Orthopedics

    Orthopaedic Trauma Managment

    Management in ER:

    1. Complete primary survery and resuscitiation
    2. Begin prophylactic antibiotic treatment
    3. Control bleeding with direct pressure or tourniquet
    4. Apply saline soaked sterile dressing over open wound
    5. Split/stabilize
    6. Appropriate xray views 

     

    Management in OR:

    1. Aggresive debridement and irrigation
    2. Low pressure saline lavage
    3. Remove loose bony fragments
    4. Fracture stabilization
    5. Debridement and irrigation every 24-48 hours
    6. 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:
    1. Xray - displaced? callus formation?
    2. Point tenderness over the fracture? (should not be any)
    3. Appropriate amount of time in cast?
    • t/hen decide if to put cast back on or consult ortho or leave it.
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