Fakultas Kedokteran

Program Studi Pendidikan Profesi Dokter

Universitas Malikussaleh

Orthopaedics Emergencies
Preseptor:
dr. Syafruddin, Sp.B

Penyusun:
Maulana Arya Jimbaran, S.Ked
NIM. 2006112026
LIMB THREATENING LIFE THREATENING

X X
G O L DE N PE RI O D

0-6 JAM
1. Open Fracture
2. Compartment Syndrome
3. Dislokasi
4. Septic Arthritis
5. Sindrom Emboli Lemak (FES)
OPEN FRACTURE
Radiography
Management
Open Fracture

The purpose of early fracture treatment is to maintain a patient's life and

maintain limb anatomy and function as before

pressure
bandage
Survey immobilization
Evaluation X-ray and close
primary the
wound

ABCDE Traction splint

Long leg splint

Antibiotics
refer to
The orthopedic
&
antitetanus
center
emergency
 Management
Open Fracture

how the stages of fracture healing ?

Tissue destruction and haematoma formation

Inflammation

Callus formation

Consolidation

Remodelling
 Complication
Open Fracture

Early complications :
shock, venous thrombosis and pulmonary embolism, fat embolism, infection, tetanus

Late complications :
delayed union, non union, malunion
COMPARTMENT SYNDROME
 Compartment syndrome is increased pressure from a
progressive edema in the osteofacial compartment that is
rigid and anatomically disrupts the circulation of
intracompartmental muscles and nerves so that it can cause
intracompartmental tissue damage.

The incidence of emergency orthopedi

compartment syndrome is
reported to range from
0.6-2%
PATOFISIOLOGY

mechanism compartment syndrome is a reduction in size of the

compartment and increasing the kompertemen contents.

When the pressure in the compartment exceeds the blood pressure in the
capillaries, the capillaries collapse.

This will block blood flow to muscles and nerve cells. The reduced supply of
oxygen and nutrients, nerve cells and muscle ischemia.

Tissue edema in kompertemen causing increased pressure

intrakompertemen disturbing venous and lymphatic flow in the injured
area.

Acute compartment syndrome is a medical emergency. Without treatment,

this can lead to paralysis, loss of distal organs, and even death.
Diagnose
Compartemen Syndrome

History

• The inspection is carried out with the aim of measuring the pressure in the
compartment

Phisycal Examination

Look-feel-move
• Pain
• Pallor and palpable swelling
• Paresthese
• Parese/paralysis
• pulselesness
Compartemen Syndrome
Compartemen Syndrome
 Management
CS

MEASUREMENT
Elevation of the extremities at heart level TECHNIQUE

Take off the bandage

• Needle manometer
• Wick catheter
Evaluation for 2 hours, every 15 minutes • Slit catheter
• Styker pressure
monitoring system
Management
CS

MEASUREMENT LOCATION

Anatomical Area Catheter Placement

Femur Anterior compartment
Cruris Anterior compartment
Profunda posterior
compartment (if suspected
clinically)

Pedis Interosseus compartment

Antebrachii Fleksor compartment
Manus Interosseus compartment
Needle
Manometer
Wick
Catheter
Slit
Catheter
DISLOKASI
DISLOCATION IS ?
dislocation is a joint surface of bone that form
the joint is no longer associated anatomically

avascular necrosis

DISLOCATION DIVISION :

congenital pathological traumatic

dislocation dislocation dislocation

orthopedic emergencies
 Type of Dislocation

Acute Chronic Recurrent

dislocation dislocation dislocation
Diagnose
Dislocation
History

• ask for pain, history of trauma, mechanism of trauma, joint pain, if trauma and
repeated events, this can occur in recurrent dislocations.

