# Orthopedic Emergencies: A Rapid Review ## Introduction Certain orthopedic conditions demand urgent recognition and immediate intervention to prevent irreversible tissue damage, limb loss, or death. The orthopedic resident and surgeon must be able to identify these emergencies rapidly and initiate treatment without delay. This lecture provides a concise review of the major orthopedic emergencies and the time-critical actions required for each. | Emergency | Key Diagnostic Finding | Critical Time Window | Definitive Treatment | |-----------|----------------------|---------------------|---------------------| | Compartment syndrome | Pain with passive stretch; delta P < 30 mmHg | 6-8 hours before irreversible damage | Emergency fasciotomy | | Open fracture | Wound communicating with fracture | Antibiotics within 1 hour; debridement within 24 hours | I&D + stabilization + soft tissue coverage | | Septic arthritis | Synovial WBC > 50,000; > 75% PMNs | Hours (cartilage destruction in 24-48 hours) | Urgent I&D + IV antibiotics | | Vascular injury (knee dislocation) | ABI < 0.9; absent pulse | 6 hours warm ischemia | Emergent reduction + vascular repair | | Cauda equina syndrome | Saddle anesthesia; urinary retention | 24-48 hours (ideally < 24 hours) | Emergent surgical decompression | | Necrotizing fasciitis | Rapid spread; crepitus; systemic toxicity | Hours | Emergent radical debridement | | Unstable spine with cord compression | Neurologic deficit; canal compromise | Hours | Emergent decompression + stabilization | | Hip dislocation | Shortened, internally rotated limb | 6 hours (AVN risk) | Emergent closed/open reduction | ## Compartment Syndrome ### Recognition Compartment syndrome occurs when elevated pressure within a closed fascial compartment compromises tissue perfusion. It is most common in the **leg** (anterior compartment) and **forearm**, though it also occurs in the thigh, foot, and hand. The classic findings are described by the **6 Ps**: pain out of proportion, pain with passive stretch (earliest and most reliable), pressure (tense compartment), paresthesias, paralysis, and pulselessness (a late finding). **Pain with passive stretch of the muscles within the compartment** is the most sensitive clinical sign. A high index of suspicion should be maintained in tibial shaft fractures, forearm fractures, crush injuries, prolonged limb compression, and patients on anticoagulation. Compartment pressure measurement is diagnostic when the **absolute pressure exceeds 30 mmHg** or the **delta pressure is less than 30 mmHg** (diastolic blood pressure minus compartment pressure). ### Action **Emergency fasciotomy** of all involved compartments is the definitive treatment. The leg has **four compartments** (anterior, lateral, superficial posterior, and deep posterior), all of which must be released. The forearm has **three compartments** (volar, dorsal, and mobile wad). Delay beyond **6-8 hours** leads to irreversible muscle necrosis, manifesting as Volkmann ischemic contracture in the forearm or foot drop and claw toes in the leg. Wounds are left open with planned return for closure or skin grafting at 48-72 hours. One must **not wait for all 6 Ps to develop**, as pulselessness and paralysis indicate tissue death has already occurred. ![Clinical photograph showing tense, swollen leg with markings for four-compartment fasciotomy incisions](/images/orthopedic-surgery/compartment-syndrome-fasciotomy.jpg) ## Open Fractures ### Recognition An open fracture is a fracture communicating with the external environment through a skin wound. The **Gustilo-Anderson classification** stratifies these injuries: **Type I** has a wound less than 1 cm with a clean, simple fracture pattern; **Type II** has a wound of 1-10 cm with moderate soft tissue damage and no extensive flap; **Type IIIA** is a high-energy injury with adequate soft tissue coverage after debridement; **Type IIIB** involves extensive soft tissue loss requiring flap coverage; and **Type IIIC** has an associated vascular injury requiring repair. ### Action **Antibiotics** must be administered within **1 hour** of presentation: a first-generation cephalosporin for Type I-II, with an aminoglycoside added for Type III, and penicillin added for farm or soil