• Bed sores commonly occur in elderly and
paralysed patients.
• The skin over the sacrum and heels is
especially vulnerable Bed Sores
• Careful nursing and early activity can usually
prevent bed sores
• Heterotopic ossification in the muscles occurs after an
injury
– Dislocation of the elbow
– Severe contusion to brachialis, deltoid or quadriceps
• It may occur without a local injury in unconscious or
🔹
paraplegic patients
Clinical features
• Pain Myositis Ossificance
• Local swelling
• Soft tissue tenderness
🔹
• Limitation of joint movement
X-ray
• Fluffy calcification in soft tissues by 3 weeks
• Bony mass by 8 weeks
• Early bone scan usually shows increased activity
This complication follows arterial injury or compartment syndrome due
🔹
to ischaemic contracture of affected muscles
Common sites
• Forearm and hand
🔹
• Leg and foot
Clinical features
• Deformity and stiffness at hand and foot
• Muscle wasting
• Occasional numbness
• Clawing of fingers or toes In the wrist and hand:
• If the wrist extended the IPJs are forced into flexion Volkmann Ischaemic Contracture
🔹
• If the wrist is flexed the IPJs can be extended
Treatment
• Detachment of flexors origin and along the interosseousmembrane may
improve deformity
• Tendon transfer (e.g. wrist extensors to finger and thumb flexors)
🔹 Common sites of nerve compression and entrapment:
• Radial palsy due to faulty use of crutches
• Ulnar nerve due to valgus deformity of the elbow
• Carpal tunnel syndrome
• Gyon canal syndrome
• Common peroneal nerve compression following fracture neck
fibula or poorly placed short leg cast
🔹 Clinical features
🔹
• See the lecture of peripheral nerve injuries
Treatment
• Early decompression
Nerve Entrapment
• Anterior transposition of the ulnar nerve Philosophy of Care
🔹 Factors go into treatment decision
– Necessary
– Effective
– Benefits vs. risks and psychological effect
🔹 Responsibilities of the physician
• Establish Correct Diagnosis:
– Local proper examination
• Improper reduction of a fracture may lead to tendon friction, – General musculoskeletal screening
tendinitis and rupture. • Identify Treatable Conditions and have Potential to Cause
• Chronic tendinitis and late rupture of the rotator cuff following Disability
improper reduction of a fracture of the greater tuberosity of • Develop high suspicion index of possible complication
humerus • Communicating the findings to the patient
• Tendinitis and late rupture of the long head of the biceps after a
fracture of the neck of humerus Tendinitis and Tendon Rupture
• Rupture of extensor pollicislongus tendon may occur 6-12 weeks
🔹
after a fracture of the lower radius (e.g. Colles’ fracture).
Treatment
• Tendon repair
• Tendon transfer
• No treatment
• Systemic reduction in tissue perfusion
• Failure to correct the systemic tissue
Non-Union perfusion may lead to irreversible shock and
• The fracture fragments show no evidence of union.
• The fragments are still mobile at the fracture site with no or minimal pain. 🔸
permanent damage to body organs.
Types of post-traumatic shock:
🔹
• The gap becomes a type of pseudoarthrosis.
Causes (CASS) Shock 1. Hypovolemic shock
2. Neurogenic shock
• Contact
• Alignment Delayed Union Late Local 3. Cardiogenic shock
4. Septic shock
• Stability
🔹
There is no absolute time beyond which a fracture is in a state of delayed union. Complications 5. Anaphylactic shock
🔹
• Stimulation Criteria for delayed union 3-4 months after injury: 6. Spinal shock
• pain on stress• Mobile fragments
Radiographs
• A visible fracture line with increased gap• Fracture ends show exuberant
calcified callus and rounded ends in hypertrophic non-union.
🔹 Causes:
1. Inadequate blood supply
• Fracture ends show atrophy with tapered sclerotic ends in atrophic non- 2. Severe soft tissue damage
union. 3. Periosteal stripping
4. Infection
Mal-union
🔹
Treatment 5. Incorrect splint
• Malunion is the union of a fracture in unaccepted position: Conservative Treatment a) Persisting mobility
b) Over traction
🔹
– Angulation– Overlapping– Rotation • Functional bracing in lower limb non-united fractures
Cause: • Pulse electromagnetic fields 6. Intact fellow bone in the forearm or leg
• Low frequency pulsed ultrasound These methods may provide good 7. Patient related factors Disseminated Intravascular Coagulopathy
– Failure to reduce a fracture Coagulopathy is common after major trauma when micro-vascular
🔹
– Failure to maintain a reduced fracture results with hypertrophic type but with prolonged splintage
. 🔹 Clinical Features -union 🔸
bleeding occurs due to deprivation or dilutions of clotting factors.
