Local Complications of Fractures:
Fractures around the trunk are often complicated by visceral injury.
E.g. Rib fractures are associated with life threatening pneumothorax or with spleen, liver injuries.
E.g. Pelvic injuries are associated with bladder or urethral rupture and cause sever hematoma in the retroperitoneum .
Surgery of visceral injuries should take precedence over the treatment of fracture.
E.g. Rib fractures are associated with life threatening pneumothorax or with spleen, liver injuries.
E.g. Pelvic injuries are associated with bladder or urethral rupture and cause sever hematoma in the retroperitoneum .
Surgery of visceral injuries should take precedence over the treatment of fracture.
VASCULAR INJURIES
Most associated with injuries around knee, elbow, humerus and femoral shaft.
Commonly associated with high-energy open fractures.
They are rare but well-recognized.
Cause : From initial trauma or from bone fragment
Mechanism of injuries:
** The artery may be cut or torn.
** Compressed by the fragment of bone.
** normal appearance with intimal detachment that lead to thrombus formation.
** segment of artery may be in spasm.
Most associated with injuries around knee, elbow, humerus and femoral shaft.
Commonly associated with high-energy open fractures.
They are rare but well-recognized.
Cause : From initial trauma or from bone fragment
Mechanism of injuries:
** The artery may be cut or torn.
** Compressed by the fragment of bone.
** normal appearance with intimal detachment that lead to thrombus formation.
** segment of artery may be in spasm.
—
Classical presentation of ischemia 5 Ps:
Pain , Pallor, Pulseless , Paralysis , and Paraesthesia
X-ray: suggest high-risk fracture.
Angiogram should be performed to confirm diagnosis.
Classical presentation of ischemia 5 Ps:
Pain , Pallor, Pulseless , Paralysis , and Paraesthesia
X-ray: suggest high-risk fracture.
Angiogram should be performed to confirm diagnosis.
— Management
this is an emergency because the effect of ischemia especially on the muscle is irrevesible after 6 hours.
1. Temporary vascular shunt to perfuse distal limb.
2. Skeletal stabilization – temporary external fixation often used.
3. Definitive vascular repair.
4. Staged definitive skeletal internal fixation if required.
this is an emergency because the effect of ischemia especially on the muscle is irrevesible after 6 hours.
1. Temporary vascular shunt to perfuse distal limb.
2. Skeletal stabilization – temporary external fixation often used.
3. Definitive vascular repair.
4. Staged definitive skeletal internal fixation if required.
— - It’s more common than arterial injuries.
- The most commonly injured nerve is the radial nerve
in its groove or in the lower third of the upper arm especially in oblique fracture of the humerus.
- Common with humerus, elbow and knee fractures
- Most nerve injuries are due to tension neuropraxia.
- The most commonly injured nerve is the radial nerve
in its groove or in the lower third of the upper arm especially in oblique fracture of the humerus.
- Common with humerus, elbow and knee fractures
- Most nerve injuries are due to tension neuropraxia.
—The nerve is rarely severely affected (just neuropraxia or axontmesis) and spontaneous recovery is usually the role.
—If not; the nerve should be explored because it sometimes trapped between the fragment and occasionally it is found to be divided and more likely to be completely injured.
—And should be explored during wound debridement or in 2nd operation.
•A complete lesion(neurotmesis) is more likely, the nerve is explored during wound depridement and repaired, either then or 3weeks later by nerve suturing and grafting.
—
**Most commonly in forearm and calfs.
**Muscles are arranged in different compartments and surrounded by one fascia , this arrangement called osteofascial compartment.
**Compartment syndrome occurs when muscle swells within osteofacial compartment and occluds its blood supply >> infarction and late ischemic contracture.
**Trauma is the most common cause.
reasons that lead to increase the pressure inside:
1. Bleeding
2. Edema
3. Infection
**Most commonly in forearm and calfs.
**Muscles are arranged in different compartments and surrounded by one fascia , this arrangement called osteofascial compartment.
**Compartment syndrome occurs when muscle swells within osteofacial compartment and occluds its blood supply >> infarction and late ischemic contracture.
