Complications of open fractures of the lower limb

Joint may become permanently stiff if the fracture is through or near the joint

Bone or bone marrow may be infected by bacteria or fungi. If this becomes chronic it is called osteomyelitis. Pus is produced within the bone, creating an abscess that stops the bone from getting its blood supply. In chronic osteomyelitis the bone dies due to the loss of blood (avascular necrosis).

Avascular necrosis may also occur if the bones refuse to join back up again or take a long time in doing so.


http://www.nhsdirect.nhs.uk/articles/article.aspx?articleId=166§ionId=6
http://www.nlm.nih.gov/medlineplus/ency/article/000437.htm
http://www.nlm.nih.gov/medlineplus/ency/article/000001.htm

PCL 12- Language and kinship

• Aboriginal language
o Complex grammar and vocabulary
o Can be split broadly into 2 types
 Pama-Nyungan and non- Pama-Nyungan
 More than 200 indigenous languages exist
 20 of them are used more commonly
o Language changes depending on the situation:
 Formal (during ceremonies), talking to relatives, talking about sacred matters
o Various form are present depending on age, status
o There are classes that teach indigenous languages, taught by aborigines
• Aboriginal kinship
o Based on classes or skins (eg: 2 groups), it’s the indigenous people’s way to maintain social structure
o Contains the norms, roles, institutions and cognitive processes in relationships
o Kinship dictates whom an aborigine can speak and not speak to (if communication is needed, a third party is required to pass messages)
 This is regarded as an act of respect between certain classes of relatives
 Sharing food or giving gifts to certain relatives can happen, but there are also those you can play tricks on or tease.
o Marriage
 Cannot marry into your own skin group (like incest)

http://www.dnathan.com/VL/austLang.htm
http://indigenousaustralia.frogandtoad.com.au/language.html
http://acl.arts.usyd.edu.au/projects/wangkamaya/index.php?option=com_content&task=view&id=105&Itemid=144
http://indigenousaustralia.frogandtoad.com.au/social3.html

Damage to Neurovascular supply

Damage to the neurovascular supply of the leg in a compound fracture
• Damage to popliteal region, with associated nerve, vein and artery injury, very serious. Damage is easily missed.
•Arteries that could be damaged in leg:
o Anterior tibial artery
o Fibular artery
• Nerves
o Common fibular nerve – often injured with tibia/fibula fractures
o Superficial fibular nerve
o Saphenous nerve
o Deep fibular nerve
o Sural nerve
• Peripheral nerves can be possibly damaged.

Fracture of the leg -- Surgical Management

Before the surgery, the patient is assessed under general anesthetic…

Open fracture: Tibial shaft fracture is associated with a break in the skin

For successful treatment of contaminated open tibial fractures, patient undergoes
1.Radical debridement of necrotic tissue (within 6 hours of injury)
2.Pulsed lavage of the area to remove bacteria
3.Prophylactic intravenous antibiotics (Often, Aminoglycosides + Cephalosporin. For low-grade open fractures, antibiotics such as first-generation cephalosporins are used. For higher-grade injuries with dirty wounds & infection, penicillin + aminoglycosides used)

Repeat debridements (every 24 h, as needed) are often used in
-Injuries with extensive soft tissue injury
-Severely contaminated wounds
-Wounds with vascular compromise in which additional necrotic tissue may present itself.
Soft tissue is usually covered (using sterile technique) within 1 week of injury

A splint should be used for stabilization. The splint usually remains intact until the patient is prepared in the operating room.

Intramedullary (IM) Rodding [Preferred treatment]

Intrameduallary rodding is a procedure to place a medal rod down the center of the tibia to hold the alignment ofthe bone. - A tibial rodding is a surgical procedure that lasts about an hour and half
- Usually done under general anaesthetic
1.Patients will have an incision over the knee joint, and small incisions below the knee and above the ankle. In addition, some fractures may require an incision near the fracture to realign the bones.
2.IM rods are secured within the bone by screws both above and below the fracture.
3.The metal screws and the rod can be removed if they cause problems, but can also be left in place for life.

Tibial rodding provides excellent fixation and alignment of the bones
-Most common risk of surgery is knee pain
-Most common complication is infection  Infection of the rod may require removal of the rod in order to cure the infection

Plates and Screws

Plates and screws are less commonly used, but are helpful in some fracture types, especially those closer to the knee or ankle joints.
Most surgeons choose an IM rod for tibial shaft fractures unless the fracture is too close to the joint to allow for placement of the IM rod  In fractures close to the joint surface, a plate and screws may be the ideal method of fixation.

External Fixator

External fixators tend to be used in more severe fractures, especially open fractures with associated lacerations and soft-tissue damage
-Placement of IM rods or plates may not be possible because of soft-tissue injury
-When there is significant soft-tissue injury, the external fixator may provide excellent immobilization while allowing monitoring and treatment of the surrounding soft tissues

Amputation

Amputation is uncommon but is sometimes indicated for severe tibial fractures, especially those with large soft tissue injury or those in patients with vascular compromise, such as in diabetic patients.

Amputation for grades I and II fractures is rare, but the rate of amputation is increased for grade III fractures. In fact, fractures requiring revascularization (type IIIc fractures) have a corresponding amputation rate of greater than 20%.

