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Orthopedic EmergenciesEmergency Care Conference 2019
Dani Wooldrik, DO, CAQSM
CHI Health Good Samaritan Orthopedics & Sports Medicine
September 6, 2019
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Objectives
• Describe selected orthopedic emergencies
• Discuss immediate evaluation and treatment of orthopedic emergencies
• Review reduction and splinting techniques
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Disclosures
None
Opinions are my own and do not represent CHI Health
I am Primary Care Sports Medicine not Orthopedic Surgeon
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FYI
The scene is safe
Check pulse, motor, sensory before and after intervention Image before and after reduction of dislocation or fracture
Do not hesitate to consult orthopedics sooner rather than later
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DISLOCATIONS
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Shoulder
Most common dislocation in adults High recurrence rate, especially if younger
Anterior, posterior, inferior May be associated fracture of humeral head or glenoid Also possible rotator cuff or labral tears
Exam Detailed neurovascular exam (axillary nerve, axillary artery, brachial plexus) Obvious deformity, palpable humeral head, limited ROM
Imaging X‐rays: AP, Scapular Y, Axillary CT: help identify fracture MRI: identify soft tissue injuries, especially inferior dislocations
Treatment Closed reduction
May be attempted immediately on the field May require analgesia/sedation, multiple techniques Immobilize in sling
Surgery Irreducible, fracture, prolonged posterior dislocation
Shah, V., Stanislavsky, A., Radiopedia.org, rID: 12341
Murphy, A., Radiopedia.org, rID: 12243
Weerakkody, Y., Stanislavsky, A., Radiopedia.org, rID: 12342
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Elbow
Second most common joint dislocation in adults Most common in children
Simple vs. complex w/o fracture, 50‐60% w/ fracture, “terrible triad”
Radial head, coronoid tip, UCL tear
Exam Detailed neurovascular exam (ulnar nerve, brachial artery)
Monitor for compartment syndrome
Imaging X‐rays: AP, Oblique, Lateral CT: help identify fracture or other injuries
Treatment Closed reduction for simple
Analgesia/sedation, Inline traction, forearm supination, elbow flexion Splint at 90° and sling
Surgery Irreducible, terrible triad
Cuete, David., Radiopedia.org, rID: 26558
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Hip
Rare, associated with high energy trauma Often multiple injuries, always examine knee
Posterior “dashboard injury” Flexion, adduction, IR
Exam Detailed neurovascular exam (sciatic nerve, femoral vessels)
Imaging X‐rays: AP, Cross‐table lateral CT: help identify fracture, required after reduction
Treatment Closed reduction within 6 hours
Requires analgesia/sedation, apply traction, crutches Contraindicated if femoral neck fracture
Surgery Irreducible, fracture, delayed presentation
Salam, Hani., Radiopedia.org, rID: 10397
Jones, Jeremy., Radiopedia.org, rID: 65457
Sorrentino, Sajoscha., Radiopedia.org, rID: 14836
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Knee
Very rare, high risk of neurovascular injury Often multiple injuries; fracture or internal derangement
High energy vs. low energy MVA, fall, dashboard injury ADLs w/ morbid obesity, athletic injury
Exam Detailed neurovascular exam (peroneal nerve, popliteal vessels) Up to 50% spontaneously reduce
Imaging X‐rays: AP & lateral CT: help identify fracture if concern on x‐ray, angiogram to assess vasculature MRI: post reduction but prior to surgery
Treatment Closed reduction
May require analgesia/sedation, apply traction and reduce deformity ASAP
Surgery Almost all require some intervention Likely need vascular consult
RMH Core Conditions, Radiopedia.org, rID: 42775
Craig Hacking, Radiopedia.org, rID: 48246
FRACTURES
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Open Fracture
Fracture with direct communication to external environment High risk of infection & neurovascular injury
Often additional injuries Compartment Syndrome
Exam Assess for soft‐tissue damage, may be deep Evaluate for vascular insult
Imaging X‐rays include joint above and below fracture site
Treatment In the field, stabilize, control bleeding, and apply sterile (saline soaked)
dressings In ER, antibiotics (3 hours of injury) and tetanus
Avoid aggressive irrigation in ER as may push debris deeper
Need I&D and operative stabilization Goal of 6 hours
