3
Injuries that are considered potentially lifethreatening include major arterial hemorrhage crush
syndrome and pelvic ring fracture.

Limb-Threatening Injuries3
Injuries that are considered potentially limb threatening include open fractures and joint injuries,
vascular injuries, compartment syndrome, neurologic injury secondary to fracture dislocation and
septic arthritis.
L I F E - T H R E AT E N I N G

Major Arterial Hemorrhage

Penetrating extremity wounds may result in major arterial vascular injury.
Blunt trauma resulting in an extremity fracture or joint dislocation in close
proximity to an artery also may disrupt the artery. These injuries may lead
to significant hemorrhage through the open wound or into the soft tissues.
M AJ O R AR T E R I A L H E M O R R H AG E

Assessment
Assess injured extremities for external bleeding, loss of a
previously palpable pulse, and changes in pulse quality, Doppler
tone, and ankle/brachial index.
A cold, pale, pulseless extremity indicates an interruption in arterial
blood supply. A rapidly expanding hematoma suggests a
significant vascular injury.
M AJ O R AR T E R I A L H E M O R R H AG E

Management
If a major arterial injury exists or is suspected, immediate consultation
with a surgeon is necessary. Management of major arterial
hemorrhage includes application of direct pressure to the open wound
and appropriate fluid resuscitation.
The judicious use of a tourniquet may be helpful and lifesaving. It is not
advisable to apply vascular clamps into bleeding open wounds while
the patient is in the ED, unless a superficial vessel is clearly identified.

If a fracture is associated with an open hemorrhaging wound, it should

be realigned and splinted while direct pressure is applied to the open
wound. A joint dislocation should be reduced if possible; if the joint
cannot be reduced, emergency orthopedic intervention may be required.
L I F E - T H R E AT E N I N G

Crush Syndrome
Crush syndrome refers to the clinical effects of injured muscle that, if
left untreated, can lead to acute renal failure. This condition is seen in
individuals who have sustained a crush injury of a significant muscle
mass, most often a thigh or calf.

The muscular insult is a combination of direct muscle injury, muscle

ischemia, and cell death with release of myoglobin to bloodstream
(Rhabdomyolysis) that lead to acute renal failure
C r u s h S yn d r o m e

Assessment
The myoglobin produces dark amber urine that tests positive for
hemoglobin. The myoglobin assay must be specifically requested
to confirm the presence of myoglobin.

Rhabdomyolysis may lead to metabolic acidosis, hyperkalemia,

hypocalcemia, and DIC.
C r u s h S yn d r o m e

Management
The initiation of early and aggressive intravenous fluid therapy during the
period of resuscitation is critical to protecting the kidneys and preventing
renal failure in patients with rhabdomyolysis.

Myoglobin induced renal failure may be prevented by intravascular fluid

expansion and osmotic diuresis to maintain a high tubular volume and
urine flow. It is recommended to maintain the patient’s urinary output at
100 mL/hr until the myoglobinuria is cleared.
L I F E - T H R E AT E N I N G

Pelvic Fractures
Pelvic ring injuries are associated with significant morbidity and mortality. Is
important to quickly identify unstable pelvic disruptions and associated
injuries. Because the pelvis is a ring structure.

Hemorrhagic shock can occur in about 10% of pelvic ring injuries.

Hemorrhage is the major potentially reversible contributing factor to mortality.

Pelvic ring injury may be caused by motorcycle crashes and pedestrian-

vehicle collisions, direct crushing injury to the pelvis, and falls from heights
greater than 12 feet (3.6 meters).
P E LV I C F R AC T U R E

Assessment
Stable and Unstable.
Stable Fracture. In this type of fracture, there is often only one break in
the pelvic ring and the broken ends of the bones line up adequately.
Low-energy fractures are often stable fractures.

Unstable fracture. In this type of fracture, there are usually two or

more breaks in the pelvic ring and the ends of the broken bones do not
line up correctly (displacement). This type of fracture is more likely to
occur due to a high-energy event.
 Types of stable pelvic fractures:
(Left) Iliac wing fracture.
(Right) Sacrum fracture.

Superior and inferior pubic

ramus fracture
 Types of unstable pelvic fractures:
(Left) Anterior-posterior compression
fracture.
(Right) Lateral compression fracture.
In this fracture, the pelvis is pushed
inward.

