Transcript Post-operative complications in orthopedics

Post-operative complications in
orthopedics
 1. Soft tissue swelling;
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Its common after limb surgery its aggravated by
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tight dressing or POP it may affect wound healing &
delay joint movement sometimes its so serious causing
vascular ischemia & compartment syndrome.
Prevention is by;
a. Dressing must not be tight.
b. Elevation of the limb.
c. Encourage early joint movement.
d. POP cast must be well padded & not tight.
 2. Heamatoma formation;
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By post-operative bleeding or ooze sometimes it’s considerable.
It’s reduced by using suction drain.
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 3. Delayed wound healing;
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Usually due to poor circulation.
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 4. Infection;
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It’s seriously disturbing especially in joint replacement surgery.
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 5. Thromboembolism;
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The incidence of DVT is 20%, only 2% gets pulmonary embolism
and only
 0.2% will die of it.
 Highest incidence in hip surgery especially in old
debilitated patient.
 The commonest type of DVT is that occurring in calf
vein which carry better prognosis than that in
proximal thigh vein thrombosis.
Clinical features
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DVT usually silent, if it’s manifested it may cause
calf or thigh pain sometimes swelling & local
tenderness.
 In calf vein thrombosis there will be positive Homan’s
sign i.e. increased calf pain on passive dorsiflexion of
the foot. Sudden slight increase in temperature may
occur.
 If pulmonary embolism occurs patient may have
shortness in breath, mild chest pain & sometimes
heamoptysis, rarely sudden severe cardiovascular
collapse & death.
Investigations:
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Doppler U/S can prove the diagnosis. More accurate is
ascending veinogreaphy.
 In pulmonary embolism ECG changes may happen.
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 Prevention:
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Pre-operative; by decrease smoking, walking exercises,
treatment of systemic diseases & calf muscle massage with preoperative Heparin 5000 IU twice daily for high risk patients.
Recently we can use low molecular weight heparin.
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Per-operative; avoid trauma to calf veins & frequent
massage or use of special elastic stokes.
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• Post-operative; calf muscle massage, elastic stokes, early
active movement & ambulation, leg elevation together with few
days of subcutaneous heparin therapy.
Treatment:
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Calf vein DVT treated by heparin 5000 IU s.c. For
10-14 days then change to oral warfarin 5mg once daily
for 2-3 months (all under strict supervision by the
doctor with frequent PT & PTT check).
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Thigh or proximal vein thrombosis is more serious
it needs full heparin therapy of 5000 IU four times
daily intravenously 1-2 weeks followed by 5mg warfarin
orally for 3-6 months (all under strict supervision by
the doctor with frequent PT & PTT check).
Physiotherapy
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It’s used to:
1-Reduce pain.
2-Increase range of motion.
3-Strengthen muscles.
4-Restore function.
All achieved by;
A-Heat; its useful to reduce pain & muscle spasm.
B-Cold; like ice packs it decreases pain & reduces swelling.
C-Transcutaneous nerve stimulation; also relieves pain.
D-Traction; intermittent traction of the spine can relieve neck pain or low back
pain.
 E-Electrical stimulation & muscle exercises; it builds up muscles & improves
weakness.
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 Occupational therapy
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Its used to improve function i.e. teaching the patient to use
his skeleton & muscles to perform useful daily activities as
feeding, hygiene, walking. .Etc.
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 Functional aids
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These are used to decrease stresses on musculoskeletal
system during weight bearing like: stick, cane, crutches or frame.
During weight bearing these patient uses these to decrease the
mechanical stresses passing through his joints & bones.
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Fractures-general principles
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A fracture is an interruption in the bone continuity
caused usually by strong trauma in healthy bones
(traumatic fracture).
 Pathological fracture Stress fr.
 Simple or closed fr
 Compound or open
complete fr.
Incomplete or partial fr.
Called comminuted fr.
Segmental fr.
Intra-articular fr
Mechanism of fr.:
 Direct trauma: the bone usually breaks at point of impact.
 Indirect trauma: as angulation or rotation or compression
of the limb, this can cause fr. Away from the site of injury.
 Multiple or complex injury of different forces at the same
time that may cause serious complex fracture.
 Muscle violence: sudden strong muscle pull on the
localized bony attachment may cause (avulsion fr) of the
bony fragment with or without displacement, eg.
Quadriceps pull on the patella cause transverse fr, triceps
pull on the olecranon causes avulsion fr of olecranon.
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Fracture displacement:
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Fr may be undisplaced or usually displaced
according to the; type of injury and the direction of ft
line also depends on localized muscle action and
gravity, displacement described according to the
direction of the distal segment, this can be in form of;
Overlap.
Side displacement.
Angulation.
Rotation.
Fracture healing or union
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Tissue death and heamatoma formation:
Local bony necrosis will occur about 1 to 2 mm back from the fracture line and capillary
bleeding will lead to localized fr heamatoma that bridges the fr and later clots.
Inflammation and cellular proliferation:
Within 8 hours there will be acute inflammatory cell reaction, within few days there is
chronic inflammatory cell accumulation. This later will lead to local granulation tissue formation
after capillary growth; cellular proliferation will take place as well.
Callus formation:
Proliferating cells will show variable chondrogenic and osteogenic activities with subsequent
cartilage and finally bone tissue formation that will later replaces the whole granulation tissue mass
leading to a big irregularly laid fusiform bony mass called the CALLUS that bridges the fr and locally
fix it, the fr now is united but its not healed yet.
Consolidation stage:
Here the callus is gradually replaced by physiologically normal solid bone that will cross
through the fr line and fill the gap, the fusiforrn callus replaced by variable osteoclastic (bone
resorbing) and osteoblastic (bone forming) cellular activity, the newly laid solid bone is of near
normal shape and can take normal forces and loading.
Remodeling stage
Gradual bone resorbtion and new bone formation will occur where the solid
deformed bone is replaced by new normal bone that takes the original bone shape with reformation
of the medullary canal, this may take months or even years to occur.