Common pitfalls in orthopedics

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  • 1. Common Orthopedic Pitfalls for Emergency Specialist
  • 2. The Emergency Specialist’s Approach For Orthopaedic Patient
  • 3. Why is consultation necessary?
    • “ Call for help” in emergency
    • Admission
    • Equivocal diagnosis
    • Follow-up plan
  • 4. Orthopedic Consultation in the Emergency Department
    • "In many cases, such as fracture of the hip, the need for hospital admission and/or orthopedic consultation in the emergency department is obvious. In some situations, however, differences of opinion may exist among emergency physicians and among orthopedists as to whether the patient needs to be seen by an orthopedist in the emergency department, or whether the patient may be treated in preliminary fashion and referred for subsequent definitive orthopedic management. Even patients with injuries that ultimately may require surgical repair, such as an unstable ankle fracture, sometimes may be immobilized and discharged for prompt orthopedic follow-up.The physiology and potentially catastrophic consequences of compartment syndrome are described in Chap. 278. In cases of known or suspected compartment syndrome, orthopedic consultation should be obtained promptly. Emergency surgical intervention may be required to try to avert permanent tissue damage and muscle contracture...."
  • 5. Orthopedic Consultation in the Emergency Department
    • S ections: Compartment Syndrome, Irreducible Dislocation, Circulatory Compromise, Open Fracture, Injuries Requiring Surgical Repair. Topics Discussed: blood circulation; compartment syndrome; dislocations; fractures; fractures, open; muscle injury; musculoskeletal system; orthopedics; skeletal injury.
  • 6. Tintinalli 6 th Edition
    • 1651 - 1805
  • 7. Orthopaedic Emergency Examples?
  • 8. Orthopaedic emergency
    • Non-trauma
    • - Osteomyelitis, Septic arthritis, Pyomyositis
    • - Gouty arthritis
    • - C1 - C2 subluxation
    • (Grisel’s syndrome, Rheumatoid arthritis)
    • - Acute disc syndrome
    • Trauma
  • 9. Management in Musculoskeletal Injury
    • R = Rest
    • I = Ice
    • C = Compression
    • E = Elevation
  • 10. วิธีการทำ Ice compression ที่ถูกต้อง
    • ประคบด้วยน้ำแข็ง 15 – 20 นาที แล้วพัก 5 นาที สลับไปจนไม่บวม
    • เพิ่มขึ้น
  • 11. Principles to approach severe musculoskeletal injury
    • First aids
    • Initial treatment of major fractures / dislocation
    • Standard radiographs of fractures / dislocation
    • Immediate definitive treatment of fracture / dislocation
    Principles to approach severe musculoskeletal injury
  • 12. A. First aids
    • Bleeding control
    • Immobilization
    • Pain control
    • Antibiotic administration
    • Tetanus prophylaxis
    • Improve microcirculation
    Principles to approach severe musculoskeletal injury
  • 13. Technique of Immobilization
    • Check distal neurovascular status; if no pulse: equivocal to gentle traction until pulse return
    • Treat any wound โดยการปิดแผล
    • Pad bony prominence โดยการปูผ้าหรือบุด้วยสำลี
    • Apply adequate splint; 1 joint (bone) above 1 joint (bone) below in nearly normal position
    • Reassess distal neurovascular status
  • 14.  
  • 15.  
  • 16.  
  • 17. Methods of immobilization
    • Splinting; wooden, commercial
    • Brace or support
    • Strap
    • Slab immobilization
    • Cast immobilization
    • Traction
    • External fixation
    • Open reduction and internal fixation
  • 18. Purpose of immobilization
    • Temporary
    • Definite
  • 19. Complication of immobilization
    • Too fit
    • Too loose
    • Too long interval
    • Too short interval
    ; pressure sore, compartment syndrome ; inadequate immobilization (loss reduction, delayed, mal or nonunion) ; muscle atrophy, osteoporosis, joint stiffness, maceration of skin ; inadequate immobilization (loss reduction, delayed, mal or nonunion)
  • 20.  
  • 21.  
  • 22. A. Taylor brace B. Chairback brace
  • 23. C. Jewett hyperextension brace D. Lumbosacral support
  • 24. Strap immobilization
    • Figure of eight strap
    • Gibney’s strap
    • Velpeau’s strap
    ; A band or slip used in attaching parts to each others
  • 25.  
