complicationoffracture-110112042527-phpapp01

8/16/2019 complicationoffracture-110112042527-phpapp01

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FRACTURESAnandkumar Balakrishna

Wong Poh SeanMohd Hanaf Ramlee


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CONTENT DEFINITION

PRINCIPLE MANAGEMENT

COMPLICATIONS


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EF!N!T!ON

A "ra#$ure is a

%reak in $hes$ru#$ural

#on$inui$& o"%one'


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CAUSES Sudden trauma

direct(fracture of the ulna caued !" !lo# onthe arm$

indirect(%iral fracture of the ti!ia and &!uladue to torion of the le' )erte!ralcom%reion fracture a)ulion fracture$

Stre or fati'ue*re%etiti)e tre(athlete

dancer arm" recruit$ Patholo'ical(oteo%oroi Pa'et+ dieae

!one tumour$


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T(PES OF FRACTURESC)OSE*S!MP)E

• noo+ening in$he skin'

OPEN*COMPOUN

• %one"ragmen$sha,e

%roken$hrough$he skin'


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COMP)ETE

• %one is#om+le$el&%roken in$o - ormore "ragmen$s'

• .eg/• $rans,erse

"ra#$ure• o%li0ue "ra#$ure

• s+iral "ra#$ure• im+a#$ed

"ra#$ure• #omminu$ed

"ra#$ure• se men$al

!NCOMP)ETE

• %one isin#om+le$el&di,ided and $he+erios$eumremains in#on$inui$&'

• .eg/• greens$i#k

"ra#$ure• $orus "ra#$ure• s$ress "ra#$ure• #om+ression

"ra#$ure'


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COMP)ETE FRACTURES


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OB)!1UEFRACTURE

SE2MENTA) FRACTURE


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SP!RA)FRACTURE

TRANS3ERSEFRACTURE


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COMM!NUTE FRACTURE

!MPACTEFRACTURE


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!NCOMP)ETE FRACTURE


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2REENST!C4

TORUS


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FRACTURES !SP)ACEMENT After a com%lete fracture the fra'ment

uuall" di%laced, %artl" !" the force of in-ur"

%artl" !" 'ra)it" %artl" !" the %ull of mucle attached to them.

/ t"%e,

Tranlation0Shift Ali'nment0An'ulation

Rotation0T#it

Altered len'th


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SHIFT ANGULATION

/TILT

TWIST/

ROTATION

S!EWA(S

O3ER)AP

!MPACT!ON


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HOW FRACTURES HEA)1 2ealin' !" callu

2ealin' #ithout callu


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Healing %& #allus

Callu i the re%one to mo)ement at thefracture ite to ta!ili3e the fra'ment ara%idl" a %oi!le.

Ste%,

Tissue des$ru#$ion and haema$oma "orma$ion'

!n5amma$ion and #ellular +roli"era$ion'

Callus "orma$ion/ dead %one is mo++ed u+ 6 7o,en%one8imma$ure9 a++ears in "ra#$ure #allus'

Consolida$ion/ 7o,en %one8imma$ure9 is re+la#ed %&lamellar %one8ma$ure9'

Remodelling/Ne7l& "ormed %one is remodelled $oresem%le $he normal s$ru#$ure'


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Healing 7i$hou$ #allus

For fracture that i a!olutel" immo!ile, im%acted fracture in cancellou !one.

fracture ri'idl" immo!ili3ed !" internal &4ation

Ne# !one formation occur directl" !et#een

fra'ment. Ga% !et#een the fracture urface are in)aded

!" ne# ca%illarie 5 !one formin' cell 'ro#in'in from ed'e.

For )er" narro# cre)ice(6788um$ oteo'enei

%roduce lamellar !one(mature$. For #ider 'a% oteo'enei !e'in #ith #o)en

!one (immature$ &rt #hich i then remodelledto lamellar !one (mature !one$.


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RATE OF REPA!R EPENS UPON/

T&+e o"%one

#an#ellous

%oneheals"as$er$han

#or$i#al%one'

T&+e o""ra#$ure

s+iral"ra#$ure heals"as$er$han

$rans,erse

"ra#$ure'

S$a$e o"%lood5o7

+oor#ir#ula$ion 7ill

slo7$he

healing

+ro#ess'

Pa$ien$:sgeneral

#ons$i$u$ion

heal$h& %oneheals"as$er'

Pa$ien$:sage

healingis

"as$erin

#hildren $hanadul$s'


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CA9SES OF E)A(E UN!ONOR NON.UN!ON OF T2E

FRACT9RESis$ra#$ion 6se+ara$ion o"$he "ragmen$s

!n$er+osi$ion o"so"$ $issues%e$7een $he"ragmen$s'

E;#essi,emo,emen$ a$$he "ra#$ure

si$e

Poor lo#al%lood su++l&

Se,ere damage$o so"$ $issues7hi#h makes

$hemnearl&*non.

,ia%le'

!n"e#$ion

A%normal%one'


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FRACT9RES*PRINCIPLE OF TREATMENT


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Mana'ement

of CloedFracture


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Firt aid managemen$ Air#a" :reathin' and Circulation

S%lint the fracture

Loo; for other aociated in-urie

Chec; dital circulation < i dital circulationatifactor"1

Chec; neurolo'" < are the ner)e intact1

AMPLE hitor"* Aller'ie Medication Pat

medical hitor" Lat meal E)ent Radio'ra%h < 7 )ie# 7ide 7 -oint 7

time.


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2eneral Resus#i$a$ion

Mani+ula$ion

8im+ro,e +osi$ion o" "ragmen$s9

S+lin$age

8hold "ragmen$s $oge$her un$il uni$e9

E;er#ise 6 7eigh$.%earing


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HoldE;er#iseRedu#e

Princi%le Of Trea$men$


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Sa"e$&Mo,eS+eedHold

The Fracture 1uar$e$

Ou$ n


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Ou$ ne

C l o s e d

F r a # $ u r e

Redu#e

ClosedRedu#$ion

Me#hani#alTra#$ion

O+enRedu#$ion

Hold

Sus$ained

Tra#$ion

Cas$S+lin$age

Fun#$ional

Bra#ing!n$ernalFi;a$ion

E;$ernalFi;a$ion

E;er#ise


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Redu#e Aim for ade=uate a%%oition and normal

ali'nment of the !one fra'ment

The 'reater contact urface area !et#een

fra'ment the more li;el" i healin' to occur


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2o#e)er there are omeituation in #hichreduction i unnecear",

