Orthopaedic Risk and Complication Avoidance Department of Orthopaedic Surgery  Faculty of Medicine Siriraj Hospital Mahido...
Orthopaedic Risk and  Complication Avoidance <ul><li>Cast/Slab application </li></ul><ul><li>Missed injuries </li></ul><ul...
ที่ห้องพิจารณาคดีที่  5  ศาลจังหวัดนนทบุรี คดีที่ จ่าสิบเอก ********* ฟ้องสำนักปลัดกระทรวงสาธารณสุข และแพทย์ โรงพยาบาล ***...
Cast/Slab Application <ul><li>Before applying a cast, evidence of neurological injury must be documented </li></ul><ul><li...
Cast/Slab Application <ul><li>Infections including gas gangrene, ischemic muscle necrosis from compartment syndrome, and u...
Cast/Slab Application <ul><li>Make a next day follow up in every case after cast or slab application  </li></ul>ถ้าลักษณะท...
F/U  พรุ่งนี้ ดู   NV <ul><li>Sensation ( Dermatome sensation) </li></ul><ul><ul><li>Radial n. = 1 st  web space,Median n....
Missed injuries
Missed injuries <ul><li>At risk patients: </li></ul><ul><ul><li>who cannot cooperate (drug/alcohol/head injury) </li></ul>...
 
 
 
Missed injuries <ul><li>Prevention: </li></ul><ul><ul><li>Awareness of lesion by mechanism of injury </li></ul></ul><ul><u...
Compartment syndrome <ul><li>Definition: </li></ul><ul><ul><li>A condition in which the circulation within a closed compar...
Compartment syndrome Pathophysiology <ul><li>Increased compartment pressure </li></ul><ul><li>Venous outflow obstruction <...
Compartment syndrome Pathophysiology <ul><li>Temperature </li></ul><ul><li>Patient coagulation status </li></ul><ul><li>Fr...
Compartment syndrome <ul><li>Diagnosis: </li></ul><ul><ul><li>Disproportionate pain in the limb (guide by lecturer) </li><...
Differential Diagnosis  <ul><li>Adapted from Mubarek SJ: Treatment of acute compartment syndromes. In Willy C, Sterk J, Ge...
Compartment syndrome <ul><li>Compartment pressure measurement: </li></ul><ul><ul><li>If confirmation of the diagnosis is r...
Compartment syndrome <ul><li>Absolute pressure measurements </li></ul><ul><li>Relative pressure measurements (delta P) </l...
Treatment alternatives: Early Treatment Alternatives: Early <ul><li>Splint the extremity in a functional position </li></u...
Compartment syndrome As a general rule, when in doubt ,  the compartment should be released
Compartment syndrome
Vascular injury <ul><ul><li>5 P: </li></ul></ul><ul><ul><li>Pain </li></ul></ul><ul><ul><li>Paresthesia </li></ul></ul><ul...
Vascular injury <ul><li>Hard Sign </li></ul><ul><li>Soft Sign </li></ul>
Don’t even think that no one knows about   Golden Period 6 hrs  for Open Fracture
Thank you and Good luck
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ortho 02 orthopaedic complication & prevention + orthopaedic trauma (practical + pitfalls)

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ortho 02 orthopaedic complication & prevention + orthopaedic trauma (practical + pitfalls)