  • 26.  
  • 27. Gibney’s strap Ankle sprain Nondisplaced fracture of ankle
  • 28.  
  • 29.  
  • 30. Velpeau’s strap Injury of shoulder region
  • 31. Slab immobilization
    • U or Sugar tong slab for humerus fracture
    • U slab for fracture of forearms
    • Short or long arm slab with or without thumb spica
    • Short or long leg slab
    • Mid-leg mid-thigh slab
  • 32. Sugar tong slab Fracture of humeral shaft
  • 33. U slab for fracture of forearms Fracture of forearm Fracture of distal radius or ulna
  • 34. Short arm slab
  • 35. Long arm slab
  • 36. Thumb spica slab
  • 37. Short leg slab
  • 38. Long leg slab
  • 39. Casting
    • How to get success in treating fracture by casting
    • Good soft tissue hinge
    • Potential for three-point fixation
    • Proper immobilization
    - Degree of deformity - Fracture type (simple, oblique, spiral)
  • 40.  
  • 41. Three point fixation
    • Produce tension in the intact soft tissue
    • Produce compression across the fracture sites to immobilize the fracture
    • * This principle is used in nearly all immobilization technique for fractures
    • * A straight cast will usually contain a crooked bone, but a curved cast will generally contain a well-aligned bone
  • 42.  
  • 43.  
  • 44.  
  • 45.  
  • 46. Advice to give patients before casting
    • Objectives and advantages of casting
    • Duration of casting
    • Activities to do and not to do during casting
    • Good co-operation is needed
  • 47. Complications of casting Pressure sores Cast sores
  • 48. Measured time from the point which the plaster is wetted to the point at which the cast has become firm A period during setting time when the plaster became dry or sticky like rubber and color changed. At this point, the plaster should keep still without any movement or molding Setting time Critical setting time
  • 49. Duration for completely dry of plaster of Paris
    • Wettness of plaster
    • Number of plaster
    • Humidity of environment
    • Ventilation
    Depend on Normally 48 – 72 hours
  • 50. Well-molded, one solid piece Laminated layer
  • 51.  
  • 52. Casting
    • Short or long arm cast with or without spica
    • Hanging cast
    • Short or long leg cast
    • Cylinder cast
    • Functional cast ; patellar tendon bearing cast
    • Boot cast
  • 53.
    • Bolero cast
    • Shoulder spica cast
    • Hip spica cast
    • Minerva cast
    • Body jacket
    Casting (cont.)
  • 54. Short arm thumb spica cast
  • 55. Long arm cast
  • 56. Hanging cast
  • 57. Long leg cast
  • 58.  
  • 59. Sarmiento or Functional cast
  • 60. Bolero cast
  • 61. Shoulder spica cast
  • 62. Hip spica cast
  • 63. Adult hip spica cast
  • 64. Minerva cast
  • 65. Body jacket
  • 66. Traction
    • Skin traction
    • Skeletal traction
    • Skull traction
  • 67. Skin traction
    • Buck’s traction
    • 1861 by Gurdon Buck
    • Full extension
  • 68. Modified Buck’s traction
  • 69.
    • Bryant’s traction
    • The treatment of choice for fracture shaft of femur (esp. subtrochanteric fracture) in infant young children
    Skin traction
  • 70. Skeletal traction 1 lbs of traction for every 7 lbs of body weight (usually uncomfort if > 35 lbs)
  • 71. Skeletal traction in upper extremities Dunlop traction for supracondylar fracture In children Overhead olecranon pin traction
  • 72. Skull traction
    • Gardner-Wells tong
  • 73.
    • Crutchfield tongs
    Skull traction
  • 74.
    • Halo Vest
  • 75.  
