EVALUATION AND

MANAGEMENT OF
ORTHOPEDIC INJURIES IN
ER

Moderator : Dr Jeedhu
Presenter : Dr Abhijeet
 INTRODUCTION
 Classification of different Orthopedic injuries in ER :

 Fracture: A disruption of bone tissue.

 Dislocation: Complete disruption of a joint.

 Subluxation: Partial disruption of a joint,

in which some degree of contact between the
articular surfaces remains.
 Fracture-dislocation or fracture-subluxation: Disruption of a
joint combined with fracture of at least one of the bones involved
in the articulation.

 Diastasis: A separation of the interosseous membrane connecting

two syndesmotic joints as seen between the radius and ulna.

 Strain: A tearing injury to muscle fibers resulting from excessive

tension or overuse.

 Sprain: A tearing injury to one or more ligaments of a joint

PATHOPHYSIOLOGY OF FRACTURES

 Properly assessing and treating bony injuries in the ED requires an

understanding of the physiologic processes by which fractures are created
and healed.

Types of fractures :
“Common” Fractures Most fractures are the result of significant trauma to healthy
bone.

Pathologic Fractures Fractures that result from relatively minor trauma to diseased or
otherwise abnormal bone are termed pathologic fractures.

Stress Fractures Bone may undergo a “fatigue” fracture by being subjected to low-
intensity trauma or repetitive forces.

Salter (Epiphyseal Plate) Fractures Fractures involving the physis, the cartilaginous
epiphyseal plate near the ends of the long bones of growing children.
 Following the fracture, secondary healing begins,
which consists of four steps:
 Hematoma formation.

 Fibrocartilaginous callus formation.

 Bony callus formation.

 Bone remodeling.

 Multiple terms are used to describe fracture healing.

 Union refers to the complete healing of a fracture.
 Malunion refers to a healing fracture with some residual deformity.
 Delayed union refers to prolonged healing time, usually longer than 6 months.
 Nonunion refers to failed fracture healing
ORTHOPEDIC EMERGENCIES
WHICH REQUIRE URGENT
INTERVENTION :
 OPEN FRACTURE :An open fracture is a fracture
associated with overlying soft tissue injury, creating
communication between the fracture site and the skin.

  SUBLUXATION AND DISLOCATION : Subluxation is

a condition in which the articular surfaces of a joint are
nonconcentric to any degree.

 NEUROVASCULAR INJURY : Any injury associated with

neurologic or vascular compromise should be addressed as
soon as possible.
Assesing a patietnt with Trauma :

 PRIMARY SURVVEY IN TRAUMA :

 Rapid assessment of ABC,s and threatening life threatening
problems
 Place large IV bore cannula and begin fluid for pateints in shock

 Trauma XRAYS

chest, pelvis and lateral C-spine

SECONDARY SURVEY :
Assessing entire patient for other non life threatening injuries .
Orthopedic assesment :
Splint fractures
Reduce disloactions
Evaluate distal pulse and peripheral nerve function
PHYSICAL EXAMINATION :
Essential components of the examination for musculoskeletal trauma in ER are
(1) inspection for wounds, swelling, discoloration, or deformity;

(2) assessment of active and passive range of motion of the joints proximal and
distal to the injury;

(3) palpation for tenderness or deformity; and

(4) assessment of neurovascular status.

(5) Inspection and Range of Motion : Gross deformity along the shaft of a
long bone is pathognomonic for fracture
 DIAGNOSIS
 IMAGING :
 Plain radiographs like X-RAY are still the mainstay for fracture diagnosis.

 The use of bedside Ultrasound can be used for pediatric and pregnant
patients.

 CT scan maybe diagnostic modality of choice in stress fractures, epiphyseal

fractures etc

DESCRIBING RADIOGRAPHS :
Proper management of the patient may depend on the emergency physician’s
ability to convey the radiographic appearance of the injury to the consultant.
INCLUDE THE FOLLOWING DETAILS FOR AN
ACCURATE DESCRIPTION OF THE FRACTURE :

 • Closed versus open: whether overlying skin is intact (closed) or

not (open).
 • Location: location of fracture,
 • Orientation of fracture line

 • Displacement: amount and direction distal fragment is offset from

proximal fragment.

 • Separation: amount 2 fragments have been pulled apart; unlike

displacement, alignment is maintained.

 • Shortening: reduction in bone length due to impaction or

overriding fragments.
Fracture line orientation Fracture displacement and separation
• Fractures involving the growth plate of long bones in pediatric patients are
described by the Salter-Harris classification . Note Type I and V may be
radiographically undetectable.
 TREATMENT
 Provide adequate fluid replacement, analgesia, splintage,
antibiotics, and tetanus prophylaxis prior to surgical treatment.

 Treat life-threatening injuries before limb threatening injuries.

 Control swelling with cold packs and elevation. Provide pain control.

 Control obvious hemorrhage by direct manual pressure whilst commencing

IV fluids and/or blood replacement.

.
WITHHOLD ORAL INTAKE

REDUCE FRACTURE DEFORMITY : Reduction of

fracture deformity with steady, longitudinal traction is
indicated to:

(a ) relieve pain;

(b ) relieve tension on associated neurovascular structures;

( c ) minimize the risk of converting a closed fracture to an

open fracture

( d ) restore circulation to a pulseless distal extremity

 REDUCE DISLOCATIONS : Shoulder dislocations account for
50 percent of all major joint dislocations . Anterior dislocation is
most common.