>hen there i little or no di%lacement

>hen di%lacement doe not matter (e.'. inome fracture of the cla)icle$

>hen reduction i unli;el" to ucceed (e.'.#ith com%reion fracture of the )erte!rae$


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O+era$i,e

Closed redu#$ion

Me#hani#alTra#$ion

Non.o+era$i,e

O+en redu#$ion

Redu#$ion


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Cloed Reduction

Suita!le for Minimall" di%laced fracture

Mot fracture in children

Fracture that are li;el" to !e ta!le afterreduction


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Mot e?ecti)e #hen the %erioteum andmucle on one ide of fracture remain intact

9nder anaetheia and mucle rela4ation a

threefold manoeu)re a%%lied, Dital %art of the lim! i %ulled in line of the

!one

Dien'a'ed re%oitioned

Ali'nment i ad-uted


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Mechanical Traction

Some fracture (e4am%le fracture of femoralhaft$ are di@cult to reduce !" mani%ulation!ecaue of %o#erful mucle %ull

2o#e)er the" can !e reduced !" utainedmucle mechanical traction alo er)e tohold the fracture until it tart to unite


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O%en Reduction

O%erati)e reduction under direct )iion

Indication, >hen cloed reduction fail

>hen there i a lar'e articular fra'ment thatneed accurate %oitionin'

For a)ulion fracture in #hich the fra'mentare held a%art !" mucle %ull

>hen an o%eration i needed for aociatedin-urie

>hen a fracture need an internal &4ation


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NonO+era$i,

e

•

Sus$ained$ra#$ion• Cas$ S+lin$age• Fun#$ional

Bra#ing

O+era$i,e

• !n$ernalFi;a$ion

• E;$ernalFi;a$ion

2old


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2OLD

To +re,en$dis+la#eme

n$

To alle,ia$e+ain %&some

res$ri#$iono"

mo,emen$

To +romo$e

so"$.$issuehealing

To allo7"ree

mo,emen$o" $heuna


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Safet"Mo)e

S%eed

2old

Sus$ained Tra#$ion

• Traction i a%%lied to lim! dital to thefracture

• To e4ert continuou %ull alon' the lon' a4iof the !one


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• Can mo,e =oin$• Can e;er#ise musle

Ad,an$age

• Use"ul "or s+iral "ra#$ures o"long %one sha"$s/•

Sha"$ o" "emur• Ti%ia• )o7er humerus

!ndi#a$ion


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isad,an$age and #om+li#a$ions

Pa$ien$ ke+$ on %ed "or long $ime Pressure ul#er 2eneral 7eakness Pulmonar& in"e#$ion Con$ra#$ure Pin $ra#$ in"e#$ion Throm%oem%oli# e,en$

Me$hods Tra#$ion %& gra,i$& Balan#ed $ra#$ion Fi;ed $ra#$ion


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Tra#$ion B&2ra,i$&

E4am%le,

Fracture ofhumeru

>ei'ht of arm tou%%l" traction

Forearm i

u%%orted in a#rit lin'


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Tra#$ion is a++lied $o$he lim% ei$her %& 7a&o" adhesi,e s$ra++ing>ke+$ in +la#e %&%andages skintraction• Sus$ain a +ull no more $han ?.@ kg

Con$raindi#a$ions/

• A%rasion> derma$i$is> 7ound• 3as#ular insu#ien#ies• When grea$er $ra#$ion "or#e

in needed

:alanced Traction


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Thomas:s S+lin


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Tra#$ion a++lied ,ia

s$i< 7ire or +ininser$ed $hrough $he%one dis$al $o $he"ra#$ure skeletaltraction

• Can a++l& se,eral$imes as mu#h "or#e

Com+li#a$ions/

•Pin $ra#$ in"e#$ion

• amage $o e+i+h&sealgro7$h +la$e

• 3er$i#al "ra#$ure o" $he%one

• !n=ur& $o $he ,essels or

ner,es


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Fi4ed Traction

Princi%le B !alanced traction

9eful for #hen %atient ha to !etran%orted

Thoma+ %lint


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Cat S%linta'e Method,

Plater of Pari

Fi!re'la

E%eciall" for dital lim! and for motchildren

Diad)anta'e, -oint encaed in %latercannot mo)e and lia!le to ti?en

Can !e minimi3ed, Dela"ed %linta'e (traction initiall"$

Re%lace cat !" functional !race after fe##ee;


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Com+li#a$ions


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Safet"Mo)eS%eed2old

Tigh$ #as$

+u$ on$oo $igh$l&*lim% s7ells

Pressure sores e,en

a 7ell.f$$ing #as$ ma&+ress u+on $he skino,er a %on&

+rominen#e 8$he+a$ella> $he heel9

Skin a%rasion orla#era$ion during

remo,al o" $he +las$er

Com+li#a$ions


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:race

u%%orti)e de)icethat allo#continued

function of the%art

Princi%le functional lon'

!one i u%%ortede4ternall" !" POP

or !" amoulda!le %laticmaterial !ut the

function of -ointare %reer)ed

Indication fracture of haftof femur or ti!ia

Fun#$ional Bra#ing


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Functional !racin'i not ri'id

a%%lied #henfracture i!e'innin' to uniteafter a!out *#ee; of tractionor retricti)e%linta'e

Ad)anta'e,

• Fracture held reaona!l"#ell

• oint can !e mo)ed• Patient can lea)e ho%ital• Method i afe

Safet"Mo)eS%eed2old


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INTERNAL

FIATION


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Prin#i+le

Bon& "ragmen$ma& %e f;ed 7i$h/

• s#re7s>• $ransf;ing +ins or

nails>• a me$al +la$e held %&

s#re7s>

• a long in$ramedullar&nails>

• #ir#um"eren$ial %and>• or a #om%ina$ion 7i$h

$hese me$hod

I di i


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Indication

H. Fracture that #anno$%e redu#ed e4ce%t !"o%eration

7. Fracture that are

inheren$l& uns$a%leand %rone todi%lacement after

reduction

.Fracture that uni$e+oorl& and slo7l&

• Princi%all" fracture ofthe femoral nec;

?'Pa$hologi#al"ra#$ure

• :one dieae ma"%re)ent healin'

