Chapter 7
ORTHOPEDIC EMERGENCIES
Learning Objectives:
• Take a proper relevant history, and perform a “Focused Physical Examination “or a
“Rapid Trauma Examination” based on the mechanism of injury or illness.
• Identify orthopedic emergencies as well as common orthopedics injuries in the
community
• Recognize situations which call for urgent or early treatment at specialized centers and
make a prompt referral
• Plan and interpret relevant investigations, particularly x- rays
• Arrive at a logical working diagnosis after examination and review of investigations
• Order relevant laboratory investigations and imaging studies and interpret them.
• Plan and provide emergency care or initiate treatment.
,CLINICAL ORIENTATION MANUAL ORTHOPEDIC EMERGENCIES
INTRODUCTION
Orthopedic emergencies especially from trauma have been increasing exponentially over the
years. A study of JDWNRH surgical admission records carried out in 2006 showed that 60.8%
of the trauma cases were admitted in the orthopedic ward. It is a known fact that in any mass
casualty situation, orthopedic injuries out number all other injuries.
Orthopedic or musculoskeletal injuries can result either from falls, road traffic crashes or from
exposure to mechanical forces. Musculoskeletal injuries can range from minor to limb
threatening and even life threatening in serious cases. Proper and timely intervention of these
injuries can go a long way in reducing the complications and thereby morbidity.
orthopedic infections such as septic arthritis or acute osteomyelitis also require immediate
attention as any delay will cause increased morbidity later on.
It is our experience that the primary care of orthopedic cases in the districts is not up to the
mark especially in relation to the management of orthopedic emergencies. Many cases which
can easily be managed at the district hospitals get unnecessarily referred to the higher
centers. Keeping in view these facts a guideline for the primary care of orthopedic
emergencies is developed in order to improve emergency care of orthopedic patients in the
peripheral hospitals and thereby reduce unnecessary and inappropriate patient referrals.
APPROACH TO ORTHOPEDIC PATIENTS
History:
• Chief complaint.
• Mechanism of injury.
• History: OPQRST (Onset, Provoking/ alleviating factors, Quality/ Quantity, Radiation, Site,
Timing)
• Constitutional symptoms- fever, night sweats, fatigue, wt. loss.
• Referred symptoms
• AMPLE history (Allergies, Medications, past medical history, last eaten Events leading to)
Physical Examination:
• Look: SEADS (swelling, erythema, atrophy, deformity and skin changes).
• Move: Active then passive range of movement (ROM) for affected joint(s) and joints
above & below.
• Neurovascular tests: Pulse, sensation, reflexes, power (0 to 5).
Investigations:
• Plain x-ray: AP, lateral and oblique
• It is very important to get correct views for proper diagnosis.
• X-Ray rule of 2s:
• 2 sides= bilateral (comparison views in children when in doubt)
• 2 views= AP + lateral
• 2 joints= joint above + below
• 2 times= before and after reduction
• Blood: CBC, Grouping
• Aspiration: aspirate fluid from joint for analysis
• Ultrasound where appropriate
EMERGENCY MEDICAL SEVICES DIVISION, 2018 87
, CLINICAL ORIENTATION MANUAL ORTHOPEDIC EMERGENCIES
Principles of Emergency Care of Musculoskeletal Injuries
• Perform initial patient assessment- obtain relevant history and perform a “Focused PE” or
“Rapid Trauma/Illness Survey” based on the nature or injury or illness.
• During a rapid trauma exam, apply a cervical collar if spine injury is suspected.
• After life-threatening conditions have been addressed, any patient with a swollen or
deformed extremity must be splinted.
• If an initial assessment reveals the patient is unstable, managing extremity injuries
become a low priority.
• An unstable patient with “load and go” problems must have the ABCs managed and the
entire body splinted or immobilized on a long spine board.
• No time should be wasted to splint each injury individually.
• Irrigate open wounds with plenty of NS and cover with sterile dressings and start IV
antibiotics.
• DO NOT SUTURE dirty or complex wounds.
Basic Fracture Evaluation & Management
• Start with ABCs, primary & secondary surveys.
• Thorough exam of the fracture location:
o Location along the length of bone– proximal 1/3, middle 1/3, distal 1/3.
o Open or closed?
o Associated dislocation?
o Perform a complete neurovascular exam.
• Carry out relevant imaging studies.
• R/o other associated injuries- chest, abdomen, etc.
• Take AMPLE history.
• Give analgesics as required.
• Carry out appropriate splinting of injured limbs before moving the patient.
• If reduction performed, test neurovascular status before AND after.
• Refer if necessary.
Complication of Fractures
Local:
• Early:
– Compartment syndrome
– Neurovascular injury
– Infection
– Fracture blisters
• Late:
– Mal/nonunion
– Avascular necrosis (AVN)
– Osteomyelitis
– Post-traumatic arthritis
– Reflex sympathetic dystrophy (RSD)
Systemic:
– Sepsis
– Deep vein thrombosis
– Pulmonary embolism
EMERGENCY MEDICAL SEVICES DIVISION, 2018 88
ORTHOPEDIC EMERGENCIES
Learning Objectives:
• Take a proper relevant history, and perform a “Focused Physical Examination “or a
“Rapid Trauma Examination” based on the mechanism of injury or illness.
