Orthopedic Emergencies: When to Ask for a Little Help from Our Friends – Part Deux
- Oct 15th, 2018
- Brett Lee
Authors: Brett Lee, MD (EM Resident Physician, LAC+USC Medical Center); Patrick Kellam, MD (Orthopedic Resident Physician, University of Utah); Jeff Riddell, MD (Assistant Professor of Clinical Emergency Medicine, LAC+USC Medical Center) // Edited by: Alex Koyfman, MD (@EMHighAK) and Brit Long, MD (@long_brit)
A 27-year-old right hand dominant male presents to the emergency department with left wrist pain after falling on a pool deck. He notes catching himself with an outstretched hand. After the fall, he had immediate pain and swelling at the level of the wrist. He states that now he is beginning to have numbness and tingling along several of his fingers. An x-ray obtained from triage is shown below. What is the best next step in management?
In part one of this series, we discussed non-traumatic orthopedic emergencies requiring orthopedic consultation. In this section, we will discuss traumatic injuries requiring consultation.
Traumatic Orthopedic Injuries: General Concepts
Any fracture that breaks the skin is high risk for infection; therefore, careful examination of the skin is required after any traumatic injury in which fracture or dislocation is suspected. A good rule of thumb is any break in skin surrounding a fracture is considered open until proven otherwise. Most open fractures require orthopedic intervention including irrigation, debridement, and wound closure; therefore, early consultation is warranted to prevent further complication. ED management requires prompt neurovascular assessment, updating tetanus, and starting IV antibiotics. In fact, the only factor proven to reduce infection rates is time to antibiotics, making the ED physician critical in reducing post-injury complications.1,2
Antibiotic therapy should be guided by the degree of soft tissue damage, degree and type of contamination, patient risk factors, and time to presentation, which is largely represented by the Gustillo-Anderson classification system. All open fractures should have antibiotic targeted therapy against gram positive organisms, traditionally with cefazolin being the agent of choice. Gram negative, MRSA, and clostridial coverage may be added for those with more extensive soft tissue damage, MRSA risk factors, and soil contamination, respectively.1,3,4 In practice, antibiotic choices vary widely, and it behooves you to gain familiarity with your local institutions’ preferences.
Wounds should be handled with care and decisiveness by either emergency department or orthopedic providers, depending on availability. Any open wound, unless proceeding to the OR for emergent procedures, should be washed out and debrided of gross contamination in the emergency department. They should then be covered with a sterile dressing (e.g. Xeroform) and splinted for stability. Avoid circumferential splinting and/or constrictive dressings, such as Kerlix wraps, as swelling can be quick and quite severe in some fractures.19
Similarly, any connection of the joint space to outside air increases the risk of infection. In addition, these connections may not be obvious. Any injury overlying or close to the joint space should be explored as best as possible in a bloodless field. Plain radiographs and/or CT scans can assist in outlining associated injuries as well as foreign bodies or air in the joint space. However, these can be misleading and should aid and not replace formal joint challenges. Joints should be challenged with an amount of fluid significant enough to reach an acceptable test sensitivity.5 CT may provide a more accurate assessment for the presence of open joint.6,7 As with open fractures, ED management of open joints includes prompt neurovascular assessment, updating tetanus, starting IV antibiotics, and early orthopedic consultation. Antibiotic therapy should be guided in similar fashion to open fractures.4,8,9
Traumatic amputations, depending on their location, can be devastating injuries. In any amputation, prompt hemorrhage control is necessary.Upper or lower limb replantation may be possible if the distal detached extremity is relatively uninjured, but is more common with upper extremity amputations given good functional outcomes with lower limb prosthetics. Regardless, preservation of all amputated parts is recommended, as replantation or usage of “spare parts” can facilitate coverage of injuries in certain upper extremity amputation. Management should be aimed at reducing warm ischemia time by wrapping the body part in saline soaked gauze and placing it in a water proof container on ice. Replantation is generally not recommended if warm ischemia time is more than 6-8 hours for limbs and 10-12 hours for a digit. Radiographs should be obtained of the injured limb and preserved body part if the patient is stable. Further ED management includes prompt neurovascular assessment, updating tetanus, starting IV antibiotics for open fracture, and early consultation with orthopedics, trauma, and vascular surgery.10-13
