ORTHOPAEDICS - ADULT

ResponseHighly muscular individuals
Less flexible fascia (young males)
Higher energy injuries
Anabolic steroids
Presence of coagulopathy

ResponseAcute extremity ischaemia with reperfusion
Burn
Crush
Spontaneous haemorrhage/haematoma
Soft tissue infection
Non traumatic myositis/myonecrosis/rhabdomyolisis
SIRS with massive fluid resuscitation
High pressure injection
Intravenous extravasation injury
Intra-arterial injection
Prolonged immobilisation
Venomous bites/stings
Tight cast/splint/dressing
Closure of fascial defects

ResponseClinical
History

• pain out of proportion to apparent injury, persistent deep ache or burning pain, parsthesia

Examination:

• Tense compartment, Pain with passive stretch, paresthesia (Decreased sensation and weakness), paralysis (late finding), pallor from vascular insufficiency, poikilothermia, (+/- pulselessness)

Pressure manometer - Commercial, Arterial line setup

• Stryker needle – proprietary device with special needle with side ports – attaches to a pressure measuring component in the Stryker kit
• “Normal” large bore needle or cannula attached to standard IV line and transduced as one would an arterial or CVP line (zero it etc)

Labs - CK

ResponseNormal compartment pressure is 0-8 mm.Hg
Preferred measure over measured compartment pressure is “Delta pressure”
Delta pressure = diastolic BP - measured compartment pressure
<20-30 indicates need for fasciotomy (ie: if compartment pressure is within 20-30 of DBP you have problems)

ResponseContains extensor muscles of foot, anterior tibial artery, deep peroneal nerve
Loss of sensation DPN (First webspace)
Weakness of foot dorsiflexion
Late = foot drop, “Claw foot” and DPN nerve dysfunction

ResponseElevation + Ice
Remove external compression (Splints, slabs, bandages)
Analgesia
Immediate orthopaedic attendance for fasciotomy

ResponseEvidence of vascular compression
Late presentation or diagnosis
Significant neurologic dysfunction
Compartment pressure >30mm.Hg, Delta pressure (diastolic -compartment pressure) >30 mm.Hg
Rhabdo (Myoglobin release continues until ischaemia is relieved)

ResponseGangrene/loss of limb viability requiring amputation
Ischaemic contracture and loss of function
Rhabdomyolysis and renal failure

Responselack of proven efficacy in preventing renal injury or need for dialysis (beyond that provided by aggressive volume increased UO) causing big fluid shifts and contributing to hypovolaemia/hypotension are potentially bad ideas in a polytrauma patient
potential haemoconcentration/increased viscosity
effects on ICP
allergy/anaphylaxis
Apparently may reduce renal injury from tubular deposition

ResponseGrade 1 - Open fracture <1cm and clean
Grade 2 - Laceration 1-10cm without extensive soft tissue damage
Grade 3
3A - >10cm, Extensive soft tissue injury or contaminated, adequate tissue for coverage(Or contaminated sewerage/farm automatically 3A regardless of size)
3B - Periosteal stripping - requires soft tissue coverage (Flap)
3C - Vascular injury requiring repair

ResponseABx within 3 hours
Cefazolin 2g (50 mg/kg) - gram positive (Eg: Staph)
If significantly contaminated - Add metronidazole 500 mg 12.5mg/kg) IV Q12H
Penicillin allergy - swap to Clinda 600 mg (15 mg/kg) IV Q8H

Water borne organisms eg: Vibrio
Cefazolin + Ciprofloxacin 400 mg (10 mg/kg) (+Metro if contaminated)
Penicillin allergy = Clinda + Cipro

ADT/Tetanus immunoglobulin

Note: Tazocin is for treatment of infection, not prophylaxis.
eTG May ‘26

ResponseJoint aspirate for M/C/S and cell count

• May give diagnosis for crystal or septic joint, Directs antibiotic therapy, Direct future preventative measures
• Painful, operator dependant, Risk of introducing infection

Septic joint

• cell count – greater than 50 000
• Organisms on Gram stain / also accept “no crystals”
• Note crystals doesn’t exclude septic arthritis. You can have gout and SA

gout

• Cell count generally less than 50 000
• Negatively bi-refringent crystals

ResponseRisk factors
Renal failure, chemotheraputics, FHx, Diuretics (thiazide, loop), Dietary (high purine foods, alcohol), Hyperuricaemia
Aspirate: negatively birefringent crystals, WBC 200 - 50,000, yellow, turbid fluid.
Colchicine 500 mg BD, Prednisone 50 mg 3 days, NSAIDS eg Ibuprofen 400 mg TDS

ResponseCalcium pyrophosphate crystal on aspirate
Analgesia

ResponseFrank blood on aspirate
Conservative, aspirate for comfort, NWB< reverse coagulopathy, manage trauma

ResponseSkin manifestations
Pathogens: Staphylococcus, gonoccoccal
Note gram NEGATIVE diplococci = Neisseria or Moraxella. Gram POSITIVE diplococci = Strep orEnterococcus
Aspirate: Organisms on gram stain, Cell count >50,000
Theatre for washout + IV antibiotics (Flucloxacillin 1g QID, Cefzolin 2g TDS)

ResponseUnknown or Gram positive cocci in clusters
Fluclox 2g QID
+/- Vanc if MRSA
Clinda if penicillin allergies

Gram positive cocci in chains (Strep)
Ceftriaxone 2g
eTG Nov 24

ResponseVisible rash sparing head - classically patechial or painful red papules on distal extremities

ResponseIBD, Gonococcal, Reiter’s

ResponseRheumatoid, SLE, Psoriatic (uncommon for knee), Bursitis

ResponseOA

ResponseOrder an aspirate and MCS including crystals
sensible shit and justify it. I’m fucking done

ResponseCondition suspected/present
Proposed procedure
Risk of procedure
Risk of not doing procedure
Alternatives