Chapter 9 Procedures for orthopedic emergencies
Orthopedic Emergencies, ed. Michael C. Bond, Andrew D. Perron, and Michael K. Abraham. Published by Cambridge University Press. © Cambridge University Press 2013.
Local anesthetics
Key facts
Ester anesthetics: procaine, tetracaine
Amide anesthetics: bupivacaine, lidocaine
Cardiac lidocaine is preservative free and may be used in patients with previous lidocaine allergy
Onset of action and duration of action varies based on agent used, concentration of agent, amount of agent and location of injection
Attention should be paid to the amount of anesthetic given to avoid toxicity
CNS excitation and lightheadedness are typically associated with toxicity
Lidocaine with epinephrine may be used on digits, nose, etc
Ensure that anesthesia is achieved prior to starting the procedure
Always use sterile gloves when administering local anesthetic agents
Indications
Local anesthesia for procedures
Sutures
Fracture/dislocation reduction
Incision and drainage
Contraindications
Cellulitis/infection at injection site
Bleeding disorders (relative)
Anticoagulant use
Previous allergic reactions to anesthetic agent
Risks
Infection
Bleeding
Nerve damage
Anxiety/agitation (particularly in children)
Tissue distortion (particularly with larger volumes)
General suggestions
Always obtain informed consent before performing a block or a procedure
Aspirate slightly before injecting anesthetic to ensure that the needle is not in a vascular structure
If paresthesias are elicited during a block it is likely that the needle is in close proximity to a nerve/nerve sheath. If this occurs withdraw the needle slightly and reassess location before continuing the injection
Hematoma block
Easily performed
Achieves reasonable anesthesia
Ideal for distal radial fractures, gaining popularity with ankle fractures
Time to onset: approximately 5 minutes
Contraindications
Open fracture
Grossly contaminated skin
Supplies needed
Chlorhexidine swabs (or other cleaning solution)
Lidocaine 1% or 2%
10 cc syringe
25-gauge needle (length dependent on patient habitus) for injection
18-gauge needle (for preparation/aspiration of solution to be injected)
Technique
Place the injured extremity in a position of relative comfort
Clean the skin overlying the hematoma with chlorhexidine swabs
Fill the 10 cc syringe with lidocaine
Insert the needle into the center of the hematoma
Enter the skin at a 90° angle
Advance the needle until it hits bone
Pull the needle back 0.5–1 cm
Draw back blood to confirm placement of the needle in the hematoma
Inject the lidocaine in a fan-like distribution
Goal: Anesthetize bone and periosteum
Remove the needle
Cover the injection site with a sterile bandage
Proceed with necessary reduction(s)
(Bier block)
Indications
Anesthesia of large portion of a limb
Large lacerations
Burn
Foreign body
Long-bone fracture
Contraindications
Hypertension
Altered mental status patient
Crush injury (relative contraindication)
Supplies
Procedure
Dilute the lidocaine to 0.5% (if not prepackaged at this concentration)
Apply the pressure controlled pneumatic tourniquet to the proximal aspect of the affected extremity
Place the 20-gauge IV on the affected extremity
Secure the IV
Elevate the extremity to facilitate effective exsanguination
Compression of proximal arteries (axillary artery in the upper extremity, femoral artery in the lower extremity) may increase the efficacy of exsanguination
Wrap the extremity (distally to proximally) with a compression bandage to further facilitate exsanguination
Inflate the tourniquet to 50 mm Hg above systolic blood pressure
Place the extremity in a neutral position
Slowly inject the lidocaine 0.5%
If less than complete anesthesia is achieved, inject 10–20 cc of normal saline
Perform the necessary procedure
Deflate the tourniquet in a cyclic fashion
Do not deflate the tourniquet until 30 minutes after infusion of the anesthetic
Deflate for 10 seconds, reinflate for 1–2 minutes
Repeat four to five times before removing tourniquet completely
Remove the IV
Serial neurovascular checks should be performed every 15 minutes following the procedure until neurologic function returns to baseline
Two-tourniquet technique
Updated technique designed to limit systemic lidocaine toxicity
Place two tourniquets in close proximity to each other on the proximal aspect of the affected extremity
Proceed with the exsanguination process as in a classic Bier block
Inflate the proximal cuff first (to 50 mm Hg above systolic blood pressure)
Inject the anesthetic
Inflate the distal tourniquet to 50 mm Hg above systolic blood pressure
Do not inflate the distal tourniquet until at least 25 minutes after anesthesia is achieved
Deflate the proximal tourniquet as per the classic technique
Perform therapeutic procedure
Deflate the distal tourniquet as per the classic technique
Results