Clinical features
• Bony deformity 🔹 Surgical Treatment • Tenderness Causes:
1. Massive transfusion The replacement of greater than one
🔹
• Joint deformity • In hypertrophic type: • Pain on stress
Radiographs circulating blood volume (approximately 10 u of blood) in less than
• Rotational deformity of the limb may be missed unless – Internal or external fixation with compression (maintain good alignment) 24 hours
🔹
compared with the other. • In atrophic type: • A visible fracture line
• Incomplete callus 2. Dilution of coagulation factors through the infusion of products
X-ray – Remove intervening fibrous tissue
• Low periosteal reaction deficient in these factors (e.g. packed red blood cells, crystalloids
• Reveals union in a displaced position – Excise bony sclerotic ends
• The bone ends are not sclerotic or atrophic as in non-union and colloids).
– Bone grafting
– Internal fixation 🔹 Treatment
• Ensure proper immobilization
3. The release of tissue thromboplastins into the circulation due to
severe injury and blood loss
• Encourage fracture loading
– Muscle exercises
– Weight bearing (Gradual) (DIC) 🔸 Consequences
• Excessive bleeding
• Surgical treatment if union is delayed for > 6 months
– Bone grafting • Organ dysfunction
– Proper fixation with minimal soft tissue damage • Haemolysis
🔸
• Disseminated thrombosis.
Clinical features
• Restlessness
• Confusion and neurological dysfunction
• Skin infarcts
• Oliguria and renal failure
• Excessive bleeding at operation
• Oozing drip sites and wounds
🔹
• Ischaemia and bone necrosis after injury
Common sites
– The head of the femur
• Spontaneous bruising
🔸
• Gastrointestinal bleeding and haematuria
Treatment
– The proximal part of the scaphoid Avascular Necrosis • Fresh frozen plasma
– The lunate bone • Platelets
– The body of the talus • Heparin
🔹
• A joint may give way following an injury
Causes
• Ligamentous injury
During the later stages of shock and septicemia,
endothelial cell damage and increased small - vessel
permeability lead to extravasation of hemorrhagic,
• Muscle weakness and imbalance protein rich fluids into the pulmonary interstitial
• Bone loss tissue and alveoli.
• Recurrent dislocation
– Glenohumeral joint
Instability Adult Respiratory
Distress Syndrome 🔸 Prevention:
• Prevent shock
– Patellofemoral joint
• Patients complaining of persistent discomfort or 🔸 Treatment:
Oxygen and ventilation
weakness after injury as in chronic carpal instability
Do not over transfuse with crystalloid
• Joint stiffness commonly occurs in the knee, elbow,
🔸 Clinical Picture
🔹
shoulder and (worst of all) small joints of the hand
Causes:
• The joint itself injured with haemarthrosis that leads to
• Shock / Drowsy
• Pulseless limb with redness and tense swelling
synovial adhesions. • Loss of muscle power
Stiffness • A serious medical condition characterized by major shock and renal failure. • Sensory loss
• Oedema and fibrosis of the joint capsule, ligaments and • It occurs when a large bulk of skeletal muscles is crushed or when a
surrounding muscles • Decreased renal secretion
tourniquet has been left too long. • Uremia and acidosis
• Prolonged immobilization makes joint stiffness worse,
particularly if the joint is immobilized in a position where the
• It is a re-perfusion injury seen after the release of crushing pressure, there
will be release of muscular breakdown products as acid myohematin
🔸 Prognosis
• The patient survive if renal function returns within one week.
ligaments in their shorter length (cytochrome C) which have nephrotoxic effect on the kidney and block the
Crush Syndrome • Most patients die within 14 days
• A fracture involving a joint or a dislocation
tubules or leading to renal artery spasm and tubular necrosis
🔸 Treatment
• Amputation if the limb severely crushed more than 6 hours.
that leads to articular cartilage damage may
• Amputation should be done before the compression (tourniquet) is
lead to osteoarthritis. Osteoarthritis released
• Malunited metaphysealfractures may lead to
osteoarthritis • Amputation should be done above the compression or crushed area.
• If compression is already released, emergency amputation is
valueless.
pain out of proportion (in both intensity and duration) to Cool the limb and treat for shock and renal failure (dialysis is
the precipitating cause, vasomotor instability, trophic skin lifesaving).
🔹
changes, regional osteoporosis and functional impairment.