 INITIAL MANAGEMENT OF OPEN FRACTURES :

Open fractures require immediate prophylactic antibiotics, irrigation,
and debridement to prevent osteomyelitis.

• Irrigate with saline, then cover the wound with a sterile moist
dressing (eg saline soaked pads). Immobilize the limb in a POP
backslab.
 URGENT ORTHOPEDIC CONSULTAION IN
ER :

 COMPARTMENT SYNDROME : In cases of known or

suspected compartment syndrome, obtain prompt orthopedic
consultation. Emergency surgical intervention may be required to
try to avert permanent tissue damage and muscle contracture.

 5P of compertment syndrome :
Pain: out of proportion , increased with passive stretch of
compartment muscle .
Parasthesia
Pulselessness
Pallor
Paralysis (late finding)

Treatement : urgent Fasciotomy

 IRREDUCIBLE DISLOCATION : The emergency
physician sometimes may be unable to reduce a
dislocation, even with the aid of a nerve block or
procedural sedation.

 CIRCULATORY COMPROMISE Circulatory deficit

due to musculoskeletal injury warrants prompt
orthopedic consultation.

  OPEN FRACTURE Some open fractures need to be

treated aggressively in the operating room.

 INJURIES REQUIRING SURGICAL

INTERVENTION : Whereas some musculoskeletal
injuries require operative intervention as soon as possibl
 COMPLICATIONS
 Complications associated with musculoskeletal injury may be early or
delayed and may occur minutes, days, weeks, or even months later.
 HEMORRHAGE : The skeleton has a rich vascular supply so a fracture
can have the potential for large blood loss, shock, and even exsanguination
causing death.

Pelvic fractures can cause large vascular compromise from an

inability to obtain adequate tamponade
 NEUROLOGIC DEFICIT : Neurologic injury resulting from long-bone
fracture or joint dislocation is usually due to traction or pressure on a
peripheral nerve or a nerve plexus.

 VASCULAR INJURY : Peripheral vessels that run close to a joint

sometimes may be compressed or disrupted when the joint becomes
dislocated,
 COMPARTMENT SYNDROME : This is a surgical emergency,
and early recognition is crucial. Pain with passive stretching, active
contraction against resistance, or direct pressure over the
compartment.

 DELAYED AND LATE COMPLICATIONS : Patients who have

sustained along bone fracture may be at risk for pulmonary fat
embolus,.

 The most delayed complications of fracture include nonunion,

malunion (healing with deformity), joint stiffness, arthritis.

 IMMOBILIZATION COMPLICATIONS :, Complications can

include infection, deep vein thrombosis, pulmonary embolism,
muscle atrophy, and even psychiatric disorders.
VERY COMMONLY MISSED INJURIES IN
ER:

 Missed diagnosis of fractures can have potentially significant

consequences for patients and medical practitioners.

  A scaphoid fracture is often caused by falling onto an

outstretched hand, from repeated stress, or a direct blow to
the palm of the hand.

  

 Lisfranc joints connect the midfoot and the forefoot. As

many as thirty per cent of Lisfranc injuries are missed at
initial diagnosis.
 A talus fracture is mainly caused by a major force
from a fall or accident. The possibility of a talus
fracture should be considered in patients with acute
and chronic ankle pain after an injury.

 Tibial plateau fractures (TPFs) can be difficult to

recognize on standard radiographs. TPFs are
sometimes overlooked on X-ray scans and can appear
“normal” .

 The undisplaced neck of femur is frequently

misdiagnosed. If it is missed, the non-displaced
fracture can become displaced, leading to further
complications. 
 Minimally crushed vertebrae fracture
Spinal fractures have the potential for damage to the spinal
cord or spinal nerves with a risk of significant consequences.

 Rib fractures :  . The anterior arc is the most commonly

involved site for missed rib fractures.

 Supracondylar fracture in children

Supracondylar fractures are one of the most frequent
traumatic injuries seen in children and the most common
paediatric elbow fracture that can be missed.
SPLINTING MATERIALS AND TECHNIQUES :
 Immobilization is indicated not only for fractures but also for
dislocated joints that have been reduced.

 The materials most commonly used for orthopedic immobilization

are plaster of Paris (calcium sulfate) and fiberglass fabric combined
with a polyurethane resin.

 Fiberglass or plaster splinting material sets by an exothermic

reaction.

 To avoid burns, use water slightly warmer than room temperature.

Splints should be long enough to immobilize the joint above and
below the fracture.
DISCHARGE AND DISPOSITION :
 Elevation of the injured part usually helps minimize pain
and swelling. Elevation must be above the level of the
heart to be effective.

 Patients should be advised to monitor the fingers or toes

for excessive swelling, decreased sensation, or cyanosis
and to be alert for a significant increase in pain. Any of
these signs or symptoms warrants a return to the ED.
THANK YOU FOR LISTENING
 Reference :
 Tintinallis book of emergency medicine

 Oxford Handbook of Emergency Medicine

 Royal college of emergency medicine