Anesthesia progresses distally to proximally
Onset of anesthesia: 3–5 minutes
Complete anesthesia: 10–20 minutes
Muscle relaxation typically follows complete anesthesia
Sensation returns within 5–20 minutes of cuff deflation
Ulnar nerve block at the wrist
Supplies
Positioning
Place the patient in a position of comfort
Keep the elbow in a position of comfort
Supinate the hand
Anatomy
Identify the flexor creases of the wrist (Figure 9.1)
Palpate the ulnar artery
Identify the flexor carpi ulnaris tendon by flexing the patient’s wrist
The ulnar nerve runs between the flexor carpi ulnaris tendon and the ulnar artery in the area between the proximal and distal palmar creases
Procedure
Radial nerve block at the wrist
Supplies
25-gauge needle for injection (length dependent on patient habitus)
18-gauge needle for preparation/aspiration of anesthetic
10 cc syringe
Skin cleaning solution
Lidocaine 1% or 2%
Positioning
Place the patient in a position of comfort
Keep the elbow in a position of comfort
Place the hand in a neutral position
Anatomy
Identify the flexor creases of the wrist (Figure 9.2)
Palpate the radial artery at the level of the proximal flexor crease
The radial nerve runs just lateral to the radial artery at this location
Procedure
Identify the landmark
Clean the skin
Enter the skin at a 90° angle
Inject 1–2 ml of lidocaine to the skin and subcutaneous tissue
Advance the needle to the anatomic location of the radial nerve
The radial nerve is relatively superficial, sitting less than 1 cm deep
Inject 3–5 ml of lidocaine
Digital block
Supplies
25-gauge needle for injection (length dependent on patient habitus)
18-gauge needle for preparation/aspiration of anesthetic
3 cc syringe
Skin cleaning solution
Lidocaine 1% or 2%
Positioning
Place the patient in a position of comfort
Keep the elbow in a position of comfort
Pronate the hand
Anatomy
Procedure
Identify the landmarks
Clean the skin
Enter at the midportion of the web space (Figure 9.3) or at the base of the metacarpal (Figure 9.4)
Hold the needle at a 90° angle to the skin
Advance the needle to the anatomic location of the digital nerve
The digital nerves are relatively superficial, sitting less than 1 cm deep
Inject 1 ml of lidocaine
Repeat the procedure on the other side of the affected digit
Figure 9.4 An alternate location for a digital nerve block is at the base of the metacarpal head. The needle cap is pointing to this location.
Ring block
Supplies
25-gauge needle for injection (length dependent on patient habitus)
18-gauge needle for preparation/aspiration of anesthetic
3 cc syringe
Skin cleaning solution
Lidocaine 1% or 2%
Positioning
Place the patient in a position of comfort
Keep the elbow in a position of comfort
Pronate the hand
Anatomy
Procedure
Identify the landmarks
Clean the skin
Enter the radial aspect of the affected digit at the metacarpal head (Figure 9.5)
Advance the needle horizontally across the base of the affected phalanx
Inject 1 ml of lidocaine across the dorsum of the phalanx while withdrawing the needle to the point of insertion
Remove the needle and then reinsert the needle, advancing toward the volar aspect of the digit
Inject another 1 ml of lidocaine along the side of the digit
Remove the needle
Supinate the hand
Insert the needle at the radial side of the volar aspect of the affected digit
Advance the needle horizontally across the base of the affected phalanx
Inject 1 ml of lidocaine across the volar surface of the phalanx while withdrawing the needle to the point of insertion
Femoral nerve block
Supplies
25-gauge needle for injection (length dependent on patient habitus)
18-gauge needle for preparation/aspiration of anesthetic
30 cc syringe
Skin cleaning solution
Lidocaine 1% or 2%
Positioning
Place the patient supine on a stretcher
Externally rotate the leg approximately 15–20°
Anatomy
The femoral nerve runs in parallel with the femoral artery and femoral vein in the inguinal area
The mnemonic NAVEL (nerve, artery, vein, empty space, lymphatic) is often used to remember the anatomy, with the femoral nerve being the most lateral of the structures
The ideal approach is at the midpoint between the anterior superior iliac spine and the lateral aspect of the pubic symphysis, approximately 2 cm distal to the inguinal ligament
Procedure
Identify the landmarks
Clean the skin
Palpate the femoral artery
Inject 1–2 ml of lidocaine to the skin and subcutaneous tissue just lateral to the palpable femoral pulse
Enter the skin at a 90° angle
Advance the needle to the anatomic location of the femoral nerve
Pull the needle back 5 mm (or until paresthesias resolve) before injecting 15–20 ml of lidocaine
Arthrocentesis
Indications
Contraindications
Absolute
Infection overlying the joint
Relative
Known bacteremia
Bleeding diathesis
Prosthetic joint
Equipment
Sterile drapes and gloves
Skin preparations
Local anesthetic
