Salter Chapter 15

8/18/2019 Salter Chapter 15

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• Sclerosis increase the risk ofposttraumatic arterial thrombosis


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Initial pallor of the skin

distally

Loss ofarterialpulse

Mottled

Coolness ofthe skin

Darkdiscolorationthat heraldsgangrene

Recognition of ArterialComplication

Complete arterialocclusion in a limb is

associated with:


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• Doppler probe isvery helpful indetecting a

peripheral pulse that is to weak to bepalpable

• Arteriography is

useful in localizing theprecise site ofarterial occlusion


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Compartment Syndromes

Compartment syndrome hen theincreased pressure of progressive edema

within a rigid osteofascial compartmentof either the forearm or the leg !between theknee and the ankle" threatens thecirculation to the enclosed

!intracompartmental" muscles and nerves.

Formerly known as Volkmann’s ischemia


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most

fre#uentlyinvolve:

$he %e&orcompartmentof the forearm

$he anteriortibial

compartment

of the leg


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• Peripheral nerves within thecompartment can withstand only 2 to 4

hours of ischemia

have some potentialfor regeneration

• Muscle can survive up to 6 hours ofischemia !" cannot regenerate'

• (ecrotic muscle is replaced by dense)brous scar tissue that gradually shortensto produce a *compartmental contracture+

or ,olkmann-s ischemic contracture


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A compartment syndrome may be secondary toone of two di.erent phenomena

/' 0ro&imal !e&tracompartmental" occlusion ofthe main artery supplying the compartment

1' Intracompartmental in2ury to either bone3 softtissue3 or both with resultant hemorrhage

In both types3 the intracompartmental pressurerise rapidly to dangerous levels3 unless thispressure is relieved by a complete surgicalfasciotomy


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• $he in2uries that are most fre#uently complicatedby a compartment syndrome are:

#$ Displaced supracondylar fractures of thehumerus with damage to the brachial arteryin children

2$ %&cessive longitudinal traction in treatment

of fractures of the femoral shaft in childrenwith resultant arterial spasm

'$ (ractures )as well as surgical osteotomies*of the pro&imal third of the tibia

4$ Drug+induced coma with resultant pressureon ma,or arteries from lying on hard surfacein an aw-ward position for a prolongedperiod


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$he clinical picture:

/' Severe pain after pain free internal!from muscle ischemia" !0AI("

1' $ransient decrease in peripheral

circulation with relative pallor !0A445R"6' Coolness of the skin as well as pu.y

swelling of the hand or foot !0788I(9SS"

' Ischemic disturbance of the involvedperipheral nerve function as evidencedby paresthesia3 hypoesthesia3 paralysis!0AR9S$;9SIA"


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$reatment of vascularcomplication

/' Any constricting cast or bandage must becompletely removed

1' Any distortion of the fractured limb or e&tremeposition of nearby 2oint should be lessened

6' If the fracture is being treated by continuoustraction3 the amount of traction should bedecreased

' If these measures fail to restore ade#uate

peripheral circulation3 an emergency arteriogram isindicated if there is no improvement within halfan hour3 the artery should be e&plored surgically


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Se#uelae of arterialcomplications

•


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,enous Complications

Division of a ma,or vein: In2uriesto ma2or veins should be repairedsurgically to prevent the late

se#uelae of persistent venouscongestion distally


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,enous thrombosis and

0ulmonary embolism

• $he combination of deep vein thrombosis!D,$" and pulmonary embolism !09" is acommon cause of morbidity and

mortality in adult orthopedic patients• Adults are more susceptible to

thrombosis than children

•

$he main factor that precipitatesthrombosis is venous statis3 other factorsinclude increased coagulabity and vesselwall damage


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• After a fracture3 the venous lesion is usuallya phlebothrombosis3 as opposed to anin%ammatory thrombosis

•

$he thrombus is only loosely adherent to thewall of the vein3 it may come loose and passto the lungs to produce 074=5(AR>9=?54IS=

• $here is an increased risk of D,$ and 09 insmokers and in women who are taking oralcontraceptives


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D.A/01.

