Transcript Complication of Fracture

COMPLICATION OF
FRACTURE
NATTAPONG PHOLPRADUBPET
OUTLINE
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Vascular injury
Compartment Syndrome
Thromboembolism
Fat Embolism Syndrome
Complex Regional Pain Syndrome (CRPS)
VASCULAR INJURY
ETIOLOGY
• Vast majority of arterial injuries associated with
fractures are secondary to Gunshot wounds
• Type
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Intimal flaps
Disruptions or subintimal hematoma
Wall defect
Complete transection
A-V fistula
ARTERIAL INJURY
• Associate with fractures in areas where the vessels
are close to osseous structure or held in a fixed
position
• fracture dislocation around the knee
The presentation may be delayed (intimal flap or
thrombosis), so the absence of classic signs of acute
ischemia & the presence of palpable pulses in no
way rule out the possibility
VENOUS INJURY
• Commonly associate with arterial injury
• Often multiple, lacerations, producing hematoma
• Venous repair esp. in the groin or popliteal area
• may be helpful after arterial repair to prevent hematoma
formation, distal edema, & progressive tissue destruction
DIAGNOSIS
• Awareness
• Signs & Symptoms:
• Absence of distal pulse, pallor,
differential gradient in temp, rapidly
progressing edema or hematoma
formation
• Paralysis, paresthesia
INVESTIGATION
• Investigation
• Doppler U/S
• Duplex U/S (real time B-mode U/S & pulsed Doppler flow
detection)
• Arteriogram
• Venogram
TREATMENT
• Initial
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Early resuscitation
Immobilization the traumatized limb
Do not elevate the affected limb
Direct pressure
Avoid tourniquet (temporary use only if necessary)
• Pre-op preparation
• Optimal period for restorative surgery is 6 - 8 hr
• Correct acidosis & volume depletion
• Splint or traction is applied
BONE VS VESSEL: WHAT SHOULD BE
REPAIRED FIRST?
• Depends on
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ischemic time (6 hr golden period)
amount of contamination
extent of wound
mechanism of injury
associated injury
• Team approach
• Adjust individually
• Surgery
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Constructive dialogue with vascular surgeon
Drape to permit access to sapheneous or cephalic vein
Temporary shunt ???
Fasciotomy
• Fixation
• Closed fracture: internal fixation
• Open fracture: external fixation
• place pin away from the open wound & position the bar away
from the operative field for vascular repair
• Delayed definitive fixation
COMPARTMENT SYNDROME
DEFINITION
• An increased pressure within an enclosed
osteofascial space that reduces the capillary blood
perfusion below a level necessary for tissue viability
COMMON CAUSE
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Fracture
Soft tissue injury
Arterial injury
Limb compression
Burns
SIGN & SYMPTOM
• Symptoms
• Pain out of proportion !!!
• Pain is unrelenting
• No relief following splinting or removal of casts
& bandages
• Paresthesia
• Signs
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Pain on palpation of compartment
Tense / swollen compartment
Passive muscle stretch severe pain
Sensory deficit of nerve in the compartment
Muscle weakness
• Warnings
• Pulses are present early and their absence occurs late in the
development
• Normal capillary refill also present early in development
• Paresthesia and paralysis are too late
• Pain out of proportion & pain on passive stretching are 2
most important findings
COMPARTMENT PRESSURE
MEASUREMENT (WHITESIDE)
• Sterile saline is used
• 18- gauge needle is inserted into
the muscle at the level of
fracture
• Read when saline meniscus is
“flat”
• Do not depress the plunger too
strongly (avoid saline leakage)
• 2 readings should be made
• Repeat readings should be
made at
1 hr interval
Same level with tip of needle
• What is the magic number?
