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High Risk Ortho

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Alexander Sung

on 26 December 2013

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Transcript of High Risk Ortho

Discuss common orthopedic urgencies & emergencies initially mismanaged or misdiagnosed. (Missed/mismanaged fractures are the #1 source of claims- 27% -made against EPs, 13% of $$ paid)

Detail key diagnostic findings and potential consequences of delayed diagnosis

Highlight important clinical pearls to avoid complications
Case 1
22 yo Futbol player presents to the ED with a painful right knee after being slidetackled during a match just PTA. The knee is diffusely tender. The skin is intact and there is no obvious deformity to the knee, but has increased laxity with mild swelling. You do not detect any pulse or sensory deficits.
Knee Dislocation
Usually results from high-energy mechanisms but can occur also from low velocity injuries (MVC, falls, sport injuries)

Anterior, posterior, medial , lateral

Posterior usually from dashboard injury
Knee Dislocation
Nearly
1/3
with a high-velocity injury will have associated
life-threatening
injury

6o% will have an associated fracture. 40% will have multiple fractures.
Knee Dislocation: Associated injuries
Knee Dislocation: Pathophysiology
Requires disruption of ACL, PCL and MCL/LCL

Popliteal artery tethered as it passes behind the knee

Popliteal artery injury occurs in
20-30%
of all cases (high velocity - incidence increases to 40%)
Ischemic time
is the single most important variable in determining outcome.
Amputation rate with arterial repair
delay > 8 hrs = 85%
Amputation rate with arterial repair
delay < 8 hrs = 15%
Knee Dislocation: Physical Exam
Dislocation present = joint injury
Hard vascular signs
present = popliteal artery injury easy to diagnose
Pulse deficits
Ischemic limb
Active hemorhage
Expanding/pulsatile hematoma

Pitfalls:
Knee may come in
already
reduced.
Knee swelling is
NOT
universal
Knee capsule is frequently disrupted, allowing hemarthrosis to leak into tissues
Normal pulses do
NOT
rule-out a vascular injury
10%
of vascular injuries have normal pulses
Knee Dislocation: Evaluation
Reduce if dislocated
Search for hard and soft vascular signs
Hard signs = OR +/- Angiogram prior
Soft signs = Requires further eval/studies
Soft Signs
Small/stable hematoma
Injury to anatomically related nerve
hx of hemorrhage
Vascular evaluation
Older dogma of "all knee dislocations require an a-gram" has been challenged, as only 20-30% have a vascular injury
Knee Dislocation: Evaluation
Ankle-Brachial index (ABI): Ratio of doppler SBP in leg vs arm. Normal > 0.9
2 recent studies have looked at this:
From Maryland Shock Trauma - 57 knee dislocations over 7 years. 0 of 32 patients with ABI > 0.9 required revascularization procedure. 7 of 25 patients with abnormal ABI required revascularization.
--Klineberg J Trauma 2004
From Harborview - 38 knee dislocations over 4 years. 0 of 27 patients with ABI > 0.9 required revascularization. 11 of 11 patients with ABI < 0.9 required revascularization.
-- Mills J Trama 2004
Knee Dislocation: Evaluation
Duplex Doppler Ultrasonography
Reported sensitivity of 95% and specificity of 99%
Can miss intimal tears (intimal tears >30 % of vessel lumen are felt to be "significant".
Operator dependant
Bottom line - relatively institutional and surgeon specific.
Knee Dislocation: Evaluation
CT Angiography
Many smaller studies reported

95-100% sensitivity and 97-100% specificity for clinically significant arterial injury reported

Makes sense but not a lot of actual data. No prospective studies.

PITFALL:
In the multitrauma pt this almost always represents a
second
contrast load, significantly raising the risk of contrast nephropathy
Traumatic Knee Dislocation
Vascular Assessment And Closed Reduction
Consultation
+
Angiography
Consultation
+
Observe
(CTA or Doppler ?)
Abnormal Exam
and/or
ABI < 0.90
Hard Signs = OR with on-the-table angiogram.
Normal Exam
and
ABI > 0.90
Compartment Syndrome
Compartment Syndrome: Definitive Treatment
Fasciotomy

Time from injury to this intervention is the
primary determinant
of outcome:
Rorabeck et al and Matsen reported almost complete recovery if fasciotomy done within 6 hours
Case #3
Pt is an 18 yo runway model who presents with ankle pain after twisting her ankle.

