The document provides an overview of various orthopaedic emergencies including open fractures, acute compartment syndrome, dislocations, neurovascular injuries, septic joints, and cauda equina syndrome. Open fractures are classified using the Gustilo-Anderson system and require irrigation, debridement, and antibiotics. Acute compartment syndrome causes increased pressure within muscle compartments and requires urgent fasciotomy. Common dislocations include shoulder, knee, and hip joints. Neurovascular injuries from fractures require prompt assessment. Septic joints usually involve the knee and present with joint pain, swelling, and fever. Cauda equina syndrome is a surgical emergency from compression of lumbosacral nerve roots.

1. ORTHOPAEDIC EMERGENCIES
ORTHOPAEDIC DEPARTMENT
KHOULA HOSPITAL
By
Dr. AHMED AZMY

5.  Open Fractures
 Acute Compartment Syndrome
 Dislocations
 Neurovascular injuries
 Septic Joints
 Cauda Equina Syndrome

6. OPEN FRACTURES

7. Open Fractures
 An open (or compound) fracture occurs when the skin overlying a
fracture is broken, allowing communication between the fracture and
the external environment.

8. Open Fractures- Gustilo-Anderson Classification
--Grade I: wound < 1cm
– Grade II: wound 1-5 cm without excessive
contamination, crush injury or soft tissue
loss
– Grade III: wound >5cm, or gross
contamination, crush injury, or excessive
soft tissue loss
A – adequate soft tissue coverage
B – fracture cover not possible without local
/distant flaps
C – arterial injury that needs to be repaired.

9. Open Fractures- Management
 ABCDE
 Check neurovascular status, fluid resuscitation
 Remove large pieces of debris and
cover with sterile wet dressing
 Immediate parenteral antimicrobials
– 1st generation cephalosporin
– add aminoglycoside for types ii and iii
 Urgent orthopedic consultation
 most require irrigation and debridement in OR

11. Open Fractures- Complications
 Wound infection – 2% in Type I , >10% in Type III
 Osteomyelitis – staph aureus, pseudomona sp.
 Gas gangrene
 Tetanus
 Non-union/malunion

12. Acute Compartment
Syndrome

13. Acute Compartment Syndrome
# Case
 16 yrs old , soccer player
 Forearm trauma/deformity
 Skin intact
 Placed in a long arm splint
 Neurovascular examination is normal
** C/O thumb numbness

14. Epidemiology
 Compartment syndrome (CS) is a serious life and limb threatening
complications of extremity trauma
 ACS- Etiology:-
 Crush injury
 Circumferential burns
 Snake bites
 Fractures – 75%
 Tourniquets, constrictive dressings/plasters
 Haematoma – pt with coagulopathy at increased risk

15. Pathophysiology

16. ACS- FINDINGS
(5 Ps) of ischaemia
 Pain
 Paresthesias
 Paralysis
 Pulselessness
 Pallor
 Severe pain (out of proportion to
injury)
 Pain with passive stretch
 Tense compartment
 Tight, shiny skin
Can confirm diagnosis by measuring intracompartmental
pressures (Stryker STIC)

17. 0 mm Hg
10 mm Hg
30 mm Hg
60 mm Hg
120 mm Hg
Pulse Pressure
Ischemia
Elevated Pressure
Normal
Difference between
diastolic pressure and
compartment
pressure (delta
pressure)< 30mmHg
is indication for
immediate
decompression

18. ACS - Mangement
Early recognition
Muscle necrosis at delta
pressure < 30mm Hg
Irreversible injury 4-6 hrs
Remove cast, bandages and
dressings
Arrange urgent fasciotomy

19. Fasciotomy

21. ACS- Complications
Volkman ischaemic contractures
Permanent nerve damage
Limb ischaemia and amputation
Rhabdomyolysis and renal failure

22. JOINTS
DISLOCATIONS

23. JOINT DISLOCATIONS
Displacement of bones at a joint from their normal position
Do x-rays before and after reduction to look for any associated
fractures

24. DISLOCATION- SHOULDER
Most common major joint dislocation
Anterior (95%) - Usually caused by fall on hand
Posterior (2-4%) – Electrocution/seizure
May be associated with:
Fracture dislocation
Rotator cuff tear
Neurovascular injury

26. DISLOCATION- KNEE
 Injury to popliteal artery and vein is common
 Peroneal nerve injury in 20-40% of knee dislocations
 Associated with ligamentous injury
 Anterior (31%)
 Posterior (25%)
 Lateral (13%)
 Medial (3%)

27. DISLOCATION- HIP
 Usually high-energy trauma
 More frequent in young patients
 Posterior- hip in internal rotation, most common
 Anterior- hip in external rotation
 Central - acetabular fracture
 May result in avascular necrosis of femoral head
 Sciatic nerve injury in 10-35%