In cases of distal finger tip amputation, management can potentially be made by ED provider with orthopedic follow up. Small avulsion injuries less than 1 cm without bone exposure may be suitable for healing by secondary intention. Wounds greater than 1 cm likely require closure with sutures. Wounds with small exposed bone distal to the DIP without flexor tendon involvement may be rongeured and covered with surrounding soft tissue. Wounds proximal to the DIP, with extensive soft tissue defect, or with flexor tendon involvement require orthopedic consultation. In all cases, the wounds should be irrigated copiously, tetanus updated, and patients should be given antibiotics based on Gustillo-Anderson classification system.14,15
Upper Extremity Fractures and Dislocations
Many of the fractures and dislocations that may occur following trauma can be initially managed by emergency physicians; however, some require emergent orthopedic evaluation. While institutional practices vary widely, the following tables review fractures and dislocations that often require emergent orthopedic evaluation. As a general rule with any orthopedic injury, a complete neurovascular exam is warranted, and in cases of concern for neurovascular compromise or impending open fracture (ie skin tenting), orthopedics should be consulted regardless of fracture or dislocation type.
Fractures and Dislocations of the Torso
Orthopedic injuries of the torso are generally high energy mechanisms, and other associated visceral injuries must be ruled out. While most injuries do not require emergent orthopedic consultation in the ED (ie scapular fractures), orthopedic consultation may be warranted for those who will be hospitalized for either observation or other associated injuries.
A quick disclaimer: vertebral injuries will not be covered in this section, as management by neurosurgery or orthopedics is institution dependent.
Lower Extremity Fractures and Dislocations
Lower extremity fractures tend to have higher energy mechanisms, higher morbidity and mortality, and higher complication rates than upper extremity injuries; therefore, many more lower extremity injuries require orthopedic consultation than upper extremity.
A Word on Dislocations and Extremity Splinting
All dislocations should be treated urgently. Those dislocations with any type of neurovascular compromise should be emergently reduced. Should a joint not be able to be anatomically reduced, orthopedic consultation is warranted for either re-reduction or operative intervention. A dislocated or subluxated joint should not leave the emergency department except for the operating room.
Splinting is an important part of emergency management of orthopedic injuries. However, there are many pitfalls to splinting that can lead a provider into trouble. All bony prominences, either in the upper or lower extremity, should be well padded. These include the malleoli around the ankle, the heel, the fibular head, and the olecranon. Avoid over padding flexion creases such as the dorsum of the ankle and the antecubital fossa. Avoid using constrictive circumferential wrappings such as Kerlix. Rely on cast padding or Bulky Jones padding for wrapping. Finally, molding of the splint is important to maintain acceptable reduction, but avoid using fingers to mold as these can create pressure ulcers inside the splint. Rely on using flat surfaces such as the top of the knee or palms to help mold.18
Most soft tissue injuries do not require orthopedic consultation, and as a general rule, most can be managed by ED providers or in the outpatient setting. However, some tendinous injuries can have a great impact on day to day function. Below is a list of tendon injuries that require orthopedic evaluation in the ED. Please note that flexor tenosynovitis and closed fist injury (ie fight bite) was covered in part one of this blog post.
Take Home Points
- In all traumatic injuries, don’t just focus on the orthopedic injury. Complete your primary survey and life-saving interventions first, then focus on orthopedic injury management.
- Open fractures and open joint management require IV antibiotics, tetanus update, and early orthopedic evaluation. Antibiotic choice can be made based on Gustillo-Anderson Classification system.