Pt has considerable swelling and demonstrates point tenderness proximal to the ATFL in the area of the AITF ligament

Radiographs are negative for fracture
Syndesmotic Ankle Sprain
Syndesmotic Ankle Sprain: Epidemiology
Ankle sprains are the most common lower extremity injury in sports medicine. (25% of all sports injuries)

Syndesmotic injuries result in longer periods of disability than lateral ankle sprains.

Estimated 10-17% of all ankle injuries

Not uncommonly associated with fractures.
Syndesmotic Ankle Sprain: Clinical Anatomy
The syndesmotic ligaments maintain stability between the distal tibia and fibula

Anterior tibiofibular ligament
Posterior tibiofibular ligament
Transverse tibiofibular ligament
Interosseous ligament
Injuries to the syndesmosis occur as a result of a forced external rotation of the foot, or during internal rotation of the tibia on a planted foot.
Common in soccer, skiing, motocross and football.
Syndesmosis injuries are commonly associated with ankle fractures (Weber B & C) and deltoid ligament ruptures
Weber B
Weber C
Weber A
Syndesmotic Ankle Sprain: Clinical Presentation
Unable to bear weight on leg
Pain is located anteriorly along the syndesmosis
Active movement of external rotation of the foot is painful
Positive Squeeze Test
Positive External Rotation Stress Test
Diagnosis
Clinical Diagnosis
mechanism of injury
correlative physical examination


Radiographic findings
Ottawa Ankle Rules
N
B
*or inability to bear weight for 4 steps immediately or in the ED.
Imaging
AP/Lat/Mortise
Syndesmotic Ankle Sprain: Mechanism of Injury
Injuries to the syndesmosis occur as a result of a forced external rotation of the foot, or during internal rotation of the tibia on a planted foot.

Common in soccer, skiing, motocross, and football.

Syndesmosis injuries are commonly associated with ankle fractures (Weber B & C) and deltoid ligament ruptures.
Syndesmosis Injury Radiographic Criteria
Mortise:
Medial clear space > 4-5mm
Tibiofibular overlap < 1 mm

Both AP and Mortise:
Tibiofibular clear space >10 mm (5-6mm is normal)
medial clear space = superior clear space
< 1mm
>4-5 mm
>10mm
Syndesmotic Ankle Sprain: Treatment
Ligamentous injuries WITHOUT fractue or gross widening can be treated conservatively

Fracture present or radiographic evidence of syndesmotic widening warrant Ortho consult for operative repair.
Patient is a 33 yo Mardigras reveler who presents c/o painfull wrist after FOOSH injury.

On exam, he is neurovascularly intact, has mild R wrist swelling and is tender just distal to Lister's tubercule.

Radiographs are negative for fracture.
Perilunate Injury
Perilunate injury: Epidemiology
Wrist injuries account for 2.5% of all ED visits.

Lunate and perilunate injuries are thought to represent 10% of all carpal injuries.

Estimated 25% missed.
Perilunate Injury: Clinical Anatomy
Clinical Presentation
Perilunate and lunate dislocations result from high energy hyperextension injuries

Tenderness distal to Lister's tubercule in the area of the scapholunate ligament

Most comon mechanism is a FOOSH, followed by MVA.

Spectrum of injury called "Progressive perilunate instability" with 4 stages.
There are 8 carpal bones comprising two carpal rows; the scaphoid bridges both rows

Carpals tightly linked by interosseous and extrinsic ligaments.