  • 76. Exception for non-immobilization
    • Surgical neck fracture of humerus in elderly
    • Stable fracture of radial head and neck
    • Minimal displaced fracture calcaneus
    Early, protected, gentle active motion
  • 77. Principles to approach severe musculoskeletal injury
    • First aids
    • Initial treatment of major fractures / dislocation
    • Standard radiographs of fractures / dislocation
    • Immediate definitive treatment of fracture / dislocation
    Principles to approach severe musculoskeletal injury
  • 78. B. Initial treatment of major fractures
    • Shock in orthopaedic patient
    • - Hypovolemic shock
    • - Neurogenic shock
    • Major fracture
    • - Pelvis
    • - Spine (cervical)
    • - Femur
    • - Multiple fractures
    • - Hip
    Principles to approach severe musculoskeletal injury (shock) (shock) (shock) (shock)
  • 79. Associated injury
    • Fracture pelvis ; Urethral injury
    • Fracture scapula ; Shoulder, chest
    • Fracture calcaneus ; Spine (thoracolumbar region)
  • 80.
    • ควรมีการพิจารณาส่งผู้ป่วยไป X-ray ได้ ถ้า
    • Clinical stable
    • Waiting time α Stability of condition
    C. Standard radiographs of fractures / dislocation Principles to approach severe musculoskeletal injury
  • 81. ถ้าเป็นผู้ป่วยที่หมดสติ ควรจะมีการ x-ray อะไรบ้าง
    • Chest
    • Cervical spine (lateral cross table, including C1 - C7)
    • Pelvis
  • 82. D. Immediate definitive treatment of fracture
    • กระดูกหักที่ไม่จำเป็นต้องผ่าตัด สามารถดึง reduce ที่ ER ได้ ; intrahematoma block
    • กระดูกหักที่ต้องใช้การดมยาสลบช่วยในการดึง
    • กระดูกหักที่พยายามดึงให้เข้าที่ที่ห้องฉุกเฉินแล้วแต่ไม่สำเร็จ
    Principles to approach severe musculoskeletal injury
  • 83. Objective of treatment in orthopaedic patient
    • Good function
    • Prevent further degenerative changes
    • Acceptable clinical appearance
  • 84. Management of Common Fractures and Dislocations
  • 85. Definition
    • Fracture
    • : Structural break in continuity of bony cortex
    • Dislocation
    • : Displacement of a part
    • Subluxation
    • : Incomplete or partial dislocation
  • 86. Stability of joint
    • depend on
    • Reciprocal contours of the opposing joint surfaces
    • Integrity of the fibrous capsule and ligaments
    • Protective power of muscles that move the joint
  • 87. Special types of fractures
    • Stress fractures
    • Pathological fracture
    • Epiphyseal plate injury
    • Birth fracture
  • 88. Stress fracture
    • Common at
    • Metatarsal bone 2 nd , 3 rd and 4 th (March fracture)
    • Distal fibula (runner)
    • Proximal tibia (jumper and ballet dancer)
  • 89. Birth fracture
    • Clavicle
    • Humerus
    • Femur
    • Spine
  • 90. Diagnosis of joint injuries
    • Joint swelling
    • Deformity ; angulation, rotation, loss of normal contour, shortening
    • Abnormal movement
    • Local tenderness
    • Abnormal finding on X-ray
  • 91. Common affected part related to age of patient
    • Epiphyseal plate
    • Ligament, tendon, or muscle
    • Bone
  • 92. Suspected fracture or dislocation
    • First pass evaluation
    • Focused evaluation
    • Physical examination
    • Analgesia
    • Studies
  • 93. Suspected fracture or dislocation
    • First pass evaluation
    • - Remove all rings and jewelry
    • - Keep the suspected fracture immobilized
    • - Patient NPO while awaiting x-rays or ortho consult
    • Focused evaluation
    • - Determine the history whether the injury is acute or chronic or due to trauma overuse
  • 94. Suspected fracture or dislocation
    • Physical examination esp distal to suspected injry
    • - Circulation; pulse, capillary refill, or Doppler
    • - Sensation; light touch, 2-point discrimination
    • - Palpation; bony deformity or tenderness
    • - Motor; motor and nerve function
    • - Entire extremity; examine including the joint above and below the injury
    • Analgesia
  • 95. Suspected fracture or dislocation
    • Studies
    • - Obtaining x-ray when obvious deformity, any bone tenderness, severe decreased range of motion, or significant swelling
    • - If a fracture is seen always look for a second fracture (the most commonly missed) and consider x-ray of the joint above and below the injury
  • 96. Suspected fracture or dislocation
    • Studies
    • - Acute injury to the foot and ankle; using Ottawa Ankle Rules to order x-ray
    • Ankle films ; For pain near the ankle and inability to bear weight
