Orthopaedic Emergencies Part 2 - Everything You Need To Know - Dr. Nabil Ebraheim
27.1 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.
Knee dislocations occur as a result of violent trauma. The most common mechanism of injury included exaggerated hyperextension of the knee and dashboard injuries (posterior directed force with the knee flexed 90 degrees). A posterior dislocation is associated with a high incidence of popliteal artery injury. With an established popliteal artery injury and resultant ischemia, blood flow must be restored within 6 hours. Posterior tibialis and dorsalis pedis pulses should be carefully evaluated in any patient with a knee dislocation. Look for any evidence of ischemia, diminished blood flow, or compartment syndrome. Incidence of nerve injury range from 14 percent to 35 percent. Beware of spontaneously reduced knee dislocations and its associated pathology. Urgent reduction of the knee dislocation is mandatory. Reevaluate circulation after reduction: if normal, serial follow-up to 48 hours with clinical examination and non-invasive studies (ABI). If abnormal, arteriography. If no pulses are palpable, immediate exploration will be used. The arterial injury is treated, the circulation is restored and prophylactic fasciotomy may be necessary.
A posterior sternoclavicular joint dislocation results from either a direct force applied to the front of the medial clavicle or an indirect force applied to the posterolateral aspect of the shoulder. Posterior dislocation of the sternoclavicular joint could be missed. Look for compression of the trachea, esophagus or great vessels of the neck. A posterior dislocation is difficult to diagnose by X-ray. CT scan is the best method to diagnose the dislocation and any associated complications. Urgent reduction is mandatory. Closed reduction is often successful and is stable. Open reduction may be required if closed reduction is unsuccessful. It will be performed with a cardiac surgeon on standby.
Scapulothoracic dissociation is a rare entity that consists of disruption of the scapulothoracic articulation. It is a closed avulsion of the scapular with associated clavicular fracture of disruption of its articulations and severe soft tissue injury. It has been described as closed, traumatic fore-quarter amputation. It is a traumatic lateral displacement of the scapula with intact skin. It can be associated with upper extremity fractures such as fractures of the scapula, clavicle and humerus. Most often there is varying degrees of injury to the brachial plexus and the subclavian artery resulting in flail, pulseless upper extremity. Arteriography should be performed to diagnose vascular injury. Chest x-ray shows significant lateral displacement of the scapula, this injury can be missed! Treatment will begin with advanced trauma life support, if needed. An arteriography for the evaluation of vascular injury and repair of the arterial injury, if possible.
Fat embolism syndrome is a clinical diagnosis with non-specific or insensitive diagnostic test. This occurs in trauma patients with multiple long bone fractures or pelvic fractures. Suspect fat embolism syndrome with the appropriate signs and underlying risk factors. The clinical signs usually develop within 24-72 hours of the insult. It develops earlier than a pulmonary embolism. Early stabilization of the fractures decreases the rate of incidence of this complication. It is a diagnosis of exclusion. The major signs are confusion, agitation, petechial rash (axillae, conjunctivae, and palate) and shortness of breath (hypoxemia). The minor signs include tachycardia, fever, anemia and thrombocytopenia. There must be 1 major sign and 4 minor signs. The diagnostic tests are non-specific and insensitive. The patient may need supportive treatment such as intubation and oxygenation. Prevention includes the stabilization of multiple long bone fractures and to prevent hypolemia.
In a multiple injured patient, early skeletal stabilization of a femoral fracture within 24 hours results in decreased incidence of pulmonary complications and fat embolism. The effect of reamed intramedullary nailing for femoral fractures on the incidence of pulmonary complication in a multiple injured patient or patients with concomitant chest injury is controversial. Multiple studies have shown that reamed intramedullary nailing for the acute stabilization of femoral fracture in the multiple injured patient with a thoracic injury did not increase the occurrence of pulmonary complications. External fixation is indicated for early stabilization of femoral fracture in severely injured patient as a form of damage control orthopedics and as a temporary bridge to femoral nailing. External fixation is also indicated in the presence of an associated vascular injury requiring stabilization before repair and in the presence of severe soft tissue injuries with extensive contamination.