Syringe
Needles
Collection tubes
Technique
Use strict aseptic technique
Local anesthesia
Identify landmarks
Ultrasound may help to localize the joint fluid collection
18–22-gauge needle attached to syringe (a 3-way stopcock may be used with large effusions)
Aspiration of synovial fluid should flow easily. If fluid stops, advance or retract slightly, rotate bevel, or decrease the force of aspiration. If the needle is blocked, a small amount of sterile fluid may be injected
Remove as much synovial fluid as possible
Key anatomy
Specific sites
The knee should be near full extension (flexed 10–15°) but not locked as the quadriceps must be relaxed
The middle or superior portion of the patella is the landmark
Insert an 18-gauge needle 1 cm inferior to the medial aspect of the patella (Figure 9.6). Alternatively, a lateral approach can be used
Compression of the joint effusion can increase the amount of fluid removed
Lister’s tubercle, the dorsal radial tubercle, is a prominence located in the center of the distal end of the dorsal radius
The extensor pollicis longus (EPL) runs in a groove on the radial aspect of this tubercle
Flex the wrist 20–30° with some ulnar deviation while applying traction to the hand
Insert a needle perpendicularly distal to Lister’s tubercle on the ulnar side of the EPL (see Figure 9.7)
Palpate the radial head with the arm extended then flex the elbow to 90° with the forearm pronated
Insert the needle from the lateral aspect at the center of the triangle between the radial head, olecranon, and the lateral epicondyle. Palpate a depression just proximal to radial head to identify this entry site (see Figure 9.8)
Direct the needle toward the distal edge of the antecubital fossa while keeping it perpendicular to the radius
The medial malleolus sulcus is bordered by the medial malleolus medially and the anterior tibial tendon laterally
Plantar flex the foot
Insert a 20–22-gauge needle just medial to the anterior tibial tendon directed at anterior edge of medial malleolus and advance 2–3 cm to penetrate joint
Figure 9.6 An arthrocentesis of the knee is performed by placing an 18-G needle 1cm inferior to the medial aspect of the patella as shown.
Figure 9.8 The optimal site for arthrocentesis of the elbow is shown. The needle should be inserted into the palpable depression just proximal to the radial head.
Fluid analysis
Gram stain, culture, and sensitivity
Cell count with differential
Crystals
Lactate
Glucose, protein
May see fat globules if occult fracture
Complications
Infection
Bleeding
In hemophiliacs, clotting factor is administered before arthrocentesis
Dry tap
• PEARLS:
Aseptic technique is essential
Most important aspect of technique is palpating the bony landmarks to define joint space. Ultrasound may assist
Approach is usually on the extensor surface as major vessels and nerves are located on the flexor side
Mild flexion and traction may open up the joint spaces that are being tapped from the extensor surface
Prosthetic joints are at high risk for infection. Have a low threshold for orthopedic consultation
Nail trephination
Indications
Techniques
Prep with povidone–iodine solution (not alcohol, which catches fire)
Apply slight downward pressure
Stop applying pressure when resistance gives way, to avoid damage to the nailbed
Heated paper clip
Same as above
Needle
Prep with povidone–iodine solution
Apply slight downward pressure to needle as you rotate it back and forth
Widen opening to encourage continued drainage
Some authorities advocate multiple holes
Complications
Nail loss or deformity (always warn patient)
Paronychia
Osteomyelitis (rare)
PEARLS:
> 50% subungal hematoma may warrant nail removal for nail bed repair (traditional teaching, now controversial)
Intact nail provides splint and better long-term results (modern philosophy)
X-ray to rule out underlying fracture (not mandatory, may use clinical judgement)
General fracture-reduction techniques
Indications
Key anatomy/techniques
General principles
Always assess and document neurovascular status before and after reduction
The periosteum on the side of the fracture to which the fragment is displaced usually remains intact
This periosteum forms a hinge to relocate the displaced distal fragment (see Figure 9.9)
The type of fracture and the degree of displacement will determine how much force and manipulation are required (see Figure 9.10)
After a regional block, hematoma block, or procedural sedation, traction is applied to the distal fragment with countertraction applied to the proximal fragment
The deformity is exaggerated if necessary, and any rotational deformity is corrected
The distal fragment is then reduced as the angular deformity is corrected
Appropriate immobilization is then applied. The method of immobilization varies with the specific injury involved
How do you tell if reduction is adequate?