@'Mul$i+le "ra#$ure

• >here earl" &4ationreduced the ri; of'eneral com%lication

.Fracture in %atient#ho %reent se,erenursing di#ul$&


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T"%e of internal &4ation

s#re7• !n$er"ragmen$ar& s#re7 8lag s#re79 are

used "or f;ing small "ragmen$ on$o $hemain %one

7ires

• 4irs#hner 7ire 8o"$en inser$ed+er#u$aneousl& 7i$hou$ e;+osing $he"ra#$ure

• Used in si$ua$ion 7here "ra#$ure healing is+redi#$a%l& 0ui#k


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Pla$es and s#re7• Use"ul "or $rea$ing me$a+h&seal "ra#$ure o"

long %ones and dia+h&seal "ra#$ure o"radius and ulna

!n$ramedullar& nail• Sui$a%le "or long %ones• Nail is inser$ed on$o medullar& #anal $o

s+lin$ $he "ra#$ure• Ro$a$ional o" "ra#$ure are resis$ed %&

in$rodu#ing lo#king s#re7 7hi#h $ranf;$he %one #or$i#es and $he nail +ro;imal

and dis$al $o $he "ra#$ure'


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ad)anta'e

Pre#iseredu#$ion

• OR!F.

o+enredu#$ionandin$ernal

f;a$ion

!mmedia$es$a%ili$&

• Hold $he

"ra#$urese#urel&

Earl&mo,emen$

• "ra#$ure

disease likeoedema>s$i"ness>e$

# ma&a%olish


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Com+li#a$ions

!n"e#$ion

Non.union

!m+lan$"ailure

Re"ra#$ure


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I n f e

c t i o

nIatro'enic infection chronicoteom"liti

Ri; of infection de%end on,

H$The %atient de)italiedtiue dirt" #ound un&t %atient

7$The ur'eon thorou'htrainin' a hi'h de'ree ofur'ical de4terit" and ade=uateaitant are all eential

$The facilitie ae%tic routine

The infection hould !e ra%idl"controlled !" intra)enou

anti!ioticIf infection cannot !e controlledthe im%lant hould !e re%laced#ith ome form of e4ternal&4ation


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N

o n u

n i o n

Caue,

H$ e4cei)etri%%in' of ofttiue

7$ unnecear"dama'e to !loodu%%l" in the coure

of o%erati)e &4ation$ri'id &4ation #ith a'a% !et#een the

fra'ment


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!m+lan$ "ailureMe$al is su%=e#$ed

$o "a$igue

• Me$al is

su%=e#$ed $o"a$igue

• So> undues$ress should

$here"ore %ea,oided un$il$he "ragmen$has uni$ed'

• Pain a$ $he si$eo" "ra#$ure si$eis a dangersignal'


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Re"ra#$ure• !$ is im+or$an$

no$ $o remo,e$he me$al im+lan$$oo soon

• A &ear isminimum and D

$o -? mon$h issa"er

• For se,eral7eeks a"$er $he

im+lan$ remo,al$he %one is 7eakso "ull 7eigh$.%earing should%e a,oided


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ETERNALFIATION


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Indication


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IndicationFra#$ure asso#ia$ed 7i$hso"$ $issue in=ur&

• >here the #ound can !e lefto%en for in%ection drein'and de&niti)e co)era'e

Se,erel& #omminu$edand uns$a%le "ra#$ure

• >hich can !e held out tolen'th until healin'commence

Fra#$ure o" $he +el,is

• >hich often cannot !econtrolled =uic;l" !" an"other method

Fra#$ure asso#ia$ed 7i$hner,e and ,essel

damage

!n"e#$ed "ra#$ure

• >here internal &4ationmi'ht not !e uita!le

Uni$ed "ra#$ure• >here dead or clerotic

fra'ment can !e e4cied andthe remainin' end !rou'htto'ether in the e4ternal&4ator


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(a$The %atient #a &4ed #ith a %late and cre# !ut did notunite (!$ e4ternal &4ation #a a%%lied


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Ad,an$ages

$e#hni#all& 0ui#kand eas& $o

+er"orm

no so"$ $issues$ri++ing

ease o" remo,inghard7are

risk o" in"e#$ion a$$he si$e o" $he

"ra#$ure isminimal


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Com+li#a$ion

amage$o so"$$issue

s$ru#$ure

O,erdis$ra#$i

on

Pin $ra#kin"e#$ion


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• Transf;ing +ins and 7ires ma&in=ure $he ner,e and ,essel orma& $e$her ligamen$ and inhi%i$

=oin$ mo,emen$• So> $he surgeon mus$ %e

$horoughl& "amiliar 7i$h $he sa"e

#orridor: "or inser$ing $he +ins

amage $o so"$ $issues$ru#$ure


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• !" $here is no

#on$a#$ %e$7een$he "ragmen$>

union ma& %edela&ed or+re,en$ed

O,er

dis$ra#$ion


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• There is a risk o"in"e#$ion 7here $he +insare inser$ed "rom $heskin in$o $he %one'

• So> me$i#ulous +in.si$e#are is essen$ial

• An$i%io$i# should %eadminis$eredimmedia$el& i" in"e#$ion

o##ur

Pin $ra#k in"e#$ion


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E;er#ise Pre)ention of edema

acti)e e4ercie and ele)ation

Acti)e e4ercie alo timulate the circulation.

Pre)ent oft*tiue adheion and %romotefracture healin'.

Preer)e the -oint mo)ement

Retore mucle %o#er

Functional acti)it"


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Managemen

$ o"O+enFra#$ures

A %reak in skinand underl&ingso"$ $issues leadin' directl" to

#ommuni#a$ing#ith the fracture


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O%en Fracture

First Aid & Management of the WholePatient

Prompt wound debridement

Antibiotic prophylaxis

Stabilization of the fracture

efiniti!e wound co!er


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Firt Aid 5 Mana'ement of the >hole Patient

Air7a&

Brea$hing

Cir#ula$ion

8


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H. Emer'enc" Managemen$ o"O+en Fra#$ure

A>B>C S%lint the lim!

