MANAGEMENT OF

ORTHOPAEDICS
EMERGENCY

Open Fracture
Infection
Fat Embolism Syndrome
Compartment Syndrome
Dislocation
OPEN FRACTURE
OPEN FRACTURES

 An open (or compound) fracture occurs when the skin

overlying a fracture is broken, allowing communication
between the fracture and the external environment
GUSTILO-ANDERSON CLASSIFICATION

 Type I:
Small wound (<1cm), usually clean, no soft tissue damage and no skin crushing
(i.e. a low energy fracture)
 Type II:
Moderate wound (1-10cm), minimal soft tissue damage or loss, may have
comminution of fracture (i.e. a low-moderate energy fracture)
 Type III:
Severe skin wound (>10cm), extensive soft tissue damage (i.e. high energy
fracture)
Three grades: A – adequate soft tissue coverage, B – fracture cover not possible
without local/distant flaps, C – arterial injury that needs to be repaired.
MANAGEMENT

• ABCDE – check neurovascular status (pulses, cap. refill, sensation, motor) , fluid
resuscitation, blood
• Antibiotics, tetanus prophylaxis – 48-72 hrs
• Surgical debridement – removal of de-vitalised tissue, irrigation
• Stabilization of fracture – internal/external, if closure delayed then external prefered
• Early definitive wound cover – split skin grafts, local/distant flaps (involve plastics)
INFECTION
Infections
• Gas Gangrene
• Necrotizing Faciitis
• Septic Arthritis
GAS GANGRENE
• Gas gangrene and clostridial myonecrosis are interchangeable terms used to describe
an infection of muscle tissue by toxin-producing clostridia.
• Usually caused by Clostridium perfringens
• Risk factor includes Diabetes Mellitus, blood vessel disease and colon cancer
CLINICAL FEATURES

• Within 24 hours of the injury

• Intense pain
• Swelling
• Brownish discharge
• Gas formation
• Little or no pyrexia
• Pulse rate is increased
• Characteristic smell (once experienced this is never forgotten)
• Toxaemic
• Coma and death.
 NECROTIZING FASCIITIS
• Necrotizing fasciitis is a fulminating inflammation of the fascia that results in
thrombosis of the subcutaneous blood vessels and necrosis of the underlying tissue
• 2 types
-Type I : caused by mixed aerobic/anaerobic bacteria, including enterococci and
non-group A, streptococci (usually C or G)
-Type 2 : caused by group A streptococci,
either alone or in combination with other
organisms
MANAGEMENT OF GAS GANGRENE & NECROTIZING
FASCIITIS
• Early diagnosis is extremely important
• Fluid replacement
• Intravenous antibiotics
• Prompt decompression (ASAP)
• Debridement of all dead tissue (ASAP)
• Hyperbaric oxygen
• Advanced cases, amputation
SEPTIC ARTHRITIS

• Inflammation of a synovial membrane with purulent effusion into the joint capsule.
Followed by articular cartilage erosion by bacterial and cellular enzymes.
• Usually monoarticular
• Usually bacterial
• Staph aureus
• Streptococcus
• Neisseria gonorrhoeae
LOCATION

• Knee- 40-50%
• Hip- 20-25%*
• *Hip is the most common in infants and very young
children
• Wrist- 10%
• Shoulder, ankle, elbow- 10-15%
SIGNS AND SYMPTOMS

• Rapid onset
• Joint pain
• Joint swelling
• Joint warmth
• Joint erythema
• Decreased range of motion
• Pain with active and passive ROM
• Fever, raised WCC/CRP, positive
blood cultures
TREATMENT

• Diagnosis by aspiration
• Gram stain, microscopy, culture
• Leucocytes >50 000/ml highly
suggestive of sepsis
• Joint washout in theatre
• IV Antibiotics 4-7 days then orally
for another 3 weeks
• Analgesia
• Splintage
FAT EMBOLISM SYNDROME
• A serious manifestation of fat embolism occasionally causes multisystem
dysfunction
• Mostly associated with long bone and pelvic fractures, more frequently in
closed fracture
• Asymptomatic at first, presents 24 - 72 hours after the initial injury

• Classical triad of FES :

• Respiratory compromise ( LUNGS )
• Neurological abnormalities ( BRAIN )
• Petechial rash ( SKIN )
RISK FACTORS
DIAGNOSIS CRITERIA (Gurd & Wilson)

Major criteria ( 1 ) Minor criteria ( 4 )

Acute respiratory insufficiency Tachycardia
Alterations in CNS Fever
Petechiae Retinal changes
Urinary changes
Sudden decrease in HCT
Thrombocytopenia
Fat is sputum
Increased ESR
OTHERS :
Schonfeld Index
Lindeque Indez
MANAGEMENT
Primarily are supportive treatment
• Immobilize frature
• Optimise oxygenation
• Protective lung ventilation
• Avoid hypovolemia (some use albumin based fluids as albumin binds free fatty acids)
• DVT and peptic ulcer prophylaxis
• These therapies have been suggested but are considered ineffective: steroids,
heparin, alcohol, and dextran
PREVENTION
• Early fracture stabilization 
• early fracture stabilization (within 24 hours) of long bone fracture is most
important factor in prevention of FES

