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Summary orthopedics emergencies for junior doctors
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orthopedics emergencies summary for junior doctors
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Primary survey tamponade, airway obstruction, tensionIs a very short and rapid process initial pneumothorax, flail chest, massive
assessment and management for patient that haemothorax, sucking chest wound(open
has serious trauma injury(such as polytrauma). pneumothorax)(ATOMFC)
there are 5 key elements : Airway(A) ,
breathing(B), circulation(C), disability(D), Secondary survey
exposure(E) Secondary survey is done after resuscitation and
life threatening conditions must be assessed stabilization of patient is completed(primary
and managed accordingly survey)
A- airway : airway obstruction; facial fractures; Rapid head to toe examination to detect other
larynx injuries and etc significant but not immediate life threatening
injuries, and to get history from patient or
Management: patient's relatives or caretaker if patient's
1. simple airway maneovres unconscious.
2. remove foreign body/blood/excessive
secretion if airway is obstructed. History taking : AMPLE
3. insert oropharyngeal A- allergy history
airway(OPA)/nasopharyngeal airway(NPA) M - medications
4. consider intubation if patient unconscious P - previous medical illness/condition/pregnany
L - last meal
Ensure cervical collar is maintained throughout E- events/ environment related to injury
the assessments as spinal injuries are always
suspected. Head and toe examination:
B- Breathing : Spinal injury; chest injuries(rib check for:
fracture, tension pneumothorax, haemothorax, scalp hematoma/ skull depression or laceration
pulmonary occlusion, flail chest, massive that indicates head trauma
haemothorax, open pneumothorax and etc), fat eyes - any subconjunctival bleeding/ blurring of
embolism and etc. vision/ eye movement etc
Always assume cervical injury until proven ENT - check if any bleeding/discharges
otherwise. mouth: check for swelling/ loosening of teeth
Assessment of chest : chest fully exposed and ear - hearing
inspected for any open wound or deformities.
Assess patient's respiratory effort, breathing neck: check for any open wound/
rate and oxygen saturation. hematoma/bruises/veins distension/any
Oxygen should be administered and ensure difficulties swallowing
SPO2 >95% (Nasal prong/VM/HFM).
Chest x-ray should be done ASAP chest: check for any chest
deformities/tenderness. Assess respiratory
C- Circulation : hypovolaemic shock due to effort and any labor breathing pattern.
massive blood loss(most common). Can be auscultate lung and heart sound.
managed by fluid resuscitation and to control
external haemorrhage. FAST scan can be abdomen: assess and look for any abdominal
performed if patient is hemodynamically distension or tenderness. look for bruises or
unstable and suspicion of internal wound/laceration. auscultate bowel sounds
haemorrhage(intra abdominal
injury/intraperitoneal bleeding) perineum: DRE to look for gross blood, assess
D- disability: assessment of patient's sphinter tone
consciousness level (GCS score), exclude
hypoglycemia(metabolic causes) extremities: assess and look for any
E- exposure: patient should be fully exposed to fracture/deformities/wound/bruises/bleeding.
check to ensure there is no injuries missed that Check for ROM and neurovascular status.
is immediate life threatening. Exposure can be palpate for bony and soft tissue tenderness.
sequentially to avoid hypothermia.
6 things to look for in secondary survey:
Pulmonary contusion, aortic disruption,
6 life threatening condition: cardiac tracheobrachial injuries, myocardial contusion,
,esophageal injury, diphragmatic antibiotic and coverage : IV cefuroxime : gram
injuries(PATMED) neg ; IV flagyl : anaerobic ; IV gentamicin :
aerobic gram neg
Open fracture - golden hours (6hours post trauma), infection
Definition: A fracture or it’s hematoma risk higher after 6hours
communicates with environment. 6.Irrigation and debridement ***most
important in open fracture
Classification: Gustilo Anderson(for prognostic - wound debridement under GA/LA. Remove all
and management of patient) foreign body/devitalized tissues/free fragment
Type 1: of bones
Wound size small (<1cm) -wound cleaning : irrigation with copious
soft tissue injury minimal, no crush. amount of normal saline and remove all foreign
Contamination mild; clean puncture material, blood clots and tissue debris. Repeat
Usually low impact: simple fracture(transverse, irrigation at regular intervals to remove
short oblique, little comminution) contaminated materials and dilute bacterial
contamination.
Type 2: - take wound culture after irrigation and wound
Wound size medium (1-10cm) debridement.
Soft tissue injury moderate with crushing. No -wound usually left open to drain and for
flap/avulsion reassessment later(usually with vacuum
Contamination moderate assisted closure dressing if wound is big)
Usually low impact. Moderate communition 7.Immobilization of fracture - types depending
(butterfly fragment) on severity + degree of contamination
- slings, splints, tractions (grade 1, 2)
Type 3: -external fixation(grade 3b and 3c), until wound
Wound size big (>10cm) heal
Soft tissue injury: extensive injury to skin, 8.To review wound after 48hrs, reassess if
muscle and neurovasculature repeating irrigation and wound debridement is
Contamination significant (high contamination) necessary.