Sterile co)er * %re)ent contamination

Loo; for other aociate in-ur"

Chec; dital circulation < i dital circulation atifactor"1

Chec; neurolo'" < are the ner)e intact1

AMP)E his$or&. Aller'ie Medication Pat medical hitor" Latmeal E)ent

Radiogra+hs < 7 )ie# 7ide 7 -oint 7 time. Relie)e %ain

Tetanu %ro%h"la4i

Anti!iotic

>ahout 0 Irri'ation

>ound de!ridement

fracture ta!iliation

O+en Fra#$uresClassif#a$ion


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Classif#a$ion


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Preo+era$i,e Assessmen$

H!STOR(

Age

2eneral heal$h 6#omor%idi$ies

Al#ohol 6 drugs

Am%ula$or& s$a$us

Cause o" in=ur&

• High or lo7 energ&• Po$en$ial "or in"e#$ion• Pre,ious in=uries

PH(S!CA)

EGAM!NAT!ONAT)S

O$her in=uries

3as#ular s$a$us o" lim%• )im% #olor> +ulse> #a+illar& refllNeurologi#al s$a$us o" lim%

• Po7er> sensa$ion


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Preo+era$i,e Assessmen$

EGAM!NAT!ON OFOPEN WOUN)o#a$ion 6 e;$en$ o" $he 7ound

)eng$h o" 7ound

Num%er o" skin 7ounds

egree o" skin #on$amina$ion

RA!O)O2!CA)EGAM!NAT!ON

G.ra&/ AP>la$eral

CT 6 MR!/ o+en+el,i#> in$ra.

ar$i#ular>#ar+al> $arsal

"ra#$ures

T $ $ O $li


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Trea$men$. Ou$line

!rriga$ion

e%ridemen$/ Skin> Fa$> Mus#le>Bone

Wound #losure

Analgesi# An$i%io$i# An$i$e$anus 8AAA9/ !3> !M

Fra#$ure s$a%iliIa$ion


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9 Analgesi# An$i%io$i# An$i$e$anus Pro+h&la;is

Antitetanu

To4oid for immunied2uman antierum for non*

immunied

:road %ectrum rd 'eneration ce%halo%orin amino'l"coideGentamicin or metronida3ole for 'ram ne'ati)e or'anim.

8*J8K of o%en #ound are aociated #ith %oiti)e culturemotl" normal ora

Anal'eicPethidine0mor%hine


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An$i%io$i# Gutilo Grade I* &rt 'eneration of ce%halo%orin

for J7 hour

Gutilo Grade II* &rt 'eneration ce%halo%orinfor J7 hour Gram ne'ati)e co)era'e

('entamicin$ for at leat J7 hour Gutilo Grade III* &rt 'eneration ce%halo%orin

G


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7$ Irri'ationFluids su#h as

normal iso$oni#saline oran$i%io$i#

solu$ions

h&drogen+ero;ide

A method of #ound

cleanin' !" remo)in'de!ri mechanicall"

#ith %reuried uid.

Ad,an$ages/

• Flushes a7a&$he "oreign

ma$$er and#on$amina$ed%lood #lo$

• Hel+s inassessmen$ o",ia%ili$& o"$issues

• Redu#es%a#$erial

+o+ula$ion


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J9 e%ridemen$

All dead and #on$amina$ed$issues mus$ %e remo,ed

Per"ormed in a s&s$ema$i#manner

• Skin 6 "as#ia• Mus#les• Tendon• Bone


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Surgi#al e%ridemen$ T"%e II and t"%e III re=uire ur'ical

de!ridement.

Im%ortant a%ect of #ound

mana'ement. Reduce !acteria remo)e forei'n

!odie remo)e de)itali3ed tiue.

Remo)al of dead tiue reduce

!acterial !urden and acceleratehealin'.

?9 Wound Closure


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?9 Wound Closure

• For 7ounds less $han D hours old

a"$er de%ridemen$Primar& #losure

• Wound le"$ o+en a"$erde%ridemen$ "or -.J da&s

• !" #lean> #lose $he 7ound

ela&ed +rimar&#losure 8K@da&s9

• T&+e !!!Ano$her

de%ridemen$

• For in"e#$ed 7oundSe#ondar& #losure

• Par$ial $hi#kness• Full $hi#kness

Skin gra"$ing


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>ound Cloure

9ncontaminated I 5 II can !e utured <%ro)ided #ithout tenion

All other #ound left o%en %ac;ed #ith

moit terile 'au3e to !e in%ected 7/*/hour < %rimar" dela"ed cloure

If #ound cannot !e cloed #ithout tenion <;in 'raftin'

@9 F $ S$ %ili $i


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@9 Fra#$ure S$a%iliIa$ion

•A #indo# i made in the %later o)er the#ound for drein'Immo!iliationin a %later

• E'. o%en fracture of ti!iaS;eletaltraction

• Can !e eail" a%%lied• Readil" reduced and ad-uted• >ound can !e aeed for drein'• E4cellent ta!ilit"

E4ternal&4ator

• Rarel" uedInternal &4ator


93/160

S$a%iliIa$ion o" $he "ra#$ure To reduce infection and ait reco)er" of oft

tiue

De%end on, de'ree of contamination

len'th of time from in-ur" to o%eration amount of oft tiue dama'e

If 6 hour, u% to IIIA treated a cloed fracture, S%linta'e

Intramedullar" nailin' Platin'

E4ternal &4ation

Other, E4ternal &4ation


94/160


95/160

Earl& )a$e

G l Sh ; C h S d


96/160

General Shoc;Di?ue Coa'ulo%ath" Tetanu

Re%irator" D"functionDT 5 Pulmonar" Em!.Fat Em!oli S"ndrome

Cruh S"ndromeChet Infection9rinar" Tract Infection

Ga Gan'rene

:one Infection Non*union 0 Mal*union 0 Dela"edunionA)acular Necroi

Len'th dicre%anc"Diue Oteo%oroi

oint 2aemarthroiLi'ament in-ur"

Inta!ilit" 0 Mal*ali'nmentOteoarthritiSti?neO)erue in-urie

Soft Tiue

Plater Sore Tendon Ru%tureNeuro)acular In-ur"Com%artment S"ndromeiceral in-ur"

Ner)e com%reionol;mann+ contracture:edoreM"oiti Oi&can Tendiniti 5 Tendon ru%ture

2ENERA)