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Closed Fracture
Fracture without open skin Can range from buckle to severely angulated and comminuted
Check for additional injury Joints around the fracture, compartment syndrome
Exam Evaluate and document pulse, motor, sensory Careful evaluation of skin
Imaging X‐rays before attempted reduction
Treatment In the field, stabilize as found and splint w/ appropriate material
SAM splint, pelvic binder, traction splint, c‐collar, spine board
In ER, after imaging reduce as appropriate and splint or consult ortho Hematoma block Do not hesitate to call
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ACUTE COMPARTMENT SYNDROME
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Compartment Syndrome
Fascial compartment pressures rise to level that decrease perfusion to tissues Muscle and nerve damage
Occur anywhere muscle is surrounded by fascia Leg, thigh, forearm, hand, foot, buttock, shoulder, paraspinals Trauma (fracture, crush, contusion, GSW), tight cast/dressing, burns, IV
extravasation, vascular injuries Trauma ‐> bleeding/edema ‐> increased pressure ‐> loss of perfusion ‐> ischemia
Exam Pain out of proportion, pain w/ stretching, paresthesia, paralysis, swelling, absent
pulses Often clinical diagnosis in alert patients, may need testing
Imaging/Testing X‐ray to evaluate for fracture Compartment Pressure Testing
Treatment Emergent fasciotomy of all compartments as indicated Loosen cast/dressings if not true compartment syndrome
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Compartment Pressure Testing
Stryker Needle Needle entry within 5cm of fracture site
Pressures within 30mm Hg of DBP
Orthobullets
Stryker
CONCUSSION
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Definition
Clinical syndrome of biomechanically induced alteration of brain function (coup and contrecoup/rapid rotation); affects memory and orientation, may involve loss of consciousness
No grading system
https://upload.wikimedia.org/wikipedia/commons/thumb/0/09/Contrecoup.svg/1200px‐Contrecoup.svg.png
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On the Sideline
If suspicious of a concussion – immediate removal from activity
Symptoms: confusion, amnesia, loss of consciousness, headache, dizziness, nausea or vomiting, emotional changes, vacant stare, photo/phonosensitivity, delayed verbal expression, loss of focus
Standard who, what, where questions not enough
Rule out neck or spinal cord trauma
If loss of consciousness or neck concern– immobilize and transport to ER
Common tools
Symptom Checklist
Sport Concussion Assessment Tool (SCAT)
Standardized Assessment of Concussion (SAC)
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Imaging
Not routine – cannot diagnosis concussion with a scan
CT scan Use if need to rule out more serious injury
Obtain if loss of consciousness, severe vomiting, neurologic deficit, concern for skull fracture, seizure, altered mental status
90% are negative
MRI Use for long term symptom evaluation
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Blood Testing
Brain Trauma Indicator approved by FDA in Feb 2018
Measures levels of UCH‐L1 & GFAP Released at elevated levels after brain/nerve injury
Can be detected in approx. 20 mins
Predict absence of lesion on CT scan with 99% accuracy
Does not “rule out” concussion
CT does not DIAGNOSE concussion
Only approved in adults
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Initial Care
Need responsible adult to monitor first 6‐12 hours after injury
No need to awaken from sleep Monitor for signs of distress every 2‐3 hours
Warning signs: inability to awaken, worsening headache, vision changes, continued vomiting, incontinence, neurologic changes
Needs physician follow up in 1‐2 days after injury
Anticipate resolution in 14‐21 days
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Medications
Pain & headache Acetaminophen (Tylenol) only for first 2‐3 days
Once ok’d by physician can use ibuprofen (Advil, Motrin)
Sleep Can use OTC or prescription med, but needs physician ok first
Nausea Can get prescription from physician
Mood Long term symptoms may need prescription
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TIPS, TRICKS, & TECHNIQUES
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Hematoma Block
Prior to reduction of fracture Marcaine 5cc & lidocaine w/o epi 5cc
Inject into fracture site and aspirate
Want hematoma return then inject
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Reductions
Shoulder
Hip
Elbow, Knee
Scott C Sherman, MD.