The Mangled Extremity Severity Score is a tool that has been developed to help the surgeon decide whether or not amputation is indicated, but it is only part of the equation. Surgical expertise and patient communication are of vital importance when making amputation decisions.

http://www.emedicine.com/orthoped/TOPIC340.HTM
http://www.emedicine.com/orthoped/topic336.htm
http://orthopedics.about.com/od/brokenbones/a/tibia.htm

Definition - Tetanus + 'Tetanus-prone wound'

Tetanus is a medical condition characterized by an acute onset of hypertonia, painful muscle contractions (usually of the jaw and neck), and generalized muscle spasms without any other apparent medical causes. Symptoms are caused primarily by tetanospasmin, a neurotransmitter produced by the anaerobic bacterium ‘Clostridium tetani’.

A wound is classified as ‘tetanus-prone’ if it has one or more of the following characteristics.

1) Age of wound > 6hrs
2) Type of wound = Stellate (star shaped or radiating from central wound), abrasion, avulsion
3) Depth > 1cm
4) Mechanism of injury = Projectile, crush, burn, frostbite
5) Signs of infection present
6) Gross contamination (feces, saliva, grass, dirt) present
7) Ischemic tissue present

General measures for treating tetanus prone wounds - Eunice

General measures for treating tetanus-prone wounds

Types of wounds likely to favour the growth of tetanus organisms:
- Compound fractures
- Deep penetrating wounds
- Wounds containing foreign bodies, especially wood splinters
- Wounds complicated by pyogenic infections
- Wounds with extensive tissue damage (e.g. contusions or burns)
- Any wound obviously contaminated with soil, dust or horse manure, especially if topical disinfection is delayed more than 4 hours
- Re-implantation of an avulsed tooth is also a tetanus-prone event, as minimal washing and cleaning of the tooth is conducted to increase the likelihood of successful re-implantation.

Management
- Wounds must be cleaned, disinfected and treated surgically if appropriate
- Recommended protocols for prophylactic vaccination
- The new Immunisation Schedule recommends that 10-yearly tetanus boosters are no long required up until the age of 50, provided that the primary series of 3 vaccinations plus 2 boosters have been given
- Instead, one Td (ADT) booster isrecommended ≥ 10 years of age, after completion of the childhood vaccination schedule, and another Td(ADT) booster is recommended at 50 years of age.
- If a person who is 50 years of age has had a Td (ADT) booster within 10 years, then this dose can be omitted.
- Every person should have had at least 5 routine doses of tetanus and diphtheria vaccines before 50 years of age, the first 3 doses 1-2 months apart, and the next 2 doses 10 years apart.
- A combination vaccine should be used in order to boost community protection against pertussis:
• < 8 years old DTPa-IPV (Infanrix-IPV®)
• > 8 years old dTpa (Boostrix®)
- A diphtheria/ tetanus toxoid vaccine (ADT® ) can be used if pertussis vaccination is contraindicated.

http://www.rch.org.au/clinicalguide/cpg.cfm?doc_id=5221
http://hsd.odgp.com.au/projects/immunisation/download_update_2006/Tetanus_Prophylaxis_for_Wound_Management.pdf

Compartment Syndrome (PCL 12)

Compartment Syndrome - Penny and Ben

Definition: compression of nerves and blood vessels within a compartment of the body (confined space surrounded by fascia), which can lead to impaired blood flow, muscle damage and nerve damage.

Pathophysiology: since fascia does not expand, swelling within a compartment can lead to increased pressure in the compartment, causing compression of muscle, nerves and blood vessels. If the pressure is high enough, blood flow may be blocked and permanent damage may occur. If the pressure lasts long enough, the limb may die.

When the pressure in the compartment exceeds the pressue in the capillaries, the capillaries will collapse and can no longer deliver oxygen and nutrients to the muscles and nerves within the compartment, and they will start to die in a matter of hours.

Causes: compartment syndrome is caused by increased pressure in the compartment, which may be due to a) increased fluid content or b) decreased compartment size.

• Swelling from a high-trauma injury such as a car crash or surgery
• Swelling from repetitive activities such as runing may cause chronic compartment syndrome
• Burns
• Fractures
• Hemorrhage
• Tight bandages or casts
• Use of creatinine monohydrate by athletes to build muscle

Signs and Symptoms
Severe pain, especially when the muscle is stretched, and out of proportion to the injury, which does not respond to pain medication.
Tingling or burning sensation in the muscle (parasthesia)
Muscle feeling tight or full
Paralysis = cell death has already begun

Diagnosis

• Measurement of compartment pressure ( >30 mm Hg suggests compartment syndrome)
• Lab Studies
• CT to look at the bones
• Vascular pathologies can be evaluated with arterial and venous Doppler ultrasonography
• Magnetic resonance imaging (MRI) to see muscle tears

Treatment

• Physical rehabilitation that decreases activity or load acting on affected compartment
• Aquatic exercises can improve mobility and strength
• Massage and stretching exercises also have been shown to be effective
• For worse compartment syndromes, a fasciotomy is performed

Complications

• Irreversible tissue ischemia can develop in the acute setting → permanent muscle and nerve damage, along with chronic pain, may occur.
• Peroneal nerve palsy, in particular, may develop.
• Muscle contractures may be observed.
• Infection is a major issue after fasciotomy and in some cases becomes chronic. Patients, especially those with multiple traumatic injuries--> can lead to death through metabolic complications
• Calcific myonecrosis - latent formation of a dystrophic calcified mass occurring almost exclusively in the lower limb

References
http://www.emedicine.com/EMERG/topic739.htm
http://www.nlm.nih.gov/MEDLINEPLUS/ency/article/001224.htm
http://orthoinfo.aaos.org/topic.cfm?topic=a00204