Clinical Features
• Continuous burning pain in hand or foot
pain out of proportion (in both intensity and
duration) to the precipitating cause,
vasomotor instability, trophic skin changes, DVT is a Very common complication after fractures
• Local swelling, redness, warmth and shiny skin regional osteoporosis and functional and major orthopaedic operations
🔸 Prevention
🔸
• Tenderness at fingers & toes impairment. • Most frequently in the calf
High risk people • Elastic stockings
• stiffness of nearby joints • Precipitating Causes:
• Old people • Elevation of the foot
• Atrophic changes at distal regions of the fingers or toes • Trauma (30% of patients with fractures of the
Reflex Sympathetic • Early mobilization
🔹
(thin and cold skin with tapered ends).
Prevention 🔹
extremities)
Clinical Features Osteodystrophy Deep Vein
• Bedridden patients
• Patients with cardiovascular disease • Low molecular weight heparin (40 mg/day)
🔸
• Regular check for coagulation haemostasis
• High index of suspicion • Continuous burning pain in hand or foot (Algodystrophy) • Patients with trauma
General Complications Thrombosis Treatment
🔸
• Active use • Local swelling, redness, warmth and shiny skin • Patients undergoing surgery
(DVT) • Anticoagulant (Heparin)
🔹
• Avoid oedema by elevation
Treatment
• Rest and elevation
• Tenderness at fingers & toes
• stiffness of nearby joints
Complications of Fractures and
Clinical features
• Pain in calf or thigh
• Tenderness
– Bolus: 10-15 units
– Continuous infusion 1000 units/hr
• Atrophic changes at distal regions of the – PTT Control
• Physiotherapy
• Active use and manipulation
fingers or toes (thin and cold skin with tapered
Joint Injuries • Sudden increase in temperature and PR
– Shift to Warfarin
🔸
ends). • Positive Homan’s sign
• Calcium supplement • Streptokinase to dissolve clots
Investigations
• Steroids • Duplex ultrasound
🔸
DVT disseminates to produce fatal PE
Clinical appearance
• Fractures around the trunk are often complicated by injuries to • Shortness of breath
underlying viscera. • Tachypnea
• The most important being penetration of the lung with life-threatening • Chest wall rash
pneumothorax following rib fractures. • Agitation
• Then, rupture of the bladder or urethra in pelvic fractures.
🔸
• Confusion
• These injuries require emergency treatment Investigations
• The fractures most often associated with damage to a major artery are Pulmonary Embolism • Decreased PaO2
those around the knee and elbow, and those of the humeral and femoral (PE)
🔸
• CT pulmonary angiogram
shafts. Prevention
🔸
• Prevent DVT
🔸 Vascular Lesion
• Spasm, kinking, compression, intimal tear, thrombus and
Treatment
• Cardiorespiratory resuscitation
rupture Visceral Injuries • Anticoagulants
🔸 Clinical features
• The patient may complain of
• Streptokinase to dissolve clot
• Thrombectomy
• Paraesthesia
• Numbness • It may occur in wounded patients or patients with open fractures.
• Cold injured limb • An infection caused by Clostridium Tetani invading dead tissues.
• pale or slightly cyanosed • Tetanus toxin is fixed in anterior horn cells and can’t be neutralized
• Pulse is weak or absent
🔸 🔸
• It is characterized by hyper excitability ad reflex muscle spasm
Prevention Prophylaxis
• Early and careful splinting of the fractured limb during • If immunized (DPT), give a booster dose of toxoid
transport and in hospital. • If not immunized, start a standard dose of toxoid and give a booster
🔸 Treatment
• If a vascular injury is suspected
Tetanus dose 6 weeks later.
🔸 Treatment
• Remove any pressure • IV antitoxin
• Reduce the fracture • IV antibiotics (Penicillin)
• Check pulse within 30 minutes• If circulation still impaired • Muscle relaxants
then an angiogram should immediately be performed. • Tracheal intubation
• If the angiogram is positive, emergency treatment must be • Cotrol respiration
started without further delay • Wound debridement
• Fractures of the arm, elbow, forearm or leg bones can give rise to • An infection caused by Clostridium Welchii which
severe ischaemia even if there is no damage to a major vessel. multiply in tissues with low oxygen tension.
• There is reduced capillary flow which result in muscle ischaemia, • Leading to extensive necrosis of muscles, gas formation
further oedema , still greater pressure and yet more profound ischaemia and systemic toxicity (particularly after early closure on
infected wounds or improper debridement).
• Vicious circle that ends, after 12 hours or less , in necrosis of nerve and
muscle within the compartment .