BONE O!NT

SOFT T!SSUE

2eneralCom+li#a$ion


97/160

Com+li#a$ions

H. Shoc;

7. Di?ue coa'ulo%ath"

. Re%irator"d"function

/. Cruh "ndrome

. enou throm!oi 5Pulmonar" em!olim

. Fat em!olimJ. Ga Gan'rene

. Tetanu

G l H Sh k


98/160

General H, Sho#k Al$ered +h&siologi# s$a$us 7i$h generaliIed

inade0ua$e $issue +er"usion rela$i,e $ome$a%oli# re0uiremen$s' irre,ersi%le

damage $o ,i$al organs

• dire#$ in=ur& $o hear$ e


99/160

@.ml

.Jml

.-ml

.-ml

@.Jml

@.Jml

3O)UME !STR!BUT!ON

General H Sho#k


100/160

General H, Sho#k Wh& 7e need $o $rea$

sho#k

• Blood reditri!ution• Renal hutdo#n• !n$es$inal ichemia• Tiue h&+o;ia• Meta!olic a#idosis• Reduced he+a$i# %lood

o#• Acute Res+ira$or&

is$ress S"drome

• Altered #ons#iousness

Ho7 $o manage sho#k

• Identif", Thirs$> ra+idshallo7 %rea$hing> $heli+s and skin are +aleand $he e;$remi$ies

"eel #old> im+airedrenal "un#$ion $es$ andde#reased urinar&ou$+u$'

• A:C• I line, uid and !lood

• O4"'enation0entilation• 9rinar" Catheter• Central enou Preure• Ionotro%ic dru'

General 7, !FFUSE


101/160

COA2U)OPATH(

Conum%ti)eCoa'ulo%ath"

• acti)ation !"

tiuethrom!o%latin• endothelial in-ur"

acti)atin'%latelet

• mai)e !loodtranfuion

Mana'ement

• Sto% the !leedin'

• Freh Fro3enPlama (FFP$• Cr"o%reci%itate• Platelet

tranfuion• 2e%arin

General , RESP!RATOR((SFUNCT!ON


102/160

(SFUNCT!ON

Patho%h"iolo'"• Al)eolar edema• endothelial

in-ur"• ca%illar"

%ermea!ilit"• Poor lun'

com%liance

• inacti)atedurfactant

• Arterialh"%o4emia

Mana'ement• O4"'enation• entilation• %oiti)e end

e4%irator"%reure (PEEP$


103/160

General /, Crush S&ndrome[traumatic rhabdomyolitis]

Serious medi#al #ondi$ion

#hara#$eriIed %& ma=or sho#k 6renal "ailure "ollo7ing a #rushing

in=ur& $o skele$al mus#les or

$ourni0ue$ le"$ $oo long

When

#om+ression

released

M&ohaema$in release"rom #ells

Ne+hro$o;i# e

uremia>me$a%oli#a#idosis

B&7a$ers: S&ndrome


104/160

General /, Crush S&ndrome

Clinicall"

• Shoc;• Pulele lim! redne

#ellin'• Lo of mucle enation

and %o#er• Decreae renal ecretion• 9remia acidoi• Pro'noi• If renal ecretion return

#ithin H #ee; the %atient

ur)i)e• :ut mot of them die

#ithin H/ da"

Mana'ement

• PRE3ENT!ON• Strict tourni=uet timin'

• Am+u$a$ion• lim! cruhed e)erel"

• tourni=uet left on Q hr• a!o)e ite of com%reion

5 !efore com%reionreleaed

• Monitor inta;e 5 out%ut• Dial"i

• Correct electrol"te 5acidoi

• Anti!iotic


105/160

General , ee+ ,ein $hrom%osis

and +ulmonar& em%olism' ircho#+ triad factor Clot formation

in lar'e )ein throm!u !rea; o? Em!oli

Site, le' thi'h and %el)ic )ein.

Ri; factor,

nee and hi%re%lacement

Elderl" Immo!ilit" Mali'nanc"

Cardio)acular dieae

Trauma2"%ercoa'ula!le tatu

General , Managemen$ ee+ ,ein


106/160

General , Managemen$ ee+ ,ein$hrom%osis and +ulmonar&

em%olism'

PREENTION

Correct h"%o)olemia

Calf mucle e4ercie Pro%er %oitionin'

>ell &ttin' !anda'e 5cat

Lim! ele)ation

Graduated com%reiontoc;in'

Calf mucle timulation

Anticoa'ulation

Am!ulate %atient

Eta!lihedthrom!oi0em!olim Lim! ele)ation

2e%arini3ation

Throm!ol"i

O4"'enation or)entilation


107/160

General , Fa$ Em%olism

Fa$ glo%ules "rom marro7 +ushed in$o#ir#ula$ion %& $he "or#e o" $rauma $ha$

#ausing em%oli# +henomena

Fra#$ures$ha$ mos$o"$en#ause FES

• )ong%ones

• Ri%s

• Ti%ia• Pel,is

Closed*o+en Fra#$ure

Fa$ in%onemarro7es#a+e

Forma$iono" "a$glo%ules in

,essels

Fa$em%olus

S$i#k in$arge$organ

Triad o"s&m+$oms

l % li


108/160


Triad of S"m%tom

• Brain/ mentalconfuion

• )ung/!reathleneARDS

• Skin/ Petechia

Mana'ement

• Pre)ent h"%o4emia• o4"'enation or

)entilation• Rule out head

in-ur"• CT Scan of !rain

• Monitor uid 5electrol"te !alance• CP urinar"

catheter



109/160

S4!N/ Fa$ dro+le$s o%s$ru#$ al,eolar

#a+illaries $hrom%o+las$in release #onsum+$ion o"#oagula$ion "; 6

+la$ele$s !3C*Skinne#rosis Pe$e#hia

)UN2/ Fa$ dro+le$s o%s$ru#$ al,eolar

#a+illaries $hrom%o+las$inrelease al$er

mem%rane+ermea%ili$& * lung

sur"a#$an$ oedema res+ira$ior& "ailure

Q3*1 Misma$#h

BRA!N/ Fa$ dro+le$s o%s$ru#$ #a+illaries

#on"usion #oma*f$s dea$h


110/160

General J, 2as 2angrene

Ra+id and e;$ensi,e ne#rosis o" $he mus#lea##om+anied %& gas "orma$ion and s&s$emi#$o;i#i$& due $o #los$ridium +er"ringens

in"e#$ion

Clinical Feature

• udden onet of %ainlocali3ed to the infectedarea.

• #ellin' edema• 0* %"re4ia• %rofue erou dichar'e

#ith #eetih and mou"odor .

• Ga %roduction

Mana'ement

• earl" dia'noi .• ur'ical inter)ention and

de!ridement are themainta" of treatment.