• Identify orthopedic emergencies as well as common orthopedics injuries in the
community
• Recognize situations which call for urgent or early treatment at specialized centers and
make a prompt referral
• Plan and interpret relevant investigations, particularly x- rays
• Arrive at a logical working diagnosis after examination and review of investigations
• Order relevant laboratory investigations and imaging studies and interpret them.
• Plan and provide emergency care or initiate treatment.
,CLINICAL ORIENTATION MANUAL ORTHOPEDIC EMERGENCIES
INTRODUCTION
Orthopedic emergencies especially from trauma have been increasing exponentially over the
years. A study of JDWNRH surgical admission records carried out in 2006 showed that 60.8%
of the trauma cases were admitted in the orthopedic ward. It is a known fact that in any mass
casualty situation, orthopedic injuries out number all other injuries.
Orthopedic or musculoskeletal injuries can result either from falls, road traffic crashes or from
exposure to mechanical forces. Musculoskeletal injuries can range from minor to limb
threatening and even life threatening in serious cases. Proper and timely intervention of these
injuries can go a long way in reducing the complications and thereby morbidity.
orthopedic infections such as septic arthritis or acute osteomyelitis also require immediate
attention as any delay will cause increased morbidity later on.
It is our experience that the primary care of orthopedic cases in the districts is not up to the
mark especially in relation to the management of orthopedic emergencies. Many cases which
can easily be managed at the district hospitals get unnecessarily referred to the higher
centers. Keeping in view these facts a guideline for the primary care of orthopedic
emergencies is developed in order to improve emergency care of orthopedic patients in the
peripheral hospitals and thereby reduce unnecessary and inappropriate patient referrals.
APPROACH TO ORTHOPEDIC PATIENTS
History:
• Chief complaint.
• Mechanism of injury.
• History: OPQRST (Onset, Provoking/ alleviating factors, Quality/ Quantity, Radiation, Site,
Timing)
• Constitutional symptoms- fever, night sweats, fatigue, wt. loss.
• Referred symptoms
• AMPLE history (Allergies, Medications, past medical history, last eaten Events leading to)
Physical Examination:
• Look: SEADS (swelling, erythema, atrophy, deformity and skin changes).
• Move: Active then passive range of movement (ROM) for affected joint(s) and joints
above & below.
• Neurovascular tests: Pulse, sensation, reflexes, power (0 to 5).
Investigations:
• Plain x-ray: AP, lateral and oblique
• It is very important to get correct views for proper diagnosis.
• X-Ray rule of 2s:
• 2 sides= bilateral (comparison views in children when in doubt)
• 2 views= AP + lateral
• 2 joints= joint above + below
• 2 times= before and after reduction
• Blood: CBC, Grouping
• Aspiration: aspirate fluid from joint for analysis
• Ultrasound where appropriate
EMERGENCY MEDICAL SEVICES DIVISION, 2018 87
, CLINICAL ORIENTATION MANUAL ORTHOPEDIC EMERGENCIES
Principles of Emergency Care of Musculoskeletal Injuries
• Perform initial patient assessment- obtain relevant history and perform a “Focused PE” or
“Rapid Trauma/Illness Survey” based on the nature or injury or illness.
• During a rapid trauma exam, apply a cervical collar if spine injury is suspected.
• After life-threatening conditions have been addressed, any patient with a swollen or
deformed extremity must be splinted.
• If an initial assessment reveals the patient is unstable, managing extremity injuries
become a low priority.
• An unstable patient with “load and go” problems must have the ABCs managed and the
entire body splinted or immobilized on a long spine board.
• No time should be wasted to splint each injury individually.
• Irrigate open wounds with plenty of NS and cover with sterile dressings and start IV
antibiotics.
• DO NOT SUTURE dirty or complex wounds.
Basic Fracture Evaluation & Management
• Start with ABCs, primary & secondary surveys.
• Thorough exam of the fracture location:
o Location along the length of bone– proximal 1/3, middle 1/3, distal 1/3.
o Open or closed?
o Associated dislocation?
o Perform a complete neurovascular exam.
• Carry out relevant imaging studies.
• R/o other associated injuries- chest, abdomen, etc.
• Take AMPLE history.
• Give analgesics as required.
• Carry out appropriate splinting of injured limbs before moving the patient.
• If reduction performed, test neurovascular status before AND after.
• Refer if necessary.
Complication of Fractures
Local:
• Early:
– Compartment syndrome
– Neurovascular injury
– Infection
– Fracture blisters
• Late:
– Mal/nonunion
– Avascular necrosis (AVN)
– Osteomyelitis
– Post-traumatic arthritis
– Reflex sympathetic dystrophy (RSD)
Systemic:
– Sepsis
– Deep vein thrombosis
– Pulmonary embolism
EMERGENCY MEDICAL SEVICES DIVISION, 2018 88
