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Toronto Notes 2019 Orthopedic Emergencies Orthopedic Emergencies
Trauma Patient Workup
Etiology
• highenergytraumae.g.MVC,fallfromheight
• maybeassociatedwithspinalinjuriesorlife-threateningvisceralinjuries
Clinical Features
• localswelling,tenderness,deformityofthelimbs,andinstabilityofthepelvisorspine • decreasedlevelofconsciousness,hypotension/hypovolemia
• considerinvolvementofEtOHorothersubstances
Investigations
• traumasurvey(seeEmergencyMedicine,ER7)
• x-rays:lateralcervicalspine,APchest,APpelvis,APandlateralofallbonessuspectedtobeinjured • CTisalsoutilizedtoinspectformusculoskeletalinjuriesinthetraumasetting
• otherviewsofpelvis:AP,inlet,andoutlet;Judetviewsforacetabularfracture(ClassificationofPelvic
Fractures see Table 19, OR28)
Treatment
• ABCDEsandinitiateresuscitationforlife-threateninginjuries
• assessgenitourinaryinjury(rectalexam/vaginalexammandatory) • externalorinternalfixationofallfractures
• DVTprophylaxis
Complications
• hemorrhage–life-threatening(mayproducesignsandsymptomsofhypovolemicshock)
• fatembolismsyndrome(SOB,hypoxemia,petechialrash,thrombocytopenia,andneurologicalsymptoms) • venousthrombosis–DVTandPE
• bladder/urethral/bowelinjury
• neurologicaldamage
• persistentpain/stiffness/limp/weaknessinaffectedextremities
• post-traumaticOAofjointswithintra-articularfractures
• sepsisifmissedopenfracture
Open Fractures
• fracturedboneandhematomaincommunicationwiththeexternalorcontaminatedenvironment
Emergency Measures
• ABCs,primarysurvey,andresuscitationasneeded • removalofobviousforeignmaterial
• irrigatewithnormalsalineifgrosslycontaminated • coverwoundwithsteriledressings
• immediateIVantibiotics
• tetanustoxoidorimmunoglobulinasneeded
• NPOandprepareforOR(bloodwork,consent,ECG,CXR)
■ operative irrigation and debridement within 6-8 h to decrease risk of infection
■ ORIF
■ traumatic wound often left open to drain with vacuum-assisted closure if necessary ■ re-examine with repeat irrigation and debridement in 48 h if necessary
Orthopedics OR9
Orthopedic Emergencies
VON CHOP
Vascular compromise
Open fracture
Neurological compromise/cauda equina syndrome
Compartment syndrome
Hip dislocation
Osteomyelitis/septic arthritis
Unstable Pelvic fracture
Controversies in Initial Management of Open Fractures
Scand J Surg 2014;103(2):132-7
Study: Literature review examining the initial management of open fractures. 40 studies included. Findings:
• Afirst-generationcephalosporin(orclindamycin) should be administered upon arrival. In general, 24 h of antibiotics after each debridement is sufficient to reduce infection rates.
• Although cultures are taken from delayed (>24 h) or infected injuries, it may not be necessary to routinely take post-debridement cultures in open fractures.
• Openfracturesshouldbedebridedassoonas possible, although the “6-h rule” is not generally valid.
• Woundsshouldbeclosedwithin7doncesoft tissue has stabilized and all non-viable tissue removed.
• Negativepressurewoundtherapy(NPWT)has been shown to decrease infection rates in open fractures.
33% of patients with open fractures have multiple injuries
Antibiotics for Preventing Infection in Open Limb Fractures
Cochrane DB Syst Rev 2004;1:CD003764 Purpose: To review the evidence regarding the effectiveness of antibiotics in the initial treatment of open fractures of the limbs.
Methods: Randomized or quasi-randomized controlled trials comparing antibiotic treatment with placebo or no treatment in preventing acute wound infection were identified and reviewed. Data were extracted and pooled for analysis.
Results: Eight studies (n=1,106) were reviewed. The use of antibiotics had a protective effect against early infection compared with no antibiotics or placebo (RRR=0.43, 95% CI 0.29, 0.65; ARR=0.07, 95% Cl 0.03=0.10).
Conclusions: Antibiotics reduce the incidence of early infections in open fractures of the limbs.
Table 6. Gustilo Classification of Open Fractures
Gustilo Grade
I
II III*
Length of Open Wound
<1 cm
1-10 cm >10 cm
Description
Minimal contamination and soft tissue injury Simple or minimally comminuted fracture
Moderate contamination Moderate soft tissue injury
IIIA: Extensive soft tissue injury with adequate ability of soft tissue to cover wound
IIIB: Extensive soft tissue injury with periosteal stripping and bone exposure; inadequate soft tissue to cover wound
Prophylactic Antibiotic Regimen
First generation cephalosporin (cefazolin) 2 g IV q8h for 2 d
If allergy use clindamycin 900 mg IV q8h
If MRSA positive use vancomycin 15 mg/kg IV q12h
As per Grade I
First generation cephalosporin (cefazolin) for 2 d plus Gram-negative coverage (gentamicin or ceftriaxone) for at least 3 d
For soil or fecal contamination, metronidazole is added for anaerobic coverage
IIIC: Vascular injury/compromise
*Any high energy, comminuted fracture, shot gun, farmyard/soil/water contamination, exposure to oral flora, or fracture >8 h old is immediately classified as Grade III
If MRSA positive use vancomycin 15 mg/kg IV q12h