  1. 1. Orthopaedic Risk and Complication Avoidance Department of Orthopaedic Surgery Faculty of Medicine Siriraj Hospital Mahidol University
  2. 2. Orthopaedic Risk and Complication Avoidance <ul><li>Cast/Slab application </li></ul><ul><li>Missed injuries </li></ul><ul><li>Compartment syndrome </li></ul><ul><li>Vascular injury </li></ul><ul><li>Nerve injury </li></ul>
  3. 3. ที่ห้องพิจารณาคดีที่ 5 ศาลจังหวัดนนทบุรี คดีที่ จ่าสิบเอก ********* ฟ้องสำนักปลัดกระทรวงสาธารณสุข และแพทย์ โรงพยาบาล ****** ที่ร่วมกันรักษา ด . ญ . ด ******* โดยศาลอุทธรณ์ พิพากษาให้กระทรวงสาธารณสุข ชดใช้เป็นเงิน 3,424,010 บาท ด . ญ . ดริษา ล้มหัวเข่ากระแทกพื้นมีอาการปวดบวมที่เข่าซ้าย เข้ารักษาตัวโรงพยาบาลลงความเห็นว่าคนไข้มีอาการกระดูกเคลื่อนจึง ใส่เฝือกดาม ไว้โดยไม่ต้องผ่าตัด ต่อมาคนไข้มีอาการ ปวดบวมที่เท้าปลายเท้ามีสีเขียวคล้ำ และไม่มีความรู้สึก ไม่สามารถจะขยับนิ้วเท้าได้ ทางแพทย์ที่รักษาจึงแก้ไขด้วยการผ่าเฝือกออกหลังจากนั้นก็นำเฝือกมาใส่ใหม่ จากนั้นไม่นานคนไข้มีอาการไข้ขึ้นสูง และเจ็บปวดทรมานที่เฝือกมาก ญาติขอร้องให้ทางแพทย์ผ่าเฝือกออกพบว่าขาซ้ายมีอาการเน่า แพทย์จึงส่งตัวไปรักษาต่อที่โรงพยาบาล ********* จ . อุบลราชธานี และแพทย์ ตัดขาซ้ายที่เน่าทิ้ง จนกลายเป็นเด็กหญิงพิการขาซ้ายด้วน
  4. 4. Cast/Slab Application <ul><li>Before applying a cast, evidence of neurological injury must be documented </li></ul><ul><li>If there is any question of circulatory loss, the cast must not be applied until the circulatory status is clarified and circulation is restored. </li></ul>
  5. 5. Cast/Slab Application <ul><li>Infections including gas gangrene, ischemic muscle necrosis from compartment syndrome, and unrecognized vascular injuries can be hidden under a cast and lead to limb loss </li></ul>
  6. 6. Cast/Slab Application <ul><li>Make a next day follow up in every case after cast or slab application </li></ul>ถ้าลักษณะทางคลีนิคดี F/U พรุ่งนี้ ดู NV ( เสมอ ) ถ้าลักษณะทางคลินิกมี risk แนะนำ admit observe
  7. 7. F/U พรุ่งนี้ ดู NV <ul><li>Sensation ( Dermatome sensation) </li></ul><ul><ul><li>Radial n. = 1 st web space,Median n.= Index finger tip Ulnar = little figner tip </li></ul></ul><ul><ul><li>Peroneal n.= dorsum of foot, Plantar n.=Plantar of foot </li></ul></ul><ul><li>Motor </li></ul><ul><li>Capillary refill < 2 seconds, Distal Pulsation </li></ul><ul><li>Pain Score </li></ul><ul><li>Passive stretching test positive/ negative </li></ul>
  8. 8. Missed injuries
  9. 9. Missed injuries <ul><li>At risk patients: </li></ul><ul><ul><li>who cannot cooperate (drug/alcohol/head injury) </li></ul></ul><ul><ul><li>Who need to manage hemodynamic instability </li></ul></ul><ul><ul><li>Multiorgan injuries </li></ul></ul><ul><li>At risk bones/organs: </li></ul><ul><ul><li>Spinal fractures </li></ul></ul><ul><ul><li>Hand fractures </li></ul></ul><ul><ul><li>Foot fractures </li></ul></ul><ul><ul><li>Neurological injuries </li></ul></ul>
  10. 13. Missed injuries <ul><li>Prevention: </li></ul><ul><ul><li>Awareness of lesion by mechanism of injury </li></ul></ul><ul><ul><li>Tertiary survey ( Clinical reassessment within 24 hours of admission) </li></ul></ul><ul><ul><li>Take an x-ray at doubtful area/ incorporate patient </li></ul></ul><ul><ul><li>Communication with radiologist reviewing the film </li></ul></ul>