Rotational deformity is completely corrected regardless of age
Angular deformity is corrected for adults
Children tolerate some angular deformity (15–20°) if it is near the joint and in the same plane of motion
Weight-bearing joints require precise, anatomic reduction
Proper length is mandatory in lower extremity injuries
Anatomic reduction is confirmed by repeat radiographs, portable fluoroscopy, or bedside ultrasonography as clinical assessment of reduction is difficult
Figure 9.10 A: The fracture at baseline before any reduction attempt is made. Notice how the distal fragment is displaced superiorly in the photo; this could be reduced with longitudinal traction. B: Shows a distal fragment that is shortened and overlaps the proximal bone. The longitudinal traction will need to be applied to the distal fragment to disengage the bone from the proximal portion and pressure is applied to push the distal fragment into its proper position. C: Demonstrates the next step where the distal fragment is then swung into proper position. D: Shows how the well-reduced bone is properly aligned. Force was applied to points 1 and 2 while point 3 was stabilized in order to get a good reduction.
Specific sites
Colles fracture – refer to orthopedist after reduction because of high incidence of complications (stiffness, arthritis, compartment syndromes)
Only reduce those without intra-articular involvement
Procedural sedation, hematoma block, or Bier block can be used for anesthesia
Longitudinal traction (finger traps if available) to disimpact the distal fracture fragment (see Figure 9.11)
Recreating the mechanism of injury and the position of the bony fragments at injury to relax the periosteal ligaments allows more effortless reduction of the fracture
Extend the wrist to 90°, with the elbow fixed and the forearm supinated, and pull the distal segment back, up, and out at approximately 120°
Apply dorsal pressure over distal fragment with both thumbs and apply volar pressure. With the thenar eminence of physician’s hand over fracture site, direct the fragment in an ulnar and volar direction to achieve proper position
Immobilize the wrist at 15° of flexion and with 20° of ulnar deviation. (Though some orthopedists prefer pronation) application of a plaster sugar tong splint or bivalve cast with the wrist held in slight flexion, with slight ulnar deviation and pronation of the forearm
Obtain post-reduction radiographs
Goals for adequate reduction
Restore length of radius. Normal distance from articular surface of ulnar to tip of radial styloid is 12 mm
Normal radial inclination is 15–30° (see Figure 9.12)
Achieve at least a neutral volar tilt (0°). Optimally, re-establish a normal volar tilt (10–15°) (see Figure 9.13)
Reassess and document neurovascular status of the extremity after reduction. Document function of the median nerve and the sensory branch of the radial nerve
Evaluate for rotational deformity
Mechanism of injury results in angulation of distal segment toward palm (volarly); usually occurs as a result of a direct blow to the knuckles
Index(2nd) and middle(3rd) fingers:
Eliminate angulation at the fracture sites of these fingers. Patients cannot tolerate more than 10–15° angulation of these fractures. Goal is minimal angulation to precise anatomic reduction
Ring(4th) and little(5th) fingers:
The metacarpals of the ring and little fingers allow flexion and extension at carpal attachments. These patients can tolerate greater angulation at the fracture site without loss of function. Although up to 30–40° of angulation is acceptable, the goal is 10–15° of angulation or less for 4th metacarpal neck fractures and 20–30° of angulation or less for 5th metacarpal neck fractures
After hematoma block, apply longitudinal traction either manually or with finger traps to disimpact the distal fragment
Flex the involved finger to 90° at MCP joint and 90° at PCP joint with the palm facing the floor
Stabilize the metacarpal and apply force longitudinally upward through the proximal phalanx to reduce angulation deformity (see Figure 9.14)
Immobilize with ulnar gutter splint for 4th and 5th metacarpal fractures with the wrist extended 20–30° and the MCP joint flexed 90°. Immobilize with a radial gutter splint for 2nd and 3rd metacarpal fractures
Metacarpal neck fractures are easy to reduce but hard to maintain. These fractures often require wire placement to maintain alignment
Figure 9.11 A: The fingers are placed in fingertraps and weight is applied to the flexed elbow in order to introduce traction that will separate the bone fragments. B: The fracture, that is under traction, is then manipulated with volar pressure to reduce the fracture. C: Longitudinal traction can be further applied to ensure proper alignment. D: A posterior arm or sugar tong splint can be applied while traction is maintained to ensure the reduction is maintained until splinted. E: The arm is shown with finished splint in place.
