Complex fractures/Complications of Fractures (Open Fractures, Dislocations, Acute Compartment Syndrome, Fat Embolism syndrome, Complex regional Pain Syndrome Type 1, Crush Syndrome) Flashcards
What is compartment syndrome?
A pathological condition characterised by elevated interstitial pressure in a closed osseofascial compartment that results in microvascular compromise (restriction of capillary blood flow)
What condition occurs as a result of compartment syndrome?
Rhabdomyolysis
What is the pathophysiology of compartment syndrome?
Haemorrhage within the compartment or direct trauma to the muscles with subsequent oedema can lead to increased pressure to above the capillary level, which restricts capillary flow.
This results in tissue necrosis secondary to oxygen deprivation.
The resulting reducion in venous drainage causes a further rise in interstitial tissue pressures with the formation of tissue eodema. Only in the late stages is arterial flow comprimised.
There is evidence that muscle necrosis can occur even in the face of apparently normal circulation, if the intracompartmental pressure is >30 mmHg for >8 hours
What is increased pressure in compartment syndrome most commonly caused by?
Oedema or haemorrhage
Causes of compartment syndrome
- Decrease in comparment size
- Closure of fascial defects
- Tight plaster casts
- Localised external pressure (lying on limb
- Pneeumatic antishock garments/burns
- Increase in comparment content
- Haemorrhage following soft tissue injury/fracture
- Post op swelling and oedema
- Post ischaenia swelling
What are signs that someone might have compartment syndrome?
- Swelling
- Redness
- Mottling
- 6 Ps - pain, paralysis, pallor, pulselesness, parasthesia, perishingly cold,
- Loss of muscle function
- Pain on passive muscle stretching - disproportionate to injury
PAIN IS OUT OF PROPORTION TO INJURY, NOT IMPROVING WITH SIMPLE ANALGESIA
If you suspected someone had compartment syndrome, what might you do to investigate?
- Examine them
- Bloods - Serum CK, U+E’s
- Specific - compartment pressure metre, Urine myoglobin
How would you manage someone with compartment syndrome?
ABCDE
- Dressing release
- Hold the limb at the level of the heart (not above) to promote arterial flow
- Analgesia
- IV fluids
-
GOLD STANDARD:
- Surgical - fasciotomy/Amputation
- Consider haemodialysis - if severe AKI from Rhabdo
What is involved in compartment pressure reading?
Measure compartment pressure and compare to diastolic BP
DBP - compartment pressure
How long have you got to save the limb?
From onset of ischaemia:
- 4 hours - muscle and nerves will tolerate and functionally survive
- 6 hours - variable injury to muscle and nerve
- 8 hours - ischaemia yields permanent damage to both nerve and muscle.
What is diagnostic on compartment pressure monitoring of compartment syndrome?
Differential pressure within 20-30 mmHg of the diastolic pressure (delta pressure) is considered a strong indicator for fasciotomy
A compartment pressure of > 30 mmHg is considered critical
What differential would you consider in someone with suspected compartment syndrome?
- Deep vein thrombosis
- Cellulitis
- Peripheral vascular disease/ischaemic limb
- Septic Arthritis
- Rhabdomyolysis
What is fat embolism?
Type of embolism in which the embolus consists of fatty material. They are often caused by physical trauma such as fracture of soft tissue trauma, and burns
What are causes of fat embolism?
Long bone fratures - typically after pelvis or femur
What are features of a fat embolism?
- Altered mental state
- Pyrexia
- SOB/hypoxia
- Tachycardia
- Petechial rash
Respiratory
- Early persistent tachycardia
- Tachypnoea, dyspnoea, hypoxia usually 72 hours following injury
- Pyrexia
Dermatological
- Red/brown impalpable petichial rash
- Subconjunctival and oral haemorrhage/petechiae
CNS
- Confusion and agitation
- Retinal haemorhages and intra-arterial fat globules on fubdosocopy
Where are petechial rashes found in fat ambolism syndrome?
- Axillary region
- Conjunctivae
- Oral mucosa
How would you approach investigating someone for fat embolism syndrome?
- Examination
- Bedside - temperature
- Bloods - ABG, FBC
- Specific - urine for fat globules, sputum for fat globules
Imaging may be normal - fat emboli tend to lodge distally and therefore CTPA may not show any vascular occlusion, a ground glass appearance may be seen at the periphery
What is the mortality rate for fat embolism syndrome?
15%
How would you manage someone with fat embolism syndrome?
Supportive management in ITU
- Mechanical ventilation to support respiratory failure
Prompt fixation of long bone fractures needed
DVT prophylaxis
What measures can be taken to prevent fat embolism?
Early fracture stabilization (within 24 hours) of long bone fracture - most important factor in prevention of FES
What classification system is used to classify open fractures?
Gustilo classification system
What is gustilo type I open fracture?
- Low-energy wound < 1cm long
- Clean
- Simple fracture pattern
What is gustilo type II open fracture?
- Low-energy wound > 1cm long
- Moderate soft tissue damage
- Simple fracture pattern
- Adequate skin coverage
What is gustilo type IIIa open fracture?
- High energy injury
- Extensive soft tissue damage
- Complex fracture pattern
- Adequate periosteal coverage
What is gustilo type IIIb open fracture?
- High energy injury
- Extensive soft tissue damage
- Complex fracture pattern
- Tissue loss requiring soft tissue coverage procedure
What is gustilo type IIIc open fracture?
- High energy injury
- Extensive soft tissue damage
- Complex fracture pattern
- Vascular injury requiring repair
How would you grade the following fracture?
Gustilo type I
How would you grade the following fracture?
Gustilo type II
How would you grade the following open fracture?
Gustilo IIIa
How would you grade the following open fracture?
Gustilo IIIb
How would you grade the following fracture?
Gustilo IIIc
