Residency · Residency · Orthopedic Surgery

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.

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.

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).

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.

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.

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