• Bleeding , oedema or inflammation (Infection) may increase the
🔸 Clinical features (24 hours after injury):
• Sudden onset of severe localized pain at the infected
pressure within one or more of the fibro-fascio-oseous compartments area
• Nerve is capable of regeneration but muscle, once infracted, can never • Swelling and oedema
recover and is replaced by inelastic fibrous tissue? ( volkmman`s • No pyrexia
ischaemiacontracture) • Increased pulse rate
• A similar cascade of events may be caused by swelling of a limb inside • Profuse brownish dischageand mousy odour
a tight plaster cast • Gas production
• Toxaemia / Coma / Death
🔸 Important Clinical findings
• Tense and tight limb 🔸 Clinical Features
Gass Gangrene
🔸 Prevention
• pain with passive motion (passive extension) of the muscles The standard findings of ischemia (5Ps):
• Explore and decompress any deep muscle tissue
passing through the compartment (usually flexors) • Pain: Severe & persisting
involved in penetrating injury
• weakness of the muscles. • Paraesthesia
• Perform proper debridement and remove dead tissue.
• Hypesthesia or paresthesia(consider full sensory • Pallor
• There is no effective antitoxin against C. welchii.
examination)
• The most important finding is pain out of proportion to that
• Paralysis
• Pulseless 🔸 Treatment
• Early diagnosis is the key stone.
expected with the injury. • Poikilothermia: Cool
• Maintain fluid balance
• Start IV antibiotics
🔸Measurement of compartment pressure in incipient ischemia or • Hyperbaric oxygen
• Debride the wound and remove dead tissues
unconscious patients • Amputation in advanced cases
• The Wick or slit catheter is introduced into the compartment
• The pressure is measured close to the level of the fracture (injury).
• A differential pressure (ΔP) – the difference between diastolic pressure and FE Usually occurs in young adults with multiple closed
compartment pressure – of less than 30 mmHg is an indication for immediate Compartment Syndrome fractures of long bones.
compartment decompression. It is characterized by occlusion of the small blood vessels by
fat globules.
• A compartment pressure >30 mmHg
🔸 Risky patients:
• Multiple closed fractures (long bones, pelvis and ribs)
• Pulmonary contusion
🔸 Clinical appearance:
• Early warning signs (24-72 hours of injury– Rise in
temperature and PR
• More pronounced case
– Breathlessness
🔸 Early Preventive and Treatment Measures
• splitting of the cast and underlying padding
– Mild mental confusion
– Petechia on chest, conjuctival fold and axilla
• Most severe case
• Release any circular bandages. – Marked respiratory distress (ARDS)
• Positioning of the limb is important; placing the limb at the level of the heart produces – Coma
the highest arterio- venous gradient. Fat Embolism (FE)
🔸
Elevation of the limb decreases arterial inflow without significantly increasing venous
outflow, increasing local ischemia. Laboratory findings
Early Local
🔸 If symptoms do not resolve within 30 to 60 minutes after appropriate treatment
• pressure measurement should be repeated Complications
• Fat macroglobulinemia
• Anaemia
• Thrombocytopenia
• and, if equivocal, fasciotomy is indicated. • High ESR
• Compartment syndrome associated with a fracture of the lower extremity should be
treated at the time of fracture stabilization.
🔸 Prevention
• Early stabilization of the fractures
• Delayed primary closure / skin grafting
🔸 Treatment
• Intensive care
• Oxygen adminstration with assisted ventilaton
• Fluid and electrolyte balance
• Supportive drugs– Heparin– Steroid– Aprotinin
• Stabilization of fractures
• This is particular common with fractures of the humerus or injuries around the
elbow or the knee.
• In closed injuries the nerve is seldom severed ,and spontaneous recovery should
be expected Nerve Injuries
• In open fractures a complete lesion (neurotmesis) is more likely.
• The nerve is explored during wound debridement and repaired, either then or as a
" secondary" procedure 3 weeks later.
• Torn muscle fibers are common with any fracture
• Unless the muscle is actively exercised the torn
fibers may become adherent to untorn fibers, Torn Muscles and Tendons
capsule or bone.
• Fracture blisters occur during limb swelling and are due to elevation of
the epidermal layer of skin from the dermis.
• Two distinct blister types are sometimes seen after fractures: – clear
fluid-filled vesicles– blood-stained ones.
• There is no advantage to puncturing the blisters
Fracture Blisters by fatema okoff
• Surgical incisions through blisters should be undertaken only when limb
swelling has decreased.
• Plaster sores occurs where skin presses directly on to bone
• They should be prevented by padding the bony pointsand
by molding the wet plaster so that pressure is distributed to Plaster and Pressure Sores
the soft tissue around the bony points.
• Open fractures and even closed fractures if
operated upon them are complicated with
acute and then chronic osteomyelitis.
• This dose not necessarily prevent the fracture
from uniting, but union will be slow and the
chance to refracture is increasing. Infection (Osteomyelitis)
Treatment
• Drainage
• Surgical toilete
• Antibiotics.
• Fracture involving a joint may cause acute haemarthrosis
• The joint is swollen and tense and the patient resists any
attempt at moving it Haemoarthrosis
• The blood should be aspirated before dealing with the
fracture under aseptic condition
Injury to the Ligaments
paralysed patients.
