Complication of fractures Part A .ppt
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This document discusses various complications that can arise from fractures, including general complications like shock, fat embolism, and disseminated intravascular coagulation. Local early complications within hours to days include visceral injury, nerve injury, vascular injury, compartment syndrome, and infection such as gas gangrene. Late bone complications occurring weeks to months include delayed union, malunion, nonunion, avascular necrosis, and joint instability. Late soft tissue complications can involve joint stiffness, muscle contractures, heterotopic ossification, and nerve entrapment. Treatment of complications depends on early identification and may involve supportive care, antibiotics, surgery, and hyperbaric oxygen in some cases of gas gangrene.
Complication of fractures Part A .ppt
- 1. Complication of fractures Dr Siddhartha Sinha Assistant Professor, Department of Orthopaedics Hamdard Institute of Medical Sciences and Research, New Delhi
- 3. General complication 1. Shock 2. Acute respiratory distress syndrome 3. Fat embolism 4. Tetanus 5. Crush syndrome 6. Disseminated intra-vascular coagulation
- 4. Local complications A) EARLY COMPLICATIONS (HOURS TO DAYS) 1. VISCERAL INJURY 1. Head 2. Abdomen 3. Pelvis 4. Chest 2. NERVE INJURY 3. VASCULAR INJURY . 4. COMPARTMENT SYNDROME 5. HAEMARTHOSIS. 6. INFECTION 7. GAS GANGRENE
- 5. 2) Late bone complication 1. Delayed union . 2. Mal-union . 3. Non –union 4. Avascular necrosis. 5. Joint instability. 6. Growth disturbances. 7. Osteoarthritis.
- 6. 3) Late soft tissue complication 1) Joint stiffness 2) Muscle contractures 3) Hetrophic ossification 4)Nerve entrapment 5)Tendon rupture. 6)Nerve compression
- 7. SHOCK Shock is a systemic state of low tissue perfusion which is inadequate for normal cellular respiration Low tissue perfusion Insufficient delivery of oxygen and glucose, Switch from aerobic to anaerobic metabolism
- 9. Types of Shock and Characteristics
- 10. CIRCULATION Replenish blood loss
- 11. Compensate d Mild Moderate Severe Blood loss 0-15% 15-30% 30-40% >40% Conscious level Normal Mild anxiety Drowsy, mild confusion Comatose Pulse Mild increase, Cool peripheries, CFT Increased, peripheries, increased CFT Increased Increased, cold peripheries Respiratory rate Normal Increased Increased Labored BP Normal Normal Mild hypotension Severe hypotension Pulse pressure Decreased Decreased Decreased narrowed pulse pressure (or immeasurable diastolic pressure)
- 12. Consequences of shock Unresuscitatable shock • ability of the body to compensate is lost. • myocardial depression and Multiple organ failure • Multiple organ failure is defined as two or more failed organ systems • Lung: Acute respiratory distress syndrome • Kidney: Acute liver insufficiency • Clotting: Coagulopathy • Cardiac: Cardiovascular failure • NO SPECIFIC TREATMENT, ONLY SUPPORTIVE OR PREVENTIVE • 60% mortality
- 13. Diffuse Coagulopathy Consumption Coagulopathy Activation of thromboplastin and platets Rapid consumption of coag factors Bleeding diathesis Treatment FFP Platelet transfusion Cryoprecipate Heparin
- 15. Respiratory Dysfunction Alveolar damage Ineffective surfactant Poor compliance T/T Oxygen Ventilation PEEP
- 16. Fat embolism mortality rate of 10-20%. Marrow fat enters circulation Mechanical block to circulation Inflammatory response Risk factors :- Closed fractures Multiple fractures Pulmonary contusion Long bone/pelvis/rib fractures
