EMERGENCY IN ORTHOPAEDIC

CRITICAL CARE

I . COMPARTEMEN SYNDROME
Definition : A complex symptom in which caused by elevated pressure in an enclosed
osseofacial space, can damage irreversibly the contents of the space.
Volkmanns Ischemia Volkmanns contracture

Cause : a. Decrease size of compartment : - Tightened fascia

- Tight dressing
- Local compression

b. Increase the contain of the space : - Primary edema

- Blood accumulation
- Combined
Patophysiology :
Vascular congestion capillary beds occluded muscle & nerve
Ischemia transudation of colloid plasma into the surrounding tissues
increase of tissue pressure arterial flow impaired
Diagnosis: (7P)/(5P) : - Pain on passive stretching - Pallor
- Pain at rest - Pulselessness
- Paresthesia - Poikilothermia
- Paralysis
Gold standard for measurement :
- Wick catheter technique
- Slit catheter technique normal : 20 30 mmHg
- Stic catheter technique > 30 mmHg need fasciotomy
- Continuous infusion technique
- Needle manometer technique
Necrosis of the muscle happened, 8 hours in 30 mmHg intra compartment pressure.
Others examinations:
Blood: Hb
Urine: myoglobinuria, oligouria
 EMG
Initial management:
- Constrictive dressing should be removed or split.
- Circumferential cast should be bivalved
- Limb should be placed at the level of the heart

Definitive treatment: Fasciotomy, skin and fascia are left open; skin is grafted at a later
date.

Prophylactic fasciotomy should be performed on : - Tibia osteotomy

- Leg lengthening
- Arterial repair
- Open tibia fractured

II. FAT EMBOLISM

Definition: A syndrome due to the entry of neutral fat into the vascular system.
The syndrome usually develops 24 48 hours.

Pathophysiologi:
Fat in the myellum into vascular system obliterated vascular in lungs and brain
ventilator distress & brain function disorder.
Theory:
1. Mechanical (marrow globular) : Bauss 1924.
It is caused : damage of the adipose tissue
damage of venous system
higher pressure in the bone marrow than in the venous system.
2. Biochemistry
Disorder of the stability chylomicron emulsion emboli of microglobules
3. Cathecolamine adrenal steroid pathway
stress mobilization of fat from the depot increase of FFA & triglyceride.

Clinical Symptoms: Sevitt

a. Major (min 1) : Respiratory disorder Ptechie
Brain (CNS) disorder
b. Minor (min 2) : Pyrexia Icterus
Tachicardi Retina disorder
Renal disturbance

c. Laboratory (min 1) Fat macroglobulin Anemia

Thrombocytopenia blood
Urine Increase of ESR

Radiology: fluffy infiltrate of the lungs (snow storm)

ECG : Cardiac failure, Abnormal T wave cause of ischemia

Base of treatment :
1. Proper and adequate of fracture management
2. Adequate shock management
3. Adequate pain control with analgetic
4. Respiratory support
5. Corticosteroid administration:
- Decrease of cerebral edema
- Anti aggregation of thrombosis
- Decrease of FFA in plasma
- Prevent decrease of pa O2
6. Restore of fluid and electrolyte balance
7. Others : - Antibiotic prophylaxis
- Digitalis
- Bronchodilator

III. OPEN FRACTURE

Definition: Fracture with open wound, which the bone fragment had been exposed with
the other space.
Classification: Gustillo Anderson : depend on :- Mode of injury
- Soft tissue damage
- Bone comminution
Grade I : 1 cm wounds or less
Grade II : > 1 cm wound with moderate soft tissue damage
Grade III : Extensive soft tissue damage and crushing due to high velocity trauma.
Type III is further subdivided into three subtypes :
A : Adequate coverage
B : Bone exposed with periosteal stripping
C : Circulation distrupted, arterial repair required

