Pitfalls in orthopaedics


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Pitfalls in orthopaedics

  1. 1. Pitfalls in Orthopaedic<br />opps<br />Lt Col S K RAI<br />Capt PramodMahender<br />
  2. 2. Case Study<br />A case was tried where a 10-month-old girl suffered anoxic brain injury after “being deprived of oxygen for 40 minutes, forgot the keys to an onboard medicine cabinet and later falsified records related to the rescue”<br />
  3. 3. Medicolegal Outcome<br />The girl, now 5, is a spastic quadriplegic with severe brain damage <br />State health officials heard of the case only after a story appeared in the state Lawyers Weekly <br /> The $10.2 million(50 crores) settlement included a confidentiality agreement that kept secret the identities of the family, the hospitaland the EMS technicians <br />
  4. 4. Errors<br />Not all errors result in harm to the patient, and many react only to errors that are considered to have an adverse effect on a patient (injury or death)<br />
  5. 5. Orthopaedic Emergency<br />Examples?<br />
  6. 6. Orthopaedic emergency<br /><ul><li> Trauma</li></ul>Non-trauma<br /> - Osteomyelitis, Septic arthritis, Pyomyositis<br /> - Gouty arthritis<br /> - C1 - C2 subluxation<br />( Rheumatoid arthritis)<br /> - Acute disc syndrome<br />
  7. 7. Assume the cervical spine to be unstable until proven otherwise <br />up to 50% of patients sustaining C-spine trauma develop neurologic abnormalities (nerve root compression and weakness to quadri- plegia and death). <br />10% are initially neurologically intact, but develop deficits during emergency care <br />risks of airway management<br />
  8. 8.
  9. 9. C-spine evaluation<br />bone and soft tissue<br />X-ray exam: „one view is no view”,<br /> AP-lateral<br />open mouth view -atlanto-occipital and atlanto-axial joints, the odontoid process,oblique – intervert. foramina<br />CT<br />lateral cervical spine - sensitivity of about 85%<br /> 92% in a three view series <br /> 100% when selective CT scanning is employed<br />
  10. 10.
  11. 11. The primary survey –life threatening conditions are identified and management is begun simultaneously!<br />A - Airway maintenance with cervical spine control <br />B - Breathing and ventilation <br />C - Circulation with hemorrhage control <br />D - Disability: neurological status <br />E - Exposure: completely undress the patient<br />
  12. 12. Circulation<br /><ul><li>Does patient have radial pulse?</li></ul>Absent radial = systolic BP < 80<br /><ul><li>Does patient have carotid pulse?</li></ul>Absent carotid = systolic BP < 60<br />
  13. 13. Circulation<br /><ul><li>No carotid pulse?</li></ul>intubate<br />CPR<br />Pneumatic AntishockGarment<br /><ul><li>Survival rate from cardiac arrest secondary to blunt trauma is < 1%</li></li></ul><li>Circulation<br /><ul><li>Serious external bleeding?</li></ul>Direct pressure <br />Tourniquet as last resort<br /><ul><li>All bleeding stops eventually!</li></li></ul><li>Circulation<br /><ul><li>Is patient in shock?</li></ul>Cool, pale, moist skin = shock, until proven otherwise<br />Capillary refill > 2 sec = shock until proven otherwise<br />Restlessness, anxiety= shock until proven otherwise<br />
  14. 14. Circulation<br /><ul><li>If possible internal hemorrhage, QUICKLY expose, palpate:</li></ul>Abdomen<br />Pelvis<br />Thighs<br />
  15. 15. Circulation<br />Large bore IV lines<br />BP<br />HR <br />Alghevar scheme - quantification of shock: <br />SBP / HR <br /> >1 no or minor clinical symptoms<br /> <1 major shock<br />Pulses<br />Indirect signs: UO, skin, tachypnoe, altered consciousness, empty” periferal veins <br />
  16. 16. Circulation<br />warmed intravenous infusions<br />Control: <br />external hemorrhage<br />internal hemorrhage:<br />MAST suit<br />Pelvic binders<br />Surgery  stabilisation  secondary survey<br />
  17. 17. Disability (CNS Function)<br /><ul><li>Level of Consciousness = Best brain perfusion indicator
  18. 18. Check pupils</li></ul>The eyes are the window of the CNS<br />
  19. 19. Disability (CNS Function)<br />Decreased LOC in trauma = Head injury until proven otherwise<br />
  20. 20. B. Initial treatment of major fractures<br />Shock in orthopaedic patient<br /> - Hypovolemic shock<br /> - Neurogenic shock<br />Major fracture<br /> - Pelvis<br /> - Spine (cervical)<br /> - Femur <br /> - Multiple fractures <br /> - Hip<br />(shock)<br />(shock)<br />(shock)<br />(shock)<br />
  21. 21. Associated injury<br />Fracture pelvis ; Urethral injury<br />Fracture scapula ; Shoulder, chest<br />Fracture calcaneus ; Spine (thoracolumbar region)<br />
  22. 22. Which are Emergencies?<br />Closed fracture, n.v. normal<br />Closed dislocation, n.v. normal<br />Open fracture<br />Open dislocation<br />
  23. 23. Mercifully Few Emergencies<br />Open Fractures and Dislocations<br />with or without vascular injury<br />with or without neurological impairment <br />
  24. 24. Not “broken”…<br />…but still a <br />limb-threatening<br />emergency!<br />
  25. 25.