• I anti!iotic• uid re%lacement.• h"%er!aric O4"'en


111/160

General J, 2as 2angrene

Pre,en$ion/ A)) EA T!SSUEQ?C SHOU) BE COMP)ETE)(

EGC!SE>

General Te$anus


112/160

General , Te$anus

A #ondi$ion a"$er #los$ridium $e$ani in"e#$ion$ha$ +asses $o an$erior horn #ells 7here i$f;ed and #an$ %e neu$raliIed la$er +rodu#esh&+er.e;#i$a%ili$& and re5e; mus#le s+asm

Clini#al Fea$ures• Toni# and #loni#

#on$ra#$ions o" es+' =a7> "a#e> around $he7ound i$sel" >ne#k>$runk> fnall& s+asm o"$he dia+hragm andin$er#os$al mus#lesleads $o as+h&;ia anddea$h'

Managemen$• Pro+h&la;is• Trea$men$• An$i$o;in 6 an$i%io$i#• Mus#le rela;an$

• Tra#heal in$u%a$ion• Res+ira$ion #on$rol

Earl&Com+li#a$ion


113/160

+s

' 3is#eral !n=ur&

-' 3as#ular !n=ur&

J' Com+ar$men$S&ndromes

?' Ner,e in=ur&

@' Haemar$hrosis

' !n"e#$ion


114/160

Earl" H, 3is#eral in=ur&

Fracture around the trun; areoften com%licated !" )iceralin-ur". E.'. Ri% "ra#$ures

%neumothora4 0 %leen trauma 0li)er in-urie.

E.'. Pel,i# in=uries !ladderor urethral ru%ture 0 e)erehematoma in the retro*%eritoneum .

R4, Sur'er" of )iceral in-urie


115/160

Earl" 7, 3as#ular in=ur& Commonl" aociated #ith hi'h*

ener'" o%en fracture. The" are rare!ut #ell*reco'ni3ed.

Me#hanism o" in=uries/ The arter" ma" !e cut or torn.

Com%reed !" the fra'ment of !one. normal a%%earance #ith intimal

detachment that lead to throm!uformation.

e'ment of arter" ma" !e in %am.

It ma" caue Tranient diminution of !lood o#

Profound ichaemia

Tiue death and 'an'rene

l l i =


116/160

Earl" 7, 3as#ular in=ur&

@ P : s o "

i s # h

e m i a

Pain

Pallor

PulselessParal&sis

Paraes$hesia

G.ra&/ u''et hi'h*ri; fracture.Angiogram hould !e %erformed to con&rm dia'noi.

l 7 l i =


117/160

Earl" 7, 3as#ular in=ur&

mucle ichaemic iirre)ei!le after hour. Remo,e all !anda'e

and %lint 5 ae

circulation Skele$al s$a%iliIa$ion

< tem%orar" e4ternal&4ation.

De&niti)e ,as#ular

re+air. eel utured

endarterectom"

3essel !n=ur&su%#la,ian

s$ ri% "ra#$ure

A;illar& Shoulder dislo#a$ion

Bra#hial Humeralsu+ra#ond&lar"ra#$ure

Bra#hial El%o7 dislo#a$ion

Presa#ral andin$ernalilia#

Pel,i# "ra#$ure

Femoral Femoralsu+ra#ond&lar"ra#$ure

Po+li$eal 4nee dislo#a$ion

Po+li$eal

or i$s

Pro;imal $i%ial

"ra#$ure

E l C $ $ S d


118/160

Earl" , Com+ar$men$ S&ndrome

)eg

• ? #om+ar$men$s/an$erior> la$eral>su+erf#ial and dee+

+os$erior• NOT in$er#onne#$ed

Forearm

• J #om+ar$men$s/dorsal> su+erf#ialand dee+ ,olar

• in$er#onne#$ed>hen#e "as#io$om& o" #om+ar$men$ ma&de#om+ress $heo$her -

A #ondi$ion in 7hi#h in#rease in +ressure7i$hin a #losed "as#ial #om+ar$men$ leads $ode#reased $issue +er"usion'

Un$rea$ed> +rogresses $o $issue is#haemiaand e,en$ual ne#rosis

E l C $ $ S d


119/160


Mos$ #ommon si$es 8in "re09/ le' (afterti!ial fracture$ forearm thi'h u%%er arm.Other ite, hand foot a!domen 'luteal andcer)ical re'ion.

High risk in=uries/ of el!o# forearm !one and %ro4imal rd of

ti!ia (8*J8K after ti!ial $

multi%le fracture of the foot or hand

cruh in-urie

circumferential !urn



120/160

Earl" , Com+ar$men$ S&ndromeQae$iolog&

Com%artmental )olume (uid content$

• Trauma < fracture

0oteotomie cruh in-ur"• 3as#ular < haemorrha'e

%ot*ichaemic #ellin'• So"$ $issue in=ur& < !urn

%rolon'ed lim!com%reion

•!a$rogeni# < intraoeouuid reucitation inchildren intraarterial dru'in-ection

• E4treme mus#ulare;er$ion

U Com%artment )olume(contriction of the

com%artment$

• Contricti)e

drein'0%later cat• Thermal in-urie #ith

echar formation• Pneumatic antihoc;

'arment (MAST$• Sur'ical cloure of facial

defect

3i#ious #le



121/160

↑ fluid content "onstriction of compartment

# $%'A"(MPA'M)%A* P')SS+')

O!truct )enou return

acular con'etion

Further # intracompartmental

pressure, capillary perfusion

Mucle and ner)eis#haemia

Ca%illar" !aementmem!rane !ecome

lea;" - oedema

Com%romie arterial circulation

- PROGRESSIE NECROSIS OF M9SCLES AND NERES VV


122/160

Se0uen#e s$ar$ed 7i$h/

se,ere +ain*%urs$ing sensa$ion8earl&9

+araes$hesia*h&+oaes$hesia

mo$or 7eakness

loss o" +eri+heral +ulses and#a+illar& refll 8la$e signs> +oor+rognosis9

A !icious circle that ends after ./ hours or less


123/160

A !icious circle that ends after ./ hours or less

%ecrosis of the ner!e and muscle within the compartment

%er!e

0capable to regenerate

Muscle

0infarcted

%e!er reco!er

'eplaced by inelastic fibrous tissue

1 2ol3mann4s ischaemic contracture5

In)eti'ation of #om+ar$men$


124/160

In)eti'ation of #om+ar$men$s&dromes !n$ra.#om+ar$men$ Pressure

Measuremen$ 8!CP9 9e of lit catheter =uic; and ea"

Indication, 9nconciou %atient

Thoe #ho are di@cult to ae

Concomitant neuro)acular in-ur"

E=ui)ocal "m%tom

E%eciall" lon' !one in lo#er lim! Perform a oon a d4 conidered

Q /8mm2' < ur'ent R4V (normal 8 < H8 mm2'$


125/160

In)eti'ation of #om+ar$men$ s&ndromes

O$her !; limi$ed ,alue ,e onl& 7henCS is ad,an#ed Plama creatinine and CP

9rinanal"i < m"o'lo!inuria

Ner)e conduction tudie

!; $o es$a%lish underl&ing #ause ore;#lude di


126/160

Mana'ement

Prom+$ ECOMPRESS!ON of a?ectedcom%artment

Remo)e all !anda'e cat and drein'

E4amination of #hole lim!

