2.2 Trauma, complications, surgery, healing

Question 1

Complication of distant tissue damage?

Answer 1

• haemorrhage and shock
• fat embolism syndrome
• muscle damage and rhabdomyolysis

Question 2

What are the symptoms of Fat Embolism Syndrome?

Answer 2

When multiple small fat emboli are released into the circulation. Typically presents 1-3 days post injury.

• respiratory distress and hypoxia
• agitation and delirium
• anaemia and thrombocytopenia
• petechial rash (only in 1/3 of cases)

Management is supportive. Avoid by reducing fractures. Rare.

Question 3

What happens in rhabdomyolysis?

Answer 3

People who have been immobilised on the floor with pressure on muscles (drunk overnight or elderly fall).
Breakdown releases myoglobin which causes acute renal failure.
Pain and compartment syndrome possible.

Risk of rhabdo? Then:
Measure CK and U+Es. CK can continue rising 12 hours after injury and stay high for days.
Hyperkalaemia is often seen.
IV normal saline
Monitor U+Es
Catheterise to monitor fluid (urine will be dark brown ‘myoglobulinuria’)

Question 4

Complication of prolonged bed rest?

Answer 4

• chest and UTIs
• pressure sores and muscle wasting
• DVT and PE (CTPA and ECG)

Question 5

ECG changes in a PE?

Answer 5

“S1 Q3 T3”
Deep S wave on lead I
Deep Q wave on lead III
Inverted T wave on lead III

Question 6

What are some fracture specific complications?
Immediate
Early
Late

Answer 6

Immediate:

• haemorrhage
• vascular injury
• neurological injury (neuropraxias, 3 types in Seddon classification)
• visceral injury

Early:

• compartment syndrome
• infection (worse if associated with metalwork)

Late:

• malunion
• delayed and nonunion
• avascular necrosis
• CRPS (complex regional pain syndrome)
• myositis ossificans
• joint stiffness

Question 7

Haemorrhage Classes of Shock 1-4

mls, BP, bpm, RR

Answer 7

mls, BP, bpm, RR

Class 1: <750, normal BP, <100bpm, 14-20RR.

Class 2: 750-1500, normal BP, 100-120bpm, 20-30RR

Class 3: 1500-2000, BP decreased, 120-140bpm, 30-40RR

Class 4: >2000, BP decreased, >140bpm, >40RR

Question 8

Vascular injury

Answer 8

Complete transection uncommon.
More common is compression from a fracture or dislocation.
Examine limb distal to # for its blood supply.

Question 9

Visceral injury

Answer 9

Pelvic fractures carry the highest risk.
Be careful if you want to catheterise - only a urologist can do it if there is blood at the urethral meatus.

Rib fractures causing pneumothorax can also be common.

Question 10

Compartment syndrome
SS
Management

Answer 10

After 6 hours the lack of perfusion leads to tissue necrosis. Often tibial # or forearm.

SS
pain, parathesia, tight throbbing, warm and red.
Best early sign is extreme pain on passive stretching of the muscles.

Initially elevate the limb and remove dressing, open plaster and remove if opening hasn’t helped.

Dx usually clinical but if a probe is used then you should decompress compartment if the difference between compartment pressure and diastolic BP is less than 30mmHg.

Question 11

When is it considered nonunion?

Types?

Answer 11

When a fracture has failed to unite after twice the expected healing time (eg 24weeks for a tibia)

Hypertrophic - ends look large and round, dense and sclerotic. Bone has formed but ends have not met.

Atrophic - rarer, no callus formation and looks osteopaenic.

Question 12

What is myositis ossificans?

Answer 12

New bone forms in soft tissues following injury or surgery.
Restricted painful movement.
Most often in the elbow. Can be after a dislocation. Surgically excise the new bone.

Question 13

What is Complex Regional Pain Syndrome?

Answer 13

CRPS
Collection of Sx, pain, swelling, redness, sweating.

Thought to be an abnormal sympathetic response to injury.
Often not noticed until plaster has been removed after several weeks.
Usually self limiting but can be quite disabling and need MDT. Can take two years. Guanethidine nerve blocks and sympathectomy can help

Question 14

Common bones for avascular necrosis?

Answer 14

Femoral head after displaced intracapsular neck of femur #
Proximal scaphoid after a displaced wrist fracture.
Can get spontaneous AVN without a fracture, associated with infection, sickle cell disease, Perthes’ disease and alcohol abuse.
(Perthe’s disease is AVN of femoral head in children, commonly boys 8-10, family smoke, low social index)

Question 15

ASA 6 classifications when considering patients’ fitness for theatre.

Answer 15

1. a normal healthy patient
2. patient with mild systemic disease such as mild diabetes or moderate anaemia
3. patient with severe systemic disease such as uncontrolled severe diabetes or cardiorespiratory disease
4. patient whose life is under constant threat from a severe systemic disease
5. patient is moribund and not expected to survive without surgery eg active bleeding from a ruptured AAA
6. reserved for patients who have already been declared brain dead and whose organs are being removed for donation

E after a number indicates that is an emergency operation and that delay would risk life or limb.

Question 16

Immediate postoperative complications

Answer 16

In the hours following surgery:

Compartment syndrome

Intraoperative blood loss
- tranfuse if their Hb is less than 8g/dL or 9g/dL and they are symptomatic of anaemia.

Question 17

Early postoperative complications

Answer 17

Days following surgery:

• Infection: 1-2% of cases
• Stroke risk: returns to baseline after 6weeks
• Acute renal failure: 1% of surgery patients go into ARF. Check bloods, catheterise at surgery.

Question 18

Infection 3 stages post surgery

Organisms

Answer 18

Stages:

Early: (two weeks post surg)
- Staphylococcus aureus then 
- coag -ve Staphylococcus and 
- Enterococcus
Mx: Abx, surg washout of wound + MCS, amputation.

Delayed:
(2-10weeks post surg)
often multiple organisms, anaerobes like:
- Clostridium, 
- Bacteroides and 
- Peptostreptococcus

Late:
(>10weeks post surg)
Delayed and late presentation can be subclinical with mild Sx. Consider it in cases of delayed or nonunion.

Question 19

Late postoperative complications

Answer 19

Infection
Malunion
Failure of metalwork (fixation fails, cycles of loading)

Question 20

Fracture healing depends on the rigidity of the stabilisation. Examples of non-rigid and rigid stabilisation?

Answer 20

non-rigid: eg. plaster cast or inter medullary nail

rigid: eg. compression plating with an interfragmentary lag screw

Question 21

How does bone heal in unstable conditions?

Answer 21

with callus formation.
1. INFLAMMATION. Fracture end bleed –> haematoma –> inflammatory response –> vasoactive factor over 1-7day –>capillary network –> fibrin network begins to form.

2. SOFT CALLUS. Vascular network and fibrous tissue replaces the haematoma over 1-3 weeks.
3. HARD CALLUS. Calcification of the soft callus takes place over 1-4months forming rigid calcified tissue.
4. REMODELLING. Once solidly united over the following months/years the new woven bone is replaced by lamellar bone and the medullary canal is restored.

Question 22

How does bone heal in stable conditions?

Answer 22

Surgical intervention gives absolute stability to the fracture site and inter fragmentary compression. Reduces strain and fracture gap allowing for direct bone healing.
Only minor xray changes are observed.

(haematoma is resorbed in the first few days and the Haversian system internally remodels the bone through ‘cutter cones’)

This process TAKES LONGER and is not as STRONG. However it prevents incongruity of the joins and prevents callus formation so is important for some joints in avoiding post traumatic arthritis.