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NATTAPONG PHOLPRADUBPET COMPLICATION OF FRACTURE.

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Presentation on theme: "NATTAPONG PHOLPRADUBPET COMPLICATION OF FRACTURE."— Presentation transcript:

1 NATTAPONG PHOLPRADUBPET COMPLICATION OF FRACTURE

2 OUTLINE Vascular injury Compartment Syndrome Thromboembolism Fat Embolism Syndrome Complex Regional Pain Syndrome (CRPS)

3 VASCULAR INJURY

4 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

5 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

6 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

7 DIAGNOSIS Awareness Signs & Symptoms: Absence of distal pulse, pallor, differential gradient in temp, rapidly progressing edema or hematoma formation Paralysis, paresthesia

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9 INVESTIGATION Investigation Doppler U/S Duplex U/S (real time B-mode U/S & pulsed Doppler flow detection) Arteriogram Venogram

10 TREATMENT Initial Early resuscitation Immobilization the traumatized limb Do not elevate the affected limb Direct pressure Avoid tourniquet (temporary use only if necessary)

11 Pre-op preparation Optimal period for restorative surgery is 6 - 8 hr Correct acidosis & volume depletion Splint or traction is applied

12 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

13 Surgery Constructive dialogue with vascular surgeon Drape to permit access to sapheneous or cephalic vein Temporary shunt ??? Fasciotomy

14 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

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16 COMPARTMENT SYNDROME

17 DEFINITION An increased pressure within an enclosed osteofascial space that reduces the capillary blood perfusion below a level necessary for tissue viability

18 COMMON CAUSE Fracture Soft tissue injury Arterial injury Limb compression Burns

19 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

20 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

21 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

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23 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

24 MANAGEMENT Release constrictive dressings, bivalve cast & webril Fasciotomy

25 Fracture stabilization External fixator is the implant of choice

26 THROMBOEMBOLISM

27 Risk depends on Age Extent & duration surgery Type of anesthesia Spinal & epidural  lower than GA Degree & duration of immobilization Severity of underlying systemic disease

28 CLINICAL SYMPTOM Leg pain Swelling Warmth Dilated vein Erythema Pitting edema

29 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

30 INVESTIGATION Duplex ultrasound Venogram

31 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

32 FAT EMBOLISM SYNDROME

33 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

34 PREVALENCE Fat emboli : 90% after major trauma Fat embolism syndrome 0.25-1.25% Higher prevalence in multiple bone fractures

35 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

36 CLINICAL FINDINGS Classic triad Pulmonary Cerebral Cutaneous manifestations

37 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

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40 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)

41 TREATMENT Supportive pulmonary care Pulse oximetry: < 90%  blood gas (maintain PaO2 > 90) Persistent or worsening hypoxemia (PaO 2 < 60) & resp. distress despite O 2 ET tube + ICU Early fracture stabilization Appropriate fluid resuscitation to avoid shock

42 COMPLEX REGIONAL PAIN SYNDROME (CRPS)

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44 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

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47 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

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50 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

51 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

52 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

53 MANAGEMENT Reassurance excellent analgesia intensive, careful physical therapy avoiding exacerbation of pain

54 Six-Pack Exercises

55 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

56 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

57 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

58 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.”

59 Surgery rarely indicated treat fixed contractures delayed until the active phase of CRPS has completely passed at least 1 year since

60 THANK YOU


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