• The skin over the sacrum and heels is
especially vulnerable Bed Sores
• Careful nursing and early activity can usually
prevent bed sores
• Heterotopic ossification in the muscles occurs after an
injury
– Dislocation of the elbow
– Severe contusion to brachialis, deltoid or quadriceps
• It may occur without a local injury in unconscious or
🔹
paraplegic patients
Clinical features
• Pain Myositis Ossificance
• Local swelling
• Soft tissue tenderness
🔹
• Limitation of joint movement
X-ray
• Fluffy calcification in soft tissues by 3 weeks
• Bony mass by 8 weeks
• Early bone scan usually shows increased activity
This complication follows arterial injury or compartment syndrome due
🔹
to ischaemic contracture of affected muscles
Common sites
• Forearm and hand
🔹
• Leg and foot
Clinical features
• Deformity and stiffness at hand and foot
• Muscle wasting
• Occasional numbness
• Clawing of fingers or toes In the wrist and hand:
• If the wrist extended the IPJs are forced into flexion Volkmann Ischaemic Contracture
🔹
• If the wrist is flexed the IPJs can be extended
Treatment
• Detachment of flexors origin and along the interosseousmembrane may
improve deformity
• Tendon transfer (e.g. wrist extensors to finger and thumb flexors)
🔹 Common sites of nerve compression and entrapment:
• Radial palsy due to faulty use of crutches
• Ulnar nerve due to valgus deformity of the elbow
• Carpal tunnel syndrome
• Gyon canal syndrome
• Common peroneal nerve compression following fracture neck
fibula or poorly placed short leg cast
🔹 Clinical features
🔹
• See the lecture of peripheral nerve injuries
Treatment
• Early decompression
Nerve Entrapment
• Anterior transposition of the ulnar nerve Philosophy of Care
🔹 Factors go into treatment decision
– Necessary
– Effective
– Benefits vs. risks and psychological effect
🔹 Responsibilities of the physician
• Establish Correct Diagnosis:
– Local proper examination
• Improper reduction of a fracture may lead to tendon friction, – General musculoskeletal screening
tendinitis and rupture. • Identify Treatable Conditions and have Potential to Cause
• Chronic tendinitis and late rupture of the rotator cuff following Disability
improper reduction of a fracture of the greater tuberosity of • Develop high suspicion index of possible complication
humerus • Communicating the findings to the patient
• Tendinitis and late rupture of the long head of the biceps after a
fracture of the neck of humerus Tendinitis and Tendon Rupture
• Rupture of extensor pollicislongus tendon may occur 6-12 weeks
🔹
after a fracture of the lower radius (e.g. Colles’ fracture).
Treatment
• Tendon repair
• Tendon transfer
• No treatment
• Systemic reduction in tissue perfusion
• Failure to correct the systemic tissue
Non-Union perfusion may lead to irreversible shock and
• The fracture fragments show no evidence of union.
• The fragments are still mobile at the fracture site with no or minimal pain. 🔸
permanent damage to body organs.
Types of post-traumatic shock:
🔹
• The gap becomes a type of pseudoarthrosis.
Causes (CASS) Shock 1. Hypovolemic shock
2. Neurogenic shock
• Contact
• Alignment Delayed Union Late Local 3. Cardiogenic shock
4. Septic shock
• Stability
🔹
There is no absolute time beyond which a fracture is in a state of delayed union. Complications 5. Anaphylactic shock
🔹
• Stimulation Criteria for delayed union 3-4 months after injury: 6. Spinal shock
• pain on stress• Mobile fragments
Radiographs
• A visible fracture line with increased gap• Fracture ends show exuberant
calcified callus and rounded ends in hypertrophic non-union.
🔹 Causes:
1. Inadequate blood supply
• Fracture ends show atrophy with tapered sclerotic ends in atrophic non- 2. Severe soft tissue damage
union. 3. Periosteal stripping
4. Infection
Mal-union
🔹
Treatment 5. Incorrect splint
• Malunion is the union of a fracture in unaccepted position: Conservative Treatment a) Persisting mobility
b) Over traction
🔹
– Angulation– Overlapping– Rotation • Functional bracing in lower limb non-united fractures
Cause: • Pulse electromagnetic fields 6. Intact fellow bone in the forearm or leg
• Low frequency pulsed ultrasound These methods may provide good 7. Patient related factors Disseminated Intravascular Coagulopathy
– Failure to reduce a fracture Coagulopathy is common after major trauma when micro-vascular
🔹
– Failure to maintain a reduced fracture results with hypertrophic type but with prolonged splintage
. 🔹 Clinical Features -union 🔸
bleeding occurs due to deprivation or dilutions of clotting factors.
