MSK and Skin Injuries

Open fractures, neurovascular injury

What are the 2 orthopedic emergencies that might walk into the ED?

Open fractures

A fracture associated with overlying soft tissue injury that extends to the depth of the bone - worried about infection

Neurovascular injury

Any neuro or vascular compromise must be corrected prior to permanent damage - worried about loss of function or limb itself

subluxation/dislocation, fracture w/ or w/o dislocation

Common etiologies of neurovascular injuries

Cap refill, distal pulses, nerve checks

What are we checking pre- and post-splinting?

x-rays above and below the injury (1 view is no view)

Imaging orders for fracture r/o

Splint, follow up for more imaging in 7-10 days

If it’s giving fracture, but x-rays are negative (especially kids) what is the game plan?

Mechanism of injury, location, point tenderness, pain with premature rupture of membranes, old school tuning fork test

Red flags for fracture

Check neurovascular status 1st, attempt to reduce angulation/shortening/displacement, recheck neurovascular and document w/ repeat x-rays in splint

Pro tips for extremity fractures in the ED

Salter Harris Classification (or the concern for a fracture here), parent education/understanding

In kids that are acutely tender over the growth plate, what is it important to document?

straight across

Type 1 Salter harris fracture

Above

Type 2 Salter harris fracture

lower

Type 3 Salter harris fracture

through everything

Type 4 Salter harris fracture

crushed (rammed, compression of the growth plate)

Type 5 Salter harris fracture

2-3 days (if it’s really not aligned shoot for 24 hours)

Follow up with ortho after an extremity fracture should occur within

elevate and keep the splint clean, dry and intact; monitor fingers/toes (nail beds) and loosen the splint elastic for swelling, severe pain, grey/blue discoloration or decreased sensation

Discharge instructions for an extremity fracture

Loss of movement (motor neuron injury or tendon injury), impaired sensation (damage to sensory neurons), abnormal digit movement/scissoring ✂ (fracture)

Functional limitations associated with Hand injuries

2 point discrimination 2-4x on each side of the digit, the okay sign (median nerve), adduct vs. resistance (ulnar), MCP extension vs. resistance (radial), PA, Lateral and oblique x-rays (at minimum)

Basic workup of hand injuries

vascular injury with signs of ischemia/poorly controlled hemorrhage, irreducible dislocations, grossly contaminated wounds, severe crush injuries, open fractures, compartment syndrome, high pressure injection injury, hand/finger amputation (de-gloving)

Immediate hand surgery consultations

palm, flexor

Burns to the _______ and _______ surfaces of the hand can lead to long term disabilty

can involve tendon/nerve, scar tightening can lead to loss of function

Concerns with hand burns

clean with cool water (10-25 degrees C), remove nonviable loose tissue, topical abx, place the hand in anatomical position when covered

Game plan for Hand burns once stabilized

tendon damage (look in the lac while the fully flexed and extended, pain along the tendon during resistance suggest a partial lac)

Concerning hand lacerations, what do we need to check for?

local nerve function, full AROM movements, light touch sensation (before anesthesia DUH), U/S digits in a water bath

Work-up for hand lacerations - if pain limits exam, a digital block might help

Hand High pressure injection injuries

High pressure leads to dissection along planes of least resistance AKA the neurovascular bundles and facial planes

tetanus, broad spectrum abx, immobilization, admission, adequate pain relief, immediate hand surgeon consultation

Game plan for Air and Water induced Hand High pressure injection injuries

Immediate debridement in the OR, tetanus, broad spectrum abx, immobilization, admission, adequate pain relief, immediate hand surgeon consultation

Game plan for Hand High pressure injection injuries with anything except air and water

early surgical decompression and debridement of injected areas

Definitive treatment of high pressure injuries is…

fight bite

What happens when you punch someone in the teeth, bust your knuckles, and saliva gets up in there?

fight bites, animal bites, other puncture

What are high risk injuries for hand infections?

Movement of the tendons seeds the infection along tendon sheaths and fascial planes

Why do hand infections spread fast?

Flexor tenosynovitis

A closed space infection of the flexor tendon sheath that is an ortho emergency

Fusiforms swelling, finger held in slight flexion, pain with passive extension, pain with palpation of the tendon sheath

Findings of Flexor tenosynovitis (usually a complication of paronychia or fight bites)

IV abx with elevation, emergent ortho consult

ED management of Flexor tenosynovitis

AAA or dissection, ureterolithiasis, pyelonephritis, cauda equina, epidural abscess, discitis, tumor/mass (more common under 18), fracture, GI pathology, Herpes zoster, muscle strain/spasm, spinal stenosis/arthritis, herniated disc

Common causes of back pain

fever (or rigors), immune compromise, IVDA, recent abx use in the last 30 days, significant spinal pain, advanced age, DM

