Orthopaedic Emergencies Part 1 - Everything You Need To Know - Dr. Nabil Ebraheim
56.5 هزار بار بازدید -
12 سال پیش
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Dr. Ebraheim’s educational animated video
Dr. Ebraheim’s educational animated video about Orthopaedic Emergencies.
Pelvic fractures may cause significant bleeding. Hemorrhage is the most life-threatening complication associated with pelvic fractures. When the bleeding is severe, the superior gluteal artery is responsible for the majority of bleeding, however the bleeding is usually venous and from the fracture. Patients older than 55 years of age are more likely to have bleeding from a pelvic fracture than required transfusion and may need angiography. The mortality rate is directly related to shock at the time of presentation. Mortality rates range from 41% to 57% for patients with pelvic fractures and hemodynamic shock with systolic blood pressure of 90 mm Hg or less. Fracture patterns that are highly unstable to both rotational and vertical stress (usually anteroposterior compression or vertical shear injuries) are consistently associated with a higher risk of mortality from bleeding. Abdominal and pelvic CT scan will clearly define the bony injury and the extent of bleeding. Management always begins with ABCs (airway, breathing and circulation). Emergency pelvic stabilization with external fixator is thought to tamponade bleeding by decreasing pelvic volume. A pelvic binder can be used in the ER in cases of open book injury. Angiography and embolization may be useful to control arterial bleeding, especially if the patient is given four units of blood and is still in shock. Embolization has no effect on venous bleeding. Massive blood transfusion is usually required for the unstable patient. Observe the patient for disseminated intravascular coagulation and hypothermia.
Femoral neck fracture in young adults most often results from a high energy trauma. The fracture is usually a high angle shear type fracture and the blood supply to the femoral head could be at risk. There is a high incidence of avascular necrosis and non-union. Ascending retinacular arteries may be disrupted. Fixation must be achieved within 12 hours of injury or as soon as possible. Anatomic reduction must be obtained through closed manipulation or open reduction, if necessary. The fracture is usually fixed with multiple cancellous screws.
Arterial injuries can be associated with fractures in areas where the arteries are held close to the bony structures or in a fixed position by muscles and ligaments. The femoral artery is vulnerable to injury along the entire femoral shaft because of its proximity to the femur. Fractures involving the femoral condyles or tibial plateau, particularly if there is posterior displacement of the fragments carry a high risk of vascular injury because of the relatively fixed position of the popliteal artery. If vascular injury is not corrected, it can lead to gangrene and amputation. Presence of concomitant shock with vascular injury may result in early soft tissue necrosis due to hypotension and ischemia. The single most important factor determining the outcome of the limb with vascular compromise is the duration of warm ischemia. Warm ischemia time of less than 6 hours is associated with a lower rate of amputation. Skeletal stabilization with simultaneous vascular exploration or repair offers the best chances of limb survival. Prophylactic fasciotomy may be needed!
Compartment syndrome is the increased pressure in a closed space the decreases the tissue perfusion resulting in tissue ischemia and necrosis. The leg is the most common site affected, followed by the forearm. There are four compartments within the leg. The anterior (extensor) compartment contained the deep peroneal nerve and if involved results in numbness in the first web space of the foot, it is the most commonly affected compartment. The lateral compartment contains the superficial peroneal nerve and if involved results in numbness on the dorsum of the foot. The deep posterior compartment is the one that is commonly missed and may lead to claw toe and cavus foot deformity. The deep posterior compartment is supplied by the tibial nerve, if involved, it results in numbness on the sole of the foot. The superficial compartment is supplied by the sural nerve. If involved, it results in numbness on the lateral border of the foot. Pain on passive stretch of the toes is the most important diagnostic sign. Pallor, pulselessness, paralysis and paresthesia are late findings. It is imperative to diagnose compartment syndrome in the impending stage (reversible) rather than diagnosing it once it is fully established (late and irreversible). Late diagnosis will result in weakness and Volkmann’s ischemic contracture.
Pelvic fractures may cause significant bleeding. Hemorrhage is the most life-threatening complication associated with pelvic fractures. When the bleeding is severe, the superior gluteal artery is responsible for the majority of bleeding, however the bleeding is usually venous and from the fracture. Patients older than 55 years of age are more likely to have bleeding from a pelvic fracture than required transfusion and may need angiography. The mortality rate is directly related to shock at the time of presentation. Mortality rates range from 41% to 57% for patients with pelvic fractures and hemodynamic shock with systolic blood pressure of 90 mm Hg or less. Fracture patterns that are highly unstable to both rotational and vertical stress (usually anteroposterior compression or vertical shear injuries) are consistently associated with a higher risk of mortality from bleeding. Abdominal and pelvic CT scan will clearly define the bony injury and the extent of bleeding. Management always begins with ABCs (airway, breathing and circulation). Emergency pelvic stabilization with external fixator is thought to tamponade bleeding by decreasing pelvic volume. A pelvic binder can be used in the ER in cases of open book injury. Angiography and embolization may be useful to control arterial bleeding, especially if the patient is given four units of blood and is still in shock. Embolization has no effect on venous bleeding. Massive blood transfusion is usually required for the unstable patient. Observe the patient for disseminated intravascular coagulation and hypothermia.
Femoral neck fracture in young adults most often results from a high energy trauma. The fracture is usually a high angle shear type fracture and the blood supply to the femoral head could be at risk. There is a high incidence of avascular necrosis and non-union. Ascending retinacular arteries may be disrupted. Fixation must be achieved within 12 hours of injury or as soon as possible. Anatomic reduction must be obtained through closed manipulation or open reduction, if necessary. The fracture is usually fixed with multiple cancellous screws.
Arterial injuries can be associated with fractures in areas where the arteries are held close to the bony structures or in a fixed position by muscles and ligaments. The femoral artery is vulnerable to injury along the entire femoral shaft because of its proximity to the femur. Fractures involving the femoral condyles or tibial plateau, particularly if there is posterior displacement of the fragments carry a high risk of vascular injury because of the relatively fixed position of the popliteal artery. If vascular injury is not corrected, it can lead to gangrene and amputation. Presence of concomitant shock with vascular injury may result in early soft tissue necrosis due to hypotension and ischemia. The single most important factor determining the outcome of the limb with vascular compromise is the duration of warm ischemia. Warm ischemia time of less than 6 hours is associated with a lower rate of amputation. Skeletal stabilization with simultaneous vascular exploration or repair offers the best chances of limb survival. Prophylactic fasciotomy may be needed!
Compartment syndrome is the increased pressure in a closed space the decreases the tissue perfusion resulting in tissue ischemia and necrosis. The leg is the most common site affected, followed by the forearm. There are four compartments within the leg. The anterior (extensor) compartment contained the deep peroneal nerve and if involved results in numbness in the first web space of the foot, it is the most commonly affected compartment. The lateral compartment contains the superficial peroneal nerve and if involved results in numbness on the dorsum of the foot. The deep posterior compartment is the one that is commonly missed and may lead to claw toe and cavus foot deformity. The deep posterior compartment is supplied by the tibial nerve, if involved, it results in numbness on the sole of the foot. The superficial compartment is supplied by the sural nerve. If involved, it results in numbness on the lateral border of the foot. Pain on passive stretch of the toes is the most important diagnostic sign. Pallor, pulselessness, paralysis and paresthesia are late findings. It is imperative to diagnose compartment syndrome in the impending stage (reversible) rather than diagnosing it once it is fully established (late and irreversible). Late diagnosis will result in weakness and Volkmann’s ischemic contracture.
12 سال پیش
در تاریخ 1391/02/05 منتشر شده
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