Figure 9.12 A goal of reduction is to ensure there is a normal radial inclination of 15–30°.
Figure 9.13 A goal of reduction is to ensure there is a normal volar tilt of 10–15°, but you need to ensure that the volar tilt is at least neutral. The volar tilt angle is shown.
Complications of closed reductions
Irreducible fractures
Failure to maintain reduction
Neurovascular injuries
Malrotation
PEARLS:
Closed reduction is ineffective for spiral fractures or comminuted fractures as the ends cannot be engaged to prevent shortening
Accurate reduction of the fracture is essential for obtaining good functional results
Early reduction lessens morbidity and improves patient comfort
Pediatric Salter–Harris Type III and IV fractures require precise anatomic reduction to prevent growth disturbance
Ankle dislocation
Key facts
Tibiotalar dislocations without fracture are rare and often are open dislocations caused by the amount of force required to cause the dislocation
Bimalleolar and trimalleolar fractures often are associated with tibiotalar subluxation or dislocation
Early reduction is recommended to prevent further osteochondral injury and vascular injuries
Subtalar dislocations are rare with medial dislocation making up 85% of these dislocations
Clinical presentation (see Chapter 5: Foot and ankle emergencies)
PEARL: Evaluate for vascular compromise, specifically dorsalis pedis artery, which is often compressed with anterior dislocations.
Fast facts
Lateral ankle fracture dislocations are most common, followed by posterior and then anterior. Usually there is obvious deformity of the foot and ankle with foot displaced laterally and skin very taut medially
Foot is usually plantar flexed and shortened
Decreased dorsalis pedis pulse is common with anterior dislocations
Open dislocations occur in up to 25% of ankle dislocations
Reduction techniques (see Figure 9.15)
Always flex hip and knee to 90° to relax gastroc-soleus complex
Posterior dislocation: Grasp heel with one hand and dorsum of mid-foot with other hand. Pull longitudinal traction and then anterior traction. Second practitioner can place hands under distal thigh and pull countertraction while hip and knee are 90° flexed. Can also perform one person reduction while patient is seated with leg hanging off edge of stretcher
Anterior dislocation: Grasp foot in same way as posterior dislocation. Initially dorsiflex the foot slightly to disengage the talus. Then apply axial traction followed by pushing foot posteriorly. Second practitioner can hold traction on tibia while pulling it anteriorly
Lateral dislocation: Apply distal traction to plantar flexed foot and then rotate to proper anatomic position
Figure 9.15 Ankle dislocation reduction. An assistant should stabilize the proximal leg as marked by the red arrow. The provider will apply longitudinal traction as noted by (1) while applying first an upward force (2) and then a downward force (3) to cause the reduction.
Clavicle dislocations/fractures
Key facts
Sternoclavicular joint is made up of sternoclavicular ligament and costoclavicular ligament
Acromioclavicular joint is made up of acromioclavicular ligament, coracoclavicular ligament and coracoacromial ligament
Posterior sternoclavicular dislocation can be a true orthopedic emergency because of other injuries including tracheal rupture, pneumothorax, esophageal injuries or vascular injuries, thus requiring emergent reduction
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