General complications of fractures

presented by: Anas AL-Karasneh

www.icareunit.com

General complications
** Deep vein thrombosis and pulmonary embolism. **Tetanus. **Gas gangrene. ** Fat embolism syndrome. ** hypovolemic Shock.

**crush syndrom.
www.icareunit.com

Deep vein thrombosis and pulmonary embolism.

** DVT is very common complication after fracture and major orthopedic operation. ** Site: leg, thigh and pelvic vein.

**Risk factors: Knee and hip replacement Elderly Immobility Malignancy and CV disease Trauma ( fracture of spine , pelvis , femur and tibia) hypercoagulable status
www.icareunit.com

Symptoms and signs

1. Pain and tenderness in calf or thigh usually unilateral 2. swelling 3.hotness 4. positive homans sign. 5. pulmonary embolism as primary presentation ( dyspnea, hemoptysis , tachypnea and fever).
www.icareunit.com

Diagnosis: Duplex ultrasonography , V-Q scan, spiral CT and angiography. Prevention: 1.Elastic stockings. 2.Elevation the foot. 3.Early mobilization. 4.Low molecular weigh heparin 40mg\day .
www.icareunit.com

Tetanus
** Is wound infection caused by C.tetani . ** Tetanus toxin passes to anterior horn cells where it fixed and cant be neutralized so produces hyper excitability and reflex muscle spasm. Symptoms: **Tonic and clonic contractions of esp. jaw, face, around the wound itself ,neck ,trunk, finally spasm of the diaphragm and intercostal muscles leads to asphyxia and death.
www.icareunit.com

Prophylaxis: :DTP for general population (pediatrics)

>10 years booster dose of toxoid after all trivial skin wound

Not immunized and wounded ? wound toilet and antibiotic ( consider antitoxin if contaminated wound and give the toxoid immunization )
www.icareunit.com

Treatment: 1. IV antitoxin. 2. IV antibiotics (penicillin). 3. Muscle relaxant. 4. Tracheal intubation. 5. Control respiration.
www.icareunit.com

Gas gangrene

Cause: It caused by clostridium (perfringens) and this organism survive and multiply only in tissue with low oxygen tension. Characterized by rapid and extensive necrosis of muscle accompanied by gas formation and systemic toxicity .
Its associated with traumatic wounds that are deep, necrotic and without communication to the surface.
www.icareunit.com

Clinical features:
1. sudden onset of pain localized to the infected area. 2. swelling , edema 3.no pyrexia (cool) 4.profuse serous discharge with sweetish and mousy odor . 5. Gas production

www.icareunit.com

Treatment:
1. early diagnosis . 2. surgical intervention and debridement are the mainstay of treatment. 3. IV antibiotics 4.fluid replacement. 5. hyperbaric Oxygen

www.icareunit.com

Fat embolism
Usually occurs in young adult after closed fractures of long bone . Characterized by occlusion of the small blood vessels by fat globules. Risk factors - Closed fractures - Multiple fractures - Pulmonary contusion - Long bone/pelvis/rib fractures
www.icareunit.com

Closed/open Fracture

Fat in bone marrow escape

Formation of fat globules in vessels

Trigger clotting cascade

Stick in pulmonary bed

Fat embolus

www.icareunit.com

Clinical feature:
- Sudden onset dyspnoea - Hypoxia - tachypnea and tachycardia - Confusion, coma, convulsions -Transient red-brown petechial rash affecting upper body, especially axilla

*no defenitive test, but hypoxia <60mmHg after major trauma is suspicious
www.icareunit.com

Treatment :
Supportive treatment - O2 administrated. -Blood, fluid replacement - Iv steroid + heparin ( may reduce pulmonary edema and IV clotting ) -Surgical stabilization of fracture
www.icareunit.com

shock
**A generalized state of decreased tissue perfusion. **If prolonged it may lead to irreversible damage of the life supporting organs. causes: Cardiogenic:direct injury to heart, the pump is not working properly ( massive MI).
www.icareunit.com

II. Neurogenic: injury to brain stem (vasomotor center) spinal cord loss of sympathetic tone increase venous capacitance low venous return low cardiac output ( but bradycardia ) III.Hypovolaemic: reduction of blood volume
the most important one to be dealt with firstly

www.icareunit.com

Low cardiac output

Low B.P

Decreased tissue perfusion

ORGAN FAILURE

Progressive cell damage

Hypoxia and acidosis

www.icareunit.com

Clinical features
Thirst, rapid shallow breathing, the lips and skin are pale and the extremities feel cold,if the compansation fails.. impaired renal function test and decreased urinary output.

www.icareunit.com

treatment
1.IV morphine and oxygen: to arrest bleeding and replace blood loss. 2.Early reduction and splinting of fracture. 3.Restoration of blood volume by rapid infusion of crystalloid solution. 4.Keep monitoring of vital signs.
www.icareunit.com

If no quick respond, blood transfusion is mandatory ( we can use O blood group Rh (-) until cross matching is available

www.icareunit.com

CRUSH syndrome
Serious medical condition characterized by major
shock & renal failure following a crushing injury to skeletal muscles or tourniquet left too long

Its a re-perfusion injury seen after the release

of crushing pressure, there will be release of muscular breakdown products(myoglobin,k+,p) which have nephrotoxic effect on the kidney

www.icareunit.com

When compression released

Myohaematin release from cells

Block tubules

To kidney

Alternative mechanism : renal artery spasm tubular necrosis

www.icareunit.com

Clinically:
Shock Pulsless limb redness swelling Loss of muscle sensation and power Decrease renal secretion Uremia, acidosis

www.icareunit.com

CRUSH syndrome: prognosis

If renal secretion return within 1

week the patient survive

But most of them die within 14

days

www.icareunit.com

CRUSH syndrome : treatment

Avoid the disaster by amputation
above the site of compression and before compression release

If compression is already released

cool the limb and treat for shock and renal failure (dialysis)

www.icareunit.com

www.icareunit.com