Red flags for infection induced back pain - get a CBC, ESR, UA

Recent trauma (unless the patient is old)

Red flags for fracture induced back pain

Numbness/paresthesias in lower extremities, saddle paresthesias, lower extremity weakness, foot drop (loss of S1), bowel or bladder retention or incontinence, hyporeflexia

Red flags for Cauda Equina/Central cord compression

AAA (abd pain, bruit, pulsating masses are other red flags)

Upper back pain with a neuro deficit is what until proven otherwise?

pain worsened by coughing/valsalva maneuver/sitting, pain relieved with lying supine

Red flags for disc herniation

temperature, skin condition overlying the pain (intact doesn’t count 😉), abdominal exam, midline spine tenderness, ROM, straight leg raise, Neuro exam (no focal deficits, LE strength bilateral great toes, foot plantar/dorsiflexion, LE sensation of the lateral foot, 5th toe, and medial thigh, LE reflexes), rectal tone (in suspected cauda equina)

All back pain patients must have which documented physical findings?

recent trauma, elderly patient, any cancer concern (winking owl)

When should xrays be ordered for back pain - CT is better for fractures?

Symptoms of cord compression, cauda equina, stroke

When are we allowed to order MRIs in the ER (everybody else is outpatient)?

Necrotizing fasciitis

A fast spreading, gas producing in infection

Outline the cellulitis, palpate for crepitus and severe tenderness, X-ray/CT to look for gas production

Game plan for Nec Fas r/o

1st gen CPH (cefazolin), add metro (flagyl) if there’s any contamination

Which abx you want for a Gustilo-anderson fracture type 1 (low energy with wound under 1 cm and no contamination) and 2 (moderate injury with comminution, 1-10 cm lac, some contamination)?

AMG or 3rd gen CPH (ceftriaxone), add metro (flagyl) if there’s any contamination

What abx for you want for a Gustilo-anderson fracture type 3 (high energy, 10+ cm, gross contamination)?

Abx, irrigate superficial debris (NO high pressure), call ortho to schedule for surgery

General game plan for open fractures

Spontaneous (seeding from other sources - septic arthritis, meningococcal), associated with penetrating injury

Etiology of joint infections

injection with sterile saline or methylene blue (look to see if there’s resistance or if anything comes out)

Ways to check for a compromised joint capsule

IV abx (maybe wait for ortho to get cultures but if the patient looks bad then give’em), surgery

Game plan for Joint Infection

Fever, joint is erythematous warm to the touch, swelling and effusion, pain with ROM and axial load, elevated WBC

Common Findings in a joint infection

Arthrocentesis

Any erythematous, warm, painful joint must have WHAT before discharge

purulent appearance, leukocytes 50K+, positive gram stain and culture

Synovial results for septic arthritis

Compartment syndrome

An injury leading to increased pressure within a fascial compartment compromising the circulation of the tissues within that leads to tissue necrosis if not corrected by alleviating pressure (like 8 hours)

Crush injuries, fractures, soft tissue injuries with severe pain, hemophilia, rhabdo

Compartment Syndrome should be expected in any patient with

Pain out of proportion, pain with passive stretch, paresthesia, paresis/paralysis, pallor, poikilothermia, pulselessness, tense/wood-like feeling with palpation

Findings in compartment syndrome

Direct compartment pressure testing

What is the gold standard diagnostic for compartment syndrome

Fasciotomy

Treatment plan for Compartment syndrome

stop the bleed, perform neurovascular and functional assessment, assess wound duration, assess cosmetic impact of wound and closure, tetanus status (5+ years needs a booster), clean well with antiseptic

Pro tips for dealing with lacerations

staples, glue, sutures

Definitive closure options for lacerations

suture, gauze/occlusive dressing

Temporary closure options for lacerations - like if they are going to see a specialist

Stop the bleed, check the depth/area (can go all the way to the bone), assess cosmetic impact (asphalt may cause a tattoo), tetanus (if over 5 yrs), clean well with antiseptic (maybe OR surgical scrub)

Management of Abrasions/Skin tears

Cover in abx ointment, place a NON-STICK bandage (iodoform for continue debridement), severe abrasions of palms and over joints may require PT

Coverage and Care of Abrasions/Skin tears

Was the animal acting aggressively, odd, or feral? Was the vaccination up to date?

Consideration for animal bites

Quarantine the animal and monitor for 10 days

If the animal can be found?

1st dose of the vaccine (not at wound site) and the Ig (at wound site) given in ED, doses 2-4 in public health or local clinic

If the animal cannot be found → if its a racoon or bat you’re giving it regardless

Clean with antiseptic, tetanus PRN, Closure (only on face or scalp, NO fight bite closure), Augmentin is the treatment of choice

Gameplan for ALL types of bites