**Trauma is the most common cause.
reasons that lead to increase the pressure inside:
1. Bleeding
2. Edema
3. Infection
— Fracture of the arm and leg can give rise to severe ischemia even if there is no damage to major vessel. Bleeding or edema will increase the pressure within one of the osteofascial compartments, this lead to decrease in capillary blood flow which in turn leads to muscle ischemia, further edema, still greater pressure, and yet more profound ischemia….vicious circle.
— After 12 hours or less, this vicious circle ends in necrosis of nerves and muscles within the compartment.
Nerve are capable of regeneration, but the muscle once infarcted can never recover and are replaced by fibrous tissue. This condition is called volkmann s ischemic contracture.
Nerve are capable of regeneration, but the muscle once infarcted can never recover and are replaced by fibrous tissue. This condition is called volkmann s ischemic contracture.
— Distal pulses and neurological functions are normal until very late.
Muscle will be dead after 4-6 hrs of total ischemia so there is no time to lose!
Muscle will be dead after 4-6 hrs of total ischemia so there is no time to lose!
— When do we have to suspect compartment syndrome?
1..High-risk injuries : -fracture of the elbow
- fracture of the forearm
- fracture of the proximal third of the tibia
2.Predisposing factor: operation ( internal fixation) ,infection.
3.Classical feature of ischemia ( 5ps)
4. very painful, swollen, tense limb.
1..High-risk injuries : -fracture of the elbow
- fracture of the forearm
- fracture of the proximal third of the tibia
2.Predisposing factor: operation ( internal fixation) ,infection.
3.Classical feature of ischemia ( 5ps)
4. very painful, swollen, tense limb.
— Cont..
5. the muscle should be tested by stretching; if the pain increase then this goes with compartment syndrome.
6. In doubtful cases, the diagnosis is confirmed by measuring the compartment pressure by using a catheter which is introduced into the compartment close to the level of fracture.
àA differential pressure (the difference between diastolic and compartment pressure) of less than 30mmHg is an indication for immediate decompression
5. the muscle should be tested by stretching; if the pain increase then this goes with compartment syndrome.
6. In doubtful cases, the diagnosis is confirmed by measuring the compartment pressure by using a catheter which is introduced into the compartment close to the level of fracture.
àA differential pressure (the difference between diastolic and compartment pressure) of less than 30mmHg is an indication for immediate decompression
— Treatment :
1. Decompression ….by Immediate open fasciotomy
(open all compartment through medial and lateral incisions) and left open for 2 days
2. If there is muscle necrosis , debridement can be done
3.if tissue is healthy the wound can be sutured, or skin-grafted. or the wound is left to heal by secondary intention
4. Limb should be examined every 15 min for 2 hours if there is no improvement , or if the pressure falls below 30 …
1. Decompression ….by Immediate open fasciotomy
(open all compartment through medial and lateral incisions) and left open for 2 days
2. If there is muscle necrosis , debridement can be done
3.if tissue is healthy the wound can be sutured, or skin-grafted. or the wound is left to heal by secondary intention
4. Limb should be examined every 15 min for 2 hours if there is no improvement , or if the pressure falls below 30 …
— *Bleeding into a joint spaces.
*Occurs if a joint is involved in the fracture.
Presentation:
swollen tense joint; the patient resists any attempt to moving it.
treatment:
blood aspiration before dealing with the fracture; to prevent the development of synovial adhesions.
*Occurs if a joint is involved in the fracture.
Presentation:
swollen tense joint; the patient resists any attempt to moving it.
treatment:
blood aspiration before dealing with the fracture; to prevent the development of synovial adhesions.
—
*usually seen in open fractures; rarely with closed fractures unless opened by operation (ex; internal fixation).
*Open fracture in 6 hrs the risk of infection increases up to 10x.
*All open fracture should be treated by prophylactic antibiotics ,
*appropriate early management; wound excision and debridement, skeletal stabilization and wound closure.
*Post-traumatic bone infection is the most common cause of chronic osteomyelitis
*Infection may be early within days after surgery or late occurring months after surgery
*usually seen in open fractures; rarely with closed fractures unless opened by operation (ex; internal fixation).
*Open fracture in 6 hrs the risk of infection increases up to 10x.
*All open fracture should be treated by prophylactic antibiotics ,
*appropriate early management; wound excision and debridement, skeletal stabilization and wound closure.
*Post-traumatic bone infection is the most common cause of chronic osteomyelitis
*Infection may be early within days after surgery or late occurring months after surgery
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