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- 1. Dr. Krishna, PGIMS,Rohtak COMPLICATIONS OF FRACTURE General Local Early Late
- 2. Dr. Krishna, PGIMS,Rohtak General Complications Bed sore & other complications of recumbency Crush Syndrome (rhabdomyolysis) Diffuse Coagulopathy Embolism – Pulmonary & Venous Thrombosis & Electrolyte Imbalance Fat Embolism Gas gangrene Hospital related - Complications of anaesthesia & Surgery Infections incl Tetanus Jolt (Shock)
- 3. Dr. Krishna, PGIMS,Rohtak
- 4. Dr. Krishna, PGIMS,Rohtak SHOCK *A generalized state of decreased tissue perfusion *If prolonged it may lead to irreversible damage of the life supporting organs Causes: I. Cardiogenic II. Neurogenic III. Hypovolaemic
- 5. Dr. Krishna, PGIMS,Rohtak Low cardiac output Low B.P Decreased tissue perfusion Hypoxia & acidosis Progressive cell damage ORGAN FAILURE SHOCK
- 6. Dr. Krishna, PGIMS,Rohtak Crush syndrome Occurs when Large bulk of muscle is crushed Tourniquet left for too long
- 7. Dr. Krishna, PGIMS,Rohtak What happens? 1st Theory Compression released Acid myohaematin enters circulation Blocks the tubules In kidney SHOCK
- 8. Dr. Krishna, PGIMS,Rohtak SHOCK Limb Pulseless pallor Swollen Renal Low output uremia Acidosis Neurologically Drowsy → not treated → DEATH
- 9. Dr. Krishna, PGIMS,Rohtak 1st rule = Limb crushed severely (>6hrs) = Amputation -Above the compression or crushed injury -Before compression is released Dialysis
- 10. Dr. Krishna, PGIMS,Rohtak Venous thrombosis & Pulmonary Embolism Commonest complication of Trauma & Surgery Most frequently Calf veins Less frequent in proximal thigh & pelvic veins Pulmonary Embolism From Proximal thigh & pelvis Incidence = 5% & Fatal = 0.5%
- 11. Dr. Krishna, PGIMS,Rohtak VTE The primary cause in surgical HYPERCOAGULABILITY of the Blood due to activation of Factor X by Thromboplastin from damaged tissues Thrombosis occurs → secondary factors involved Stasis Pressure Prolonged immobility Endothelial damage Increase in No. & stickiness of platelets
- 12. Dr. Krishna, PGIMS,Rohtak c
- 13. Dr. Krishna, PGIMS,Rohtak VTE - high risk group Old age Cardiovascular Disease Bedridden patient Patients undergoing hip arthroplasty
- 14. Dr. Krishna, PGIMS,Rohtak VTE symptoms Pain the calf or thigh Soft tissue tenderness Sudden slight increase in temperature Sudden increase in pulse rate Homann’s Sign positive
- 15. Dr. Krishna, PGIMS,Rohtak
- 16. Dr. Krishna, PGIMS,Rohtak Diagnosis of DVT USG Doppler technique (measure blood flow) Ascending venography (bilaterally) Radioactive iodine labelled fibrinogen(clot)
- 17. Dr. Krishna, PGIMS,Rohtak Pulmonary Embolism Difficult to diagnose =only minority have symptoms (chest pain, dyspnea, hemoptysis) • So high risk patients should be examined for pulmonary consolidation • X-ray • Lung scintigraphy • Pulmonary angiography • Normal D-dimer has almost 100% negative predictive value (virtually excludes PE) • CT
- 18. Dr. Krishna, PGIMS,Rohtak H A M P T O N ’ S H U M P
- 19. Dr. Krishna, PGIMS,Rohtak Prevention Prophylactic treatment Foot elevation Graduated compression stockings Exercise Anticoagulant treatment Subcut heparin or LMW heparin
- 20. Dr. Krishna, PGIMS,Rohtak Rx of Pulmonary Embolism Cardiorespiratory resuscitation Vasopressor for shock Oxygen Large dose heparin (15 000 units) Streptokinase (dissolve clot) Antibiotics (prevent lung infection)
- 21. Dr. Krishna, PGIMS,Rohtak TETANUS Tetanus organism live only in dead tissue → exotoxin → blood & lymph to CNS →anterior horn cell Will develop Tonic clonic contraction Jaw & face (trismus & risus sardonicus) Neck & trunk Diaphragm & Intercostal muscle → spasm → ASPHYXIA https://www.youtube.com/watch?v=2baVlK5Uvyc
- 22. Dr. Krishna, PGIMS,Rohtak Prophylaxis Active immunization (tetanus toxoid) Booster doses (immunized patients) Non Immunized patients Wound toilet & antibiotics If wound contaminated →antitoxin
- 23. Dr. Krishna, PGIMS,Rohtak Treatment for Tetanus IV antitoxin Heavy Sedation Muscle Relaxant drug Tracheal Intubation Controlled respiration
- 24. Dr. Krishna, PGIMS,Rohtak GAS GANGRENE By clostridial infection (esp C. perfringens) Anaerobic with low oxygen tension Produce toxins → destroy cell wall → tissue necrosis → Spreading
- 25. Dr. Krishna, PGIMS,Rohtak Clinical Features Within 24 hours Intense pain Swelling Brownish discharge Pulse rate increased Characteristic smell sweetish & mousy odor Little or no pyrexia Gas formation not marked Toxaemic → coma → DEATH