• 30 mmHg (corresponds with normal capillary pressure)
Mubarak, SJ & Hargens, AR
• 45 mmHg (capillary pressure rises in compartment
syndrome)
Matsen, FA
• 20 mmHg below DBP
Whiteside, TE
• 30 mmHg below DBP
McQueen, MM & Court-Brown, CM
MANAGEMENT
• Release constrictive dressings, bivalve
cast & webril
• Fasciotomy
• Fracture stabilization
• External fixator is the implant of choice
THROMBOEMBOLISM
• Risk depends on
• Age
• Extent & duration surgery
• Type of anesthesia
• Spinal & epidural  lower than GA
• Degree & duration of immobilization
• Severity of underlying systemic disease
CLINICAL SYMPTOM
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Leg pain
Swelling
Warmth
Dilated vein
Erythema
Pitting edema
PHYSICAL EXAMINATION
• Measure leg circumference
• Tenderness along deep venous system
• Homans’ sign
• Pain in the calf or popliteal region on forceful & abrupt
dorsiflexion of ankle with knee in a “FLEXED” position
PHE has low sensitivity & specificity
INVESTIGATION
• Duplex ultrasound
• Venogram
MANAGEMENT
• Prophylaxis
• LMWH 30 mg subcutaneously twice daily  no monitor is
required
• Warfarin 5 - 10 mg/day  INR 2 -2.5
• Treatment
• Heparin intravenously
5,000 units followed by cont infusion of 30,000 - 35,000 units /
24 hr  APTT
• Warfarin
5 - 10 mg/day starts 24 hr later  INR 2 - 3
• Stop heparin when therapeutic range of INR is achieved for
at least 2 days
FAT EMBOLISM SYNDROME
DEFINITION
• Presence of fat globules in lung parenchyma &
peripheral circulation after fracture of long bone &
pelvis, other major trauma, or non-traumatic
conditions
• “Fat embolism syndrome”  term to describe a
serious manifestation of the phenomenon of fat
emboli
PREVALENCE
• Fat emboli:
• 90% after major trauma
• Fat embolism syndrome
• 0.25-1.25%
• Higher prevalence in multiple bone fractures
• Mostly have a latent period of 12 - 72 hr after
trauma
• Movement of unstable fracture ends & reaming of
medullary cavity promote entrance of marrow
contents to the circulation
CLINICAL FINDINGS
• Classic triad
• Pulmonary
• Cerebral
• Cutaneous manifestations
• Pulmonary
• Tachypnea, pleuritic chest pain, dyspnea, cyanosis,
tachycardia, pyrexia
• PHE: rales, rhonchi, pleural rub
• Hypoxemia
• Cerebral
• Headache, irritability, delirium, stupor, convulsion, coma
• Focal neurological deficit (rare)
• Cutaneous
• Manifest on 2nd or 3rd day in 50% of pts
• Petechial rash in nondependent portions of body:
chest, ant axillary fold, conjunctiva
• Retinal findings
INVESTIGATION
• Blood gas: hypoxemia
• Blood test: thrombocytopenia, anemia, hypocalcemia
• EKG:
• Right axis deviation (prominent S in lead I,
Q in III, ST segment changes)
• CXR:
• Varies
• Severe cases:
• diffuse, bilateral infiltration (interstitial or
alveolar)
• opacify both lungs diffusely (capillary
permeability-type edema)
TREATMENT
• Supportive pulmonary care
• Pulse oximetry: < 90%  blood gas
(maintain PaO2 > 90)
• Persistent or worsening hypoxemia (PaO2 < 60)
& resp. distress despite O2
ET tube + ICU
• Early fracture stabilization
• Appropriate fluid resuscitation to avoid shock
COMPLEX REGIONAL PAIN
SYNDROME (CRPS)
CLINICAL FEATURES
• biphasic condition
• early swelling and vasomotor instability
• late contracture and joint stiffness
• hand and foot are most frequently involved
• usually begins up to a month after the precipitating
trauma
BONE CHANGES
• increased uptake on bone scanning in early CRPS
• Later, the bone scan returns to normal
• there are radiographic features of rapid bone loss
• visible demineralization with patchy, subchondral or
subperiosteal osteoporosis
• metaphyseal banding
• profound bone loss
INCIDENCE
• early features of CRPS show that they occur after
30% to 40% of every fracture and surgical trauma
• severe, chronic CRPS associated with severe
contracture is uncommon with a reported
prevalence of less than 2% in retrospective series
CLINICAL DIAGNOSIS IN AN
ORTHOPAEDIC SETTING
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1 Pain
2a Vasomotor instability
2b Abnormal sweating
3 Edema and swelling
4 Loss of joint mobility and atrophy
5 Bone changes
INVESTIGATIONS
• CRPS is a clinical diagnosis and there is no single
diagnostic test
• Magnetic resonance imaging (MRI)
• early bone and soft tissue edema with late atrophy and
fibrosis
• Computed tomography (CT)
• bony compressing lesion
• Electromyographic and nerve conduction studies
• normal in CRPS 1 but may demonstrate a nerve lesion in
CRPS 2
MANAGEMENT
• Reassurance
• excellent analgesia
• intensive, careful physical therapy avoiding
exacerbation of pain
Six-Pack Exercises
• Analgesia
• Nonsteroidal anti-inflammatory drugs may give better pain
relief than opiates
• centrally acting analgesic such as amitriptyline is often
useful even at this early stage
• Secondline treatment
• centrally acting analgesic > amitriptyline, gabapentin, or
carbamazepine
• regional anesthesia
• Calcitonin
• membrane-stabilizing drugs > mexilitene
• sympathetic blockade and manipulation
• desensitization of peripheral nerve receptors > capsaicin
• Immobilization and splintage should generally be
avoided
• if used, joints must be placed in a safe position and
splintage is a temporary adjunct to mobilization
• Pain desensitization
• reminded that simple stroking cannot by definition be
painful
• instructed to stroke the affected part repetitively while
looking at it and repeatedly saying “this does not hurt, it is
merely a gentle touch.”
• Surgery
• rarely indicated
• treat fixed contractures
• delayed until the active phase of CRPS has completely passed
at least 1 year since
THANK YOU