Management:
Principal: - Prevent infection - Restore the limb functions
- Bone and soft tissue healing
Consist of:
1. Ensure the ABCs are stable
2. Complete examination include all of system organ
3. Close the wounds with the clean gauze
4. Immobilization the fracture
5. Recognition the fracture by the X-ray
6. Determined the vascular status
7. Preoperative debridement : - Fluid replacement - Anti tetanus
- Antibiotic prophylaxis
- Debridement & Irrigation
8. Reposition & fixation to secure the stability
9. Closure the wounds:
- Grade I & II Primary closure
- Grade III Delayed primary closure (3 5 days) or early free-flap
10. Early bone grafting if necessary (1 6 weeks)
11. Recognize and treat the complications adequately

Note :
If there is with vascular involvement :
< 4 hours : Stabilization fracture first than vascular repair
> 4 hours : repair vascular first than stabilize the fracture
To determine the vascular by: clinical / Doppler / arteriography
Muscle fibers edema 4 8 H
Muscle fibers die 6 12 H
IV. MULTIPLE TRAUMA
Definition: Patients with more than one organ system had been injured and they
influenced to life threatening.
Steps of ATLS (INITIAL ASSESMENT)
1. Preparation: pre hospital & in hospital phase
2. Triage: sorting the patients
3. Primary survey:
- Airway maintenance with cervical spine control. Alert
Verbal
- Breathing and ventilation Pain
Unresponsive
- Circulation with hemorrhage control.
- Disability and neurological status : - Level of conscious: AVPU
- Pupil size & reaction

- Exposure / environmental control :

- completely undressed
- warmed environment
4. Resuscitation.
5. Roentgenogram
6. Secondary survey
- a head to toe evaluation
- GCS scoring
- peritoneal lavage
- Other radiologic evaluation Allergies
- Laboratory Medication
Past illness
- AMPLE history Last meal
Environment
7. Re evaluation
8. Definitive care.

RULE OF PRIMARY AND SECONDARY SURVEY

1. Used of personal protections apparatus (gloves, goggles, mask, head cover, shoe
cover, gowns or aprons)
2. Examine the airway with cervical control, if :
obs (-) or obs (+) chin lift / jaw thrust
oropharyngeal (unconscious)
Free nasopharyngeal (conscious)

Apply the collar brace endotracheal intubations or

cricothyroidotomy

3. Oxygenation
- Evaluation: Blood pressure, pulses, Respiratory rate
- Evaluation: breathing sound, heart beat sound.
if none * Tension pneumothorax: contraventile
* Hematothorax : chest tube
* Cardiac tamponade : pericardiocentesis4. IV line
administration:
- 2 (two) IV line with big and short needle, by taking blood sample (cross match,
pregnancy test for female, others)
- Bolus 1-2 liters of ringer lactate
- If need with venasection
5. Re-evaluation: I P P A, completely with:
- ECG observation
- Pulse oxymetry
- RT DC & MS
- Evaluate: AVPU and pupils
6. Open all of dress (undress), find the all source of external bleeding,
Stop the bleeding with clean / sterile gauze.
Remember, preventing iatrogenic hypothermia by coverage the patients.
7. Re-evaluation again : - All the vital sign
- Blood gas analysis
- Urine output
V. ACUTE HEMATOGENOUS OSTEOMYELITIS
Definition : acute infection of the bone (metaphysis) & marrow
Cause : - Staphylococcus aureus !!!
- Streptococcus pyogenes / pneumoniae (infant)
- Haemophylus influenza (child < 4 years)
- E.coli, Pseudomonas, Proteus (gram neg)
- Bactericides (an aerobe)
- Salmonella
Predisposing Factor:
- DM, malnutrition, drug addict, very elderly, debility
- Immunosuppressive therapy, immunodeficiency.
Site or infection: metaphysis area because:
- Area of growth cells
- Rich of vascular
- Thin cortex
- Slow blood flow

