N AT TA P O N G P H O L P RA D U B P E T

COMPLICATION OF FRACTURE

OUTLINE

• Vascular injury• Compartment Syndrome• Thromboembolism• Fat Embolism Syndrome• Complex Regional Pain Syndrome (CRPS)

VASCULAR INJURY

ETIOLOGY

• Vast majority of arterial injuries associated with fractures are secondary to Gunshot wounds

• Type• Intimal flaps• Disruptions or subintimal hematoma• Wall defect• Complete transection• A-V fistula

ARTERIAL INJURY

• Associate with fractures in areas where the vessels are close to osseous structure or held in a fixed position• fracture dislocation around the knee

The presentation may be delayed (intimal flap or thrombosis), so the absence of classic signs of acute ischemia & the presence of palpable pulses in no way rule out the possibility

VENOUS INJURY

• Commonly associate with arterial injury • Often multiple, lacerations, producing hematoma• Venous repair esp. in the groin or popliteal area • may be helpful after arterial repair to prevent hematoma

formation, distal edema, & progressive tissue destruction

DIAGNOSIS

• Awareness• Signs & Symptoms:

• Absence of distal pulse, pallor, differential gradient in temp, rapidly progressing edema or hematoma formation• Paralysis, paresthesia

INVESTIGATION

• Investigation• Doppler U/S• Duplex U/S (real time B-mode U/S & pulsed Doppler flow

detection)• Arteriogram • Venogram

TREATMENT

• Initial• Early resuscitation• Immobilization the traumatized limb• Do not elevate the affected limb• Direct pressure• Avoid tourniquet (temporary use only if necessary)

• Pre-op preparation• Optimal period for restorative surgery is 6 - 8 hr• Correct acidosis & volume depletion• Splint or traction is applied

BONE VS VESSEL: WHAT SHOULD BE REPAIRED FIRST?

• Depends on• ischemic time (6 hr golden period)• amount of contamination• extent of wound• mechanism of injury• associated injury

• Team approach• Adjust individually

• Surgery• Constructive dialogue with vascular surgeon• Drape to permit access to sapheneous or cephalic vein• Temporary shunt ???• Fasciotomy

• Fixation• Closed fracture: internal fixation• Open fracture: external fixation • place pin away from the open wound & position the bar away

from the operative field for vascular repair

• Delayed definitive fixation

COMPARTMENT SYNDROME

DEFINITION

• An increased pressure within an enclosed osteofascial space that reduces the capillary blood perfusion below a level necessary for tissue viability

COMMON CAUSE

• Fracture• Soft tissue injury• Arterial injury• Limb compression• Burns

SIGN & SYMPTOM

• Symptoms• Pain out of proportion !!!• Pain is unrelenting• No relief following splinting or removal of casts &

bandages• Paresthesia

• Signs• Pain on palpation of compartment• Tense / swollen compartment• Passive muscle stretch severe pain • Sensory deficit of nerve in the compartment• Muscle weakness

•Warnings• Pulses are present early and their absence occurs late in

the development• Normal capillary refill also present early in development• Paresthesia and paralysis are too late• Pain out of proportion & pain on passive stretching are 2

most important findings

COMPARTMENT PRESSURE MEASUREMENT (WHITESIDE)

• Sterile saline is used• 18- gauge needle is inserted

into the muscle at the level of fracture

• Read when saline meniscus is “flat”

• Do not depress the plunger too strongly (avoid saline leakage)

• 2 readings should be made• Repeat readings should be

made at 1 hr interval

Same level with tip of needle

• What is the magic number?• 30 mmHg (corresponds with normal capillary pressure)

• 45 mmHg (capillary pressure rises in compartment syndrome)

• 20 mmHg below DBP

• 30 mmHg below DBP

Mubarak, SJ & Hargens, AR

Matsen, FA

Whiteside, TE

McQueen, MM & Court-Brown, CM

MANAGEMENT

• Release constrictive dressings, bivalve cast & webril • Fasciotomy

• Fracture stabilization• External fixator is the implant of choice

THROMBOEMBOLISM

• Risk depends on• Age• Extent & duration surgery• Type of anesthesia • Spinal & epidural lower than GA

