Outline

• Vascular injury & Nerve Injury

• Compartment syndrome
Early • Fat embolism syndrome
Complications • Infections (Gas gangrene, fracture
blisters, tetanus infection)

• Bones (Non-union, Malunion,

Osteomyelitis)
Late • Joints (Instability, stiffness, premature
Complications OA)
• Soft tissues –Muscles, Tendons.
 Vascular Injury
• Often associated with damage to major arteries
• Which can be due to cut, torn, compression or contusion from
initial injuries or jagged bone fragments

• Outward appearance may be normal

• Intima may be damaged and vessel blocked by thrombus or
segment of artery in spasm
Pathophysiology
Trauma

External bleeding Internal bleeding

Reduced intravascular volume

Less blood flow to the

Decreased preload to heart vessels which cannot
constrict enough to
maintain the resistance

Insufficient organ perfusion

Drop in blood
pressure

Skin Brain Heart Kidney All body

tissues
 Body Decreased Decreased BP,
Increased lactic acid
preferentially cerebral blood compensatory
production due to
vasoconstrict flow increased in
inadequate delivery of
extremities to heart rate to
oxygen
preserve maintain
central perfusion
Cerebral
circulation to
hypoxia
vital organs Decreased
clearance of
Tachycardia
lactic acid
Progressive
Cold, mottled reduce in LOC
extremities Renal ischemia Reduced GFR

Acute tubular Oliguria

necrosis
Lactic acidosis

Renal failure
Clinical features

• Paraesthesia or numbness (toes or fingers)

• Cold/pale/slightly cyanosed
• Weak pulse/absent pulse

Investigations
• X-ray may show high risk fracture
• If vascular injury is suspected, angiogram need to be done
immediately
 Treatment

• All bandages and splints should be removed

• Re-x-ray, if position of bones suggest the artery is compressed
or kinked, proceed with reduction
• Reassess the circulation, repeat over next 30 min
• If no improvement, explore by operation

•With pre-operative or peroperative angiography

•Colour of skin •Cut vessels can be sutured
•CRT<2 s •Segment can be replaced by vein graft
•warm/cold •If thrombosis occurs in vessel, endarterectomy may
•Pulse restore the blood flow
•Ability to feel (sensation) •Patient needs internal fixation after the vessel repair
•Ability to move (motor)
 Axillary Nerve
• Arises from C5,C6 ( nerve roots ), posterior
cord of brachial plexus.
• Course of axillary nerve :

• Injury due to fracture of the humeral neck or

shoulder dislocation
 Treatment
• Spontaneous recovery ( 80%)
• No sign of recovery at the deltoid ( 8 weeks ),
EMG should be performed
• Surgical approach is used ( expected recovery
in 3 months )
- Excision of nerve end and grafting
 Radial Nerve
• Arises from C5 – T1 nerve roots , posterior
cord of brachial plexus
• Course of the radial nerve :
 Treatment
• Patient with humerus fracture : radial nerve
injury must be assessed on admission
• Observe for 12 weeks
• If does not recover ( proceed with EMG )
• Surgical approach
 Ulnar nerve
• Medial cord of the brachial plexus
• Course of the nerve :
 DEFINITION
• fat embolism syndrome (FES) is a rare
clinical condition which releases fat
into the circulation, resulting in
multisystem dysfunction
 CAUSES OF FAT
EMBOLISM SYNDROME
 RISK FACTORS
• Young age
• Closed fractures
• Multiple fractures
• Conservative therapy for long bone
fractures
 PATHOPHYSIOLOGY
Fat from disrupted bone
marrow or adipose tissues
enter venous system
Trigger rapid aggregation of Local hydrolysis
platelet and accelerate fibrin of fat emboli by
generation pneumocytes 
free fatty acids
Lodge in pulmonary
arterial circulation
and will result in FFA travel to
obstruction other organs
via the
systemic
• Interstitial circulation
• haemorrhage
Interstitial and
edema
haemorrhage and
• Alveolar
edema collapse
• Reactive
Alveolar collapse End organ
• hypoxemic
Reactive hypoxemic damage
vasoconstrictions
vasoconstrictions
Proposed pathophysiologic mechanisms for the clinical findings
observed in fat embolism syndrome.

Ethan Kosova et al. Circulation.