Clinical features
• Bony deformity 🔹 Surgical Treatment • Tenderness Causes:
1. Massive transfusion The replacement of greater than one
🔹
• Joint deformity • In hypertrophic type: • Pain on stress
Radiographs circulating blood volume (approximately 10 u of blood) in less than
• Rotational deformity of the limb may be missed unless – Internal or external fixation with compression (maintain good alignment) 24 hours
🔹
compared with the other. • In atrophic type: • A visible fracture line
• Incomplete callus 2. Dilution of coagulation factors through the infusion of products
X-ray – Remove intervening fibrous tissue
• Low periosteal reaction deficient in these factors (e.g. packed red blood cells, crystalloids
• Reveals union in a displaced position – Excise bony sclerotic ends
• The bone ends are not sclerotic or atrophic as in non-union and colloids).
– Bone grafting
– Internal fixation 🔹 Treatment
• Ensure proper immobilization
3. The release of tissue thromboplastins into the circulation due to
severe injury and blood loss
• Encourage fracture loading
– Muscle exercises
– Weight bearing (Gradual) (DIC) 🔸 Consequences
• Excessive bleeding
• Surgical treatment if union is delayed for > 6 months
– Bone grafting • Organ dysfunction
– Proper fixation with minimal soft tissue damage • Haemolysis
🔸
• Disseminated thrombosis.
Clinical features
• Restlessness
• Confusion and neurological dysfunction
• Skin infarcts
• Oliguria and renal failure
• Excessive bleeding at operation
• Oozing drip sites and wounds
🔹
• Ischaemia and bone necrosis after injury
Common sites
– The head of the femur
• Spontaneous bruising
🔸
• Gastrointestinal bleeding and haematuria
Treatment
– The proximal part of the scaphoid Avascular Necrosis • Fresh frozen plasma
– The lunate bone • Platelets
– The body of the talus • Heparin
🔹
• A joint may give way following an injury
Causes
• Ligamentous injury
During the later stages of shock and septicemia,
endothelial cell damage and increased small - vessel
permeability lead to extravasation of hemorrhagic,
• Muscle weakness and imbalance protein rich fluids into the pulmonary interstitial
• Bone loss tissue and alveoli.
• Recurrent dislocation
– Glenohumeral joint
Instability Adult Respiratory
Distress Syndrome 🔸 Prevention:
• Prevent shock
– Patellofemoral joint
• Patients complaining of persistent discomfort or 🔸 Treatment:
Oxygen and ventilation
weakness after injury as in chronic carpal instability
Do not over transfuse with crystalloid
• Joint stiffness commonly occurs in the knee, elbow,
🔸 Clinical Picture
🔹
shoulder and (worst of all) small joints of the hand
Causes:
• The joint itself injured with haemarthrosis that leads to
• Shock / Drowsy
• Pulseless limb with redness and tense swelling
synovial adhesions. • Loss of muscle power
Stiffness • A serious medical condition characterized by major shock and renal failure. • Sensory loss
• Oedema and fibrosis of the joint capsule, ligaments and • It occurs when a large bulk of skeletal muscles is crushed or when a
surrounding muscles • Decreased renal secretion
tourniquet has been left too long. • Uremia and acidosis
• Prolonged immobilization makes joint stiffness worse,
particularly if the joint is immobilized in a position where the
• It is a re-perfusion injury seen after the release of crushing pressure, there
will be release of muscular breakdown products as acid myohematin
🔸 Prognosis
• The patient survive if renal function returns within one week.
ligaments in their shorter length (cytochrome C) which have nephrotoxic effect on the kidney and block the
Crush Syndrome • Most patients die within 14 days
• A fracture involving a joint or a dislocation
tubules or leading to renal artery spasm and tubular necrosis
🔸 Treatment
• Amputation if the limb severely crushed more than 6 hours.
that leads to articular cartilage damage may
• Amputation should be done before the compression (tourniquet) is
lead to osteoarthritis. Osteoarthritis released
• Malunited metaphysealfractures may lead to
osteoarthritis • Amputation should be done above the compression or crushed area.
• If compression is already released, emergency amputation is
valueless.
pain out of proportion (in both intensity and duration) to Cool the limb and treat for shock and renal failure (dialysis is
the precipitating cause, vasomotor instability, trophic skin lifesaving).
🔹
changes, regional osteoporosis and functional impairment.