    • (4 steps) both immediately after injury and in ED or bony tenderness
    • at the posterior edge or inferior tip of either malleolus
    • 2. Foot films ; For midfoot pain and inability to bear weight both
    • immediately after injury and in the ED or bony tenderness in
    • navicular area or base of 5th metatarsal
  • 97. Suspected fracture or dislocation
    • How to present to orthopedic surgeon
    • - Open or closed fracture
    • - Exact anatomic location
    • - Simple versus comminuted
    • - Position; displacement, angulation
    • - Complete versus incomplete
    • - Articular (joint) involvement
  • 98. Suspected fracture or dislocation
    • - Position; displacement, angulation
    • 1. Displacement: 50% displacement means the distal fragment has shifted sideways toward the dorsal surface of the extremity a distance of about 50% the thickness of the fractured bone
    • 2. Angulation: the sharp angle and its direction (dorsal, volar) is your angulation
    • * As displacement and angulation increases, the risk of nonunion and compartment syndrome, and thus the need for operative management
  • 99. How to describe
    • Site
    • Extent
    • Configuration
    • Relation between fragment
    • Relation to external environment
    • Complications
  • 100. Site
    • Diaphyseal
    • Metaphyseal
    • Epiphyseal
    • Intraarticular
  • 101. Extent
    • Complete
    • Incomplete
    • - Hairline
    • - Plastic deformation
    • - Buckle
    • - Greenstick
  • 102. Configuration
    • Transverse
    • Oblique
    • Spiral
    • Comminuted
  • 103. Relation between fragment
    • Nondisplace
    • Displace
  • 104. Relation to external environment
    • Closed
    • Open
  • 105. Complications
    • Uncomplicated
    • Complicated
  • 106. Duration for bone healing
    • Age
    • Location and configuration of fracture (more muscle, more cancellous and oblique or spiral)
    • Degree of displacement
    • Blood supply at fracture site (femoral neck,
    • scaphoid and talus)
  • 107. Complication of fractures
    • Early
    • Late
  • 108. Goal of treatment
    • Pain free or less
    • Good healing
    • Good alignment
    • Good function
    Acceptable alignment
  • 109. Methods of treatment for closed fracture
    • Protection alone
    • External splinting
    • Closed reduction and immobilization
    • Closed reduction by continuous traction and immobilization
  • 110. Methods of treatment for closed fracture
    • Closed reduction and skeletal traction
    • Open reduction and Internal fixation
    • Excised of the fracture fragment and prosthetic replacement
  • 111. Methods of treatment for open fracture
    • Cleansing of the wound
    • Debridement
    • Treatment of the fracture
    • Closure of the wound
    • Antibiotics
    • Prevention of tetanus
  • 112. Different point of musculoskeletal injury between children and adult
    • More incidence of fracture in children
    • More stronger and more rapid growth of periosteum
    • More difficult to diagnose
    • More ability of remodeling
    • Difference in treatment or complication
    • Less incidence of ligamentous injury or dislocation
    • Less tolerability to blood loss
  • 113. Prognosis of epiphyseal plate injury
    • Type of injury
    • Age of patient
    • Blood supply of the epiphysis
    • Method of reduction
    • Open or closed injury
  • 114. Before any treatment Firstly Do No Harm
  • 115. Acceptable Alignment Indication form Surgery Proper Treatment
  • 116. Open Fracture
  • 117. 1 2 3 4 5 6
  • 118. 1 2 3 4 5 6
  • 119. Open fracture The fracture in which a break in the skin and underlying soft tissues leads directly into or communicates with it and its hematoma
  • 120. Diagnosis
    • Small puncture wounds and deep abrasions on extremities with fractures
    • The presence of crepitance (subcutaneous emphysema from trapped air due to open wounds or gas gangrene)
    • Fluctuance from soft tissue stripping and internal degloving are signs of extensive soft tissue damage. (even a small puncture wound or laceration that appears remote from the fracture may indeed communicate with the fracture)
  • 121.
    • Air can be sucked into the soft tissues of an extremity
    • as a result of penetrating or blunt trauma because of the
    • occurrence of a temporary vacuum phenomenon, as
    • energy is dissipated throughout the soft tissues.