- 26. Dr. Krishna, PGIMS,Rohtak Prevention Deep penetrating wound should be EXPLORED ALL dead tissue → completely EXCISED Doubt about tissue viability → leave it OPEN No antitoxin
- 27. Dr. Krishna, PGIMS,Rohtak Treatment for gas gangrene The key = EARLY DIAGNOSIS General measures (fluid, IV antibiotics) Hyperbaric oxygen (limiting spread) Decompression of wound Removal of all dead tissue Amputation (advanced case)
- 28. Dr. Krishna, PGIMS,Rohtak FAT EMBOLISM Only minority patients with circulating fat globules will develop POST TRAUMATIC RESPIRATORY DYSFUNCTION Source of fat emboli = bone marrow Usually in MULTIPLE CLOSED FRACTURE But other condition also reported (burns, renal infarction, cardiopulmonary operation)
- 29. Dr. Krishna, PGIMS,Rohtak Closed/open Fracture Fat in bone marrow escapes Formation of fat globules in vessels Fat embolus Stick in pulmonary bed Trigger clotting cascade
- 30. Dr. Krishna, PGIMS,Rohtak Features After 1-2 days of trauma Usually young adults with LL fracture Early warning signs Rise in temperature & pulse rate More pronounced case(classical triad) Breathlessness Mild mental confusion Petechia (chest & conjuntival fold)
- 31. Dr. Krishna, PGIMS,Rohtak Most severe case Marked respiratory distress →coma →ARDS no definitive test, but hypoxia <60mmHg after major trauma is suspicious
- 32. Dr. Krishna, PGIMS,Rohtak Gurd’s Criteria Major Features (at least 1) Minor Features (at least 4) Lab Features (at least 1) -Respiratory Insufficiency -Cerebral involvement -Petechiae Rash -Pyrexia -Tachycardia -Retinal changes -Jaundice -Renal changes -Fat macroglobulinemia -Anaemia -Thrombocytopenia -High ESR
- 33. Dr. Krishna, PGIMS,Rohtak
- 34. Dr. Krishna, PGIMS,Rohtak Treatment Mild case Monitoring of blood PO2 Signs of hypoxia (<8kPa @ 60mmHg) Oxygen If severe ICU with sedation & assisted ventilation Swan ganz Catheterization (monitor cardiac Fx) Fluid balance Supportive Heparin-thromboembolism Steroids-pulmonary oedema Aprotinin - prevent aggregation of chylomicrons
- 35. Dr. Krishna, PGIMS,Rohtak Early (& immediate) Complications Local Visceral Injury Vascular Injury Nerve Injury Compartment Syndrome Hemarthrosis Infection Gas gangrene
- 36. Dr. Krishna, PGIMS,Rohtak Local visceral Injury Fracture around the trunk are often Complication by injury to the adjacent viscera: Etc: Pelvic fracture Etc : Rib fracture → penetration to the lungs → Pneumothorax Bladder & urethral rupture This requires Emergency Rx → chest tube insertion
- 37. Dr. Krishna, PGIMS,Rohtak
- 38. Dr. Krishna, PGIMS,Rohtak Vascular injury commonly – knee, femoral shaft, elbow & humerus Artery may be cut, torn, compressed or contused Intima may be detached, thrombus block, artery spasm Effect → ↓↓ bld flow coz Ischemia leads to tissue death & peripheral gangrene
- 39. Dr. Krishna, PGIMS,Rohtak Vascular Injury - Clinical features Pt with ischemia may have 5 P’s: - paraesthesia/numbness - pain - pallor - pulselessness - paralysis Investigate if suspect vascular injury : CT Angiogram
- 40. Dr. Krishna, PGIMS,Rohtak Treatment Emergency treatment All bandages/splints removed X-Ray The fracture again Circulation reassessed for next half hour If no improvement, do vessels exploration Suture torn vessels, vein grafting, if thrombosed do endarterectomy Aim: to restore bld flow
- 41. Dr. Krishna, PGIMS,Rohtak Nerve Injury Variable degree of motor & sensory loss along the distribution of the nerve May be neurapraxia, axonotmesis or neurotmesis
- 42. Dr. Krishna, PGIMS,Rohtak
- 43. Dr. Krishna, PGIMS,Rohtak Nerve Trauma Effect Axillary Dislocation of shoulder Deltoid paralysis Radial # of humerus Wrist drop Median Supracondylar # of humerus Pointing index Ulnar # medial epicondyl humerus Claw hand Sciatic Post dislocation of hip Foot drop Common peroneal Knee dislocation # neck of fibula Foot drop
- 44. Dr. Krishna, PGIMS,Rohtak In closed injuries – nerve is seldom severed & spontaneous recovery should be awaited In open fractures – complete lesion (neurotmesis): the nerve is explored during wound debridement & repaired Acute nerve compression – occur with fracture or dislocation around the wrist. C/o numbness in median & ulnar dist. If no improvement >48 hours → after fracture reduction, do nerve exploration & decompression