The lunate is the key to carpal stability
Mayfield Classification
Stage I: Disruption of SL - Scapholuate dissociation

Stage II: Capitate and scaphoid separate from lunate - perilunate dislocation

Stage III: Force transmits ulnarly disrupting LT ligaments completely separating lunate from carpals -triquetral dislocation

Stage IV: Lunate dislocation
Diagnosis
High index of suspicion

Palpation over dorsum of the wrist

Watson Test

Radiographs
Imaging
PA and lateral radiographs

PA view:
3 arcs
constant 2 mm intercarpal joint space

Lateral view:
Four aligned Cs

Stress views
Treatment
Consultation with a hand surgeon to discuss management

Literature review: Closed reduction with splinting does poorly - most will need open reduction, ligament reconstruction, internal fixation
4 yo F pulled by arm, won't use it

Elbow in slight flexion, pronated
Bonus!!
Radial head subluxation, annular ligament displacement

Age 6m-6yo (usually 2-3yo)

Xray?
swelling (dimples)
point tenderness
not using arm 15 min s/p reduction
Nursemaid 's elbow
Reduction
Supination / flexion





Hyperpronation
Studies
Macias, Pediatrics, 1998:
- Prospective, randomized, 90 kids
- Supination/flexion vs hyperpronation
- Pronation (95% vs 77%, 1st attempt)

McDonald, Acad Emerg Med, 1999:
- Prospective, randomized, 135 kids
- Pronation (80% vs 69%, 1st attempt)

Bek, Eur J Emerg Med, 2009:
- 66 kids (94% vs 69%, 1st attempt)
References
Cone JB: Vascular injury associated with fracture-dislocations of the lower extremity. Clin Orthop 1989
Jun; (243): 30-5.
Dennis JW, Jagger C, Butcher JL: Reassessing the role of arteriograms in the management of posterior
knee dislocations. J Trauma 1993; 35: 692-697.
Frassica FJ, Sim FH, Staeheli JW, Pairolero PC: Dislocation of the knee. Clin Orthop 1991 Feb; (263):
200-5.
Perron AD, Brady WJ, Sing RF: Orthopedic Pitfalls in the Emergency Department: Vascular Injury
Associated with Knee Dislocation. Am J Emerg Med 2001;19(7):583-588.
Mars M, Hadley GP: Raised intracompartmental pressure and compartment syndromes. Injury
1998;29:403-411
Matsen FA, Winquist RA, Krugmire RB: Diagnosis and management of compartmental syndromes. J Bone
Joint Surg 1980; 62A: 286-91.
Owen CA, Mubararak S, Hargens A, et al: Intramuscular pressures with limb compression. N Engl J Med
1979; 300: 1169-72.
Perron AD, Brady WJ, Keats TE: Orthopedic Pitfalls in the Emergency Department: Acute Compartment
Syndrome. Am J Emerg Med 2001;19(5):413-417.
Germann CA, Perron AD: Risk Management and Avoiding Legal Pitfalls in the Emergency Treatment of
High-Risk Orthopedic Injuries. Emerg Med Clin NA. 2010:28;969-996.
Perron AD: Approach to Musculoskeletal Injuries. In Wolfson AB (ed) The Clinical Practice of Emergency
Medicine, 4th Edition. 2005 Philadelphia, Lippincott, Williams & Wilkins pp. 1022-1032
Perron AD, Brady WJ: Evaluation and Management of the High-Risk Orthopedic Emergency. In Peth H
(ed): Emergency Medicine Clinics
Wattel F, Mathieu D, Neviere R, Bocquillon N: Acute peripheral ischaemia and compartment syndromes: a
role for hyperbaric oxygenation. Anaesthesia 1998 May; 53 Suppl 2: 63-5.
Nursemaid Elbow Reduction
Conclusion
- The ABI is a rapid, reliable, noninvasive tool for diagnosing vascular injury associated with knee dislocation. Routine arteriography for all patients with knee dislocation is not supported.
Sin Quo Non
High-Risk Emergency Orthopedics
T-minus 290 days = Graduation!
Look for significant ligament laxity
Caveat: Rate of arterial injury is the SAME
Case #2
Patient is a 32 y/o mountainbiker who presents to the ER with a painful forearm after a FOOSH injury. He is quite tender to palpation over the proximal forearm and has visible deformity. The skin is intact. Neurovascular examination is normal.