    Gas can also be produced by Clostridium perfringens and enteropathogens such as Escherichia coli . The presence of air or gas in the soft tissues on initial radiographs in the presence of a fracture strongly suggests an open fracture.
  • 122.
    • Injecting sterile saline or methylene blue to distend the joint capsule and watching for fluid extravasation from the open wound
    • (not 100% sensitive)
  • 123. Open fracture
    • Classification
    • What to do at ER
    • - Irrigation ด้วย NSS เพื่อกำจัดและเจือจางสิ่งแปลกปลอมและ
    • ปิดด้วย sterile dressing ห้าม explore แผล
    • - Tetanus prophylaxis
    • - Start antibiotic IV หรืออย่างช้าก่อน start debridement
    • ให้เหมาะสม (S. Aureus, or Gram negative)
  • 124.  
  • 125. Infection rate
    • Type I ; 0 – 2 %
    • Type II ; 2 – 7 %
    • Type III ; 10 – 50 % (26 – 41%)
    • IIIA : 10 %
    • IIIB : 10 – 50 %
    • IIIC : 25 – 50 % (amputation rate > 50 %)
  • 126. Recommendations for acute management of open fractures
    • 1. Airway management and urgent resuscitation (ABC)
    • 2. Immobilize the injured extremity and apply sterile dressing to the wound.
    • 3. Administer early intravenous antibiotics.
    • 4. Perform urgent operative wound debridement and irrigation, leave the wound open, and stabilize unstable skeletal injuries.
    • 5. Perform repeated debridements, as needed.
    • 6. Delay wound closure/coverage.
  • 127. Examination of the wound and initial emergency management
    • Foreign bodies or obvious debris such as leaves, stones, or grass found in open wounds should be manually removed with sterile forceps.
  • 128.
    • If the patient will be going to surgery within 1 or 2 hours of injury, the wound can be covered with a sterile bandage and the patient transported to the operating room for definitive irrigation and debridement.
    • If the patient will not get to the operating room for several hours, we prefer to irrigate the wound with 1 to 2 L of saline fluid before placing the sterile dressing
  • 129.
    • Povidone interferes with osteoblast function
    Predebridement culture from the wound in the emergency department before administration of antibiotics or any antiseptics is not useful
  • 130. Orthopaedic patients : Antibiotics
    • Cefazolin
    • Cloxacillin
    • Gentamicin
    • Amikacin
    • Metronidazole
    • Clindamycin
    • Ofloxacin
    • Cotrimoxazole
  • 131.  
  • 132.  
  • 133.  
  • 134.
    • May result from
    • 1. Internal cause ; inflammation and edema in a closed compartment, fracture, significant soft tissue injury, arterial injury leading to ischemia, necrosis, burns
    • 2. External cause ; prolonged external compression
    • Calculate the perfusion by measuring the disastolic pressure in the involved extremity; then subtract the measured compartment pressure. A perfusion pressure of < 30 mm Hg in a symptomatic patient is an indication for fasciotomy
    Compartment Syndrome
  • 135. Compartment Syndrome
    • When treated case of multiple fractures or with significant fractures (long bones, large degree of displacement or angulation), the following complications should always be kept in mind
    • 1. ARDS (due to fat embolism or pulmonay contusion)
    • 2. Thrombo-embolic disease
    • 3. Atelectasis
    • 4. Compartment syndrome
  • 136. ท่านจะทำอย่างไร ?
  • 137. Traumatic amputation
    • Appropriate technique to keep the amputated part
    • Keep moist by gauze with NSS or RLS and put in a plastic bag or cup
    • Soak in RLS in a plastic bag or sterile cup, then keep cold by ice (not dry ice)
  • 138. * Safety time for inappropriate technique for warm ischemia ; 6 hr * Safety time for inappropriate technique for cold ischemia ; 12 hr (fingers ; 30 hr, but less in major limb according to more muscles involvement) * The amputated part should be sent for X-ray Traumatic amputation
  • 139. Traumatic amputation
    • Indication for replantation
    • 1. Thumb
    • 2. Multiple digits
    • 3. Metacarpal (palm)
    • 4. Almost any part in a child
    • 5. Wrist or forearm
    • 6. Elbow or proximal arm (sharp, moderate severe
    • avulsion in a young patient)
    • 7. Individual digit distal to FDS insertion
  • 140. Traumatic amputation
    • Contraindication for replantation
    • 1. Severely crushed or mangled part
    • 2. Multiple levels
    • 3. Serious co-injury or diseases
    • 4. Arteriosclerosis
    • 5. Mentally unstable
    • 6. Individual digit proximal to FDS insertion
    • 7. Prolonged warm ischemia
  • 141.  