28. NEUROVASCULAR
INJURIES

29.  Fractures and dislocations
 Always check before and after reduction

30. Neurovascular Injuries - Etiology
 Fracture
 Humerus, femur
 Dislocation
 Elbow, knee
 Direct/penetrating trauma
 Thrombus
 Direct Compression/
Acute Compartment Syndrome
 Cast, unconscious

31. Common vascular injuries
Injury Vessel
1st rib fracture Subclavian artery/vein
Shoulder dislocation Axillary artery
Humeral supracondylar fracture Brachial artery
Elbow Dislocation Brachial artery
Pelvic fracture Presacral and internal iliac
Femoral supracondylar fracture Femoral artery
Knee dislocation Popliteal artery/vein
Proximal tibial Popliteal artery/vein

32. CLINICAL FEATURES & MX.
Paraesthesia/numbness
Injured limb cold, cyanosed, pulse weak/absent
Call for help!
 Remove all bandages and splints
 Reduce the fracture/ dislocation and reassess
circulation
If no improvement then vessels must be explored
by operation
If vascular injury suspected angiogram should be
performed immediately

34. Injury Nerve
Shoulder dislocation Axillary
Humeral shaft fracture Radial
Humeral supracondylar fracture Radial or median
Elbow medial condyle Ulnar
Monteggia fracture-dislocation Posterior-interosseous
Hip dislocation Sciatic
Knee dislocation Peroneal
Common nerve injuries

35.  Paraesthesia and weakness to supplied area
 Closed injuries: nerve seldom severed, 90% recovery in 4 months. If not do
nerve conduction studies +/- repair
 Open injuries: Nerve injury likely complete. Should be explored at time of
debridement/repair
 Indications for early exploration:
 Nerve injury associated with open fracture
 Nerve injury in fracture that needs internal fixation
 Presence of concomitant vascular injury
 Nerve damage diagnosed after manipulation of fracture
Clinical Features & Mx

36. SEPTIC JOINTS/
SEPTIC ARTHRITIS

37. SEPTIC JOINT/SEPTIC ARTHRITIS
Inflammation of a synovial membrane with purulent effusion
into the joint capsule. Followed by articular cartilage erosion by
bacterial and cellular enzymes.
Usually monoarticular
Usually bacterial
Staph aureus
Streptococcus
Neisseria gonorrhoeae

38. SEPTIC JOINT- ETIOLOGY
Direct invasion through penetrating wound, intra-
articular injection, arthroscopy
Direct spread from adjacent bone abcess
Blood spread from distant site

39. SEPTIC JOINT- LOCATION
Knee- 40-50%
Hip- 20-25%*
*Hip is the most common in infants and
very young children
Wrist- 10%
Shoulder, ankle, elbow- 10-15%

40. SEPTIC JOINT- RISK FACTORS
Prosthetic joint
Joint surgery
Rheumatoid arthritis
Elderly
Diabetes Mellitus
IV drug use
Immunosupression
AIDS

41.  Rapid onset
 Joint pain
 Joint swelling
 Joint warmth
 Joint erythema
 Decreased range of motion
 Pain with active and passive ROM
 Fever, raised WCC/CRP, positive blood
cultures
Septic Joint- Signs and Symptoms

42. Septic Joint- Diagnosis
Diagnosis by aspiration
Gram stain, microscopy, culture
Leucocytes >50 000/ml highly
suggestive of sepsis

43. Septic arthritis
vs.
Cellulitis

44.  Joint washout in theatre
 IV Abx 4-7 days then orally for another 3 weeks
 Analgesia
 Splintage
Septic Joint- Treatment

45. Septic Joint- Complications
 Rapid destruction of joint with delayed treatment (>24
hours)
 Growth retardation, deformity of joint (children)
 Degenerative joint disease
 Osteomyelitis
 Joint fibrosis and ankylosing
 Sepsis
 Death

46. CAUDA EQUINA
SYNDROME

47. CAUDA EQUINA SYNDROME
Compression of lumbosacral nerve roots below
conus medullaris secondary to large central
herniated disc/extrinsic mass/infection/trauma

48. Clinical Features
 Motor (LMN signs)
-weakness/paraparesis in multiple root distribution
-reduced deep tendon reflexes (knee and ankle)
-sphincter disturbance (urinary retention and fecal
incontinence due to loss of anal sphincter tone)
 sensory
-saddle anesthesia (most common sensory deficit)
-pain in back radiating to legs, crossed straight leg test
-bilateral sensory loss or pain: involving multiple dermatomes

49. Management
 Surgical emergency - requires urgent investigation and
decompression (<48 hrs) to preserve bowel and bladder
function

50. Take
Home
message

51. Thank
you