2015;131:317-320

Copyright © American Heart Association, Inc. All

 CLINICAL FEATURES
(within 72 hours of injury)

Classic triad : hypoxemia (PaO2 <60mmHg), neurological

abnormalities and petechiae
1. Pulmonary ( most common initial signs) : hypoxemia, dyspnea,
tachypnea and respiratory failure
2. neurological abnormalities : focal deficits, confusion, lethargy,
restlessness and coma
3. petechial rash : common found in nondependent regions such as
head, neck, anterior thorax, axilla and sub-conjunctiva

- early warning signs are slight rise of temperature and pulse rate.
- haematological : thrombocytopenia and anemia
 INVESTIGATIONS
• Arterial blood gas (ABG) : PaO2 <
60mmHg
• blood investigations :
thrombocytopenia, anemia ,
hypofibrinogenemia and increase ESR
• decrease in Hematocrit (within 24- 48
hrs)
• urinalysis : fat globules
• chest X-ray : ‘snow storm’ appearance
 MANAGEMENT
• high flow rate of oxygen  to maintain the
arterial oxygen
• maintenance of intravascular volume 
because shock can exacerbate lung injury
• monitoring of blood gases, fluid and
electrolytes

PREVENTION :
• early fracture stabilization (within 24 hours)
 to prevent or decrease the severity of FES
 Infections
• Open fracture may become infected easily compared to
closed fracture
• Closed fracture hardly get infected unless they are opened by
operation
 Gas Gangrene
• Caused by clostridial infection
• Clostridium perfrigens, Clostridium welchii are the common
anaerobic organism that can survive and multiply only in
tissues of low oxygen content
• It will release toxin and destroy the cell wall, which causes
tissue necrosis and promoting spread of disease
Clinical features
• Intense pain
• Swelling around wound with brownish discharge
• Gas formation usually not very marked
• Little or no fever
• Increased pulse rate
• Characteristic smell
• Toxaemic and may lapse into coma and death
Prevention
• All deep penetrating wounds in muscular tissues are
dangerous
• They need to be explored and all dead tissues should be
completely excised
• If there is slightest doubt about the tissue viability, leave the
wound open
Treatment
• Fluid replacement
• IV antibiotics IV Penicillin G, Clindamycin, Metronidazole
• Hyperbaric oxygen to limit the spread Limit the multiplication
and stop the production of toxin, but not available in all
hospital, cannot stand alone in treatment, must be given
together with antibiotics
• Prompt decompression of the wound
• Removal of all dead tissues
• In advance cases, amputation may be needed
 Fracture Blisters
• Developed over the site of traumatic fractures after 1-2 days
of trauma
• Contains clear fluid in partial thickness of skin injury, contains
blood in full thickness of skin injury or haemorrhagic injury
• Commonly at tibia, ankle and elbow
• Should not be disrupted
• Once disrupted, can be exposed to infection with skin flora
Treatment

If the blister disrupted-

• Ointment, such as Silver Sufadiazine can be applied, which

can help in promoting re-epithelization and prevent infection

OR

• Leaving the blisters covered with a biologic dressing after

drainage
 Tetanus Infection
• Tetanus is a nervous system disorder characterized by muscle
spasms that is caused by toxin-producing anaerobe Clostridium
tetani, which is found in soil
• This organism will not grow in healthy tissues, thus combination of
factors needed to predisposed a person to this infection

• Penetrating injury
• Devitalized tissues
• Localized ischemia
• Foreign body
• Coinfection with other bacteria
These factors explained why
compound fractures, puncture
wounds, gunshot wounds and
burns are prone to have tetanus
infection
Management
Tetanus vaccine
- For adult and children over 10 years
• given active immunization with tetanus toxoid (TT) or with
tetanus and diptheria vaccine (Td)
• 1 dose (0.5ml) by IM or deep subcutaneous injection
- For children under 10 years
• Given diptheria and tetanus vaccine (Td)
• 1 dose (0.5ml) by IM or deep subcutaneous injection

Tetanus immune globulin (TIG)

• In addition to wound toilet and absorbed tetanus vaccine.
• Also considered if antibacterial prophylaxis is indicated
 Osteomyelitis
1. Acute hematogenous osteomyelitis
2. Subacute haematogenous osteomyelitis
3. Post-traumatic osteomyelitis
4. Chronic osteomyelitis
5. GARRÉ’S sclerosing osteomyelitis
6. Multifocal non-suppurative osteomyelitis
 Osteomyelitis
• Open fractures are prone to infection
• Combination of tissue injury , vascular
damage , oedema, haematoma , dead bone
fragments invite bacterial invasion.
• This is the most common cause of
osteomyelitis in adults.
• Staphylococcus aureus is the usual pathogen. (
E. coli, S. Pyogens, Proteus and Pseudomonas;
in presence of surgical implants.
 Clinical features
• Feverish
• pain and swelling over fracture site
• The wound is inflamed and there may
be a seropurulent discharge.
• Increase CRP level,leucocytosis.
• Elevated ESR.
 Treatment
The essence of treatment is prophylaxis:
• Through cleansing and debridement of dead and
dying tissues
• stabilization of the bone fragments
• Skin cover of the wound (suture or grafting) when
it is assuredly clean and antibiotic administered.
- Most cases a combination of flucloxacilin and
benzylpenicilin( 6 hourly for 2 days), will suffice.
- Regular wound dressing.
 1. Joint Instability
• Bone loss or malunion close to a joint may lead to
instability or recurrent dislocation. Causes includes the
following:

– Ligamentous laxity
• especially at the knee, ankle and metacarpophalangeal joint of the
thumb.
– Muscle weakness
• especially if splintage has been excessive or prolonged, and exercises
have been inadequate (again the knee and ankle are most often
affected).
– Bone loss
• especially after a gunshot fracture or severe compound injury, or from
crushing of metaphyseal bone in joint depression fractures. Injury may
also lead to recurrent dislocation.
 1. Joint Instability
• Injury may also lead to recurrent dislocation.
The commonest sites are:
– the shoulder – if the glenoid labrum has been
detached (a Bankart lesion)
– the patella – if, after traumatic dislocation, the
restraining patellofemoral ligament heals poorly.
 2. Joint Stiffness
• Often occurs at the knee, elbow, shoulders and (worst
of all) small joints of the hand.
• Common cause:
– Oedema and fibrosis of the capsule, ligaments and muscles
around the joint.
– Adhesions of the soft tissues to each other or to the
underlying bone.
• Uncommon cause:
– Injured joints -> heamarthrosis forms -> synovial
adhesions.

• Can be made worse by prolonged immobilization.

 2. Joint Stiffness
Treament
• Prevention!
– By exercises that keep the joints mobile from the
outset
– Elevate to minimise oedema
– Functional bracing instead of full cast
immobilisation
 3. Osteoarthritis (premature)
• Osteoarthritis is a progressive joint disease due to
failure in repair of joint damage and is one of the major
causes of disability in adults.

• A fracture involving a joint may damage the articular

cartilage and give rise to post-traumatic osteoarthritis
within a period of months.

• Even if the cartilage heals, irregularity or incongruity of

the joint surfaces may cause localized stress and so
predispose to secondary osteoarthritis years later.
 3. Osteoarthritis (premature)
• If the step-off in the articular surface involves a large
fragment in a joint that is readily accessible to surgery,
intra-articular osteotomies and re-positioning of the
fragment may help.

• Often though the problem arises from areas that were

previously comminuted and depressed – little can be
done once the fracture has united.

• Malunion of a metaphyseal fracture may radically alter

the mechanics of a nearby joint and this, too, can give
rise to secondary osteoarthritis.
 Muscle Contracture
• Following arterial injury/ compartment syndrome
 pt may dev ischemic contractures of the
muscles (Volkmann’s ischemic contracture)
• Volkmann contracture is a permanent shortening
(contracture) of muscles
• Nerves injured by ischemia sometimes recover, at
least partially  patient presents with deformity
and stiffness; but numbness is inconstant.
• Sites: forearm and hand, leg and the foot
Typical claw- finger deformity due to
ischemic contracture of the forearm
muscles.
Ischemic contractures of
the calf muscles with
clawing of the toes
Clinical features Treatment
- detachment of the flexor muscles
at their origin
and along the interosseous
• 5Ps membrane in the
forearm  may improve the
– Pain (earliest deformity but
sign) function is no better if sensation
and active
– Pallor movement are not restored
- Nerve grafts may provide
– Pulselessness protective sensation in the hand,
– Paraesthesias and tendon transfers will allow
active grasp
– paralysis - Less severe cases, median nerve
sensibility may be quite good and
with appropriate tendon releases
and transfers, patient regains a
considerable degree of function
 Tendon Rupture

• Rupture of the extensor pollicis

longus tendon may occur after a
fracture of the lower radius.
• Direct suture is seldom possible,
& the resulting disability is
treated by transferring the
extensor indicis proprius tendon
to the distal stump of the
ruptured thumb tendon
 Complex regional pain syndrome
• Aka: Sudeck’s atrophy (fracture), reflex
sympathetic dystrophy (neurovascular
dysfunction) or algodystrophy
• Chronic condition characterized by burning pain
& abnormalities in the sensory, motor and
autonomic nervous systems.
• Typically appears after an acute injury to a joint/
limb , although it may occur with no obvious
precipitating event
• Characterized by: pain, stiffness and osteoporosis
of the hand
 Classification:
• Type 1 and Type 2 (The International Association of the Study of Pain)
• Type 2  occurs in the presence of documented
nerve injury
• The diagnostic criteria:
– The presence of an initiating noxious event or a cause of
immobilization
– Continuing pain, allodynia, or hyperalgesia
disproprortionate to the inciting event)
– Evidence at some time of edema, changes in skin blood
flow, or abnormal sudomotor activity in the area of pain
– The dx is excluded by the existence of any condition
that would otherwise account for the degree of pain
and dysfunction
X Rays
characteristically
show patchy
rarefraction of the
bone
 Treatment

• The earlier the condition is recognized and tx

begun,  better px essential

• Elevation and active exercises are important

after all injuries, but in this condition they are
• During the early stage, anti inflammatory drugs
and amitriptyline are helpful
• Sympathetic block or sympatholytic drugs have
been advocated