$he calf:

-

local pain- there is tenderness in the midline posteriorly and

distal swelling due to congestion

- 0assive dorsi%e&ion of the ankle aggravates the

pain !;oman-s sign"

$he thigh:

- $he entire lower limb becomes swollen

4ess than @B D,$s can be diagnosed clinically

,enogram3 0lethysmography3 and Doppler

7ltrasound

other method to investigation


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"he Complication ofPulmonary %mbolism

A small size undetected3or only mild chest pain

=oderate size sudden

onset of chest pain3dyspnea3 and sometimeshemoptysis

A massive pulmonary

embolus severe chestpain3 immediatelyblanches3 and literallydrops dead


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0revention of ,enous $hrombosis

• Avoiding constant local pressure on veins

• 9ncouraging the patient to

- actively contract all muscles in the in2ured

limb- move about as much as possible given the

limits imposed by the treatment of thefracture

• 0atients at high risk of developing a D,$should be given a prophylactic anticoagulant


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$reatment of ,enous $hrombosis

• Appropriate anticoagulant drugs

• Recent thrombosis in the femoralvein is best treated by surgicalthromboectomy to decrease the riskof 09 and to prevent the late se#uelof persistent venous obstruction in

the lower limb


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(eurological Complications

(eurologicalcomplication

are relativelycommon inassociationwith speci)cfractures anddislocation


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,isceral Complications

• $hey may also be in2ured by penetrationby a sharp fracture fragment from anearby bone

• $he e&ample are:/' ;emopericardium cardiac tamponade

1' ;emothora& and hemopneumothora&

6' 0erofarte the liver3 spleen3 or kidneys' Rupture the bladder or urethra

@' etc


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5ther Complications

• oint Infectionof a 2oint !septicarthritis"

•

?one

Infection ofbone!osteomyelitis"

• Avascularnecrosis ofbone

osteomyelitis


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Remote Complications

• 8at embolism syndrome

• 0ulmonary 9mbolism

•

0neumonia• $etanus

• Delirium tremens


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8at 9mbolism Syndrome

• 8at globules can be found in the circulationof most adults after a ma2or fracture of thelong bone

•

8at embolism syndrome is the combinationof systemic fat embolization and asigni)cant respiratory distress syndromewith severe arterial hypo&ia

• $his syndrome may complicate fractures inthose who have some types of pree&istingsystemic collagen disease


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Clinical 8eatures

• 0ulmonary emboli: dyspnea3hemoptysis3 tachypnea3 and cyanosis

• Cerebral emboli: headache3 confusion3

and irritability followed by delirium3stupor3 and coma

• Cardiac emboli: tachycardia3 drop in

blood presure• Skin: petechial hemorrhages

• 5ther: febrile


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• 3adiographic features snow stormappearance

• Laboratory features: there is nopathognomonic laboratory test3 the diagnosis is

primarily clinical3 but this condition can behappened:

"he serum fatty acids are elevated

(ree fat in the sputum and urine

"he 5 usually drop sharply very early inthe process

"hrombocytopenia


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4ate Complications

• 4ocal Complications

4ate 2oint complications

?one complications=uscular complications

4ate rupture of tendons

(eurological complications


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4ate oint Complications

/' oint Sti.ness

1' 0eriarticular adhesions

6' Intraarticular adhesions' Adhesions between muscles and

muscles and bone

@' 0osttraumatic degenerative 2ointdisease or arthritis


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?one Complications

/' Abnormal healing of fractures

1' 0ersistent Infection of bone

6' 0osttraumatic osteoporosis' Sudeck-s 0osttraumatic 0ainful5steoporosis !Re%e& SympatheticDystrophy"

@' Refracture

E' =etal failure


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Abnormal healing offractures

• $he healing of fracture may beabnormal in one of three ways:

/' 7nion may occur in the usual timebut in an abnormal position!=A47(I5("

1' 7nion may be delayed beyond a

reasonable time !D94A>9D 7(I5("

6' 7nion may fail to occur !(5(7(I5("


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=alunion


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Delayed 7nion


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(onunion


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=uscular complication: $raumatic myositis

i)

Salter Chapter 15

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