Usually high impact : extensive communition - If wound is clean - consider wound coverage
and instability with flap/ skin graft
After a formal wound debridement has done, - if wound is dirty(infected)- for another
type 3 can be subtype into 3A, 3B and 3C irrigation and wound debridement
3A: adequate soft tissue coverage of
bone(muscle coverage adequate) despite of
extensive laceration/flaps. Fracture : segmental Fat embolism syndrome
3B : inadequate soft tissue coverage; periosteal Results when embolic marrow fat
stripping and exposure of bone; severe macroglobules damage small vessel perfusion
comminution leading to endothelial damage to pulmonary
3C: Any injury that requires arterial repair capillary beds
(despite of wound size/soft tissue injury)
Risk factors:
Management: 1.long bone fracture (especially femoral shaft
1.Resuscitation and stabilization of patient fracture)
(primary survey) 2.Non-operative therapy but is also higher with
2.Compression if active bleeding overzealous reaming of femoral canal
3.Early management : adequate analgesia and 3.Multiple trauma with major visceral injuries
immobilize (splinting) and blood loss
4.Secondary survey (to take history (AMPLE), **cause of death on 3rd day after pelvic
imaging and take photo of wound for fracture is due to fat embolism
documentation
5.Prepare for EMOT(irrigation and wound Clinical manifestation:
debridement) Symptoms usually begins 24-48hrs post trauma
- start broad spectrum IV antibiotic and anti-
tetanus toxoid injection (depends on the Gurd’s diagnostic criteria : 1major +4 minor
severity and contamination level) criteria+fat microglobulinemia must be present
, to formally diagnose FES leading to rhabdomyolysis > acute kidney failure
Major criteria: if left untreated.
1.Axillary or subconjunctival petechiae
2.Hypoxaemia (SpO2 <95%) Diagnosis:
3.CNS depression/AMS disproportionate to Decreased blood inflow and outflow(lack of
hypoxaemia oxygenated blood and lack of waste product
4.Pulmonary edema removal from compartment) results in pain and
decreased peripheral sensation secondary to
Minor criteria nerve irritation
1.Tachycardia (PR >110bpm) Clinical 5Ps : pain, parasthesia, pallor, palpable
2.Tachypnea tense swollen compartment, blistering
3.Hypotension *Pain out of proportion to injury that does not
4.Renal dysfunction improve after given analgesias that increased
5.Jaundice with passive stretch test (dorsiflexion of leg or
6.Pyrexia (temp >38.5degree) toes)
7.Emboli present in retina on fundoscopy
8.Fat present in urine Late sign : pulseless, paralysis of affected limb
9.Sudden unexplained drop in HCT or plt
10.Increased ESR Management
11.Fat globules present in sputum Removal of cast/splint/constrictive dressings
Elevate affected limbs
Management: Fasciotomy - open all 4 compartments with
For adequate hydration with IVD post trauma medial and lateral incision of leg
x3/7 (prevention) - Indication: 1. when there is inadequate
Treat hypoxaemia by giving oxygenation : nasal perfusion and/or ischemia with signs and
prong/VM/HFM symptoms of compartment syndrome
2.If there is no improvement of clinical signs
after 2hours splitting of dressings/cast/splint
Compartment syndrome (limb
Complications :
threatening and life threatening) 1.Volksmann ischemic contracture
Increased intracompartmental pressure 2.Permanent functional impairment
sufficient to occlude microvascular circulation 3.Renal failure from release of
causing ischemia and tissue necrosis myoglobin(rhabdomyolysis)
subsequently. 4.Death
Common sites : leg (proximal third of tibia),
forearm flexor compartment, hand, foot, elbow Accessing compartment syndrome
(because the fascia layer that defines the Principle : to increase intercompartmental
compartment of limbs do no stretch, leading to pressure
greatly increased pressure once there is minimal Early sign:
amount of bleeding into the compartment or Pain out of proportion to the injury/tightness,
swelling of muscle within the compartment. due to increased intracompartmental pressure
leading to ischemia of muscle, not relieved by
Etiology : analgesia
Trauma - crush injury, fracture, dislocation, soft Compartment on palpation is tense and firm.
tissue damage and muscle swelling Can see very swollen thigh/leg comparing to
Vascular- arterial compromise, muscle anorexia, another unaffected limb
venous obstruction, increased venous pressure There might be blister/bullae on skin
Iatrogenic - tight cast, constrictive dressing,
splint Tibia
Passive stretch test :
Pathophysiology : decreased blood inflow + Flexion of toe > anterior part of tibia
outflow Extension of toe >posterior part of tibia
Order of collapse : capillaries > venules > If positive, patient will scream out of pain when
arterioles toe is stretched
Muscle will die within 4-6hours of ischemia, -increased muscle bulk when stretching leads to
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