ORTHOPAEDICS - ADULT

ResponseHaemorrhage control - direct pressure
Analgesia (Opioids + dose or ketamine)
Consent for sedation/reduction
Procedural sedation
Scrub and irrigate wounds
Fracture reduction
Immobilise in above knee cast
Elevate to reduce risk of compartment syndrome (+Swelling)
IV antibiotics - Cefepime and metronidazole if farm
ADT/tetanus toxoid
Admit orthopaedics for fixation and washout

ResponseAPI = Injured SBP/Uninjured brachial SBP
API <0.9 is indicative of likely vascular injury - requires vascular surgical review or transfer to center with vascular surgery

Ipsilateral DP or tibial pulse is detected with doppler until clearly heard
Cuff pumped up 20 mm past point where dopplers disappear. Release cuff and measure where sound is heard (Systolic pressure)
Repeat for uninjured lower extremity and uninjured upper extremity

ResponseImage Description:
Open fracture / dislocation left ankle
Profound displacement (90o external rotation)
Large wound with high potential for contamination
Minimal active bleeding
Left calf flap wound

Assessment Priorities:
Identify life-threatening injuries = primary survey
Neurovascular status of limb / assessment of obvious injury

• Pulse / doppler assessment
• Define anatomy of bony injury with Xray

AMPLE Hx (Allergies / Medications / Past Hx / Last ate (irrelevant) / Event)

Management Priorities:
Analgesia: Titrated fentanyl IV +.- low-dose ketamine
IV Antibiotics (broad-spectrum given size of wound) / ADT

• Gustillo-Anderson classification 3

Gross wound decontamination – warm saline wash
Reduction of fracture dislocation under sedation with immobilisation and re-evaluation of neurovascular status
Admission to hospital:

• Vascular surgery input immediately if vascular compromise post-reduction
• Orthopaedic Admission with view to definitive ORIF / washout in OT emergently

ResponseMotor

• Dorsiflexion ankle and great toe, Eversion of foot

Sensory

• Dorsum foot, lateral leg below knee

ResponseAt fibular head

ResponseHigh ankle sprain
Fractured fibular
Tight plaster involving knee
Wearing hih knee boots
Prolonged bedrest/coma with pressure at knee
Habitual leg crossing
TKR
High tibial osteotomy
That time I injected local into that guys knee after a tibial plateau fracture and accidentally blocked his tibial nerve giving him a 48 hour foot drop

ResponseInversion and plantarflexion should be preserved
Decreased or absent ankle reflex in radiculopathy