Post on 16-Feb-2016
description
Musculosceletal Trauma Complications
(Fracture)(Fracture)Presentator :
Yudistira Prama TirtaModerator:
Dr. Wahyu Widodo, SpOT
Introduction
Complication : an adverse event that occurs following a procedure (risk of the procedure), treatment (side effect or toxicity), or illness
A fracture may be complicated initially by an associated injury, or it may become complicated subsequently, either early or late
The complication : local (fracture site) or remote (other organs)
May be caused by original injury or iatrogenic
General ComplicationsShock Hypovolemia : most common cause in trauma patient
Changes in BP, skin color and pulse rates guides to resuscitation
Resuscitation :crystalloid solutions through large-bore iv lines, monitored by urine output (0.5 mL/kg/hr in adults) estimated 1 liter of blood lost 3 to 4 L of crystalloid solution will be
required
Life threatening hemorrhage : X-ray head, cervical, thorax, pelvis + USG
General ComplicationsAcute Respiratory Distress Syndrome
(ARDS) ARDS direct lung injury from blunt /
penetrating trauma to the chest / alveolar injury, or prolonged shock / septicaemia
Clinical features: About 36 hours after injury : mild dyspnoea,
with diminished pO2 2nd or 3rd day : restless, mildly cyanosed, abN
blood gas (pO2 < 60mmHg) Bilateral infiltrate on CXR(some cases do
present unilaterally or with pleural effusion PCWP < 18 or PaO2/FiO2 < 200
Treatment strategy Supportive : low volume and high
frequency ventilation(ARDSNet protocol) ICU
General Complications (Infection) Tetanus
C.tetani (gram + rod, anaerobe, flourished on dead tissue)
Pathology : Tetanus toxin passes to anterior
horn cells where it fixes and can’t be neutralized so produces hyperexitability and reflex muscle spasm
Symptoms : tonic and clonic contractions of
esp. jaw, face, neck and trunk, finally spasm of diaphragm and Intercostalis muscles so death
Therapy : IV human antitoxin, IV antibiotics,
thorough wound toileting, muscle relaxant, intubation, and controlled respiration, active immunization
Gas Gangrene anaerobic clostridium
(C.Welchii) which produces a toxin that destroys cell wall leading to tissue necrosis
Symptoms: severe pain, swelling,
brownish discharge, gas production (characteristic smell), tachycardia and hyperpyrexia
Treatment: IV antibiotics with fluid
replacement, wound opening and debridment
Appley’s. System of Orthopaedics & Fractures. 8th ed. 2001
General ComplicationsCrush Syndrome Trapped limb
Deprived blood flow, tissue begin to die, toxic metabolic accumulates
When freed reperfusion injury (reactive O2 metabolites)
Failure in capillary & muscle cells ion pumps swelling compartment syndrome further ischaemia
Toxic metabolic in circulation hiperK, hypoCa, metabolic acidosis cardiac arrest
Muscle breakdown large load of myoglobin excreted by kidney renal failure
Management : Prevention; during
prolonged extrication, ensured high urine flow (large volume iv crystalloid)
Compartment syndrome fasciotomy
Provisional amputation
Classification of the ComplicationsInitial complications Local complications
Skin injuries From without From within
Vascular injuries Major artery Major vein Local Hemorrhage
Neurological Injuries
Muscular injuries Visceral injuries
Remote complications Multiple injuries Hemorrhagic shock
Early complications Local
complications Sequelae of
immediate complications
Joint complications
Bony complications
Remote complications Fat embolism Pulmonary
embolism Pneumonia Tetanus
Local complications•Joint complications : persistent joint stiffness, degenerative arthritis•Bony complications : malunion/ nonunion/ delayed union, chronic osteomyelitis, Sudeck’s posttraumatic painful osteoporosis (RSD)•Muscular complications : myositis ossificans•Neurological complications : tardy nerve palsy
Remote complications
Renal calculiAccident neurosis
Salter RB. Textbook of Disorders and Injury of Musculoskeletal System
Late complications
Initial Complications (Local)
Skin Injuries From without : abrasion (dirt)
cleansed (X) tattoo effect Laceration, puncture wounds,
penetrating missile wound, avulsion of skin, skin loss debridement + primary / delayed closure / grafts / flap
Gross swelling blister / bleb formation
From within : skin penetration by fracture fragment
During fracture treatment Bed sore (decubitus ulcer) sacrum /
heels Cast sore
Salter RB. Textbook of Disorders and Injury of Musculoskeletal System
Vascular Injuries (Artery) Major arteries are particulary vulnerable to injury in
association with specific fractures and dislocationInjuryInjuryFirst rib fractureFirst rib fractureShoulder dislocationShoulder dislocationHumeral supracondylar Humeral supracondylar fracturefractureElbow dislocationElbow dislocationPelvic fracturePelvic fractureFemoral shaft or Femoral shaft or supracondylar fracturesupracondylar fractureKnee dislocationKnee dislocationProximal tibialProximal tibialForefootForefoot
VesselVesselSubclavianSubclavianAxillaryAxillaryBrachialBrachial
BrachialBrachialPresacral & internal iliacPresacral & internal iliacFemoralFemoral
PoplitealPoplitealPoplitealPoplitealDorsalis pedisDorsalis pedis
Appley’s. System of Orthopaedics & Fractures. 8th ed. 2001
Neurological Complications Brain, Spinal Cord, Peripheral Nerves Relatively common in association with specific fracture & dislocations
Location Injury1 Brain Skull fractures2 Spinal cord Cervical & thoracic spine fr_disloc3 Cauda equina Lumbar spine fr_disloc4 Sciatic nerve Posterior hip disloc & fr_disloc5 Medial & lat popliteal
Knee dislocation
6 Lateral popliteal Vulnerable to bandage / cast pressure
7 Ulnar nerve Avulsion fr-separation medial epicondyle
8 Median nerve Humeral supracondylar fracture9 Radial nerve Humeral shaft fracture10 Circumflex nerve Shoulder dislocationAppley’s. System of Orthopaedics & Fractures. 8th
ed. 2001Salter RB. Textbook of Disorders and Injury of Musculoskeletal System
Visceral Complications Penetration by a sharp fracture fragment from nearby
bone, may damage : Heart hemopericardium with cardiac tamponade (rib
fracture) Perforate pleura hemothorax Perforate lung hemopneumothorax Perforate liver, spleen, kidneys by displaced fracture of
lower ribs Paralytic ileus & gastric dilatation thoracolumbar fracture Rupture of bladder/ urethra, or colon / rectum pelvic fracture
Require emergency treatment