Phisycal Examination

Look-feel-move
• Deformity ((loss of normal bony prominence, shortening of the bone, and
characteristic of certain dislocations)
• Swelling
• limitation of movement or abnormal movement
Diagnose
Dislocation
Diagnose
Dislocation
Diagnose
Dislocation
Diagnose
Dislocation
elbow joint dislocation
Diagnose
Dislocation

Lunatum Dislocation Normal

Management
Dislocation Management of anterior dislocation
Management
Dislocation
Management of posterior dislocation

reduction by pulling the arm forward

(A, B) and external rotation (C) and
immobilizing for 3-6 weeks
Management
Dislocation
Management of inferior dislocation
Management
Dislocation
Management of elbow joint dislocation
 Management
Dislocation
Management of lunatum dislocation

In new dislocations, it is repositioned

under general anesthesia by applying
pressure to the lunate bone.
Management
Dislocation

Management of dislocation
A few days to weeks after the reduction is carried out
3-4 times a day fine mobilization useful to restore joint
range. Provides comfort and protects joints during
healing.
SEPTIC ARTHRITIS
Arthritis
Septic is…
an inflammatory joint disease caused by a bacterial or fungal infection

Considered as medical emergancy

is the most common and most important joint infection because it is a rheumatology
emergency that has the potential to cause joint damage and irreversible loss of function if
diagnosed and treated late.

The knee is the most commonly affected but any joint may be involved
Infants Hip
Children Knee
Adults Large joints
IVDU Sacrioliac joint

population between 2-10 cases incidence in the age group is children aged less
with 100,000 people every year than 5 years and older than 64 years
Pathogenesis
Arthritis Septic
The pathogenesis of septic arthritis is multifactorial and depends on the
interaction of bacterial pathogens and the host immune response. The
process that occurs in natural joints can be divided into three stages :

bacterial colonization

infection

induction of the host inflammatory response.

Pathogenesis
Arthritis Septic
HEMATOGENOUS SPREAD
Most common from of spread, usually affects
people with underlying medical problems

DIRECT INNOCULATION
May result from penetrating trauma,
introduction of organisms during diagnostic
and surgical procedures.
E.g. intra-articular injection.

DIRECT SPREAD FROM ADJACENT BONE

More common in children.
Osteomyelitis usually begins in the metaphyseal region, from which it breaks through
the periosteum into the joint
Diagnose
Arthritis Septic
Aetiology..

The infection can originate anywhere in the body

May also begin as the result of an open wound, trauma, surgery or unsterile injection

Septic arthritis occurs when the infective organism travels through blood stream to the joint

The infection can be cause by bacterial, virus or fungus

The Clinical
Arthritis Septic
SING OF HIP INFECTION
In children
Fever
Irritable
Warm Malaise
Tenderness
local pain in the infected joint
Rapid pulse
Refused feeding Joint swelling, and decreased
range of motion

Loss of spontaneous movement of the extremity

Diagnose
Arthritis Septic
BLOOD INVESTIGATIONS
• Raised WCC
• Raised ESR and CRP
• Blood culture (+)
IMAGING
• X-ray
early stage : may look normal except widening of joint space, ultrasound helpful
late stage : narrowing and irregularity of joint space; may have OM changes of adjacent
bones

• MRI and radionuclide imaging are helpful in diagnose arthritis in obscure sites such as the
sacroilliac and sterno-clavicular joint
SYNOVIAL FLUID ANALYSIS
The Clinical
Arthritis Septic
Septic arthritis suspected

Blood and synovial fluid sample

Empiric parenteral antibiotics based on gram

stain

Joint drainage

Adjust antibiotics based on culture and

sensitivity result
Arthritis
Septic
DIFFERENTIAL DIAGNOSIS

1. Acute osteomyelitis

2. Trauma

3. Hemophilic bleed

4. Rheumatic fever

5. Juvenile rheumatoid arthritis

Arthritis
Septic

X-ray
Arthritis
Septic

X-ray
Arthritis
Septic
Management

1. Dekompresi sendi

2. Kultur dan sensitifitas

3. Farmakologi  Antibiotik IV 2 minggu + Oral 1-4 minggu

FAT EMBOLISM SYNDROME
(FES)
Fat Embolism Syndrome
(FES)

Fat Emboli is fat particles or droplets that travel through

the circulation

Fat Embolism is a process by which fat emboli passes

into the bloodstream and logdes within a blood vessel

Fat Emboli Syndrome (FES) is serious manifestation of fat

embolism occasionally causes multi system dysfunction,
the lungs are always involved and next is brain
 Fat Embolism Syndrome
(FES)
Causes of FES..