- Management of traumatic amputations should aim to reduce warm ischemia time by wrapping body part in saline soaked gauze, placing in water proof container on ice.
- Neurovascular injury likely needs orthopedic consultation regardless of fracture or dislocation type.
- Most tendon injuries do not require emergent orthopedic evaluation. The exceptions include flexor tendon injury of the hand, quadriceps tendon rupture, and patellar tendon rupture.
- Cross WW, Swiontkowski MF. Treatment principles in the management of open fractures. Indian J Orthop. 2008;42(4):377-86.
- Lack WD, Karunakar MA, Angerame MR, et al. Type III open tibia fractures: immediate antibiotic prophylaxis minimizes infection. J Orthop Trauma. 2015;29(1):1-6.
- Russell GV, King C, May CG, Pearsall AW. Once daily high-dose gentamicin to prevent infection in open fractures of the tibial shaft: a preliminary investigation. South Med J. 2001;94(12):1185-91.
- Gosselin RA, Roberts I, Gillespie WJ. Antibiotics for preventing infection in open limb fractures. Cochrane Database Syst Rev. 2004;(1):CD003764.
- Nord RM, Quach T, Walsh M, Pereira D, Tejwani NC. Detection of traumatic arthrotomy of the knee using the saline solution load test. J Bone Joint Surg Am. 2009;91(1):66-70.
- Keese GR, Boody AR, Wongworawat MD, Jobe CM. The accuracy of the saline load test in the diagnosis of traumatic knee arthrotomies. J Orthop Trauma. 2007 Aug;21(7):442-3.
- Tornetta P 3rd, Boes MT, Schepsis AA, et al. How effective is a saline arthrogram for wounds around the knee? Clin Orthop Relat Res. 2008 Feb;466(2):432-5.
- Collins DN, Temple SD. Open joint injuries. Classification and treatment. Clin Orthop Relat Res. 1989;(243):48-56.
- Konda SR, Davidovitch RI, Egol KA. Open knee joint injuries–an evidence-based approach to management. Bull Hosp Jt Dis (2013). 2014;72(1):61-9.
- Graham B, Adkins P, Tsai TM, Firrell J, Breidenbach WC. Major replantation versus revision amputation and prosthetic fitting in the upper extremity: a late functional outcomes study. J Hand Surg Am. 1998;23(5):783-91.
- Win TS, Henderson J. Management of traumatic amputations of the upper limb. BMJ. 2014;348:g255.
- Cavadas PC, Landín L, Ibáñez J, Roger I, Nthumba P. Infrapopliteal lower extremity replantation. Plast Reconstr Surg. 2009;124(2):532-9.
- Wei FC, Chang YL, Chen HC, Chuang CC. Three successful digital replantations in a patient after 84, 86, and 94 hours of cold ischemia time. Plast Reconstr Surg. 1988;82(2):346-50.
- Lamon RP, Cicero JJ, Frascone RJ, Hass WF. Open treatment of fingertip amputations. Ann Emerg Med. 1983;12(6):358-60.
- Söderberg T, Nyström A, Hallmans G, Hultén J. Treatment of fingertip amputations with bone exposure. A comparative study between surgical and conservative treatment methods. Scand J Plast Reconstr Surg. 1983;17(2):147-52.
- Routt ML, Falicov A, Woodhouse E, Schildhauer TA. Circumferential pelvic antishock sheeting: a temporary resuscitation aid. J Orthop Trauma. 2006;20(1 Suppl):S3-6.
- Craig JG, Moed BR, Eyler WR, Van holsbeeck M. Fractures of the greater trochanter: intertrochanteric extension shown by MR imaging. Skeletal Radiol. 2000;29(10):572-6.
- Fitch MT, Nicks BA, Pariyadath M, Mcginnis HD, Manthey DE. Videos in clinical medicine. Basic splinting techniques. N Engl J Med. 2008;359(26):e32.