This document discusses the management of various orthopedic emergencies including open fractures, dislocations, compartment syndrome, pelvic fractures, septic arthritis, fat embolism syndrome, and spinal cord injuries. It provides classifications for open fractures and guidelines on antibiotic use. Specific treatments are outlined for conditions like anterior shoulder dislocation reduction techniques, signs of compartment syndrome, unstable pelvic fracture stabilization, septic arthritis treatment, supportive care for fat embolism syndrome, and initial management of spinal cord injuries. References are also provided.

1. Orthopaedic Emergency
Cases: What Will We Do?
dr. Tedjo Rukmoyo, Sp. OT (K)

2. Severe injury to :
Brain, Spinal Cord, Heart,
Aorta, Large blood vessels
Subdural/epidural hematoma,
hemopneumothorax, rupture
spleen/liver, pelvic fracture,
multiple injury
Sepsis, MODS

3. •Limb Threatening
• Trauma
• Open Fracture
• Compartment
Syndrome
• Dislocation
• Non Trauma
• Septic Arthritis
•Life Threatening
• Mayor Pelvic Ring
Injuries
• Crush Injury / Syndrome
• Vascular Injuries
INTRODUCTION

4. Gustilo Type I II IIIA IIIB IIIC
Images
ENERGY Low Moderate High High High
Wound SIZE ≤ 1 cm 1-10 cm usually >10 cm usually >10 cm usually > 10 cm
SOFT TISSUE Damage Minimal Moderate Extensive Extensive Extensive
CONTAMINATION Clean Moderate contamination Extensive Extensive Extensive
FRACTURE Pattern Simple fx + minimal comminution Moderate comminution Severe comminution / segmental Severe comminution / segmental Severe comminution / segmental
PERIOSTEAL Stripping No No Yes Yes Yes
SKIN Coverage Local coverage Local coverage Local coverage
Requires free tissue flap or
rotational flap coverage
Typically requires flap coverage
NEUROVASCULAR Injury Normal Normal Normal Normal
Exposed fracture with arterial
damage that requires repair
INFECTION Rate 0 – 2% 2 – 7% 10 – 25% 10 – 50% 25 – 50%
ANTIBIOTICS
• 1st generation cephalosporin (e.g. cefazolin) • 1st generation cephalosporin  gram positive coverage
• Aminoglycoside (Gentamicin)  gram negative coverage
• + Penicillin  anaerobic organism
Anti Tetanus Toxoid dose 0.5 mL, regardless ofage or Immune globulin dosing :
OPEN FRACTURE

5. MANAGEMENT
•Follow trauma protocol
•Antibiotics
•ATS/TT
•Wound Debridement 
contaminated + dead
tissue
•Fracture Stabilization
•Wound Closure
OPEN FRACTURE

6. MANAGEMENT
OPEN FRACTURE
Vascular repair Tendon repair
Cannot repair Sutured to Fascia
Do not Expose!
Bone
Ligament
Tendon
Nerve
Vascular

7. DISLOCATION
Anterior Shoulder
Dislocation
• Arm  internally rotated - abducted
• Always check  neurovascular status

8. Milch Manuver
Kocher Manuver
Hippocratic
Method
Stimson Manuver
MANAGEMENT
Velpeau Bandage
DISLOCATION

9. HIP DISLOCATION
• Usually high-energy trauma
• Posterior hip dislocation  internal rotation (most common)
• Anterior hip dislocation  external rotation

10. MANAGEMENT
Early reduction ESSENTIAL  GOLDEN
PERIOD <6 Hr
HIP DISLOCATION

11. The 5 P’s
• Pain:
• progressive, on passive
stretch, out of proportion
• Pallor
• Paralysis
• Pulses
• Paresthesia
COMPARTMENT SYNDROME

12. • Constricting
circumferential dressings
 split down
• limb  placed at the
level of the heart
• Any fracture 
realigned, immobilized
and splinted.
• Observe/15 min  5P+
OXYMETRI
• Failed  Urgent
fasciotomy
MANAGEMENT
COMPARTMENT
SYNDROME

13. UNSTABLE PELVIC FRACTURE

14. UNSTABLE PELVIC
FRACTURE
Pelvic Injury
Resuscitation
Stable
Haemodynamic
Unstable
Haemodynamic
Unstable
Pelvic Ring
Stable
Pelvic Ring
Unstable
Pelvic Ring
Stable
Pelvic Ring
Other sources
External
Fixation
Definitive
ORIF
Conservative

