Table of contents
Orthopaedic Trauma Managment
Management in ER:
- Complete primary survery and resuscitiation
- Begin prophylactic antibiotic treatment
- Control bleeding with direct pressure or tourniquet
- Apply saline soaked sterile dressing over open wound
- Split/stabilize
- Appropriate xray views
Management in OR:
- Aggresive debridement and irrigation
- Low pressure saline lavage
- Remove loose bony fragments
- Fracture stabilization
- Debridement and irrigation every 24-48 hours
- Soft-tissue and wound coverings
Open Fractures
Gustilo and Anderson classification
-
Grade I: < 1cm non contamination incision
-
Grade II: 1-10cm incision with some contamination and soft tissue injuryI
-
Grade III: > 10cm incision with gross contamination from soil, bowel or farm injuries, or crush injury
-
IIIA: Extenstive injury but bone repairs covered with soft tissue
-
IIIB: Extensive injury and inability to close wound
-
IIIC: Vascular Injury/compromise
-
Prophylactic Antibiotic Regimen
Initiate antibiotics as soon as possible, rates of infections drastically decrease within 3 hours of administration. Continue therapy for 24-72 hours.
-
Grade I: Cefazolin (Ancef) 1g IV q8h. If MRSA +ve use vancomycin
-
Grade II: Cefazolin (Ancef) 1g IV q8h + Gentamycin 4mg/kg IV q4h
-
Grade III: As per Grade II + Anerobic coverage: Penicillin 2.4million units IV
Tetanus Prophylaxis
- Prophylaxis is given based on charactersitics of wound, if and when primary series has been completed
- Primary series is 3 doses of DTap, DTP, Tdap or DT.
- DTap: children 6 month - 7 years
- Td : children 7-9 and > 65
- Tdap: (Adacel) for 11-65, or Boosterix for 10 +
-
TIG: Tetanus immune globin:
-
< 5 years: 75U
-
5-10 years: 125U
-
>10 years: 250U
-
Tetanus Prophylaxis
Has completed primary Td series | Has not have vaccine, or unsure | |
Small, clean wound | None, if > 10 years give Td vaccine | Give Td vaccine |
Large, contaiminated, or puncture | None, if > 5 years give Td vaccine | Give TIG |
Septic Arthritis
- Most commonly affected joints: knee > hip > elbow > ankle > sternoclavicular joint
- Etiology of infection:
- Bactermia (hematogenous spread)
- Direct from trauma or surgery
- Contigious from adjacent otseomylitis
- Most common organisms include
- Staphyloccus aureus (most common cause)
- Streptococcus
- Neisseria Gonorrhea (most common in young, otherwise healthy and sexually active adults)
- H. influenza
- Salmonella
- Pseudomonas aeruginosa (IV drug use)
- Immunocompromised hosts may present with fungal septic arthritis as well
- Presentation includes pain, inability to bear weight, fever, decreased ROM
- Physical exam: Pain with PROM, effusion, warmth, joint is often "open" position to maximize volume
Distal Radius Fractures
- Fall outstretched hand.
- Cast below elbow keeping the thumb and fingers mobile.
- Follow-up:
- Return in 7 days for assessment:
- Xray: displaced? if displaced consult ortho (unstable)
- Cast too tight? or unhappy? (redo cast)
- Return in 6 weeks for removal:
- Remove cast + assess 3 things:
- Return in 7 days for assessment:
- Xray - displaced? callus formation?
- Point tenderness over the fracture? (should not be any)
- Appropriate amount of time in cast?
- t/hen decide if to put cast back on or consult ortho or leave it.
Comments