• Degree & duration of immobilization• Severity of underlying systemic disease

CLINICAL SYMPTOM

• Leg pain• Swelling• Warmth• Dilated vein• Erythema• Pitting edema

PHYSICAL EXAMINATION

• Measure leg circumference• Tenderness along deep venous system• Homans’ sign• Pain in the calf or popliteal region on forceful & abrupt

dorsiflexion of ankle with knee in a “FLEXED” position

PHE has low sensitivity & specificity

INVESTIGATION

• Duplex ultrasound• Venogram

MANAGEMENT

• Prophylaxis• LMWH 30 mg subcutaneously twice daily no monitor is

required• Warfarin 5 - 10 mg/day INR 2 -2.5

• Treatment• Heparin intravenously

5,000 units followed by cont infusion of 30,000 - 35,000 units / 24 hr APTT

• Warfarin 5 - 10 mg/day starts 24 hr later INR 2 - 3

• Stop heparin when therapeutic range of INR is achieved for at least 2 days

FAT EMBOLISM SYNDROME

DEFINITION

• Presence of fat globules in lung parenchyma & peripheral circulation after fracture of long bone & pelvis, other major trauma, or non-traumatic conditions• “Fat embolism syndrome” term to describe a

serious manifestation of the phenomenon of fat emboli

PREVALENCE

• Fat emboli: • 90% after major trauma

• Fat embolism syndrome • 0.25-1.25%• Higher prevalence in multiple bone fractures

• Mostly have a latent period of 12 - 72 hr after trauma• Movement of unstable fracture ends & reaming of

medullary cavity promote entrance of marrow contents to the circulation

CLINICAL FINDINGS

• Classic triad • Pulmonary• Cerebral• Cutaneous manifestations

• Pulmonary• Tachypnea, pleuritic chest pain, dyspnea, cyanosis,

tachycardia, pyrexia• PHE: rales, rhonchi, pleural rub• Hypoxemia

• Cerebral• Headache, irritability, delirium, stupor, convulsion, coma• Focal neurological deficit (rare)

• Cutaneous• Manifest on 2nd or 3rd day in 50% of pts• Petechial rash in nondependent portions of body:

chest, ant axillary fold, conjunctiva• Retinal findings

INVESTIGATION

• Blood gas: hypoxemia• Blood test: thrombocytopenia, anemia, hypocalcemia• EKG:

• Right axis deviation (prominent S in lead I, Q in III, ST segment changes)

• CXR: • Varies• Severe cases:• diffuse, bilateral infiltration (interstitial or

alveolar)• opacify both lungs diffusely (capillary

permeability-type edema)

TREATMENT

• Supportive pulmonary care• Pulse oximetry: < 90% blood gas

(maintain PaO2 > 90)• Persistent or worsening hypoxemia (PaO2 <

60) & resp. distress despite O2

ET tube + ICU• Early fracture stabilization • Appropriate fluid resuscitation to avoid shock

COMPLEX REGIONAL PAIN SYNDROME (CRPS)

CLINICAL FEATURES

• biphasic condition • early swelling and vasomotor instability • late contracture and joint stiffness

• hand and foot are most frequently involved• usually begins up to a month after the

precipitating trauma

BONE CHANGES

• increased uptake on bone scanning in early CRPS • Later, the bone scan returns to normal • there are radiographic features of rapid bone loss• visible demineralization with patchy, subchondral or

subperiosteal osteoporosis• metaphyseal banding• profound bone loss

INCIDENCE

• early features of CRPS show that they occur after 30% to 40% of every fracture and surgical trauma • severe, chronic CRPS associated with severe

contracture is uncommon with a reported prevalence of less than 2% in retrospective series

CLINICAL DIAGNOSIS IN AN ORTHOPAEDIC SETTING

• 1 Pain• 2a Vasomotor instability• 2b Abnormal sweating• 3 Edema and swelling• 4 Loss of joint mobility and atrophy• 5 Bone changes

INVESTIGATIONS

• CRPS is a clinical diagnosis and there is no single diagnostic test• Magnetic resonance imaging (MRI)• early bone and soft tissue edema with late atrophy and

fibrosis

• Computed tomography (CT) • bony compressing lesion

• Electromyographic and nerve conduction studies • normal in CRPS 1 but may demonstrate a nerve lesion in

CRPS 2

MANAGEMENT

• Reassurance• excellent analgesia• intensive, careful physical therapy avoiding

exacerbation of pain

Six-Pack Exercises

• Analgesia• Nonsteroidal anti-inflammatory drugs may give better

pain relief than opiates• centrally acting analgesic such as amitriptyline is often

useful even at this early stage

• Secondline treatment• centrally acting analgesic > amitriptyline, gabapentin, or

carbamazepine• regional anesthesia• Calcitonin• membrane-stabilizing drugs > mexilitene• sympathetic blockade and manipulation• desensitization of peripheral nerve receptors > capsaicin

• Immobilization and splintage should generally be avoided • if used, joints must be placed in a safe position and

splintage is a temporary adjunct to mobilization

• Pain desensitization• reminded that simple stroking cannot by definition be

painful • instructed to stroke the affected part repetitively while

looking at it and repeatedly saying “this does not hurt, it is merely a gentle touch.”

• Surgery• rarely indicated• treat fixed contractures • delayed until the active phase of CRPS has completely

passed at least 1 year since

THANK YOU