  11. 14. Compartment syndrome <ul><li>Definition: </li></ul><ul><ul><li>A condition in which the circulation within a closed compartment is compromised by an increase in pressure within the compartment, causing necrosis of muscles and nerves and eventually the skin </li></ul></ul>
  12. 15. Compartment syndrome Pathophysiology <ul><li>Increased compartment pressure </li></ul><ul><li>Venous outflow obstruction </li></ul><ul><li>Increase capillary permeability </li></ul><ul><li>Increased compartment pressure </li></ul><ul><li>Decreased arterial inflow </li></ul><ul><li>Decreased tissue oxygenation </li></ul><ul><ul><li>Muscle and nerve ischemia: reversible </li></ul></ul><ul><ul><li>Muscle and nerve ischemia: irreversible </li></ul></ul>
  13. 16. Compartment syndrome Pathophysiology <ul><li>Temperature </li></ul><ul><li>Patient coagulation status </li></ul><ul><li>Fracture </li></ul><ul><ul><li>Acute </li></ul></ul><ul><ul><li>Late complication </li></ul></ul><ul><li>Muscle contusion </li></ul><ul><li>Duration of compartment compression </li></ul><ul><li>Blood pressure </li></ul><ul><ul><li>Hypertension less likely to occur </li></ul></ul><ul><ul><li>Hypotension more likely to occur </li></ul></ul>
  14. 17. Compartment syndrome <ul><li>Diagnosis: </li></ul><ul><ul><li>Disproportionate pain in the limb (guide by lecturer) </li></ul></ul><ul><ul><li>Pain with passive stretch </li></ul></ul><ul><ul><li>Paresthesia or anesthesia </li></ul></ul><ul><ul><li>Paresis/ Paralysis </li></ul></ul><ul><ul><li>Pulselessness may or may not be detected </li></ul></ul>
  15. 18. Differential Diagnosis <ul><li>Adapted from Mubarek SJ: Treatment of acute compartment syndromes. In Willy C, Sterk J, Gerngrob H, et al( eds): Das Kompartment-Syndrom. Berlin, springer-Verlag, 1998, p 128 </li></ul>
  16. 19. Compartment syndrome <ul><li>Compartment pressure measurement: </li></ul><ul><ul><li>If confirmation of the diagnosis is required, compartment pressure reading may be obtained </li></ul></ul>
  17. 20. Compartment syndrome <ul><li>Absolute pressure measurements </li></ul><ul><li>Relative pressure measurements (delta P) </li></ul>Mubarek, Hargens 30 mm Hg 8 hours Matsen 45 mm Hg Whitesides, Heppenstall, Seiler 20 mm < DBP, 30mm<MAP 8 hours
  18. 21. Treatment alternatives: Early Treatment Alternatives: Early <ul><li>Splint the extremity in a functional position </li></ul><ul><li>Elevate the arm/ leg to heart level, but not above </li></ul><ul><li>Administer weak analgesic medications </li></ul><ul><li>Record frequent observations of the patients condition </li></ul><ul><li>Consider serial interstitial tissue pressure measurements </li></ul>
  19. 22. Compartment syndrome As a general rule, when in doubt , the compartment should be released
  20. 23. Compartment syndrome
  21. 24. Vascular injury <ul><ul><li>5 P: </li></ul></ul><ul><ul><li>Pain </li></ul></ul><ul><ul><li>Paresthesia </li></ul></ul><ul><ul><li>Pale </li></ul></ul><ul><ul><li>Pulslessness </li></ul></ul><ul><ul><li>Paralysis </li></ul></ul>
  22. 25. Vascular injury <ul><li>Hard Sign </li></ul><ul><li>Soft Sign </li></ul>
  23. 26. Don’t even think that no one knows about Golden Period 6 hrs for Open Fracture
  24. 27. Thank you and Good luck

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