Pathology: depend on :- Age - Host response

- Site of infection - Immune system
- Virulence of organism - Malnutrition

Stage of infection Pathology (Hobo s theory)

1. INFLAMATION (72 hours) Vascular congestion
Exudation
Infiltration by PMN
2. SUPPURATION Sub periosteal abscess
3. NECROSIS Sequester: pieces of dead bone separated
4. REACTIVE NEW BONE REACTION
Involucrum : new bone thickened surrounding the sequester
Cloacae : perforated area from the infolucrum

5. RESOLUTION
- Sclerosis and thickening of the bone
 - Remodeling
Stage of clinical (Trueta, 1968)
* Stage I : process in the bone : tenderness
* Stage II : pus in medullar cavity & sub periosteal malaise, fever, pain, headache
* Stage III : pus in the soft tissue (abscess) with inflammation sign (calor, dolor, tumor,
rubor, functionless)
Sign & Symptom :
- Pain, malaise, fever, tenderness
- Local redness, warmth
- Swelling / edema
- Restrict of joint motions (refuse to move the limb)
- Lymphadenopathy

Roentgen : - Swelling of subcutaneous tissue & muscle

- Periosteal reaction / bone formation / thickening of periosteum
- Patchy rarefaction of the metaphysis
- Bone destruction / destroy bone trabecullae
- Osteoporosis bone
- Small crack epiphyseal plate

Laboratory: - Leucositosis, increased of ESR

- Blood culture (+)
- Antistaphylococcal ab

Treatment:
A. General supportive treatment: - IV line (dehydration?)
- Analgetic
B. Immobilization affected part: - splintage
- Skin traction
C. Eradication infection: Antibiotic, depend on culture & sensitivity test
Adult / child: - Flucloxacillin 3 4 days ( IV ) continued with 3 6 weeks (PO)
< 4 years: Cephalosporin 2nd generation Amoxicillin & clavulanic acid
D. Drainage
Must be done, if in 36 hours without better improvement with antibiotic. (Monitoring
LED, temperature, CRP). Drained by open operation under GA (drilling into the
medullar cavity)
Complications: - Suppurative arthritis
- Altered bone growth
- Chronic osteomyellitis

VI. GAS GANGRENE

Def : Septic condition caused by microorganism producing gas due to damage soft
tissue during the open fracture of bones.

Causes : Clostridium perfringen / welchii

Clostridium septicum
Clostridium tertium
Pathogenesis:
Contaminated of tissue with (spores / vegetative forms) of
Clostridia sp & transient hypoxia (low tissue oxygen tension)

Bacterial growth

Toxin produce : (enz hyalluronidase & collagens )

(Clostridia myositis)
Local edema
Tissue destruction
Thrombosis local vessels
Gas produced (H2S & CO2)

Distant spread
(More edema & more thrombosis)
32 48 hours
 Late state

Sign & symptom: - General : toxic, irrational, mild shock

- Local : bronze color until black discoloration
blebs & bulla (sero sanguineous ), crepitating.
Laboratory:
- Hemolysis of blood droop in hemoglobin ( 12 24 hours )
- Hemoglobinuria
- ATN (decrease of RFT)
- Leucocytes
- Spore / in gram stain

X Ray gas in soft tissue

Treatment : - Secure ABC (life saving )

- Surgical debridements, irrigation, leave the wound open/amputation
- Antibiotic (triple drug) penicillin/ metronidazole
- Antitoxin ( globulin modified polyvalent )
- HBO increase of oxygen content in the soft tissue.

Complication : pneumothorax / air embolism

Note : Gas producing microorganism

* An aerob : - Gram ( - ) : - Bactericides sp
- Gram ( + ) : - bacilli : Clostridium sp
- coccus : Peptostreptococcus
* aerob : - Gram ( - ) :- E.coli - Proteus
- Klebsiella - Enterobacter
- Gram ( + ) : - Streptococcus pyogenes
- Staphylococcus aureus