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RCSI Royal College of Surgeons in Ireland Coliste Roga na Minle in

irinn

ORTHOPAEDIC EMERGENCIES
IC3
Musculoskeletal Teaching week
Gavin OReilly
6/1/15

SEPTIC ARTHRITIS

Infection in the joint


Can occur in any joint
Most common is hip in child
Children are more prone to getting septic arthritis due to
rich metaphyseal blood supply
Pathophysiology
Haematogenous spread
Osteomyelitis
Secondary to surgery

Staphylococcus Aureus is most common microorganism


through all ages (except neonates streptococcus)

SEPTIC ARTHRITIS
Inflammation and redness in joint
Systemically unwell may have SIRS
In children symptoms can be more subtle
Off food
Irritable
Wont use affected limb

Imaging
XR can should widened joint space
US if effusion is to be tapped
MRI if any collections / osteomyelitis present

DIAGNOSIS

If patient is systemically unwell then resuscitation should be performed


Vitals
Spiking temperature
Tachycardic
Bloods
Elevated WCC, ESR, CRP
Renal dysfunction indication multiorgan failure
Clotting disturbance if late stage liver failure
Kocher criteria for hip septic arthritis in children
Temperature
WCC >12
Inability to weight bear
ESR >40
IF positive there is 90% chance of septic arthritis

TREATMENT
Treatment is wash out of joint and IV antibiotics
Samples of pus should be sent for culture and sensitivity

In suspected septic arthritis a sterile joint aspiration may


be attempted
This is contraindicated if there is surrounding inflammation in
joint due to risk of seeding infection

Delayed treatment can result in sepsis and joint


destruction due to chondrolytic effects of pus
Liaison with infectious diseases team/ microbiology
regarding microorganism, antibiotic and duration of
treatment

HIP FRACTURE IN YOUNG PATIENT


Hip fracture can disrupt blood supply to the femoral head
This can result in avascular necrosis

In elderly populations the management is to excise this


potentially avascular femoral head eg hemiarthroplasty,
total arthoplasty
In young people it is preferable to reduce and fix the
fracture and monitor for signs of avascular necrosis
The sooner surgery is performed the less risk of the
femoral head becoming avascular

YOUNG HIP FRACTURE MANAGEMENT


The fracture is reduced
on a traction table
Cannulated screws /
DHS is performed
keeping the native
femoral head

OPEN FRACTURES
An open fracture occurs when the skin overlying a
fracture is broken allowing communication between the
fracture and the external environment
High risk of infection

Soft tissue
Osteomyelitis
Septic arthritis
Tetanus

OPEN FRACTURE CLASSIFICATION


Gustilo Anderson
Classification

MANAGEMENT OF OPEN FRACTURES


(BOAST GUIDELINES)

IV abx as soon as possible (with 3hrs if possible)


Tetanus
Repeated neurovascular exam especially post reduction
Immediate action if compromised vascular supply
Urgent surgery if severe injury or compromised by sewage/agricultural
matter
Combined plan for management of soft tissue and bony trauma
Wound is grossly decontaminated, picture taken of wound and then covered
in saline soaked gauze
Wound is disturbed as little as possible
If not for surgery immediately plan for theatre on the next available list

JOINT DISLOCATIONS
Dislocation is where a bone is put out of joint
Usually traumatic
Any dislocated joint should be reduced as soon as
possible once it is safe to do so

COMPARTMENT SYNDROME
A pain syndrome resulting from increased pressure in a
closed fascial compartments leading to microvascular
complications
Can technically occur in any closed compartment (eg
abdominal compartment syndrome)
Most commonly seen in leg
Characterized by pain disproportionate to injury
No relief from adequate analgesia

Pain on passive flexion of compartment


Intra-compartmental compression monitors can confirm
diagnosis but should not be relied upon
Clinical decision

COMPARTMENT SYNDROME
MANAGEMENT
If there is concern over compartment syndrome
decompressive fasciotomy needs to be performed
All compartments should be opened
E.g. for leg all four

For fasciotomy of leg usually medial and lateral incisions


are made
Wound is left open
Closed at later date