complications of fractures and life threatening ortho emergencies Flashcards
5 early types of complications from fractures
vascular nerve compartment syndrome infection fracture blisters
6 late complications from fractures
- delayed/non-union
- malunion
- avascular necrosis
- growth disturbance
- stiffness, post-trauma OA
- complex regional pain syndrome
general complications of fractures
- fat embolism syndrome
- DVT and PE
- complications of immobility
pre-op fracture considerations
- thrombophylaxis-DVT common so give LMWH
- fat emoblism syndrome
- hetertopic ossification
- infection
fat embolism syndrome
- symptoms
- fracture
- treatment
- who most commonly
symptoms: hypoxia, confusion, petechiae, tachycardia
fracture: 24-72 hrs after a pelvic or femur fracture
treatment: given oxygen and early IM stabilisation
who: young men
heterotopic ossification
- injury
- treatment
- onset
- head injury, acetabular fractures, elbow surgery
- give low dose indomethacin 25mg daily for 6 weeks or local radiation
- develops 3-6 months after
what is heterotopic ossification
bone growing in soft tissue
main prophylactix antibiotic for surgery
cephalosporin
5 fractures that are watershed areas with risk of non-union
- scaphoid
- NOF femur
- Jones of 5th metatarsal
- head of humerus
- talus
5 main orthopaedic life threatening complications
open fractures dysvascular limb compartment syndrome nerve injury ortho infections
3 main ortho infections
septic arthritis
cellulitis
necrotising fasciitis
what is an open fracture definition
a direct communication between external environment and fracture with bone penetrating the skin
history for an open fracture
- type of injury
- force
- environment
- farmyard waste or immersion in water(contamination)
- after injury
what classification is used for open fractures
gustilo classification
type 1 gustilo
low energy <1cm simple fracture minimal soft tissue minimal contamination no NV injury
type 2 gustilo
moderate energy 1-10cm moderate communition moderate soft tissue moderate contamination no NV injury
Type 3a gustilo
energy: high >10cm highly comminuted/seg soft tissue requires local flap extensive contamination NO NV injury
Type 3b gustilo
energy high >10cm highly comminuted soft tissue requires free flap extensive contamination NO NV injury
type 3c gustilo
energy high >10cm highly comminuted often requires free flap contamination extensive NV injury requires arterial repair
4 R’s for managing fracture
resuscitate
reduce
restrict
rehabilitate
what antibiotics should be given for open#
cefuroxime
clindamycin
gentamicin if heavy contamination
other consideration of infection risk for open#
tetany and anti-tetanus booster
what can be used to make a sterile saline dressing
poviclone iodine
surgical management of open#
-sequential operations
1. debridement and external fixation/ IM nailing
2.debridement and internal fixation if not done
depends on whether debriding can be done in 1st
what are dysvascular lumbs assoc too
high energy fracture after open#
sometimes
closed injuries eg knee dislocation and supracondylar # of humerus in children
what is the minimum systolic pressure needed to feel a peripheral pulse
80-90
management of dysvascular limb
- resuscitate
- realign with splint
- reduce
- restrict
- closed reduction to improve circulation
- vascular injury so use angiogram and temporary vascular shunt to perfuse limb
6p’s of critical ischaemia
symptoms -pain -paraesthesia -paralysis signs -pale -pulseless -perishingly cold
causes of critical ishceamia
-kink of major vessel in #
-disruption of vessel structure: lacerations/ transection/ dissection
-arterial spasm
-loss of blood
-thrombosis:blood in wall of artery
can be acute or delayed
3 types of nerve injuries
neuropraxia
axonotemesis
neurotemesis
what is neuropraxia
temporary
structure intact
need to remove pressure to relieve numbness
full recovery
axonotemesis is and recovery
axon damaged but myelin sheath preserved
- so distal axon needs to repair
- scarred myelin sheath may prevent full recovery
neurotemesis and recovery
complete nerve division
no myelin sheath to guide regeneration
irreversible without surgical repair
-no motor or sensory
what takes place in axonotemesis and neurotemesis
