4 Fracture Complications.pptx

COMPLICATIONS OF FRACTURES Dr. Lorenzo di Mento Head of Trauma Unit Humanitas Research Hospital - Milan Contacts: [email protected] +39 348 6716290 EARLY complications Sistemic • Shock • Fat embolism • Deep vein thrombosis (DVT) Local • Infection (mainly open fractures) • Compartment...

COMPLICATIONS OF FRACTURES Dr. Lorenzo di Mento Head of Trauma Unit Humanitas Research Hospital - Milan Contacts: [email protected] +39 348 6716290 EARLY complications Sistemic • Shock • Fat embolism • Deep vein thrombosis (DVT) Local • Infection (mainly open fractures) • Compartment syndrome LATE/DELAYED complications Sistemic • Bed rest syndrome Local • Malunion • Delayed union • Non union • Complex regional pain syndrome (algodystrophy) Hypovolemic shock Estimated average blood loss for fractures: • Pelvis: 1-4 litres • Femur: 1-2.5 litres • Humerus: 0.8-1 litres • Tibia: 0.5-1.5 litres In open fractures blood loss can increase due to the soft tissues lesion. Hypovolemic shock Pelvic Packing Damage Control Orthopaedics (DCO) Deep vein thrombosis Fracture Bed resting Without accurate DVT prophylaxis, 40–80% of in-ward patients with major trauma would face DVT. Deep vein thrombosis Complications • Pulmonary embolism • Post thrombotic syndrome Angio-TC Fat embolism Definition: Syndrome due to fat cells release in bloodstream, characterized by: • • • • Hypoxia CNS failure Pulmonary edema Skin rash Fat embolism Clinic: 1 major or 4 minor signs Imaging related diagnosis Open fractures Characterized by: • Soft tissues lesion • Neurovascolar associated lesion? • Contamination Open fractures Gustilo-Anderson classification: Classification must be done after surgical debridement! Open fractures Why immediate treatment? • Infection risk reduction • Fracture temporary fixation • Soft tissues coverage Open fractures ER evaluation: • Life>Limb>Function • Vascular lesion evaluation (before and after reduction) • 5-8 liters saline washing, debridement (foreign bodies, necrotic and contaminated tissue removal) • i.v. antibiotic therapy • Wound covering, cast Open fractures Primary surgery (within 6-8 h from trauma) 1) Debridement and Washing 2) Fracture stabilization 3) Wound dressing Open fractures Second look: • Open fr Gustilo-Anderson 2-3 degreee, or highly contaminated • Evrery 24 – 48h until complete necrotic tissue removal Definitive treatment • Bones - Intramedullary nail – plate - Mono-axial, circular or hybrid external fixator • Soft tissues - Flap - Skin graft Compartment syndrome • Ischemic syndrome • Muscular impairment due to neurovascular failure • Compartment pressure increase – From inside (edema, hematoma) – From outside (cast) • Most frequent sites – Leg – Foot – Forearm Compartment syndrome ↓ Tissue perfusion FASCIOTOMY Endothelium damage ↑ vessel permeability ↑ Edema ↑ Pressure Compartment syndrome Clinical signs – 5 P’s TIME • Paresthesia (numbness feeling) • Paralysis (due to pain – even passive) • Pallor (pale skin tone) • Pulselessness (final stage – too late!) SEVERITY • Pain (excruciating) Compartment syndrome Diagnostic? • CLINICAL!!! • Compartment pressure measurement (P compartment - PaD < 30 mmHg) Bendage/Cast removal Fasciotomy Bed rest syndrome Bed rest syndrome ↓ Malunion Fracture healing in a vicious position, causing a function impairment or loss Some of them are better tolerated (es. humeral diaphysis) Malunion • Limb dysmetria • Axis deformity - varus/valgus - procurvatum/recurvatum • Rotational deformity • Combined deformity Malunion • Intra-articulars • Meta-epiphyseal • Diaphyseal Malunion • Intra-articulars absolute indication (joint incongruency + instability = early arthritis ) • Meta-epiphyseal relative indication (pain, instability, functional impairment) • Diaphyseal relative indication (dolore, instabilità, functional impairment) Malunion Accurate preop planning Corrective Ostotomies with: - Internal fixation (immediate correction) - External fixation (progressive correction) Algodystrophy (CRPS) Complex Regional Pain Syndrome (CRPS) • Inexplicable pain • Abnormal skin colour and temperature • Edema • ROM ↓ • 90% after immobilization Algodystrophy (CRPS) Diagnostic • Budapest Diagnostic Criteria Algodystrophy (CRPS) Diagnostic • Budapest Diagnostic Criteria • Osteopenia on X-ray Therapy • Physiotherapy, criotherapy • Bisphosphonates • Painkillers, Pregabalin • For worse cases: peripheral anestesia Take Home Message Early complications • Antitrombotic prophylaxis • High risk of infection in open fractures immediate antibiotic i.v. therapy + early debridement – washing closure • Compartment treatment = PAIN. If doubtful, go for fasciotomies Take Home Message Late complications • Early mobilization (movement and weight bearing) • Delayed – non union: identify reason (mechanic/biology) • Pain + osteopenia in recent immobilization suspect CRPS