Musculosceletal Trauma Complications

(Fracture)(Fracture)Presentator :

Yudistira Prama TirtaModerator:

Dr. Wahyu Widodo, SpOT

Introduction

Complication : an adverse event that occurs following a procedure (risk of the procedure), treatment (side effect or toxicity), or illness

A fracture may be complicated initially by an associated injury, or it may become complicated subsequently, either early or late

The complication : local (fracture site) or remote (other organs)

May be caused by original injury or iatrogenic

General ComplicationsShock Hypovolemia : most common cause in trauma patient

Changes in BP, skin color and pulse rates guides to resuscitation

Resuscitation :crystalloid solutions through large-bore iv lines, monitored by urine output (0.5 mL/kg/hr in adults) estimated 1 liter of blood lost 3 to 4 L of crystalloid solution will be

required

Life threatening hemorrhage : X-ray head, cervical, thorax, pelvis + USG

General ComplicationsAcute Respiratory Distress Syndrome

(ARDS) ARDS direct lung injury from blunt /

penetrating trauma to the chest / alveolar injury, or prolonged shock / septicaemia

Clinical features: About 36 hours after injury : mild dyspnoea,

with diminished pO2 2nd or 3rd day : restless, mildly cyanosed, abN

blood gas (pO2 < 60mmHg) Bilateral infiltrate on CXR(some cases do

present unilaterally or with pleural effusion PCWP < 18 or PaO2/FiO2 < 200

Treatment strategy Supportive : low volume and high

frequency ventilation(ARDSNet protocol) ICU

General Complications (Infection) Tetanus

C.tetani (gram + rod, anaerobe, flourished on dead tissue)

Pathology : Tetanus toxin passes to anterior

horn cells where it fixes and can’t be neutralized so produces hyperexitability and reflex muscle spasm

Symptoms : tonic and clonic contractions of

esp. jaw, face, neck and trunk, finally spasm of diaphragm and Intercostalis muscles so death

Therapy : IV human antitoxin, IV antibiotics,

thorough wound toileting, muscle relaxant, intubation, and controlled respiration, active immunization

Gas Gangrene anaerobic clostridium

(C.Welchii) which produces a toxin that destroys cell wall leading to tissue necrosis

Symptoms: severe pain, swelling,

brownish discharge, gas production (characteristic smell), tachycardia and hyperpyrexia

Treatment: IV antibiotics with fluid

replacement, wound opening and debridment

Appley’s. System of Orthopaedics & Fractures. 8th ed. 2001

General ComplicationsCrush Syndrome Trapped limb

Deprived blood flow, tissue begin to die, toxic metabolic accumulates

When freed reperfusion injury (reactive O2 metabolites)

Failure in capillary & muscle cells ion pumps swelling compartment syndrome further ischaemia

Toxic metabolic in circulation hiperK, hypoCa, metabolic acidosis cardiac arrest

Muscle breakdown large load of myoglobin excreted by kidney renal failure

Management : Prevention; during

prolonged extrication, ensured high urine flow (large volume iv crystalloid)

Compartment syndrome fasciotomy

Provisional amputation

Classification of the ComplicationsInitial complications Local complications

Skin injuries From without From within

Vascular injuries Major artery Major vein Local Hemorrhage

Neurological Injuries

Muscular injuries Visceral injuries

Remote complications Multiple injuries Hemorrhagic shock

Early complications Local

complications Sequelae of

immediate complications

Joint complications

Bony complications

Remote complications Fat embolism Pulmonary

embolism Pneumonia Tetanus

Local complications•Joint complications : persistent joint stiffness, degenerative arthritis•Bony complications : malunion/ nonunion/ delayed union, chronic osteomyelitis, Sudeck’s posttraumatic painful osteoporosis (RSD)•Muscular complications : myositis ossificans•Neurological complications : tardy nerve palsy

Remote complications

Renal calculiAccident neurosis

Salter RB. Textbook of Disorders and Injury of Musculoskeletal System

Late complications

Initial Complications (Local)

Skin Injuries From without : abrasion (dirt)

cleansed (X) tattoo effect Laceration, puncture wounds,

penetrating missile wound, avulsion of skin, skin loss debridement + primary / delayed closure / grafts / flap

Gross swelling blister / bleb formation

From within : skin penetration by fracture fragment

During fracture treatment Bed sore (decubitus ulcer) sacrum /

heels Cast sore

Salter RB. Textbook of Disorders and Injury of Musculoskeletal System

Vascular Injuries (Artery) Major arteries are particulary vulnerable to injury in

association with specific fractures and dislocationInjuryInjuryFirst rib fractureFirst rib fractureShoulder dislocationShoulder dislocationHumeral supracondylar Humeral supracondylar fracturefractureElbow dislocationElbow dislocationPelvic fracturePelvic fractureFemoral shaft or Femoral shaft or supracondylar fracturesupracondylar fractureKnee dislocationKnee dislocationProximal tibialProximal tibialForefootForefoot

VesselVesselSubclavianSubclavianAxillaryAxillaryBrachialBrachial

BrachialBrachialPresacral & internal iliacPresacral & internal iliacFemoralFemoral

PoplitealPoplitealPoplitealPoplitealDorsalis pedisDorsalis pedis

Appley’s. System of Orthopaedics & Fractures. 8th ed. 2001

Neurological Complications Brain, Spinal Cord, Peripheral Nerves Relatively common in association with specific fracture & dislocations

Location Injury1 Brain Skull fractures2 Spinal cord Cervical & thoracic spine fr_disloc3 Cauda equina Lumbar spine fr_disloc4 Sciatic nerve Posterior hip disloc & fr_disloc5 Medial & lat popliteal

Knee dislocation

6 Lateral popliteal Vulnerable to bandage / cast pressure

7 Ulnar nerve Avulsion fr-separation medial epicondyle

8 Median nerve Humeral supracondylar fracture9 Radial nerve Humeral shaft fracture10 Circumflex nerve Shoulder dislocationAppley’s. System of Orthopaedics & Fractures. 8th

ed. 2001Salter RB. Textbook of Disorders and Injury of Musculoskeletal System

Visceral Complications Penetration by a sharp fracture fragment from nearby

bone, may damage : Heart hemopericardium with cardiac tamponade (rib

fracture) Perforate pleura hemothorax Perforate lung hemopneumothorax Perforate liver, spleen, kidneys by displaced fracture of

lower ribs Paralytic ileus & gastric dilatation thoracolumbar fracture Rupture of bladder/ urethra, or colon / rectum pelvic fracture

Require emergency treatment