- 17. Presentation Sudden onset dyspnoea Hypoxia Fever ,Confusion, coma, convulsions ,,Transient red- brown petechial rash affecting upper body, especially axilla ,chest , conjunctiva Management Supportive treatment oxygen therapy , Corticosteroid drugs (used in treatment, more controversial in prevention) ,,Surgical stabilisation of fracture
- 18. Diagnosis Clinical presentation Gurd’s Criteria
- 19. Radiologic: CXR: normal in most, minority with evenly distributed, fleck-like pulmonary shadows (Snow Storm appearance), increased pulmonary markings and Rt heart dilatation V/Q: mottled pattern of subsegmental perfusion defects with a normal ventilatory pattern Chest CT: Focal areas of ground glass opacification with interloblar septal thickening Brain MRI: may reveal high intensity T2 signal. PET scanning: cerebral blood flow alterations & correction
- 20. FES Prevention Appropriate Splinting Early Fracture Stabilization Oxygen Therapy
- 21. Treatment ABC and electrolytes. Oxygen to correct hypoxemia (O2 conc b/w 75 & 90 mm Hg) Mechanical ventilatory assistance - endotracheal intubation Fluid restriction , diuretics N- acetyl cysteine (may be given). IV Methylprednisolone (Solu-Medrol) 10 mg/Kg/day in 3 divided doses(8 hourly)iv for 2 days.
- 22. GAS GANGRENE
- 23. INTRODUCTION Clostridia species of anaerobic bacteria Presence of gas in a tissue simply means “ANAEROBIC BACTERIAL METABOLISM” which can be produced by other bacteria too.
- 24. ETIOLOGY Clinical Setting 1. Traumatic injury or penetrating wound 2. Soft tissue lesion associated with vascular insufficiency 3. Surgical, primarily intestinal or biliary tract 4. Uterine gas gangrene Symptoms because of toxins released by the bacteria
- 25. Pathophysiology Compression of Tissue & Blood Supply Ischemia Gas Bacterial Increase Multiplication Area of Necrosis Alpha Toxin Hydrolyze Lipids of Tissue Membranes Circulation Massive Hemolysis Death
- 27. CLINICAL PRESENTATION Classified into 3 types:- 1. Simple contamination 2. Localised infection of skin and soft tissue without systemic signs 3. Spreading cellulitis and fascitis with systemic toxicity
- 30. GAS GANGRENE OF THIGH & BUTTOCKS
- 31. Recognise the PREDISPOSING CAUSES Deep penetrating wounds of buttock and thigh. Tight plaster casts Loss of blood supply Early Surgical Treatment Meticulous and complete removal of any necrotic tissue. Better to leave wound open than close if in doubt. Prevention
- 32. TREATEMENT General Supportive measures Fluid replacement I/V antibiotics Penicillin G 20,000,000 U/day in adults. - Clindamycin - 3rd generation Cephalosporins - Chloramphenicol
- 33. Surgical Resection CT is a sensitive method of detecting soft tissue gas and to detect extent of tissue necrosis DEBRIDEMENT FASCIOTOMY AMPUTATION
- 34. HYPERBARIC OXYGEN(HBO) Controversial Used alone or in combination with Metronidazole/Penicillin/Imipenem/ Clindamycin. Patients are placed in a chamber at 3 times atmospheric pressure(100% Oxygen) for 1-2 hours q 8-12 hrs. Total 6-8 treatments. HBO can decrease mortality due to clostridia infections in animal models but no RCT in humans have been done.
- 35. Tetanus
- 37. Treatment of Tetanus Tetanus Toxoid Tetanus Ig Penicillin, tetracycline, erythromycin
- 38. Deep vein thrombosis 1. Stasis of blood flow, 2. Endothelial damage, 3. Hypercoagulabity of blood. Prolonged bed rest Traction local pressure on vein Advanced age Trauma
- 39. Prevention EARLY MOBILIZATION leg pumping, quadriceps exercises, frequent position change DVT STOCKING/PUMPS MEDICATIONs 1. LMWH (low molecular weight heparin)/ Enoxaparin 2. Aspirin