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1. Pitfalls in Orthopaedic opps Lt Col S K RAI Capt PramodMahender

2. Case Study A case was tried where a 10-month-old girl suffered anoxic brain injury after “being deprived of oxygen for 40 minutes, forgot the keys to an onboard medicine cabinet and later falsified records related to the rescue”

3. Medicolegal Outcome The girl, now 5, is a spastic quadriplegic with severe brain damage State health officials heard of the case only after a story appeared in the state Lawyers Weekly The $10.2 million(50 crores) settlement included a confidentiality agreement that kept secret the identities of the family, the hospitaland the EMS technicians

4. Errors Not all errors result in harm to the patient, and many react only to errors that are considered to have an adverse effect on a patient (injury or death)

5. Orthopaedic Emergency Examples?

7. Assume the cervical spine to be unstable until proven otherwise up to 50% of patients sustaining C-spine trauma develop neurologic abnormalities (nerve root compression and weakness to quadri- plegia and death). 10% are initially neurologically intact, but develop deficits during emergency care risks of airway management

9. C-spine evaluation bone and soft tissue X-ray exam: „one view is no view”, AP-lateral open mouth view -atlanto-occipital and atlanto-axial joints, the odontoid process,oblique – intervert. foramina CT lateral cervical spine - sensitivity of about 85% 92% in a three view series 100% when selective CT scanning is employed

11. The primary survey –life threatening conditions are identified and management is begun simultaneously! A - Airway maintenance with cervical spine control B - Breathing and ventilation C - Circulation with hemorrhage control D - Disability: neurological status E - Exposure: completely undress the patient

15. Circulation Large bore IV lines BP HR Alghevar scheme - quantification of shock: SBP / HR >1 no or minor clinical symptoms <1 major shock Pulses Indirect signs: UO, skin, tachypnoe, altered consciousness, empty” periferal veins

16. Circulation warmed intravenous infusions Control: external hemorrhage internal hemorrhage: MAST suit Pelvic binders Surgery  stabilisation  secondary survey

18. Check pupilsThe eyes are the window of the CNS

19. Disability (CNS Function) Decreased LOC in trauma = Head injury until proven otherwise

20. B. Initial treatment of major fractures Shock in orthopaedic patient - Hypovolemic shock - Neurogenic shock Major fracture - Pelvis - Spine (cervical) - Femur - Multiple fractures - Hip (shock) (shock) (shock) (shock)

21. Associated injury Fracture pelvis ; Urethral injury Fracture scapula ; Shoulder, chest Fracture calcaneus ; Spine (thoracolumbar region)

22. Which are Emergencies? Closed fracture, n.v. normal Closed dislocation, n.v. normal Open fracture Open dislocation

23. Mercifully Few Emergencies Open Fractures and Dislocations with or without vascular injury with or without neurological impairment

24. Not “broken”… …but still a limb-threatening emergency!

26. Joint Dislocations Must be reduced at once Risk to circulation and nerves Risk of Osteonecrosis (AVN)

27. Management in Musculoskeletal Injury R = Rest I = Ice C = Compression E = Elevation

28. Principles to approach severe musculoskeletal injury First aids Initial treatment of major fractures / dislocation Standard radiographs of fractures / dislocation Immediate definitive treatment of fracture / dislocation

29. A. First aids Bleeding control Immobilization Pain control Antibiotic administration Tetanus prophylaxis Improve microcirculation

32. Methods of immobilization Splinting; wooden, commercial Brace or support Strap Slab immobilization Cast immobilization Traction External fixation Open reduction and internal fixation

33. Purpose of immobilization Temporary Definite

34. Complication of immobilization Too fit Too loose Too long interval Too short interval ; pressure sore, compartment syndrome ; inadequate immobilization (loss reduction, delayed, mal or nonunion) ; muscle atrophy, osteoporosis, joint stiffness, maceration of skin ; inadequate immobilization (loss reduction, delayed, mal or nonunion)

35. Complications of casting Pressure sores Cast sores

36. Velpeau’s strap Injury of shoulder region

37. Slab immobilization U or Sugar tong slab for humerus fracture Short or long arm slab with or without thumb spica Below or above knee slab Cylindrical slab

39. Advice to give patients before casting Objectives and advantages of casting Duration of casting Activities to do and not to do during casting Good co-operation is needed

40. Skeletal traction 1 lbs of traction for every 7 lbs of body weight (usually uncomfort if > 35 lbs)

41. Disadvantages Costly in terms of hospital stay Hazards of prolonged bed rest Thromboembolism Decubiti Pneumonia Requires meticulous nursing care Can develop contractures

42. Skull traction Gardner-Wells tong

43. Skull traction Crutchfield tongs

44. Orthopaedic patients : Antibiotics Cefazolin Cloxacillin Gentamicin Amikacin Metronidazole Clindamycin Ofloxacin Cotrimoxazole

45. Pitfalls in paediatrics

46. Different point of musculoskeletal injury between children and adult More incidence of fracture in children More stronger and more rapid growth of periosteum More difficult to diagnose More ability of remodeling Difference in treatment or complication Less incidence of ligamentous injury or dislocation Less tolerability to blood loss

47. Prognosis of epiphyseal plate injury Type of injury Age of patient Blood supply of the epiphysis Method of reduction Open or closed injury

48. Fracture of Necessity Galeazzi’s fracture Monteggiae’s fracture Lateral condylar fracture Supracondylar fracture

49. Common Pitfalls Tunnel vision “Premature closure of hypothesis generation” Just the opposite “Inability to see the forest for the trees” Failure to attend to the patient “Fail to social interaction with patient and family”

50. How to approach patients Bio Psycho Social Spirit

51. TAKE HOME In emergency medicine, the central task is not diagnosis, but management Alghevar scheme BP>HR

52. THANK YOU Questions?