nattapong pholpradubpet complication of fracture
TRANSCRIPT
N AT TA P O N G P H O L P RA D U B P E T
COMPLICATION OF FRACTURE
OUTLINE
• 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• 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• 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• ischemic time (6 hr golden period)• amount of contamination• extent of wound• mechanism of injury• associated injury
• Team approach• Adjust individually
• Surgery• 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
• 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• 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)
• 45 mmHg (capillary pressure rises in compartment syndrome)
• 20 mmHg below DBP
• 30 mmHg below DBP
Mubarak, SJ & Hargens, AR
Matsen, FA
Whiteside, TE
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
• 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
• 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
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