Complications An additional diagnosis describing a condition arising after beginning of hospital observation and treatment, thus modifying the course of the patient’s illness or the medical care required. Noun Orthopaedic dictionary
Systemic complications VS Local complications Early VS late Preventable VS Inevitable
Principal of Rx 1.Save life 2.Save limb 3.Preserve function 4.Improve cosmetic
Save life ATLS Primary servey ABCD Re-evaluation Not improved Improved To 2 nd servey
Save limb Blood supply Muscle Nerves Tendons Bone
Preserve function Painless Stable joint Solid union
How to Diagnosis History taking Physical examination Investigation – Blood – Radiographic : plain film,CT,MRI,bone scan, etc.
Limitations Unconsciousness Co morbidity : HI, Nerve injury Child Language
Systemic Complications Fat embolism syndrome o Respiratory failure and adult respiratory distress syndrome ( ARDS ) Crush syndrome
Local Complications Acute compartment syndrome Pin tract infections
Fat Embolism Syndrome / FES The presence of fat globules in the peripheral circulation and lung parenchyma after fracture of long bones, pelvis or other major trauma. Zenker ***1861
Pathophysiology 1.The Mechanical theory 2.Biochemical theory 3.Coagulation theory
Clinical Features Delay presents 12-72 hrs after the initial injury Classic triad of : – respiratory manifestations (95%) Dyspnoea, tachypnoea and hypoxaemia Respiratory failure – cerebral effects (60%) Present in the early stages Wide spectrum from mild confusion and drowsiness through to severe seizures. +/- focal neurological signs – petechiae (33%). may be the last conjunctiva, oral mucous membrane and skin folds of the upper body especially the neck and axilla.
Clinical Features cont’ Ocular manifestation – Purtscher’s retinopathy CVS involvement – Early persistent tachycardia Systemic fever
Diagnosis Base on clinical findings. Gurd’s criteria at least 1 major and 4 minor criteria Lindeque’s criteria
Lindeque’s criteria Fat embolism index Semi-quantitative means of diagnosis 7 clinical features Score of >5 is required for a positive diagnosis. Ref : Schonfeld SA, et al. Fat embolism prophylaxis with corticosteroids. Ann Intern Med 1983
Investigations To support the clinical diagnosis or to monitor therapy Hematology and Biochemistry – Anemia and thrombocytopenia – Hypocalcemia – Hypofibrinogenemia – raised ESR – prolongation of Prothrombin time
Investigations Urine and Sputum examination Arterial blood gases Chest X-ray snow storm appearance Lungs scan may show ventilation perfusion mismatch. EKG,Transesophageal echocardiography Bronchoalveolar lavage CT / MRI Brain
Treatment Medical Care Surgical Care Prophylactic treatment
Medical Care Adequate oxygenation and ventilation Stable hemodynamics Hydration Prophylaxis of deep venous thrombosis Stress related gastrointestinal bleeding and nutrition. Drugs ***inconclusive results*** supportive treatment
supportive treatment 1.Spontaneous ventilation FIO2 (inspired O2 concentration) of 50 – 80%. 2.CPAP and noninvasive ventilation added to improve PaO2 3.Mechanical ventilation and PEEP
Surgical Care Early immobilization Operative VS Conservative Limit the elevation in intraosseous pressure during orthopaedic procedures
Prophylactic treatment Albumin – Restores blood volume – Binds fatty acids and may decrease the extent of lung injury. Corticosteroid – Controversial / no significant changes in mortality Methylprednisolone 1.5mg kg-1 i.v. every 8 h for 6 doses. Ref ; MG Abbott. Fat embolism syndrome : An in-depth review. Asian Journal of Critical Care 2005
Prognosis Mortality is estimated to be 5-15% overall but most patients will recover fully.