Clinical Features
• Continuous burning pain in hand or foot
pain out of proportion (in both intensity and
duration) to the precipitating cause,
vasomotor instability, trophic skin changes, DVT is a Very common complication after fractures
• Local swelling, redness, warmth and shiny skin regional osteoporosis and functional and major orthopaedic operations
🔸 Prevention
🔸
• Tenderness at fingers & toes impairment. • Most frequently in the calf
High risk people • Elastic stockings
• stiffness of nearby joints • Precipitating Causes:
• Old people • Elevation of the foot
• Atrophic changes at distal regions of the fingers or toes • Trauma (30% of patients with fractures of the
Reflex Sympathetic • Early mobilization
🔹
(thin and cold skin with tapered ends).
Prevention 🔹
extremities)
Clinical Features Osteodystrophy Deep Vein
• Bedridden patients
• Patients with cardiovascular disease • Low molecular weight heparin (40 mg/day)
🔸
• Regular check for coagulation haemostasis
• High index of suspicion • Continuous burning pain in hand or foot (Algodystrophy) • Patients with trauma
General Complications Thrombosis Treatment
🔸
• Active use • Local swelling, redness, warmth and shiny skin • Patients undergoing surgery
(DVT) • Anticoagulant (Heparin)
🔹
• Avoid oedema by elevation
Treatment
• Rest and elevation
• Tenderness at fingers & toes
• stiffness of nearby joints
Complications of Fractures and
Clinical features
• Pain in calf or thigh
• Tenderness
– Bolus: 10-15 units
– Continuous infusion 1000 units/hr
• Atrophic changes at distal regions of the – PTT Control
• Physiotherapy
• Active use and manipulation
fingers or toes (thin and cold skin with tapered
Joint Injuries • Sudden increase in temperature and PR
– Shift to Warfarin
🔸
ends). • Positive Homan’s sign
• Calcium supplement • Streptokinase to dissolve clots
Investigations
• Steroids • Duplex ultrasound
🔸
DVT disseminates to produce fatal PE
Clinical appearance
• Fractures around the trunk are often complicated by injuries to • Shortness of breath
underlying viscera. • Tachypnea
• The most important being penetration of the lung with life-threatening • Chest wall rash
pneumothorax following rib fractures. • Agitation
• Then, rupture of the bladder or urethra in pelvic fractures.
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• Confusion
• These injuries require emergency treatment Investigations
• The fractures most often associated with damage to a major artery are Pulmonary Embolism • Decreased PaO2
those around the knee and elbow, and those of the humeral and femoral (PE)
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• CT pulmonary angiogram
shafts. Prevention
🔸
• Prevent DVT
🔸 Vascular Lesion
• Spasm, kinking, compression, intimal tear, thrombus and
Treatment
• Cardiorespiratory resuscitation
rupture Visceral Injuries • Anticoagulants
🔸 Clinical features
• The patient may complain of
• Streptokinase to dissolve clot
• Thrombectomy
• Paraesthesia
• Numbness • It may occur in wounded patients or patients with open fractures.
• Cold injured limb • An infection caused by Clostridium Tetani invading dead tissues.
• pale or slightly cyanosed • Tetanus toxin is fixed in anterior horn cells and can’t be neutralized
• Pulse is weak or absent
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• It is characterized by hyper excitability ad reflex muscle spasm
Prevention Prophylaxis
• Early and careful splinting of the fractured limb during • If immunized (DPT), give a booster dose of toxoid
transport and in hospital. • If not immunized, start a standard dose of toxoid and give a booster
🔸 Treatment
• If a vascular injury is suspected
Tetanus dose 6 weeks later.
🔸 Treatment
• Remove any pressure • IV antitoxin
• Reduce the fracture • IV antibiotics (Penicillin)
• Check pulse within 30 minutes• If circulation still impaired • Muscle relaxants
then an angiogram should immediately be performed. • Tracheal intubation
• If the angiogram is positive, emergency treatment must be • Cotrol respiration
started without further delay • Wound debridement
• Fractures of the arm, elbow, forearm or leg bones can give rise to • An infection caused by Clostridium Welchii which
severe ischaemia even if there is no damage to a major vessel. multiply in tissues with low oxygen tension.
• There is reduced capillary flow which result in muscle ischaemia, • Leading to extensive necrosis of muscles, gas formation
further oedema , still greater pressure and yet more profound ischaemia and systemic toxicity (particularly after early closure on
infected wounds or improper debridement).
• Vicious circle that ends, after 12 hours or less , in necrosis of nerve and
muscle within the compartment .