• Techniques to reduce the risk of fat emboli :

• overreaming of the femoral canal during a TKA
• use of reamers with decreased shaft width reduces the risk during femoral
reaming for intramedullary fixation
• use of external fixation for definitive fixation of long bone fractures in
medically unstable patients decreases the risk
COMPARTMENT SYNDROME
DEFINITION

• An elevation of the interstitial pressure in a closed osseofascial compartment that

results in microvascular compromise

• A condition in which the circulation and function of tissues within a closed space are
compromised by an increase pressure within that space
ANATOMY

• 4 leg compartments (anterior, lateral, • 4 forearm compartments (superficial

superficial posterior, deep posterior) volar, deep volar, dorsal, mobile wad)
• 6 wrist compartments • 10 hand compartments (7 interossei,
adductor pollicis, thenar, hypothenar)
AETIOLOGY

• Fractures of elbow, forearm bones, proximal third of tibia, hand or foot

• Crush injuries
• Circumferential burns
• Operation (usually for internal fixation)
• Infection
• Tight cast, compression bandages
ACUTE vs CHRONIC

• Acute – follows traumatic event, commonly fractures with increase worsening of

symptoms and irreversible tissue damage within hours

• Chronic – a recurrent syndrome occurring with exercise or work (microtrauma or

repetitive overexertion) and symptoms usually resolve with rest
PATHOPHYSIOLOGY

High-risk Reduce
Ischaemia
injuries capillary flow Necrosis

Leaky
Shunting
vessels

Venous
obstructio Oedema
n

Increased
compartmen
t pressure
ASSESSMENT
• Classic features (of ischaemia): 5 P’s - Pain, Paraesthesia, Pallor,
Paralysis, Pulselessness *earliest features are pain (‘bursting’ sensation), altered
sensibility and paresis (usually weakness in active muscle contraction)
• Physical examination – stretching, passively hyperextended,
results in increasing pain when positive
• Compartment pressure measurement – device is introduced into
the compartment and the pressure is measured close to the level
of the fracture (injection technique, wick technique)
• Normal intracompartmental pressure (ICP) = 0-8 mmHg
*Box shown for slit catheter measurement
Differential pressure = Diastolic pressure – Compartment pressure (<30mmhg or 4.00 kilopascals
indicate immediate compartment decompression)
• Injection technique (commercial device • Wick technique
or old method if N/A)
Cont’d

• If facilities for measuring compartmental pressures are not available, the decision to
operate will have to be made on clinical grounds.
• If three or more signs are present, the diagnosis is almost certain.
• If the clinical signs are ‘soft’, the limb should be examined at 30-minute intervals and
if there is no improvement within 2 hours of splitting the dressings, fasciotomy
should be performed as muscle will be dead after 4–6 hours of total ischaemia
MANAGEMENT
• Decompress – casts, bandages and dressings completely removed and limb should
lie flat (elevation cause decrease in capillary pressure and aggravate muscle
ischaemia)
• Immediate open fasciotomy (wound left open to be inspected 2 days later – if
necrosis perform debridement, if healthy can be sutured or skin-grafted)
• Indication for fasciotomy :
A - Those who are normotensive with positive clinical findings, who have
compartment pressures >30 mmHg, and whose duration of increased
pressure is unknown or thought to be >8 hours
B - Those who are uncooperative or unconscious, with a compartment
pressure >30 mmHg
C - Those with low blood pressure and a compartment pressure >20 mmHg
COMPLICATION

• Irreversible tissue ischaemia results in permanent muscle and nerve damage with
chronic pain
• Infection (can be amputated)
• Peroneal nerve palsy
• Muscle contractures (Volkmann contracture)
• Hyperesthesia and painful dysesthesia
• Systemic complications – acute renal failure, sepsis, ARDS
DISLOCATION
• Displacement of a bone at a joint

• 5 main clinical presentations :

i. Pain
ii. Swelling
iii. Change of normal contour of joint
iv. Loss of motion
v. Postural change
PRINCIPLE OF MANAGEMENT

• General Management
1. ABCDE
2. RICE (Rest,Ice,Compression,Elevation)

• Definitive Management
1. Reduction
2. Immobilization
3. Rehabilitation
REDUCTION
• Always try closed reduction first under general/local anesthesia

• Methods of closed reduction :

1. Manipulation
2. Mechanical traction
MANIPULATION

• Distal part of limb pulled in line of the bone

• Repositioning of disengaged fragments (if involved
fracture)
• Alignment adjusted in each plane
MECHANICAL TRACTION

• When manipulation is difficult due to powerful muscle pull

OPEN REDUCTION

• Indications for open reduction :

• Failed closed reduction due to interposition of soft tissue
• Redislocation after closed reduction
• No improvement of circulation after closed reduction
• Neurological deficat after closed reduction
IMMOBILISATION
• To prevent joint from moving and allow healing
• Can be cast, splint or sling
REHABILITATION

• To gradually increase joint’s strength and restore its range of motion