All right. Thank you very much. So I appreciate the opportunity. Again, I'm filling in for Dr. Curl. I want to make sure I give her all the credit as these are her slides. I was her fellow, her resident back in the day, so I guess it's appropriate that I'm giving her a talk in this situation. These are both of our disclosures. So as we've heard, really important to have an emergency action plan, understand your personnel, understand your transportation. That can vary based on high school, college, or NFL, based on which hospital system you use. But make sure you know that well and be prepared. You can't emphasize that enough. So we're going to talk about orthopedic emergencies, and those are ones that really limb at risk where time is of the essence. Cervical spine will be covered elsewhere, but that obviously is also an orthopedic urgent emergent situation. We're going to focus on fractures, dislocations, and compartment syndromes, the ones that we know that time is of the essence. Fractures most fortunately are straightforward. We deal with these all the time. But there are some special considerations for fractures that do have some urgency that I think it's important to understand. Forearm fractures, fascial fractures in kids, they sort of act like knee dislocations, and then long bone fractures. Forearm fractures typically fall into an outstretched hand. It can also be a direct blow. That's more of an isolated ulna fracture or so-called nightstick fracture. Typically you want to mobilize these. A sugar tongue splint is what tends to be the preferred approach. Vacuum splints can be utilized. It's important to get a good neurovascular exam as it's not uncommon to get a neurovascular injury with these. Any compromise sort of ups the stress level with these and the urgency. Most of them are going to require operative fixation. You want to be aware that there is a risk of compartment syndrome. We'll talk about that more as we get into that later on. But elevate them overnight or for the next couple days. Get that swelling down and obviously plan accordingly. Pediatric knee fractures, for those of you that take care of younger football players, these in my opinion can be an emergent issue because they act like a knee dislocation. There's a high risk of puppeteer artery injury, so you need to be aware of that. If you have a concern on the field, if you're covering a high school game and there's significant crepitance around the knee in a freshman or sophomore player, there's a high chance that they have a fissile injury. That's when you want to get to the emergency room and get evaluated, get appropriate x-rays and arterial studies as needed. But typically reduction, potentially surgical repair based on the fracture pattern. But certainly the most important thing is recognizing that this needs to be evaluated in a higher level situation. Femur fractures are rare in this population. We see it a lot in trauma patients, motorcycle accidents, car accidents. It can happen from a direct blow. The best course of action is obviously to get them immobilized the best you can. Sometimes a knee immobilizer is the best thing you have for this on the field setting. Typically they're placed in traction initially, but operative repair is the mainline treatment once you get them to the hospital. Tibia fractures, the most common long bone fracture, either direct blow or rotational type injury. There's a high incidence of open fractures, so it's really important to recognize that. Sometimes they're covered up, they're taped, and you may not realize that it's an open fracture, but you want to make sure you visualize the skin. If you think about the tibia, there's not much between the tibia and the outside world, just a layer of skin, so these can become open pretty easily. Recognize that, vascular exam, make sure you document that, understand that. About a 24% of tibia fractures are open, and again, sometimes you're on the field, and I've had this happen. I had a, not a tibia fracture, but I had a player had an IP dislocation in the first quarter, reduced it, never took his glove off. End of the game, he took his glove off, and it was an open IP dislocation that he played the whole game with. It's important to realize that these can be covered up and not be obvious, so make sure that you investigate it fully, take the tape down, take the leggings down, make sure you know what you're dealing with before you make a decision. Obviously, antibiotics are something you want to get early and often in these patients, based on the amount of contamination. There's obviously a very high infection risk, up to 50%. Surgical repair, either temporize them with an X-fix or fix them right away, that can be debated, but obviously recognizing it, cleaning the wound, get them on antibiotics as early as you can, that those parts are time-sensitive, and then surgical repair also time-sensitive. Dislocation, we're going to focus on the hip and the knee, those are the ones that have some time urgency to it. Hip dislocations, fortunately rare, most are posterior on a flexed knee, often can have acetabular fractures or femoral head fractures, so it's important to recognize that, usually needs a CT scan to diagnose that. The issue with the proximal femurs, the blood supply is fixed around the femoral neck and dislocations or subluxations can put stress on the blood supply to the proximal femur. This is the Bo Jackson injury, who had a posterior hip subluxation, ended up having an injury that led to osteonecrosis or avascular necrosis of the proximal femur. It's important to recognize this, typically if it's a posterior dislocation, it's a very kind of pathognomonic position they're in with the hip flexed, ad-ducted, and internally rotated. If you have any questions or concerns, obviously x-rays at the field is ideal, I've reduced several of these in the x-ray room, it's going to take several people to do that. Without sedation, certainly it's very challenging in these big strong athletes, but I've done several of them. It's important to understand the method of reduction in this, you're basically recreating the position to unlock the femur from the back of the acetabulum, and it's about a 10 to 15% sciatic nerve injury, so it's important to document that, preferably prior to your reduction attempt to avoid anyone blaming you for the sciatic nerve injury. Once a diagnosis is made, obviously I'd prefer to reduce these at the field, again I've done several of these. If it's not feasible, you're going to need sedation, so that would have to be done in the emergency department or in the operating room. So these are going to require transportation, CT scan, evaluate for intraticular loose pieces, any of those kind of things. Two to 15% may require open reduction. The time to reduction is critical, if you look at the risk of osteonecrosis, it's less than 10% if it's reduced within six hours, which most of these are, but that number goes up significantly with longer time of dislocation. So this again is something important to identify. Knee dislocations, not surprising, a critical injury. More common in high energy injuries, motor