CHAPTER 24 Orthopedic Emergencies
I. GENERAL STRATEGY
A. Assessment
1. Primary and secondary assessment/resuscitation (see Chapter 1)
2) Past medical history
a) Current or preexisting diseases/illness
(6) Paget’s disease: localized areas of bone destruction followed by replacement with overdeveloped, light, soft, porous bone and associated with deformities such as thickening of portions of the skull and bending of weight-bearing bones; cause unknown
(8) Disorders associated with peripheral nerve injury: alcoholism, sudden significant weight loss, carcinomatous neuropathy, or diabetic peripheral neuropathy
b) Current health status
(2) Pregnancy: swelling precipitates overuse syndromes; prone to falls as a result of pelvic ligament laxity
3) Psychological/social/environmental factors related to orthopedic emergencies
1) General appearance
d) Gait: ask patient to walk, if tolerated, both away from and toward the examiner, to assess balance, control, posture, and movement of arms and legs
2) Inspection
a) Compare both sides of body to visualize symmetry, contour, size, and alignment
(1) Valgus: deformity of the distal portion of a joint that is angulated away from midline of body (e.g., knock-knees, hallux valgus)
3) Palpation
b) Muscle tone
(1) Decreased: result of musculoskeletal, neurologic, metabolic, or infectious disorders, and/or fatigue
c) Muscle strength: assess range of motion before muscle strength, because muscular contraction may produce enough pain to inhibit further examination
(2) Strength is subjectively graded by examiner on scale ranging from 1 to 5. All findings are recorded and used as a baseline:
d) Deep tendon reflexes (DTRs)
(1) Assess major reflexes: biceps, brachioradialis, triceps, patellar knee jerk, and Achilles tendon
5) Peripheral vascular assessment
1) Plain film radiographs: provide data on bone and joint changes; useful for diagnosing open joint injuries (air visible in joint space); standard for acute fractures and dislocations; does not show soft tissue disorders, except for swelling
3) Angiography: used to diagnose and treat vascular injuries, prevent hemorrhage, and relieve ischemia; useful for recognizing and selectively embolizing major bleeding vessels and injuries of extremities with suspected vascular involvement (e.g., penetrating wounds) via an arterial catheter
4) Magnetic resonance imaging (MRI): used for soft tissue disorders such as ligament injury, meniscal damage, tendon ruptures, muscle tears, tumors, hematomas, spinal structures, infection, and degenerative disorders
Table 24-1 PERIPHERAL NERVE ASSESSMENT
| Nerve | Motor | Sensory |
|---|---|---|
| Radial | Extend wrist or thumb | Feeling on dorsum of thumb |
| Median | Oppose thumb to base of small finger | Feeling on tip of index finger |
| Ulnar | Abduct (fan) fingers | Feeling on tip of small finger |
| Tibial | Plantar flex toes (curl down) | Feeling on bottom of foot |
| Superficial peroneal | Laterally evert foot | Feeling on lateral aspect of dorsum of foot |
| Deep peroneal | Dorsiflex toes (curl toes up) | Feeling in first toe web space (between first and second toes) |
C. Planning and Implementation/Interventions
F. Age-Related Considerations
1) Pulling injury to the arm can result in subluxation of the radial head (“nursemaids elbow”) and is commonly seen between 2 to 3 years of age
2) Muscles lose the ability to regenerate new fibers to replace ones lost because of age; the result is atrophy
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