This document summarizes several common orthopedic emergencies including open fractures, acute compartment syndrome, dislocations, septic joints, neurovascular injuries, and cauda equina syndrome. Open fractures are classified using the Gustilo-Anderson system and require urgent debridement, antibiotics, and stabilization. Acute compartment syndrome causes increased pressure within fascial compartments and requires timely fasciotomy to prevent muscle and nerve damage. Dislocations of major joints like the shoulder and hip can damage surrounding nerves and blood vessels and need prompt reduction. Septic joints usually involve a single joint and result from bacterial spread, requiring joint washout and prolonged antibiotics. Neurovascular injuries are a risk with fractures and dislocations near major arteries or nerves

1. Common Orthopaedic Emerg
encies Pitfalls

2. Orthopedic Emergencies
 Open Fractures
 Acute Compartment Syndrome
 Neurovascular injuries
 Dislocations
 Septic Joints
 Cauda Equina Syndrome

3. Open Fractures
 An open (or compound) fracture occurs when the skin overlying a fra
cture is broken, allowing communication between the fracture and th
e external environment

4. Open Fractures- Gustilo-Anderson Classification:
 Type I:
 Small wound (<1cm), usually clean, no soft tissue damage and no
skin crushing (i.e. a low energy fracture)
 Type II:
 Moderate wound (>1cm), minimal soft tissue damage or loss, ma
y have comminution of fracture (i.e. a low-moderate energy fract
ure)
 Type III:
 Severe skin wound, extensive soft tissue damage (i.e. high energy
fracture)
 Three grades: A – adequate soft tissue coverage, B – fracture cove
r not possible without local/distant flaps, C – arterial injury that
needs to be repaired.

5. Open Fractures- Management
 ABCDE – check neurovascular status (pulses, cap. refill, sensation, mot
or) , fluid resuscitation, blood
 Antibiotics, tetanus prophylaxis – 48-72 hrs
 Surgical debridement – removal of de-vitalised tissue, irrigation
 Stabilization of fracture – internal/external, if closure delayed then exte
rnal prefered
 Early definitive wound cover – split skin grafts, local/distant flaps (invo
lve plastics)

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

8. Acute Compartment Syndrome
 An injury or condition that causes prolonged elevation of interstitia
l tissue pressures
 Increased pressure within enclosed fascial compartment leads to i
mpaired tissue perfusion
 Prolonged ischemia causes cell damage which leads to oedema
 Oedema further increase compartment pressure leading to a viciou
s cycle
 Extensive muscle and nerve death >4 hours
 Nerve may regenerate but infarcted muscle is replaced by fibrous ti
ssue (Volkmann’s ischaemic contracture)

9. ACS- Etiology
 Crush injury
 Circumferential burns
 Snake bites
 Fractures – 75%
 Tourniquets, constrictive dressings/plaster
s
 Haematoma – pt with
coagulopathy at increased risk

10. ACS- Findings
 5 Ps of ischaemia
 Pain (out of proportion to i
njury)
 Paresthesias
 Paralysis
 Pulselessness
 Pallor
 Severe pain, “bursting” sensati
on
 Pain with passive stretch
 Tense compartment
 Tight, shiny skin
 Can confirm diagnosis by mea
suring intracompartmental pr
essures (Stryker STIC)

11. 0 mm Hg
10 mm Hg
30 mm Hg
60 mm Hg
120 mm Hg
Pulse Pressure
Ischemia
Elevated Pressure
Normal
Difference between di
astolic pressure and c
ompartment pressure
(delta pressure)< 30
mmHg is indication fo
r immediate decompr
ession

12. ACS - Mangement
 Early recognition
 Muscle necrosis at delta press
ure < 30mm Hg
 Irreversible injury 4-6 hrs
 Remove cast, bandages and dres
sings
 Arrange urgent fasciotomy

13. Fasciotomy

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

15. Dislocations
 Displacement of bones at a joint from their norma
l position
 Do xrays before and after reduction to look for an
y associated fractures

16. 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

17. 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%)

18. 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%

19. Neurovascular Injuries
 Fractures and dislocations can be associated with vascular and nerve
damage
 Always check neurovascular status before and after reduction

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

21. 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

22. 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

24. Common nerve injuries
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

25. Clinical Features & Mx
 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

27. Septic Joint/Septic Arthritis
 Inflammation of a synovial membrane with purulent effusion into t
he joint capsule. Followed by articular cartilage erosion by bacterial
and cellular enzymes.
 Usually monoarticular
 Usually bacterial
 Staph aureus
 Streptococcus
 Neisseria gonorrhoeae

28. Septic Joint- Etiology
 Direct invasion through penetrating woun
d, intra-articular injection, arthroscopy
 Direct spread from adjacent bone abcess
 Blood spread from distant site

29. 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%

30. Septic Joint- Risk Factors
 Prosthetic joint
 Joint surgery
 Rheumatoid arthritis
 Elderly
 Diabetes Mellitus
 IV drug use
 Immunosupression
 AIDS

31. Septic Joint- Signs and Symptoms
 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 bloo
d cultures

32. Septic Joint- Treatment
 Diagnosis by aspiration
 Gram stain, microscopy, culture
 Leucocytes >50 000/ml highly
suggestive of sepsis
 Joint washout in theatre
 IV Abx 4-7 days then orally for another 3 weeks
 Analgesia
 Splintage

33. 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

34. Cauda Equina Syndrome
 Compression of lumbosacral nerve roots below conus medullaris se
condary to large central herniated disc/extrinsic mass/infection/tr
auma

35. Clinical Features
 motor (LMN signs)
-weakness/paraparesis in multiple root distribution
-reduced deep tendon reflexes (knee and ankle)
-sphincter disturbance (urinary retention and fecal incontine
nce 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 dermatome
s

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

37. The End