vehicle, motorcycle accidents, you classify it based on the position of the tibia to the femur. A lot of them will spontaneously reduce or be sort of a high grade subluxation, by the time you get out there it's reduced, but it's important not to overlook that fact. If you evaluate a grossly unstable knee with more than three ligaments involved, that's a knee dislocation to prove it otherwise, and you have to recognize that and treat it accordingly even if it's reduced on the field. Fortunately, it's rare, but 30% can have popliteal artery injury, so it can be a significant problem. I've had several patients transfer us, we're a level one trauma center at the University of Florida, several high school athletes transferred us the following day after a missed knee dislocation with significant arterial injury. This is something that you've got to understand, you have to recognize, and you have to pick up and act accordingly. Again, they can be reduced on the field and still have an arterial injury, so don't just overlook that fact if you have a reduced knee on the field. On the field, get a good neurovascular assessment, reduction, if it's reduced when you get there, obviously reduction with manual traction, the sooner you can do that the better. Reassess the neurovascular status. These all typically should probably be evaluated in a hospital setting, certainly if you have to do reduction, I would say 100%. Transport the ER for further evaluation. There are some signs that are more of a concern, the pucker sign is where the medial form of condyle buttonholes through the anterior medial capsule. That usually requires an open reduction, so if you see that, you can certainly try to reduce it, but you probably won't be successful. The popliteal artery is tethered to the posterior knee at the adductor hiatus, and then distally at the soleus muscle, so you can see why a dislocation has a high risk of popliteal artery injury. In addition, a lot of these can be intimal injuries that initially look fine and then clawed off afterwards, so it's important not to think you're out of the woods because initially your exam looks fine. So the initial evaluation of a dislocated knee, once it's reduced, check your pulses distally, both the dorsalis pedis and posterior tibial. Any absence or side-to-side difference is a surgical emergency and must be picked up. An abnormal pulse, 13% of normal pedal pulses could still have a popliteal artery injury, so it's important to keep that in mind. If it is suspected or if a knee dislocation is suspected, obviously transportation to the emergency room for further evaluation, depending on where you are. If you don't have a liaison to help you, we'd like to give the ER a heads up. You don't want the person sitting in the waiting room for eight hours while they wait for the next bed. It needs to be considered an emergency and evaluated accordingly. 14% amputation rate baseline for popliteal artery injury. If it's delayed more than eight hours, almost a 90% amputation rate, so a life-changing injury to a young athlete. If you have a concern for it, we prefer a CT angiogram. It's less invasive, quicker, you get a good evaluation of it. Typically arteriograms, MRAs, Dopplers can all be used, but our preference is a CT angiogram. After you do your initial evaluation, if the pulses seem normal based on your exam, you should do an ankle brachial index. This is not always easy to do in the emergency room setting, but you effectively are looking at the cutoff pressure of the brachial artery and the dorsalis pedis artery based on a Doppler measurement and you want that to be greater than .9. Anything less than .9 needs further evaluation for a potential emergent condition. So here's the algorithm, knee dislocation reduced on the field, normal pulses, ABI greater than .9 should be observed overnight and then rechecked in the morning. Normal pulses, ABI less than .9 should have an angiogram of some sort, again our preference is a CT angiogram. No pulses or certainly no pulses or an ABI much lower than .9 should be probably taken for an emergent exploration and intraoperative arteriogram by vascular surgery. Perineal nerve injuries, high incidence, 16-40% does not make this a more emergent injury, can be sort of expected to be a problem with these. They typically recover, but there is a high level of perineal nerve injuries in this injury population. Finally, a compartment syndrome, I sort of described this to patients as you have a hose and the pressure in the hose gets to be too high, the water no longer flows into that, leads to ischemic injury to the compartment that you're referring to. The threshold is 20 millimeters of mercury below diastolic or 30 below the mean arterial, that's where the gradient is not sufficient to pump blood across the gradient. If you look at diagnosis, most of them are with fracture, but 23% are without fracture. I've seen Achilles tears turn into compartment syndrome, I've seen rhabdomyolysis turn into compartment syndrome, I've seen quad contusions turn into compartment syndrome. This should always be on your radar as a potential problem if you're not careful, and it can occur within any fascial compartment. The leg is the most common, I've seen quads, I've seen feet, I've seen forearms, I've seen hand compartment syndromes. Clinical diagnosis, if you see it, you won't forget it because they typically are pain out of proportion, exquisite pain, pain with passive stretch, can't get them feeling better, narcotics don't work, pressure and fullness in the compartment, and start to see some sensory changes. But if you've seen a patient who has a true acute compartment syndrome, it'll burn your memory what they're like because they are in exquisite pain. If you need a definitive diagnosis, compartment measurements are the go-to, not a fun procedure for the patient, but this measures the intracompartmental pressure via this device, this needle device, Surgical intervention, if the pressure is absolute pressure greater than 30 or pressures within 20 to 30 of the diastolic is kind of the definition of compartment syndrome, and if you do make that diagnosis, the only treatment is an open fasciotomy. I do endoscopic fasciotomies for exertional compartment syndrome, this is a different animal. This is a true traumatic compartment syndrome. This requires an open fasciotomy, often leading to skin graft and further operations. This compartment syndrome is a big deal. It can lead to loss of limb, amputation, Volkman's contractures, all these different things. In summary, be prepared, that's number one, two, and three. Fractures and dislocations, recognize the high-risk ones, recognize the ones that are time-sensitive. Open fractures, knee-hip dislocations, and certainly compartment syndrome, if you have a suspicion you need to act on it, don't just say, well, we'll see how we do for a few hours because once you've started that kind of pathway of thinking someone's got compartment syndrome, you're sort of obligated to make sure that's not the case. Thank you.

orthopedic emergencies

fractures

dislocations

compartment syndromes

emergency action plan