• Bleeding , oedema or inflammation (Infection) may increase the
🔸 Clinical features (24 hours after injury):
• Sudden onset of severe localized pain at the infected
pressure within one or more of the fibro-fascio-oseous compartments area
• Nerve is capable of regeneration but muscle, once infracted, can never • Swelling and oedema
recover and is replaced by inelastic fibrous tissue? ( volkmman`s • No pyrexia
ischaemiacontracture) • Increased pulse rate
• A similar cascade of events may be caused by swelling of a limb inside • Profuse brownish dischageand mousy odour
a tight plaster cast • Gas production
• Toxaemia / Coma / Death
🔸 Important Clinical findings
• Tense and tight limb 🔸 Clinical Features
Gass Gangrene
🔸 Prevention
• pain with passive motion (passive extension) of the muscles The standard findings of ischemia (5Ps):
• Explore and decompress any deep muscle tissue
passing through the compartment (usually flexors) • Pain: Severe & persisting
involved in penetrating injury
• weakness of the muscles. • Paraesthesia
• Perform proper debridement and remove dead tissue.
• Hypesthesia or paresthesia(consider full sensory • Pallor
• There is no effective antitoxin against C. welchii.
examination)
• The most important finding is pain out of proportion to that
• Paralysis
• Pulseless 🔸 Treatment
• Early diagnosis is the key stone.
expected with the injury. • Poikilothermia: Cool
• Maintain fluid balance
• Start IV antibiotics
🔸Measurement of compartment pressure in incipient ischemia or • Hyperbaric oxygen
• Debride the wound and remove dead tissues
unconscious patients • Amputation in advanced cases
• The Wick or slit catheter is introduced into the compartment
• The pressure is measured close to the level of the fracture (injury).
• A differential pressure (ΔP) – the difference between diastolic pressure and FE Usually occurs in young adults with multiple closed
compartment pressure – of less than 30 mmHg is an indication for immediate Compartment Syndrome fractures of long bones.
compartment decompression. It is characterized by occlusion of the small blood vessels by
fat globules.
• A compartment pressure >30 mmHg
🔸 Risky patients:
• Multiple closed fractures (long bones, pelvis and ribs)
• Pulmonary contusion
🔸 Clinical appearance:
• Early warning signs (24-72 hours of injury– Rise in
temperature and PR
• More pronounced case
– Breathlessness
🔸 Early Preventive and Treatment Measures
• splitting of the cast and underlying padding
– Mild mental confusion
– Petechia on chest, conjuctival fold and axilla
• Most severe case
• Release any circular bandages. – Marked respiratory distress (ARDS)
• Positioning of the limb is important; placing the limb at the level of the heart produces – Coma
the highest arterio- venous gradient. Fat Embolism (FE)
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Elevation of the limb decreases arterial inflow without significantly increasing venous
outflow, increasing local ischemia. Laboratory findings
Early Local
🔸 If symptoms do not resolve within 30 to 60 minutes after appropriate treatment
• pressure measurement should be repeated Complications
• Fat macroglobulinemia
• Anaemia
• Thrombocytopenia
• and, if equivocal, fasciotomy is indicated. • High ESR
• Compartment syndrome associated with a fracture of the lower extremity should be
treated at the time of fracture stabilization.
🔸 Prevention
• Early stabilization of the fractures
• Delayed primary closure / skin grafting
🔸 Treatment
• Intensive care
• Oxygen adminstration with assisted ventilaton
• Fluid and electrolyte balance
• Supportive drugs– Heparin– Steroid– Aprotinin
• Stabilization of fractures
• This is particular common with fractures of the humerus or injuries around the
elbow or the knee.
• In closed injuries the nerve is seldom severed ,and spontaneous recovery should
be expected Nerve Injuries
• In open fractures a complete lesion (neurotmesis) is more likely.
• The nerve is explored during wound debridement and repaired, either then or as a
" secondary" procedure 3 weeks later.
• Torn muscle fibers are common with any fracture
• Unless the muscle is actively exercised the torn
fibers may become adherent to untorn fibers, Torn Muscles and Tendons
capsule or bone.
• Fracture blisters occur during limb swelling and are due to elevation of
the epidermal layer of skin from the dermis.
• Two distinct blister types are sometimes seen after fractures: – clear
fluid-filled vesicles– blood-stained ones.
• There is no advantage to puncturing the blisters
Fracture Blisters by fatema okoff
• Surgical incisions through blisters should be undertaken only when limb
swelling has decreased.
• Plaster sores occurs where skin presses directly on to bone
• They should be prevented by padding the bony pointsand
by molding the wet plaster so that pressure is distributed to Plaster and Pressure Sores
the soft tissue around the bony points.
• Open fractures and even closed fractures if
operated upon them are complicated with
acute and then chronic osteomyelitis.
• This dose not necessarily prevent the fracture
from uniting, but union will be slow and the
chance to refracture is increasing. Infection (Osteomyelitis)
Treatment
• Drainage
• Surgical toilete
• Antibiotics.
• Fracture involving a joint may cause acute haemarthrosis
• The joint is swollen and tense and the patient resists any
attempt at moving it Haemoarthrosis
• The blood should be aspirated before dealing with the
fracture under aseptic condition
Injury to the Ligaments