Knee dislocations occur as a result of violent trauma. The most common mechanism of injury included exaggerated hyperextension of the knee and dashboard injuries (posterior directed force with the knee flexed 90 degrees). A posterior dislocation is associated with a high incidence of popliteal artery injury. With an established popliteal artery injury and resultant ischemia, blood flow must be restored within 6 hours. Posterior tibialis and dorsalis pedis pulses should be carefully evaluated in any patient with a knee dislocation. Look for any evidence of ischemia, diminished blood flow, or compartment syndrome. Incidence of nerve injury range from 14 percent to 35 percent. Beware of spontaneously reduced knee dislocations and its associated pathology. Urgent reduction of the knee dislocation is mandatory. Reevaluate circulation after reduction: if normal, serial follow-up to 48 hours with clinical examination and non-invasive studies (ABI). If abnormal, arteriography. If no pulses are palpable, immediate exploration will be used. The arterial injury is treated, the circulation is restored and prophylactic fasciotomy may be necessary.
A posterior sternoclavicular joint dislocation results from either a direct force applied to the front of the medial clavicle or an indirect force applied to the posterolateral aspect of the shoulder. Posterior dislocation of the sternoclavicular joint could be missed. Look for compression of the trachea, esophagus or great vessels of the neck. A posterior dislocation is difficult to diagnose by X-ray. CT scan is the best method to diagnose the dislocation and any associated complications. Urgent reduction is mandatory. Closed reduction is often successful and is stable. Open reduction may be required if closed reduction is unsuccessful. It will be performed with a cardiac surgeon on standby.
Scapulothoracic dissociation is a rare entity that consists of disruption of the scapulothoracic articulation. It is a closed avulsion of the scapular with associated clavicular fracture of disruption of its articulations and severe soft tissue injury. It has been described as closed, traumatic fore-quarter amputation. It is a traumatic lateral displacement of the scapula with intact skin. It can be associated with upper extremity fractures such as fractures of the scapula, clavicle and humerus. Most often there is varying degrees of injury to the brachial plexus and the subclavian artery resulting in flail, pulseless upper extremity. Arteriography should be performed to diagnose vascular injury. Chest x-ray shows significant lateral displacement of the scapula, this injury can be missed! Treatment will begin with advanced trauma life support, if needed. An arteriography for the evaluation of vascular injury and repair of the arterial injury, if possible.
Fat embolism syndrome is a clinical diagnosis with non-specific or insensitive diagnostic test. This occurs in trauma patients with multiple long bone fractures or pelvic fractures. Suspect fat embolism syndrome with the appropriate signs and underlying risk factors. The clinical signs usually develop within 24-72 hours of the insult. It develops earlier than a pulmonary embolism. Early stabilization of the fractures decreases the rate of incidence of this complication. It is a diagnosis of exclusion. The major signs are confusion, agitation, petechial rash (axillae, conjunctivae, and palate) and shortness of breath (hypoxemia). The minor signs include tachycardia, fever, anemia and thrombocytopenia. There must be 1 major sign and 4 minor signs. The diagnostic tests are non-specific and insensitive. The patient may need supportive treatment such as intubation and oxygenation. Prevention includes the stabilization of multiple long bone fractures and to prevent hypolemia.
In a multiple injured patient, early skeletal stabilization of a femoral fracture within 24 hours results in decreased incidence of pulmonary complications and fat embolism. The effect of reamed intramedullary nailing for femoral fractures on the incidence of pulmonary complication in a multiple injured patient or patients with concomitant chest injury is controversial. Multiple studies have shown that reamed intramedullary nailing for the acute stabilization of femoral fracture in the multiple injured patient with a thoracic injury did not increase the occurrence of pulmonary complications. External fixation is indicated for early stabilization of femoral fracture in severely injured patient as a form of damage control orthopedics and as a temporary bridge to femoral nailing. External fixation is also indicated in the presence of an associated vascular injury requiring stabilization before repair and in the presence of severe soft tissue injuries with extensive contamination.
12 سال پیش
در تاریخ 1391/02/07 منتشر شده
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