Blunt trauma  long bone

(femur, tibia,pelvic) factures

Non-trauma  agglutination of
chylomicrons and VLDL by high
levels of plasma CRP
• Disease-related
- diabetes, acute
pancreatitis, burns, SLE,
sickle cell crisis
• Drug-related
- Parenteral lipid infusion
• Procedure-related
- Orthopedic surgery,
liposuction
Fat Embolism Syndrome (FES)
Risk Factors for FES..

General factors males

age 10-39 yo
post traumatic hypovolumic state
reduced cardiopulmonary reserve

Injury-related factors multiple fractures

bilateral femur fractures
femur shaft fractures
lower extremity fractures
traumatic fractures
concomitant pulmonary injury

Surgery-related factors intramedullary reamed and unreamed nailing after femoral fracture
joint replacement after femoral fracture
bilateral procedures
joint replacement with high-volume prosthesis
Pathophysiology
Fat Embolism Syndrome
(FES)

Exact mechanism unknown, but two main

hypothesis

1. Mechanical hypothesis
2. Biomechanical hypothesis
Pathophysiology
Fat Embolism Syndrome
(FES)
MECHANICAL HYPOTHESIS
Obstruction of vessels and capillaries

• Increase in intermedullary pressure forces fat and marrow into bloodstream

• Bone marrow contents enter the venous system and lodge in the lungs as emboli
• Smaller fat droplets may travel through the pulmonary cappilaries into the systemic circulation:
embolization to cerebral vessels or renal vessels also leads to central nervous system and renal
dysfunction
Pathophysiology
Fat Embolism Syndrome
(FES)

BIOCHEMICAL HYPOTHESIS
Toxicity of free fatty acids

• Circulation free fatty acids directly affect the pneumocytes,

producing abnormalities in gas exchange
• Coexisting shock, hypovolemia and sepsis impair liver function
and augment toxic affects of free fatty acids
Diagnosis Fat Embolism Syndrome (FES)
Criteria Features
Gurd and Wilson (FES = 1 major + 4 minor + Major criteria
fat microglobulinemia) • Respiratory insufficiency
• Cerebral involvement
• Petechial rash
Minor criteria
• Pyrexia
• Tachycardia
• Retinal changes
• Jaundice
• Renal changes (anuria or oliguria)
• Thrombocytopenia (a drop of >50% of the
admission thrombocyte value)
• High erythrocyte sedimentation rate
• Fat macroglobulinemia
Diagnosis
Fat Embolism Syndrome
(FES) IMAGING

Chest x-ray

LABORATORY • Show multiple flocculent shadows (snow storm appearance).

Picture may be complicated by infection or pulmonary edema
Arterial Blood Gases (ABGs)
CT Scan brain
Urine and sputum examination
• May be normal or may reveal diffuse white-matter petechial
Helical CThaemorrhages
Scan chest

• May be normal as the fat droplets are lodged in capillary beds. Can
detect lung contusion, acute lung injury, or ARDS may be evident
Treatment
Fat Embolism Syndrome
(FES)
Prophylaxis
 Immobilization and early internal fixation of fracture
 High doses of corticosteroids

Medical
 Self limiting disease – support treatment for
cardiovascular and respiratory issues
 Maintenance of intravascular volume
- Albumin is recommended
 Adequate analgesia
 heparin
Fat Embolism Syndrome
(FES)

PROGNOSIS..

Most death contributed to pulmonary dysfunction

Hard to determine exact mortality rate

Estimated less than 10%

 CONCLUSION OF EMERGENCY ORTHOPEDI

Orthopedic emergency is a condition that can be life-threatening and

the loss of function of certain organs in the orthopedic field, such as
extremities and joints

Emergency orthopedics delivered about 20% of patients who came to

the hospital needed treatment

Several orthopedic emergencies within the medical world have priority

and special treatment, namely open fractures, compartment syndrome,
dislocations, vascular trauma, septic arthritis, acute osteomyelitis, fat
embolism syndrome or fat embolism syndrome (FES).