General Principles of Orthopedic Injuries

Patients with orthopedic injuries and nontraumatic musculoskeletal disorders compose a large portion of the more than 100 million patients who come to U.S. emergency departments (EDs) annually. Although only rarely life-threatening, orthopedic injuries may threaten a limb or its function, and accurate early diagnosis and treatment can avert long-term complications. Many of these injuries can and should be treated definitively by the emergency physician. Consultation with an orthopedist should be sought for the treatment of most long bone fractures, open fractures, injuries with joint violation, and injuries with neurovascular compromise and for follow-up of certain patients initially treated in the ED. Orthopedic injuries often occur as a result of accidents (industrial or otherwise) and frequently involve young, otherwise healthy, working individuals. Accurate initial diagnosis, treatment, and documentation assume great importance medically and economically. Many problems can be avoided if the following 10 general principles are kept in mind: 1. Most orthopedic injuries can be predicted by understanding the chief complaint, the age of the patient, the mechanism of injury, and an estimate of the amount of energy delivered. 2. A careful history and physical examination predict radiographic findings with a high degree of accuracy. A presumptive diagnosis before a radiographic study may prompt the physician to order special views necessary to correctly diagnose an injury. Many fractures were accurately described before the advent of roentgenology (Table 49-1). 3. If a fracture is suggested clinically, but radiographic films appear negative, the patient should initially be treated with immobilization as though a fracture were present. 4. Criteria for adequate radiographic studies exist; inadequate studies should not be accepted. 5. Radiographic studies should be performed before most reductions are attempted, except when a delay could be potentially harmful to the patient or in some field situations. 6. Neurovascular competence should be checked and recorded before and after all reductions and after application of immobilization. 7. Patients must be checked for the ability to safely ambulate before discharge from the ED and should not be discharged unless this can be established. 8. Patients should receive explicit aftercare instructions before leaving the ED, covering such areas as monitoring for signs of neurovascular compromise or increasing compartment pressure, cast care, weightbearing, crutch use, and an explicit plan and timing for follow-up. 9. In a patient with multiple trauma, noncritical orthopedic injuries should be diagnosed and treated only after more threatening injuries have been addressed. 10. All orthopedic injuries should be described precisely and according to established conventions. When communicating with an orthopedic consultant, this may affect decisions regarding disposition of a patient and operative versus nonoperative management.