  • 142. Mangled Extremity Severity Score (MESS)
    • Skeletal / soft tissue injury
    • Limb ischemia
    • Shock
    • Age
    • * If the total score is < 7, the limb is nearly almost
    • compatible with salvageable limb.
  • 143.                                                              
  • 144. A score of less than 7 points suggests that salvage should be attempted. Conversely, amputation should be considered if the score is more than 20 points.
  • 145. Open Knee Injury
  • 146. Pitfalls of Musculoskeletal Problem in Children
  • 147.  
  • 148.  
  • 149.  
  • 150.  
  • 151.  
  • 152. Staging of fracture in young children
    • Incomplete Fracture
    • Plastic deformation
    • Greenstick fracture
    • Buckle fracture
    • Torus fracture
    • Complete Fracture
  • 153.  
  • 154.  
  • 155.  
  • 156.  
  • 157.  
  • 158. Do you know these?
    • Fracture of Necessities (Fracture of medial or lateral condyle fracture, supracondylar fracture)
    • Triplane Fracture
    • Tillaux’s Fracture
  • 159. Three Part Fracture Two Part Fracture
  • 160. Common Musculoskeletal Problems
    • Fracture distal end of radius
    • Fracture neck of femur
    • Shoulder dislocation
  • 161. Fracture of Distal Radius
    • Indication for surgery
    • Intra-articular step-off > 2 mm
    • Die-punch fracture
    • Significant dorsal comminution involving > 1/3 of AP diameter of radius
    • Lost reduction within the 1 st week after injury
  • 162. Fracture of distal radius
    • Goal of treatment
    • 1. Rapid restoration of function
    • 2. Prevention of chronic disability
    • Diagnosis,
    • Appropriate intervention, and Postintervention rehabilitation
  • 163. Fracture of Necessity
    • Galeazzi’s fracture
    • Monteggiae’s fracture
    • Lateral condylar fracture
    • Supracondylar fracture
  • 164. Imperturbability
    • Remaining calm and unworried in spite of problems or difficulties
    • The physician who shows that he is flustered and hurried in ordinary emergencies, loses rapidly the confidence of his patients
  • 165. Five factors
    • The pressure of time and volume
    • The variety of conditions faced
    • The paucity of information
    • The limitation of therapeutic options
    • The constraint of disposition
  • 166. “ Treat First and Ask Questions Later”
  • 167. Most practices On average only 10 to 15 minutes per patient for the evaluation, testing, treatment, disposition, and documentation
  • 168. The way of approach
    • First question to be asked and answered
    • in the first few seconds
    Do I need to resuscitate this patient? How great is the threat? How soon must I act?
  • 169. Management, Not Diagnosis
    • In emergency medicine, the central task is not diagnosis, but management
    • If one can be made, it is extremely helpful, but if not, decisions must still be made and actions must still be taken
  • 170. Decision Thresholds “Index of Suspicion”
    • Only one disease under consideration and there are only two possible actions
    • To Treat or Not Treat
  • 171.
    • If the patient is almost certainly non-diseased (probability is near zero), then the correct decision is Not Treat, because treatment entails costs and risks of its own
    • Very low probabilities of disease, it is better not to test and not to treat
    Decision Thresholds “Index of Suspicion”
  • 172.
    • Very high probabilities, it is better not to test, but to treat
    • Intermediate probabilities, testing and treating only those with a positive test will produce the best overall outcome
    Decision Thresholds “Index of Suspicion”
  • 173. Common Pitfalls
    • Tunnel vision
    • “ Premature closure of hypothesis generation”
    • Just the opposite
    • “ Inability to see the forest for the trees”
    • Failure to attend to the patient
    • “ Fail to social interaction with patient and family”
  • 174. How to approach patients
    • Bio
    • Psycho
    • Social
    • Spirit