Crush Injury and Crush Syndrome Crush injury is a direct injury resulting from crush. Crush syndrome is the systemic manifestation of muscle cell damage resulting from pressure or crushing. 1941 / Bywaters and Beall natural or manmade disaster
Pathogenesis and Clinical Features muscle cell injury leak contents out of the cells into the circulation – Myoglobin ( nephrotoxic ) – urate and phosphate ( nephrotoxic ) – potassium ( cardiotoxic )
Pathogenesis and Clinical Features muscle cell injury allows passage of water, calcium, and sodium into the cells from the extracellular space muscle swelling and intravascular volume depletion and resulting in hypovolemic shock.
Cardiovascular instability Commonly / multifactorial hypovolemic shock myocardial toxicity from the associated electrolyte disturbance
Renal failure Most serious / multifactorial Vasomotor and nephrotoxic elements Myoglobin, urate, and phosphate distal convoluted tubules and tubular cast formation tubular obstruction.
Peak creatine kinase (CK) Correlate with development of renal failure and mortality. peak CK 75,000 U/L. Oda et al. number of crushed limbs ***more practical and immediate estimate of the severity of impending crush syndrome. Crush to one, two, and three extremities led to an incidence of renal failure of 50%, 75%, and 100%, respectively.
Management In hospital catheterized and hourly urine Electrolytes, arterial blood gases, and muscle enzymes should be measured. Central venous pressure monitoring.
Fluid Physiologic normal saline large volumes 200 mL of potassium free solution per hour target urine output of at least 8 L/day level of hydration / CVP monitoring Alkalinization / sodium bicarbonate Mannitol / benefit up to 48 hours after injury 1 to 2 g/kg over the first 4 hours ( 20%solution)
Compartment syndrome Uptake of fluid into muscle cells contained within a tight compartment. Controversial Rx ? ? ? ? Mannitol / fasciotomy
Acute compartment syndrome Compartment syndrome as an elevation of the interstitial pressure in a closed osseofascial compartment that results microvascular compromise,tissue ischemia, necrosis, and functional impairment Volkmann's ischemic contracture Mubarak
Clinical diagnosis 1948, Griffiths described four main symptoms of a manifest compartment syndrome: pain, paresthesia, paresis and pain with stretch ( the ‘‘four Ps ). Pain was identified as the earliest and most sensitive clinical sign of a manifest compartment syndrome. Early recognition most important
Clinical diagnosis The most important sign is pain out of proportion to that expected with the injury Pain with passive stretch had comparable sensitivity,specificity, and predictive values.
Compartmental Pressure Monitoring Whitesides : difference between the diastolic blood pressure and tissue pressure = ΔP Tissue pressure rises to within 10 to 30 mm Hg of the diastolic pressure Persistent ΔP of less than 30 mm Hg => fasciotomy
J Trauma. 2006;60:1037–1040.
Treatment Immediate Rx Release of external limiting envelopes such as dressings or plaster casts Limb should not be elevated above the height of the heart Corrected hypotension Oxygen therapy
Treatment Fasciotomy *** time ***
Rockwood and Green’s 8 th ed.
Pin tract infection Incidence from 11.3% to 100%. N Ferreira et.al Failure of the bone-pin interface Pin loossening Failure of construct Malalignment / malunion Chronic osteomyelitis Sepsis
Classification Rockwood and Green’s 8 th ed.
Pin Care no consensus Researchers concluded that evidence was insufficient to recommend a specific technique to minimize infection and prevent complications. AMERICAN JOURNAL OF CRITICAL CARE, July 2012, Volume 21, No. 4
Frequency Immediate postoperative – compressive dressing **stabilize the pin–skin interface and minimize pin–skin motion – 10 days to 2 weeks After skin healing – daily / weekly Rockwood and Green’s 8th ed.