Orthop Rev (Pavia)
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Splinting
Ortho‐Glass is most common Cut stockinette longer than you think
Pad more than you think, especially over bony prominences
Pull felt over the end of the splint to cover shards
Requires water to set
A good mold is key, avoid fingerprints
Ensure sling fits properly
DOCUMENT wounds under splint
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Common Splints
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Resources
Ahn, L., & Taylor, B. Open Fractures Management. Retrieved from https://www.orthobullets.com/trauma/1004/open‐fractures‐management?expandLeftMenu=true
Armstrong, A., & Hubbard, M., (2016). Essentials of Musculoskeletal Care (5th ed.). Rosemont, IL: American Academy of Orthopaedic Surgeons. Boyd, A. S., Benjamin, H. J., & Asplund, C. (2009). Splints and Casts: Indications and Methods. American Family Physician, 80(5), 491–499. Brukner, P. et al., (2017). Brukner & Khan's Clinical Sports Medicine (5th ed., Vol. 1). North Ryde, NSW: McGraw‐Hill Education. Costandi, M. (2018). FDA Okays First Concussion Blood Test –but Some Experts Are Wary. Scientific American, Feb 18, 2018. Edgington, J., & Taylor, Benjamin. Knee Dislocation. Retrieved from https://www.orthobullets.com/trauma/1043/knee‐dislocation Frank, R., & Cohen, M. Elbow Dislocation. Retrieved from https://www.orthobullets.com/trauma/1018/elbow‐dislocation Frank, R., & Lin, A. (n.d.). Luxatio Erecta. Retrieved from https://www.orthobullets.com/shoulder‐and‐elbow/3132/luxatio‐erecta‐inferior‐
glenohumeral‐joint‐dislocation Frank, R., & Lin, A. (n.d.). Traumatic Anterior Shoulder Instability (TUBS). Retrieved from https://www.orthobullets.com/shoulder‐and‐
elbow/3050/traumatic‐anterior‐shoulder‐instability‐tubs Giza, C. et al. (2013). Summary of evidence‐based guideline update: Evaluation and management of concussion in sports. Neurology, 80(24), 2250‐
2257. Gossman, W., Ginglen, J., Kwon, Y., & Kahwaji, C. (2019). EMS, Traction Splint. StatPearls, (Jan). Karadsheh, M. Leg Compartment Syndrome. Retrieved from https://www.orthobullets.com/trauma/1001/leg‐compartment‐
syndrome?expandLeftMenu=true McCrory P, Meeuwisse W, Dvorak J, et al Consensus statement on concussion in sport—the 5th international conference on concussion in sport held
in Berlin, October 2016 Br J Sports Med. McKean, J., & Badylak, J. THA Dislocation. Retrieved from https://www.orthobullets.com/recon/5012/tha‐dislocation Madden, C. C., Putukian, M., McCarty, E., Young, C., (2018). Netter's Sports Medicine (2nd ed.). Philadelphia, PA: Elsevier. Monica, J., MD, Vredenburgh, Z., MD, Korsh, J., MD, & Gatt, C., MD. (2016). Acute Shoulder Injuries in Adults. American Family Physician, 94(2), 119‐
127. Provencher, M., & Lin, A. (n.d.). Posterior Shoulder Instability & Dislocation. Retrieved from https://www.orthobullets.com/shoulder‐and‐
elbow/3051/posterior‐shoulder‐instability‐and‐dislocation Rispoli, D. (2020). Tarascon Pocket Orthopaedica (4th ed.). Burlington, MA: Jones & Bartlett Learning. Weatherford, B. Hip Dislocation. Retrieved from https://www.orthobullets.com/trauma/1035/hip‐dislocation Woodward, T. W., MD, & Best, T.M., MD. (2000). The Painful Shoulder: Par II. Acute and Chronic Disorders. American Family Physician, 61(11),
3291‐3300.
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QUESTIONS?
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Thank You!
CHI Health Good Samaritan Orthopaedics & Sports Medicine
3219 Central Ave St102AKearney, NE 308‐865‐2600