Vertical shear fracture. In this

fracture, one half of the pelvis
shifts upward.
P E LV I C F R AC T U R E

Management
Initial management of a major pelvic disruption associated with
hemorrhage requires hemorrhage control and fluid resuscitation.
Hemorrhage control is achieved through mechanical stabilization of the
pelvic ring and external counterpressure

Definitive care of patients with hemodynamic abnormalities demands the

cooperative efforts of a team that includes a trauma surgeon, an
interventional radiologist if available, and an orthopedic surgeon.
L I M B - T H R E AT E N I N G

Open Fracture and Joint Injuries

Open fractures represent a communication between the external
environment and the bone. Muscle and skin must be injured for this to
occur. The degree of soft tissue injury is proportional to the energy
applied. This damage, along with bacterial contamination, makes open
fractures prone to problems with infection, healing, and function.
O P E N F R AC T U R E AN D J O I N I N J U R I E S

Assessment
Diagnosis of an open fracture is based on the history of the incident
and physical examination of the extremity that demonstrates an open
wound on the same limb segment with or without significant muscle
damage, contamination, and associated fracture.

Documentation regarding the open wound begins during the

prehospital phase, with the initial description of the injury and any
treatment rendered at the scene
C r u s h S yn d r o m e

Management
The presence of an open fracture or a joint injury should be promptly
determined. Apply appropriate immobilization after an accurate
description of the wound is made and associated soft tissue, circulatory,
and neurologic involvement is determined.

Prompt surgical consultation is necessary. The patient should be

adequately resuscitated, with hemodynamic stability achieved if
possible. Wounds then may be operatively debrided, fractures stabilized,
and distal pulses confirmed.
All patients with open fractures should be treated with intravenous
antibiotics as soon as possible.

Currently first-generation cephalosporins are given to all patients

with open fractures and aminoglycosides or other Gram-negative
appropriate antibiotics may be given in more severe injuries.
Antibiotics are used only after consultation with a surgeon.
Example of an open fracture
L I M B - T H R E AT E N I N G
Vascular Injuries, Including Traumatic Amputation
A vascular injury should be strongly suspected in the presence of
vascular insufficiency associated with a history of blunt, crushing,
twisting, or penetrating injury to an extremity.
VAS C U L A R I N J U RY AN D T R AU M AT I C AM P U TAT I O N

Assessment
The limb may initially appear viable because extremities often
have some collateral circulation that provides enough flow. Partial
vascular injury results in coolness and prolonged capillary refill in
the distal part of an extremity, as well as diminished peripheral
pulses and an abnormal ankle/brachial index. Alternatively, the
distal extremity may have the complete disruption of flow and be
cold, pale, and pulseless.
Va s c u l a r i n j u r i e s a n d t r a u m a t i c a m p u t a t i o n

Management
An acutely avascular extremity must be recognized promptly and
treated emergently. The use of a tourniquet may occasionally be
lifesaving and/or limb-saving in the presence of ongoing hemorrhage
uncontrolled by direct pressure. A properly applied tourniquet, while
endangering the limb, may save a life.
The risks of tourniquet use increase with time. If a tourniquet must
remain in place for a prolonged period to save a life, the clinician must
be cognizant of the fact the choice of life over limb has been made.

Muscle does not tolerate a lack of arterial blood flow for longer than 6
hours before necrosis begins. Nerves also are very sensitive to an
anoxic environment.
L I M B - T H R E AT E N I N G
Compartement Syndrome
Compartment syndrome develops when the pressure within an
osteofascial compartment of muscle causes ischemia and subsequent
necrosis.
This ischemia may be caused by an increase in compartment size or
by decreasing the compartment size. Common areas for compartment
syndrome include the lower leg, forearm, foot, hand, gluteal region,
and thigh.
C o m p a r t e m e n t S yn d r o m e

Assessment
When assessing for neurovascular integrity, remember the five Ps:
• Pallor,
• Pain,
• Pulse,
• Paralysis and
• Paraesthesia.
Compartment syndrome is a time-dependent condition. The higher the
compartment pressure and the longer it remains elevated, the greater
the degree of resulting neuromuscular damage and functional deficit.
C o m p a r t e m e n t S yn d r o m e

Management
All constrictive dressings, casts, and splints applied over the affected
extremity must be released. The patient must be carefully monitored
and reassessed clinically for the next 30 to 60 minutes. If no significant
changes occur, fasciotomy is required.