Lim! hould !e maintained at hear$ le,el Ele)ation ma" U arterio*)enou %reure

'radient on #hich %erfuion de%end

Enure %atient i normo$ensi,e.

2"%otenion U tiue %erfuion a''ra)ate thetiue in-ur".


127/160

Mana'ement Meaure intra*com%artment %reure

!" V ?mmHg Immediate o%en faciotom"

!" K ?mmHg Cloe o!er)ation and re*e4amine o)er ne4t hour

If condition im%ro)e re%eated clinical e)aluationuntil dan'er ha %aed

on:$ 7ai$ "or $he o%,ious sings o" is#hemia $o a++ear' !" &ou sus+e#$An im+ending #om+ar$men$ s&ndrome> s$ar$ $rea$men$ s$raigh$a7a&


128/160

Faciotom"

O%enin' all / com%artment Di)ide ;in and dee% facia for the #hole

len'th of com%artment >ound left o%en In%ect da" later If mucle necroi do de!ridement If health" tiue for dela"ed cloure or ;in

'raftin'


129/160

C li i


130/160

Com+li#a$ions ol;mann+ ichaemic #on$ra#$ure Motor0enor" def#i$s idne" failure from rha%dom&ol&sis (if )er" e)ere$ !n"e#$ion < faciotom" con)ert cloed to o%en )oss o" lim% ela& in %one union

Prognosis

e4cellent to %oor de%endin' on ho# =uic;l" CSi treated and #hether com%lication de)elo%

Earl" /, Ner,e !n=ur&


131/160


It+ more #ommon thanarterial in-urie.

The mot commonl" in-uredner)e i the radial ner,eWin it 'roo)e or in the lo#er third

of the u%%er arm e%eciall" ino!li=ue fracture of the humeruX

Common #ith humerus>el%o7 and knee fracture

Mot ner)e in-urie are due

to $ension neuro+ra;ia.

ner)e In-ur"

A4illar" H. Shoulderdilocation

Radial 7. 2umeral haftfracture

Median . Lo#er end ofradiu

Radial ormedian(ant.interoeou$

/. 2umeralu%racond"lar(e%. children$

9lnar . Medial cond"le

9lnar . El!o# dilocation

Sciatic J. 2i% dilocation

Peroneal . nee dilocation

Peroneal . Fracture of&!ular nec;



132/160


Dama'ed !" laceration traction %reureor %rolon'ed ichaemia

Neura+ra;ia

• a;on remainsin$a#$ %u$#ondu#$ion#eases due $osegmen$aldem&elina$ion'

S+on$aneousre#o,er& in a"e7 da&s or7eeks

A;ono$mesis

• a;onalse+ara$ion7i$hdegenera$iono" dis$al+or$ions'

Shea$hremains in$a#$>$hus re#o,er&likel& %u$dela&ed

Neuro$mesis

• ner,e#om+le$el&di,ided'S+on$aneousre#o,er&unlikel&'



133/160


Clini#al "ea$ures Num!ne and

#ea;ne

S;in mooth and

hin" !ut feel dr" Mucle #atin'

and #ea;ne

Senation !lunted

Tinel+ i'n )e

!n,es$iga$ions Electrom"o'ra%h"

Ner)e conduction tud"

Ma" hel% to eta!lihle)el and e)erit" of

leion



134/160


O%en in-urie

• E4%loration• Cleanl" di)ided < re%air

immediatel"

• Torn0cruhed < left aloneor end li'htl" tac;edto'ether re*e4%lore 7 < #ee; later for cartiue remo)al anduturin'

Cloed in-urie

• 9uall" ner)e heathintact

• Rate of a4onal

re'eneration BHmm0da"• If no i'n of reco)er" <

re*e4%loration #ithe4ciion of car tiueand uturin' of clean*

cut end ner)e 'raftin'if 'a% too lar'e

• S%lintin' * #ee;then %h"iothera%"

E l H $h i


135/160

Earl" , Haemar$hrosis :leedin' into a -oint %ace.

Occur if a -oint i in)ol)ed inthe fracture.

Preentation,

#ollen tene -oint the %atientreit an" attem%t to mo)in' it

treatment, !lood a%iration !efore dealin'

#ith the fracture to %re)ent the

de)elo%ment of "no)ialadheion.

Earl" !NFECT!ON


136/160

Earl" , !NFECT!ON

Closed "ra#$ures < hardl" e)er O+en "ra#$ures < ma" !ecome infected Pos$ $rauma$i# 7ound < ma" lead to

chronic oteom"eliti

Clinical feature

• #ound i inammed• drainin' ero%urulent

uid

Treatment

• anti!iotic• e4cie the de)italied

tiue• tiue o%ened 5

drained the %u

)a$eCom+li#a$ions


137/160

s

H. Dela"ed 9nion

7. Non*union

. Mal*union/. A)acular Necroi

. Oteoarthriti

. oint Sti?ne


138/160

Late H, E)A(E UN!ON

9nion of the u%%er lim! * /*#ee;

9nion of the lo#er lim! * *H7#ee;(rou'h 'uide$

An" %rolon' time ta;en iconidered dela"ed


139/160


140/160

Late H, E)A(E UN!ON Factor are either !iolo'ical or !iomechanical

:iolo'ical , Poor !lood u%%l"

Tear of %erioteum interru%tion of intramedullar"

circulation Necroi of urface and healin' %roce #ill ta;e lon'er

Se)ere oft tiue dama'e Mot im%ortant factor

Lon'er time for !one healin' due le inammator" cellu%%l"