  26. 26. Joint Dislocations<br />Must be reduced at once<br />Risk to circulation and nerves<br />Risk of Osteonecrosis (AVN)<br />
  27. 27. Management in Musculoskeletal Injury<br />R = Rest <br />I = Ice<br />C = Compression<br />E = Elevation<br />
  28. 28. Principles to approach severe musculoskeletal injury<br />First aids<br />Initial treatment of major fractures / dislocation<br />Standard radiographs of fractures / dislocation<br />Immediate definitive treatment of fracture / dislocation <br />
  29. 29. A. First aids<br />Bleeding control<br />Immobilization<br />Pain control<br />Antibiotic administration<br />Tetanus prophylaxis<br />Improve microcirculation<br />
  30. 30.
  31. 31.
  32. 32. Methods of immobilization<br />Splinting; wooden, commercial<br />Brace or support<br />Strap<br />Slab immobilization<br />Cast immobilization<br />Traction<br />External fixation<br />Open reduction and internal fixation<br />
  33. 33. Purpose of immobilization<br />Temporary <br />Definite<br />
  34. 34. Complication of immobilization<br />Too fit<br />Too loose<br />Too long interval<br />Too short interval <br />; pressure sore, compartment syndrome<br />; inadequate immobilization (loss reduction, <br /> delayed, mal or nonunion)<br />; muscle atrophy, osteoporosis, <br /> joint stiffness, maceration of skin<br />; inadequate immobilization <br /> (loss reduction, delayed, mal or <br /> nonunion)<br />
  35. 35. Complications of casting<br />Pressure sores<br />Cast sores<br />
  36. 36. Velpeau’s strap<br />Injury of <br />shoulder <br />region<br />
  37. 37. Slab immobilization<br />U or Sugar tong slab for humerus fracture<br />Short or long arm slab with or without thumb spica<br />Below or above knee slab<br />Cylindrical slab<br />
  38. 38.
  39. 39. Advice to give patients before casting<br />Objectives and advantages of casting<br />Duration of casting<br />Activities to do and not to do during casting<br />Good co-operation is needed<br />
  40. 40. Skeletal traction<br />1 lbs of traction for every 7 lbs of body weight<br />(usually uncomfort if > 35 lbs)<br />
  41. 41. Disadvantages<br />Costly in terms of hospital stay<br />Hazards of prolonged bed rest<br />Thromboembolism<br />Decubiti<br />Pneumonia<br />Requires meticulous nursing care<br />Can develop contractures<br />
  42. 42. Skull traction<br />Gardner-Wells tong<br />
  43. 43. Skull traction<br />Crutchfield tongs<br />
  44. 44. Orthopaedic patients : Antibiotics<br />Cefazolin<br />Cloxacillin<br />Gentamicin<br />Amikacin<br />Metronidazole<br />Clindamycin<br />Ofloxacin<br />Cotrimoxazole<br />
  45. 45. Pitfalls in paediatrics<br />
  46. 46. Different point of musculoskeletal injury between children and adult<br />More incidence of fracture in children<br />More stronger and more rapid growth of periosteum<br />More difficult to diagnose<br />More ability of remodeling<br />Difference in treatment or complication<br />Less incidence of ligamentous injury or dislocation<br />Less tolerability to blood loss <br />
  47. 47. Prognosis of epiphyseal plate injury<br />Type of injury<br />Age of patient<br />Blood supply of the epiphysis<br />Method of reduction<br />Open or closed injury<br />
  48. 48. Fracture of Necessity<br />Galeazzi’s fracture<br />Monteggiae’s fracture<br />Lateral condylar fracture<br />Supracondylar fracture<br />
  49. 49. Common Pitfalls<br />Tunnel vision<br /> “Premature closure of hypothesis generation”<br />Just the opposite<br /> “Inability to see the forest for the trees”<br />Failure to attend to the patient<br />“Fail to social interaction with patient and family” <br />
  50. 50. How to approach patients<br />Bio <br />Psycho<br />Social <br />Spirit<br />
  51. 51. TAKE HOME<br />In emergency medicine, the central task is not diagnosis, but management <br />Alghevar scheme BP>HR<br />
  52. 52. THANK YOU<br />Questions?<br />