A delay in performing a fasciotomy may result in myoglobinuria, which

may cause decreased renal function. Surgical consultation for diagnosed
or suspected compartment syndrome must be obtained early.
Intraoperative photos showing fasciotomy of upper extremity compartment syndrome
secondary to crush injury.
(A) Planned skin incision for fasciotomy of the forearm.
(B) Post-surgical decompression of the forearm.
L I F E - T H R E AT E N I N G
Neurologic Injury Secondary to Fracture Dislocation
Fractures and particularly dislocations may cause significant
neurologic injury because of the anatomic relationship and
proximity of the nerve to the joint for example, sciatic nerve
compression from posterior hip dislocation or axillary nerve injury
from anterior shoulder dislocation. Optimal functional outcome is
jeopardized unless this injury is recognized and treated early.
N E U R O L O G I C I N J U RY S E C O N D ARY T O F R AC T U R E
D I S L O C AT I O N

Assessment
A thorough examination of the neurologic system is essential in patients with
musculoskeletal injury. Determination of neurologic impairment is important,
and progressive changes must be documented.
Assessment usually demonstrates a deformity of the extremity. Assessment of
nerve function usually requires a cooperative patient
In most patients with multiple injuries, it is difficult to initially assess nerve
function. However, assessment must be continually repeated, especially after
the patient is stabilized
N E U R O L O G I C I N J U RY S E C O N D ARY T O F R AC T U R E
D I S L O C AT I O N

Management
The injured extremity should be immobilized in the dislocated position,
and surgical consultation obtained immediately.
If indicated and if the treating clinician is knowledgeable, a careful
reduction of the dislocation may be attempted. After reducing a
dislocation, neurologic function should be reevaluated and the limb
splinted. If the clinician is able to reduce the dislocation, the subsequent
treating physician must be notified that the joint was dislocated and
successfully reduced.
L I M B - T H R E AT E N I N G
Septic Arthritis
Acute septic arthritis by pyogenic bacteria can cause significant long-
term joint debility if not properly recognized and treated.
Almost every organism has been reported to cause septic arthritis. The
three mechanisms of bacterial joint inoculation are hematogenous
seeding, direct inoculation (surgery, needle injection, traumatic
puncture), and contiguous spread from an adjacent infection.

The most frequently involved joints in adults, in descending order, are

the knee, hip, elbow, and ankle.
N E U R O L O G I C I N J U RY S E C O N D ARY T O F R AC T U R E
D I S L O C AT I O N

Assessment
Aspiration of the suspected joint is mandatory to establish the
diagnosis and to identify an organism.
Joint fluid is analyzed for cell count with differential, cultures
(aerobic, anaerobic, fungal, and mycobacterial cultures), glucose
level, Gram stain (including acid-fast stain), and crystal analysis
(urate and calcium pyrophosphate).
N E U R O L O G I C I N J U RY S E C O N D ARY T O F R AC T U R E
D I S L O C AT I O N

Management
The main goal of treatment is to prevent the rapid destruction of
articular cartilage.
The choice of treatment should take into consideration the following
factors: lifespan of the joint (young patients need a healthy joint for a
long period of time), associated medical comorbidities, and the ability
of the patient to sustain a surgical procedure.
Waiting for culture results can cause untoward joint destruction and
debility. In addition, bacteria may fail to grow from infected joint
fluid, particularly if the patient was pretreated with antibiotics, the
organism is fastidious, or the fluid was not optimally processed
 CHAPTER III

CONCLUSIONS
• Emergency orthopedics is a situation which poses an immediate risk and
which requires urgentattention.
• Base on characteristic of emergency orthopedic is devided into two, Life-
threatening and Limb-threatening.
• Injuries that are considered potentially lifethreatening include major arterial
hemorrhage crush syndrome and pelvic ring fracture
• Injuries that are considered potentially limb threatening include open
fractures and joint injuries, vascular injuries, compartment syndrome,
neurologic injury secondary to fracture dislocation and septic arthritis
Bedah 2019

TERIMA KASIH.