Infection, !one l"i tiue necroi and %u

Perioteal tri%%in' Le !lood circulation to !one


141/160

Mechanical O)er*ri'id &4ation*&4ation de)ie

Im%erfect %linta'e E4cei)e traction create a 'a%(dela"

oi&cation in the callu$

Late H, E)A(E UN!ON

L H E)A(E UN!ON


142/160

Clinical feature, Tenderne %erit

Acute %ain if !one i u!-ected to treY

( Y a; %t to #al; mo)e a?ected lim!$

RAZS *)ii!le line and )er" little callu

formation0%erioteal reaction

* !one end are not cleroed0 atro%hic

(it #ill e)entuall" unite$

LateH, E)A(E UN!ON

L H E)A(E UN!ON


143/160

T4, coner)ati)e and o%erati)e Eliminate %oi!le caue of dela"

Promote healin' Immo!ili3ation hould !e u@cient to %re)ent mo)ement

at ite(cat 0 internal &4ation$ Not to ne'lect loadin' o encoura'e mucle e4ercie

and #ei'ht !earin' in the cat0!race

O%eration Q mth 5 no i'n of callu formation

Internal &4ation and !one 'ra?tin'

(o%eration*leat %oi!le dama'e to the oft tiue$

Late H, E)A(E UN!ON

L t 7 NON UN!ON


144/160

Late 7 , NON.UN!ON In a minorit" of cae dela"ed union**non*union

Factor contri!utin' to non*union,* inade=uate treatment of dela"ed union

too lar'e 'a%

inter%oition of oft tiue !et#een the fra'ment The 'ro#th ha to%%ed and %ain diminihed*

re%laced !" &!rou tiue * %eudoarthroi

Treatment ,*

coner)ati)e 0 o%erati)e atro%hic non*union < &4ation and 'raftin'

h"%ertro%hic non*union < ri'id &4ation

L t 7 NON UN!ON


145/160

Late 7, NON UN!ON !one end are rounded o? or e4u!erant

2"%ertro%hic non union :one end are enlar'ed oteo'enei i till

acti)e !ut not ca%a!le of !rid'in' the 'a%

[ele%hant feet+ on ra"

Atro%hic non union Ceation of oteo'enei

No u''etion of ne# !one formation


146/160

Non.unionG. ra&

A A$ro+hi# non.union

B H&+er$ro+hi# non.union

A :

L t 7 N i


147/160

Late 7, Non union T4,

Motl" "m%tomle

Coner)ati)e Remo)a!le %lint

For h"%ertro%hic non*union functional !racin'*induceunion

Puled electroma'netic &eld and lo# fre=uenc" %uledu0 can alo !e ued to timulate union.

O%erati)e 2"%ertro%hic**Ri'id &4ation (internal or e4ternal$

Atro%hic**E4ciion of &!rou tiue clerotic tiue at !oneend !one 'raft %ac;ed around the fracture


148/160


149/160

L t MA)UN!ON


150/160

Late , MA)UN!ON

Factor,* failure to reduce the fracture

failure to hold the reduction #hile healin'%roceed

'radual colla%e of comminuted 0 oteo%orotic!one

fra'ment that are -oinedin an unatifactor"%oition

MA)UN!ON


151/160

Late Mal union


152/160

Late , Mal.union *ra" are eential to chec; the %oition of

the fracture #hile unitin'. im%ortant* the &rt #ee; o it can !e eail" corrected

Clinical feature, Deformit" uuall" o!)iou !ut ometime the

true e4tent of malunion i a%%arent onl" on 4*ra"

Rotational deformit" can !e mied in the femurti!ia humeru or forearm unle i com%ared#ith it+ o%%oite fello#

Treatment i i % $ $h d "


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e#ision a%ou$ $he need "or re.mani+ula$ion and #orre#$ion.di#ul$

!n adul$s Fra#$ure.redu#ed as near $o $he ana$omi#al +osi$ion as+ossi%lea++osi$ion "or healing

alignmen$ and ro$a$ion is im+or$an$ "or "un#$ion

Angula$ion8V.@9 in long %one or a++aren$ ro$a$ional

de"ormi$& ma& need #orre#$ion %& re.mani+ula$ion or %&os$eo$om& and in$ernal f;a$ion

!n #hildren angular de"ormi$& near $he %one ends o"$en remodel 7i$h$imeRo$a$ional de"ormi$& 7ill no$

!n lo7er lim%

shor$ening

Shor$ening less $han - #m/ #om+ensa$ed %& shoe raise

Shor$ening more $han - #m/ lim% leng$hening should %e#onsider'

)ong $erm e


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Late /, A3ASCU)AR NECROS!S

Certain re'ion*;no#n for their %ro%enit" tode)elo% ichaemia and !one necroi

2ead of femur

Pro4imal %art of ca%hoid

Lunate

:od" of talu (Actuall" thi i an earl" com%lication ho#e)er

the clinical and radiolo'ical e?ect are not een

until #ee; or e)en month$ No clinical feature of a)acular necroi !ut if

there i a failure to unite or !one colla%e*%ain


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A :

The cardinal X-ray feature – increased bone density in the weight-

bearing part of the joint(new bone ingrowth in necrotic segment)

Treatment,


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Treatment,*

A)acular necroi can !e %re)ented !" earl"reduction of uce%ti!le fracture anddilocation.

Arthro%lat" * Old %eo%le #ith necroi of the

femoral head. Reali'nment oteotom" or arthrodei * for

"oun'er %eo%le #ith necroi of the femoralhead

S"m%tomatic treatment for ca%hoid or talu

Late , OSTEOARTHR!T!S


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Late , OSTEOARTHR!T!S A fracture*-oint ma" dama'e the articular

cartila'e and 'i)e rie to %ot traumaticoteoarthriti #ithin a %eriod of month.

E)en if the cartila'e heal irre'ularit" of the

-oint urface ma" caue locali3ed tre ando %redi%oe to econdar" oteoarthriti"ear later


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Late , O!NT ST!FFNESS


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Late , O!NT ST!FFNESS Commonl" occur at the -oint cloe to

malunion or !one lo e', ;nee el!o#houlder

Caue of -oint ti?ne

haemarthroi lead to "no)ial adheion oedema and &!roi

adheion of the oft tiue

>oren !" %rolon' immo!ili3ation

Treatment %re)ented #ith e4ercie

%h"iothera%"

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T2AN ZO9VVVV

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