Santy JE, et al. The Rubber Stopper: A Simple and Inexpensive Technique to Prevent Pin Tract Infection following Kirschner Wiring of Supracondylar Fractures of Humerus in Children Malaysian Orthopaedic Journal 2015 Vol 9 No 2
Cleansing solutions Chlorhexidine 2 mg/ml 0.9% NaCl Half-strength hydrogen peroxide solutions Rockwood and Green’s 8 th ed. 70% alcohol Betadine solution ** interferes tissue healing Kramer SA. Effect of povidone-iodine on wound healing:a review. J Vasc Nurs. 2000;17(1):17-23. Mild soap and water
Dressing Immediate postoperative
Dressing After skin healing
Showering Daily showers,water flow => no major infection Gordon, et al. Pin site care during external fixation in children: Journal of Pediatric Orthopaedics, 20(2), 163–165. After 5 to 10 days. / United States and Europe Covering of the fixator during showering. W-Dahl A, et al. Pin site care in external fixation sodium chloride or chlorhexidine solution as a cleansing agent. Arch Orthop Trauma Surg. 2004;124(8):555-558.
Crusts removal ??
Recommendations =>remove the crusted material Stiffen the pin–skin interface and increase shear forces at the pin–bone interface Development of additional necrotic tissues and fluid buildup around the pin Clasper JC, et al. Fluid accumulation and the rapid spread of bacteria in the pathogenesis of external fixator pin track infection. Injury. 2001;32(5):377–381. Rockwood and Green’s 8 th ed.
ABO Ointment Not recommended for postcleansing care, as these tend to inhibit the normal skin flora and can lead to superinfection or pin site colonization Marotta JS, et al. Long-term bactericidal properties of a gentamicincoated antimicrobial external fixation pin sleeve. J Bone Joint Surg Am. 2003;85-A( Suppl 4): 129–131. Rockwood and Green’s 8 th ed
Sterile VS clean technique In hospital *** sterile At home / self – care*** clean Holmes, S. & Brown, S. (2005). Skeletal pin site care: National Association of Orthopaedic Nursing guidelines for orthopaedic nursing. Orthopaedic Nursing, 24(2), 99-107
Patient education Recommend Patient/family demonstration of pin site care before leaving the hospital. Written instructions for site care. Written description of the early signs of infection and a loose pin. Information about how to contact the orthopaedic team. W-Dahl A, et al. Pin site care in external fixation sodium chloride or chlorhexidine solution as a cleansing agent. Arch Orthop Trauma Surg. 2004;124(8):555-558.
Orthopedic pin-care protocol from Hennepin County Medical Center. in Minneapolis, Minnesota Classifies pin-site appearance and indicates the appropriate care. No redness or drainage => weekly cleansing with normal saline Slightly red => cleansing with normal saline Red and tender with a colorless watery or clear yellow drainage => cleansing with half-strength H2O2 Worsening redness,draining, or swelling => back to orthopedic clinic to start antibiotics.
Complications ≈ Bad news
Dr. Elisabeth Kübler-Ross Swiss psychiatrist On Death and Dying 1969
SPIKES model for breaking bad news Setting up the interview Perception of the patient Invitation by the patient Knowledge to the patient Emotions of the patient Strategy and summary การแจ้งข่าวร้าย
หลักการแจ้งข่าวร้าย “ SPIKES ” Setting up the interview : สถานที่ส่วนตัวและเงียบสงบไม่มีการ รบกวน Perception of the patient : การรับรู้และเข้าใจใน สถานการณ์ ทางการแพทย์กับการเจ็บป่วย อย่างไร Invitation by the patient : การได้รับคำเชิญ จากผู้ป่วยถึงความต้องการทราบข้อมูล เกี่ยวกับโรค / การตรวจ
การแจ้งข่าวร้าย Knowledge to the patient : ผู้ป่วยมีระดับความรู้เกี่ยวกับ โรคมากน้อยเท่าไร Emotions of the patient : อารมณ์ของผู้ป่วยมีการ ตอบสนองเป็นอย่างไร Strategy and summary : การใช้กลยุทธ์ที่หลากหลาย แจ้งข่าวร้าย หลักการแจ้งข่าวร้าย “ SPIKES ”