contamination. **Tetanus prophylaxis** is given as indicated. **Wound irrigation and debridement** is performed in the operating room as soon as possible, ideally within 24 hours and earlier for Type IIIB/C injuries. **Temporary stabilization** with external fixation or splinting is followed by **definitive fixation** within 24-72 hours when soft tissue conditions allow. Type IIIB injuries require **soft tissue coverage** within 72 hours to 7 days using a local or free flap. Type IIIC injuries require **vascular repair**, typically within 6 hours to prevent irreversible ischemia. ## Septic Arthritis ### Recognition Septic arthritis presents as an **acute monoarticular joint infection** with a painful, swollen, warm joint and limited range of motion. The **knee** is the most commonly affected joint, followed by the hip. In pediatric hip evaluation, the **Kocher criteria** are applied: fever greater than 38.5C, inability to bear weight, ESR greater than 40, and WBC greater than 12,000; a 99% probability of septic arthritis exists if all four criteria are met. Joint aspiration is diagnostic, revealing a **WBC greater than 50,000** with **greater than 75% PMNs** and positive Gram stain or culture. **Staphylococcus aureus** is the most common organism in all age groups except neonates (Group B Streptococcus) and young children (Kingella kingae). ### Action **Urgent surgical irrigation and debridement** (arthroscopic or open) is the primary treatment. **IV antibiotics** are initiated after joint aspiration, and surgery should not be delayed for culture results. In pediatric hip septic arthritis, concern for **femoral head AVN** from elevated intracapsular pressure makes emergent drainage mandatory. **Gonococcal arthritis** in young, sexually active adults may respond to antibiotics alone but often requires aspiration. ## Vascular Injury Associated with Fractures/Dislocations ### High-Risk Injuries **Knee dislocation** carries a popliteal artery injury rate of **20-40%**, and even spontaneously reduced dislocations carry this risk. **Supracondylar humerus fractures** in the pediatric population may injure the brachial artery. **Proximal tibial fractures** place the popliteal artery at risk where it is tethered by the soleus arch. **Elbow dislocations** can injure the brachial artery, though less commonly. ### Action Immediate **vascular assessment** includes palpating pulses, checking capillary refill, and obtaining an **ankle-brachial index (ABI)**. An **ABI less than 0.9** after knee dislocation warrants **CT angiography**. If limb ischemia is present, **emergent reduction** is performed followed by **vascular exploration and repair**. **Warm ischemia time** is approximately **6 hours** for muscle; beyond this threshold, amputation rates rise sharply. The limb should be maintained in an anatomic position without excessive manipulation before definitive vascular assessment. After vascular repair, close monitoring for **compartment syndrome** from reperfusion injury is essential. ## Cauda Equina Syndrome ### Recognition Cauda equina syndrome results from compression of the cauda equina nerve roots, typically from a large central disc herniation. **Red flag symptoms** include bilateral lower extremity weakness, **saddle anesthesia** (perianal numbness), **urinary retention** or incontinence, fecal incontinence, and decreased rectal tone. It most commonly occurs at **L4-L5 or L5-S1**. A post-void residual bladder volume greater than 100-200 mL supports the diagnosis. ### Action **Emergent MRI** of the lumbar spine is obtained immediately. **Surgical decompression** (laminectomy and discectomy) should be performed within **24-48 hours** and ideally within **24 hours**. Delayed decompression is associated with permanent bowel and bladder dysfunction and lower extremity weakness. **Incomplete CES** (urinary difficulties without retention) has a better prognosis than **complete CES** (painless urinary retention). ![MRI demonstrating large central disc herniation causing cauda equina compression](/images/orthopedic-surgery/cauda-equina-mri.jpg) ## Necrotizing Fasciitis ### Recognition Necrotizing fasciitis is a rapidly progressive soft tissue infection involving the fascia and subcutaneous tissue. It presents with **disproportionate pain**, rapidly spreading erythema, skin blistering, crepitus, and systemic toxicity (fever, tachycardia, hypotension). It may occur after trauma, surgery, or spontaneously, particularly in diabetic or immunocompromised patients. **Group A Streptococcus** and polymicrobial infections are the most common causes. The **LRINEC score** (Laboratory Risk Indicator for Necrotizing Fasciitis) can aid diagnosis but should not delay surgical intervention when clinical suspicion is high. ### Action **Emergent surgical debridement** is the definitive treatment; this condition cannot be treated with antibiotics alone. Broad-spectrum IV antibiotics (vancomycin, piperacillin-tazobactam, clindamycin) are initiated concurrently. **Serial debridements** every 24-48 hours continue until all necrotic tissue is removed. ICU admission is required for hemodynamic monitoring and resuscitation. Mortality ranges from **20-40%** even with appropriate treatment, and delays in surgical debridement dramatically increase mortality. ## Unstable Pelvic Fractures with Hemorrhage ### Recognition High-energy pelvic ring disruptions (lateral compression type III, anteroposterior compression type II-III, vertical shear) can produce hemodynamic instability from **retroperitoneal hemorrhage**, which is primarily venous plexus bleeding but arterial in 10-20% of cases. Pelvic instability may be noted on clinical examination, though repeated mechanical stability testing should be avoided. ### Action The **ATLS protocol** is followed, addressing airway, breathing, and circulation. A **pelvic binder** or sheet wrapping is applied immediately to reduce pelvic volume and tamponade hemorrhage. A **massive transfusion protocol** is activated. If the patient remains hemodynamically unstable after binder placement and resuscitation, options include **angioembolization** for arterial bleeders, **preperitoneal pelvic packing** as an alternative or adjunct, and **external fixation** for anterior ring stabilization if a binder is insufficient. Definitive fixation is performed after hemodynamic stabilization. ## Spinal Cord Compression (Metastatic) ### Recognition Metastatic spinal cord compression presents with back pain and progressive neurologic deficit in a patient with known or suspected malignancy. Findings include motor weakness, a sensory level, and bowel or bladder dysfunction. ### Action **High-dose dexamethasone** (10 mg IV bolus followed by 4 mg every 6 hours) is administered to reduce cord edema. **Emergent MRI** of the entire spine is obtained. **Radiation therapy** and/or **surgical decompression** are selected based on tumor radiosensitivity, spinal stability, and neurologic status. Surgical decompression plus radiation is superior to radiation alone for patients with a single area of cord compression and reasonable life expectancy. ![Summary table of orthopedic emergencies with time-critical interventions](/images/orthopedic-surgery/ortho-emergencies-summary.jpg) ## Key Clinical Pearls Compartment syndrome is a clinical diagnosis, and pain with passive stretch of the involved muscles is the earliest and most reliable sign; one should not wait for pulselessness or paralysis to intervene. All knee dislocations require vascular assessment even if spontaneously reduced, and an ABI less than 0.9 mandates CT angiography. Cauda equina syndrome with urinary retention requires emergent MRI and surgical decompression within 24 hours, as delays result in permanent neurologic deficits. Necrotizing fasciitis cannot be treated with antibiotics alone, and emergent surgical debridement is mandatory and should not be delayed for diagnostic studies. ## References 1. McQueen MM, Duckworth AD, Aitken SA, Court-Brown CM. The estimated sensitivity and specificity of compartment pressure monitoring for acute compartment syndrome. *J Bone Joint Surg Am*. 2013;95(8):673-677. 2. Gustilo RB, Merkow RL, Templeman D. The management of open fractures. *J Bone Joint Surg Am*. 1990;72(2):299-304. 3. Ahn UM, Ahn NU, Buchowski JM, et al. Cauda equina syndrome secondary to lumbar disc herniation: a meta-analysis of surgical outcomes. *Spine*. 2000;25(12):1515-1522. 4. Stannard JP, Schmidt AH, Kregor PJ. *Surgical Treatment of Orthopaedic Trauma*. 2nd ed. Thieme; 2016.