Complications of Fractures

•Non-union

•DVT

•Damage to Nerves and Blood Vessels

•Compartment Syndrome

•Fat Emboli

•Infection (Osteomyelitis)

Clinical DecisionsBobbie, age 14, was admitted with fx

left tibia about 10 hrs age. He has a long leg cast.

Report states: “toes warm, pink with good capillary refil, pulses present...pain not controlled with MS.”

You note: p. 88,BP 89/66, r.23, t 98.6. Bobbie reports: ‘toes feel “funny”, left leg hurts at calf.”

Questions

What additional data should you gather?

What is the medical/nursing problem of greatest Priority?

Why did this occur? What actions should you take?

Compartment SyndromeCompartment Syndrome

Compression of structures within a defined boundry; capillary perfusion decreased.

Self-perpetuating edema-ischemia cycle...inc. capillary permeability...arterial obstruction...muscle and tissue death.

Etiology

Normal compartment pressure=10mmHg

Above 30mmHg for 8 hrs = Permanent damage

Factors affecting– dec. BP– dec. oncotic

pressure– inc. capillary

permeability– obs. venous flow– length of time

Causes

Arterial circulation continues; capillary circulation stops!

Events Leading to Compartment Syndrome

Ischemia cycle Edema with inc.

capillary pressure Capillaries

dilate;hydrostatic filtration pressure becomes greater than oncotic pressure of plasma colloid

More fluid leaves capillaries than enters; inc. permeability of capillary walls due to histamine release due to ischemic muscles

Plasma proteins into interstitial fluids

Inc. intramuscular pressure-obstructs venous first, then arterial

Compartment syndrome has many causes.

Describe the etiology in these examples.

compartment

Compartment Syndrome

Types– Acute– Chronic

Microcirculation ceases when compartment pressure = diastolic BP

Lead to Volksmans ischemic contraction

May develop Crush Syndrome:Rhabdomyolosis=Myoglobinuric renal failure

Volksman’s ischemic contracture may result with compartment syndrome!

Compartments Affected Forearm

– deep volar– superficial volar

Lower leg– deep posterior

tibial– anterior with

peroneal nerve– lateral with

superficial peroneal– posterior with sural

Lower leg

•Assessment

•Pain on passive stretch•Progressive pain•Tenseness of muscle compartment•Motor weakness•Dec. sensation•Loss of pulse

Interventions

Ice and elevate Early recognition

– 5 Ps– Pressure monitors

Dec. pressure– Remove what

confines– Eval. response to

meds

Medical/Surgical Interventions

If compartment syndrome present, elevate limb only to heart level, not above!

Prevent complications associated with myogolbinuria

Monitor for compartment syndrome Prevent infection Fasciotomy

Monitor for compartment syndrome

Fasciotomy!

Treatment for compartment syndrome.

Prevent

Treatment

Fat Emboli

Fat globules obstruct blood vessels Causes

– Metabolic: biochemical changes, lipids mobilized and embolize, fatty acids toxic

– Mechanical: fat is liberated due to inc. pressure

Life-threatening: ARDS

Fat emboli

Fat Emboli Frequency Recognition

– Change in behavior

– Respiratory chg– Cardiac chg.– Integumentary

system (Late)– Urine fat, dec.

platelets Non-blanching petechiae at these sites; late finding!

Diagnostic Tests

Blood gasesLung scanChest x-raysLaboratory studies: platelets, urine fat

Nursing diagnosis

Lung changes with fat emboli (ARDS)

Interventions: Fat emboli Prevent:

recognize, immobilize, hydrate

O2 therapy Steroids Fluid volume

replacement Plasma expanders Monitoring