15. Before pelvic binder application After pelvic binder application
MANAGEMENT
UNSTABLE PELVIC
FRACTURE

16. Direct
Inoculation
Contagious
Spread
Hematogen
ous
 Rapid onset
 Severe Pain
 Joint Effusion
 Joint warmth + Erythema
 ROM ↓
 Lab :
 Blood  CRP ↗, WBC ↗, ESR ↗,
 Joint fluid  WBC ↗ ↗
 Pyrexia
 Pseudoparalysis
SEPTIC ARTHRITIS

17. • Key treatment  identify organism
• 1st Priority  Aspirate joint fluid
• General supportive care  analgesics
and IV Fluid
• Immobilization
• Antibiotics
• Empiric therapy  prior to
definitive
• Culture result (+)  organism
specific antibiotics
• Operative : Arthrotomy + Irigation
MANAGEMENT
SEPTIC
ARTHRITIS

18. • Long Bone Fractures
• Pelvic Fractures
• Orthopaedic Procedures (IM Nailing,
Arthroplasty)
• Soft tissue injuries (Chest compression)
Causes
FAT EMBOLISM SYNDROME

19. 1 Major + 4 Minor
MAJOR FEATURES
• Hypoxemia (PaO2 < 60)
• CNS depression (changes in mental
status)
• Petechial rash
• Pulmonary edema
MINOR FEATURES
• Tachycardia
• Pyrexia
• Retinal emboli
• Fat in urine or sputum
• Thrombocytopenia
• HCT ↓
FAT EMBOLISM
SYNDROME

20. •Management  SUPPORTIVE
• OXYGENATION  Ventilator
• Prompt STABILIZATION fracutes
• FIXATION  lung ventilation–
perfusion ↗
MANAGEMENT
FAT EMBOLISM
SYNDROME

21. SPINAL CORD INJURY
Why Emergency?
- Progressive neurological deficit
- Breathing problem (Cervical fracture)
- Shock (Spinal/Neurogenic)
- Pneumonia, pulmonary embolism,
septicaemia  following hospitalization

22. SPINAL CORD INJURY
Sign of Spinal Injury
Tenderness Severe Back
Pain
Paralysis Loss of
Sensation
Twisted Bowel /
Bladder
Problem
Breathing
Problem
Walking
Problem

23. INITIAL MANAGEMENT OF SPINAL CORD INJURY
• Maintain the Primary Survey (ABCDEF)
• SPINAL IMMOBILIZATION
• Rigid Collar
• Sandbag and straps
• Spine board
• Log roll to turn
• MAINTAIN OXYGENATION
• If intubation needed, DON’T move the neck!
MANAGEMENT
SPINAL CORD
INJURY
Non Operative Management

24. • Kinking of a major vessel
• Arterial spasm
• Arterial puncture
• Intimal dissection
• Compartment syndrome
Causes
VASCULAR INJURY

25. VASCULAR INJURY
• Pain
• Pale
• Pulseless
• Cold
• Vena back flow
• Needle prick test (-)
• Pulse Oxymetri (-)
Sign and Symptoms

26. INITIAL MANAGEMENT
• Maintain the Primary Survey (ABCDE)
• Realign and splint the limb  Arteriography
• Make a surgical referral
MANAGEMENT

28. References:
• Apley, A. G., & Solomon, L. (2018). Apley and
Solomon’s system of orthopaedics and trauma: 10th
edition. London: Arnold.
• Horowitz DL, Katzap E, Horowitz S, Barilla-LaBarca ML.
Approach to septic arthritis. Am Fam Physician. 2011
Sep 15;84(6):653-60. PMID: 21916390.
• Kim, Kyung & Lee, Ju & Choi, Young & Kim, Woo Sun &
Park, June & Koh, Young & Suh, Dong In. (2013). A
case of fat embolism syndrome in juvenile rheumatoid
arthritis patient. Allergy Asthma & Respiratory
Disease. 1. 94. 10.4168/aard.2013.1.1.94.
• Mabvuure, NT., Malahias, M., Hindocha, S., Khan, W.,
Juma, A. 2020. Acute Compartment Syndrome of the
Limbs: Current Concepts and Management. The Open
Orthopaedic Journal. ISSN: 1874-3250 ― Volume 14