Wallerian degeneration
signs of nerve injury
paraesthesia
dyaesthesia
pain: still kink
dermatome for
- nipple
- umbilicus
- groin crease
- radial side of hand
- middle finger
- ulna side of hand
- foot dorsum
- plant foot
- back of knee and buttocks
t4 t10 l1 c6 c7 c8 l5 s1 s3
symptoms of a radial nerve palsy and what is it assoc too and what causes it
wrist drop
assoc. to numbness over the 1st web space
caused by humeral shaft#
what area is affected in axillary nerve injury and what causes axillary nerve injury
regimental badge
shoulder dislocation
anterior interosseous nerve median nerve injury symptoms and what cant they do
cant do an ok sign
-weakness of FPL and FDL
what is at risk in a distal radius #
median nerve
what is at risk in a posterior hip dislocation
sciatic nerve
what is at risk in a knee dislocation
common peroneal nerve
what is at risk in a# at the elbow
ulnar entrapment-cubital tunnel syndrome=
what is the other type of ulnar injury
guyon’s canal nerve entrapment ulnar = motor and sensory
what can cause upper limb nerve entrapment
# dm alcohol synovitis pregnancy myxoedema
features of upper limb entrapment
pain paraesthesia numbness weakness swelling, soft tissue wasting
what is compartment syndrome
- increased pressure inside a fixed fascial compartment
- result in reduced tissue perfusion
- severe muscle pain from pressure and ischaemia
- tissue becomes necrotic
who is most likely to get compartment syndrome
young men with tibia fractures
or on a blood thinner get haematoma
how does compartment syndrome happen
-injury
-tissue swelling
-increased compartment pressure
-decreased perfusion pressure
-local hypoxia
-cell membrane damage
-tissue swelling increased
=cycl
what # is compartment syndrome usually seen with
-lower leg
forearm
crush injuries
clinical signs of compartment syndrome
- pain disproportionate to the injury and unresponsive to strong analgesia and resists movement
- tightly swollen
- paraesthesia
important thing not to mix up in compartment syndrome
DISTAL PULSE DOES NOT MEAN NO COMPARTMENT SYNDROME- by this point things are v.bad and irreversible damage
at what point do long term changes occur in compartment syndrome and when does it become irreversible
4-6
then 12 hours
management of compartment syndrome
-split cast down to skin
-limb to heart level
-compartment monitors
-decompressive fasciotomy full length
then left open
what pressure is indicative for fasciotomy incision
30-40mmHg
4 main types of bone infections
cellulitis: infection of skin and subcutaneous fat
abscess: pus
septic arthritis: in joint
prosthetic: related to joint
risk factors for cellulitis
immunodeficient
chronic venous insufficiency
differentials for septic arthritis
GRASP gout reactive autoimmune septic pseudo-gout
mortality % for septic arthritis
10%
what is the most common spread pattern for septic arthritis
haematogenous spread
clinical features of septic arthritis
- acute monoarthritis and fever
- swollen, hot and red joint
- pain at rest/moving
- throbbing, aching
- usually lower limbs knee and hip
most likely cause of septic arthritis
s.aureus
other cause of septic arthritis
- disseminated gonococcal infection from untreated gonorrhoea in young 10%
- elderly and IV gram negative bacilli or group bc and g strep
- haem influenzae in babies
- pseudomonas aeruginosa in iv drug user
- fungal in immunocompromised
risk factors for septic arthritis
dm
immunosuppression
prosthetic joint
medication for septic arthritis
diuretics
aspirin or anticoagulants
immunosuppressants
SIRS stands for and 4 def
systemic inflammatory response syndrome temp>38 HR>90 resp>20 wbcc>12
empirical iv antibiotic for septic arthritis
flucoxacillin
what must be done before giving antibiotics for septic arthritis
joint aspiration
what is necrotising fasciitis
- cellulitis and severe systemic infection and inflammatory response
- soft tissue destruction
pathogens of nf
- strep
- staph
- clostridia gas gangrene
- e.coli
3 measurements for nf
> 150 crp
wbc >15
creatinine and lactate rise
management of nf
sepsis 6 -give o2 -take blood culture -iv antibiotics -fluid challenge -measure lactate -measure urine output =radical surgical debridement strip off the skin