Radiographs

Patient is placed in a long arm splint.

Prior to discharge from the ED for Ortho f/u in the am, the patient complains of thumb numbness.
Compartment Syndrome
Can be found wherever a compartment is present. (hand, forearm, upper arm, abdomen, buttocks, lower extremities)

Can occur whenever there is increased pressure within a closed tissue space that results in compromised blood flow to muscles or nerves.
External compression - e.g. Casts
Volume expansion
Edema/hematoma
Compartment Syndrome
Increased Pressure
Impaired Perfusion
Disruption of Cellular Metabolism
Cytolysis with release of osmotically active contents into compartment
Additional fluid drawn into compartment
Compartment Syndrome
Association with common injuries
Fractures = 69%
Vascular injury = 19%
Tibia fx = 2-12%
Supracondylar humerus fx < 5%
Forearm fx <5%
Compartment Syndrome
Associated with drug overdoses
Owen et al, 1979. Intracompartmental pressures measured in various positions "common in drug overdoses".

Head resting on forearm = 48 mmHg
Forearm under rib cage = 178 mmHg
leg folded under other leg = 72 mmHg
Compartment Syndrome: ED Presentation
Hallmark: Pain out of proportion to examination

Traditional "5 P's" with the exception of pain and paresthesia are
NOT
reliable. (
P
ain,
P
araesthesias,
P
allor,
P
oikilothermia,
P
ulselessness)

Assumes a patient
without
a condition that would hinder evaluation (TBI, SCI, EtOH/Drugs)

Last 3 signal a dead or dying limb.
Compartment Syndrome: ED Presentation
Pain at rest or with passive ROM

Sensory nerves 1st to lose conductive ability
e.g. Supericial Peroneal nerve in ant. compartment of lower leg (toe web space)
Compartment Syndrome: ED Evaluation
Non-invasive tests of compatment syndrome are NOT reliable
Mars et al (1994) assessed utility of pulse oximetry

Found sensitivity of 40% at "clinically significant pressures."

With a greater than 50% false negative rate, "pulse oximetry is not recommended in the evaluation of compartment syndrome."
Compartment Syndrome: ED Evaluation
Compartment pressure measurement

Normal = 0-10 mmHg

Capillary blood flow starts to be compromised at 20 mmHg

Muscles and nerve fibers at risk at
> 30-40 mmHg
Compartment Syndrome: ED Mangement- Drop the pressure
Bivalving a cast can decrease compartmental pressures by as much as 55%. Removing it completely can reduce pressures by 85%

Raise limb to neutral position (drain edema w/o impairing arterial flow)

NO Ice (will further compromise micro circulation
Myofascial compartment
Irreversible Muscle injury
Contractions
Loss of limb
Renal failure
Death
net effect
Alexander W. Sung, MD
LSU Emergency Medicine HO IV

Maisonneuve
Case #4
Perilunate
Lunate
Median nerve injury- carpal tunnel
Degenerative arthritis

SLAC (Scapho Lunate Advanced Collapse) deformity
Complications
What a cutie!
Daddy had to bribe me with CHOCOLATE to sit still!
Pearls:
Knee dislocation: A high-index of suspicion in knee injuries regardless of mechanism.
- Beware the reduced and non-swollen knee.
- Clock is ticking, 8 hours! Get ABI's.

Compartment Syndrome: Have a low threshold for suspicion with characteristic injuries.
- Watch for pain out of proportion.
- Don't wait for late signs.
Pearls
Syndesmosis Injury: Absence of fracture = simple strain/stable ankle.
- Check medial and TF clear space, TF overlap
- Palpate prox fib/image if tender

SL/Perilunate dislocations: AP/Lat/Stress
- 2mm SL space/spilled tea/etc.
- Test median nerve

Nursemaid's: One word - Hyperpronation

Pulse deficits
Ischemic limb
Active hemorhage
Exp/pulse hematoma
Hard Signs
Full transcript