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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 - note
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
Arthorocenesis
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