COMPLICATIONS OF LIMB INJURY

COMPLICATIONS OF LIMB INJURY

the complications of injuries can be divided into early and late, local and systemic, and those specific to certain methods of fixation­ either internal or external .

Early local complications
the key complication is the loss of circulation distal to the injury a second commonly missed problem is degloving of the skin and subcutaneous fat, which lose their blood supply as they are torn from the deeper tissues. This injury is easy to miss, but if a careful check is made for loss of sensation and capillary filling, and if the history suggests a high possibility of this type of injury, then appro­priate action can be taken as all of the dead tissue needs to be "removed and skin cover is urgently needed

Compartment syndrome is a condition which develops if an

injured muscle swells inside a compartment bounded by an in elastic fascia. The most common sites for this problem are the forearm and the muscle compartments surrounding the tibia
a and fibula as the muscle swells, venous drainage is blocked and a vicious cir­cle is set up. The pressure within the compartment rises so high that it stops perfusion of tissues in the compartment. If urgent action is not taken the muscle dies, and is then replaced by fibrotic tissue producing
Volkmann's contracture an identical situation can be created if a dressing is put on too tightly or if a complete plaster is applied to a limb without adequate padding, and before the limb has finished swelling. For the first few hours after trauma it is wise to put on only well-padded back slab plasters and only
complete them on the following day. If the fracture cannot be held without a close-fitting plaster it may be better to wait before carrying out the definitive reduction as the patient needs to be admitted to hospital and to be put under very close observation.

The Simplest test for developing compartment syndrome is severe pain on extending the digits (fingers or toes) distal to the injury. Loss of pulses and/or loss of sensation can be late and unre­liable signs which should not be relied on. Measuring intra com­partmental pressures with a wick catheter is also unreliable and should be relied on only if the patient is unconscious and no other technique is possible. If there is any suspicion that a compartment syndrome might be developing, then all dressings should be removed, even if this means losing the fracture position. If this does not lead to an immediate improvement then the patient should be taken to theatre and a fasciotomy performed. The com­partment should be opened from end to end and left open until the swelling has settled

Compartment syndrome

• Develops insidiously after trauma as a result of swelling

• May be caused by patient's fascia or by circumferential dressings

• The cardinal sign is pain on moving digits

• If you think compartment syndrome might be present, assume that it is
• Removal of dressings and then immediate fasciotomy are required

Fracture blisters

These are a side-effect of the soft-tissue trauma . They are fragile and quickly burst, creating an open wound which is contaminated. They are a contraindication to internal fixation because of the risk of infection.

Swelling

Soft-tissue swelling is commonly association with fractures. If it severe it is a hindrance to open reduction and internal fixation (ORIF) because the swelling may make it impossible to close the wound at the end of operation. If severe swelling is expected (it is very common with ankle fractures) there is a short window within hours of the accident when surgery may be feasible; after that there may be a period of several days when surgery is impossible. During that time every effort should be made to reduce the swelling as quickly as possible. The techniques for reducing swelling are given by the acronym RICE: rest, ice, compression and elevation. Pneumatic stockings can pump away the swelling by intermittent compression. Elevation should be used with care if the circulation to the limb is already compromise
Summary of Early local complications
• loss of circulation

• Compartment syndrome

• loss of skin and soft-tissue over

• Fracture blisters and swelling

Early systemic complications

The main complications arise secondary to hypovolaemic shock. The second problem is that injuries come in clusters, and so a careful search must be made for other injuries to the patient, including those to soft tissues and vital organs, such as the lungs.

Late local complications

Limbs that are injured tend not to be moved. In limbs that are not moved the joints become stiff, the muscles waste and the circula­tion deteriorates, so that the healing of the limb may be compro­mised.
Summary of late local complications
Osteomtelitis non union and malunion


Osteomyelitis

If wounds are not cleaned properly, or become contaminated during surgery,the fracture may become infected. Once infection is established, it can be very difficult to eradicate; in fact, some would say that chronic osteomyelitis is never cured as it can break out again at any time.

The principles of management are to remove all dead and infected bone, then to try to achieve union with strong bone and adequate soft-tissue cover.The amount of bone that needs to be removed is always difficult to estimate and more than was originally hoped.

Non-union

Fractured bones which have lost their blood supply, either because of the energy involved at the time of injury or because of the handling of soft tissues at the time of surgery,may go on to atrophic non-union.The bone ends become thin and pointed. and there is no sign of any attempt at union.

If the fracture moves too much, then a hypertrophic non­ union may result (overabundant callus) but with a persisting fracture cleft held open by excessive movement at the fracture site. If the fracture unites in a bad position (malunion) the limb may look very ugly but may also not work properly. If the radius and ulna unite in a poor position, the forearm will lose all ability to pronate and supinate . A common cause of malunion is a failure to supervise the healing of a fracture adequately. If protection is removed too soon, or the patient is not seen often enough, then the fracture may slip and then unite in a poor position. It is preferable to avoid call­ing a patient back as an out-patient more often than is absolutely necessary,but, while the fracture is still uniting, it is important that the next appointment occurs before union has occurred, so that if there is a slip there is time for a correction of reduction and to secure fixation. Intra-articular fractures that are not anatomically reduced will lead to rapid onset of osteoarthritis. Accurate reduction can be difficult to obtain. especially if there is bone loss, and can be even more difficult to maintain until union has occurred if early movement of the limb is also a priority.

systemic complications
 

the systemic complications can be divided into organic and psychiatric . The initial period of hypovolaemia, and hypoxia, in polytrauma can lead to irreversible damage and systemically. The key to the management of these condition is prevention. Early aggressive management of the trauma with oxygen and fluids should minimise the time and severity of the insult. If there has been a significant injury, there is a high risk multiorgan failure that is best managed on an intensive care it there is an open wound with muscle necrosis, and this dead tissue is not excised, there is a risk of infection, including gas gangrene. Even if the dead tissue does not become infected, there a release of muscle degradation products into the blood­ as the tissue revascularises. These products include myoglobin  which darkens the urine to a dark-brown colour, but also
clogs the glomeruli, causing renal failure. The treatment once again is prevention. First, if possible, tissues should not be allowed to become
ischaemic Trapped limbs should be released as quick as possible, and patients should be kept well oxygenated and well perfused Dead muscle should be excised and wounds left open for further inspection and excision until cleared of all dead and contaminate tissues. The patient should be given plenty of fluids to maintain diuresis. It is thought that rapid flow of fluids through the kidneys may reduce the build-up of myoglobin and reduce the risk of renal failure.

Summary of late systemic complications

• Multiorgan failure

• Post-traumatic stress

• Shocked lung

• Myoglobinuria 

Shocking lung

this condition develops in patients who have been involved in major trauma. Over the days after the trauma, the patient's oxy­genation deteriorates despite adequate ventilation and perfusion. the lungs become stiffer and more difficult to ventilate, and chest radiographs show diffuse clouding. The condition appears to be more likely to occur if the patient is severely hypovolaemic for long periods. This is yet another reason to aim for early aggressive rehydration.

Psychiatric disorders

Patients who survive a suicide attempt may remain deeply psychi­atrically disturbed. As soon as they are conscious, a psychiatric opinion needs to be sought. If, when they start to be mobile, they continue to want to take their lives, special measures may need to be taken, especially if the orthopaedic wards are not on the ground floor.

Patients who were not psychiatrically disturbed at the time of the accident may become depressed afterwards. This is especially true if the patient lost a close relative or friend in the accident, or if there are awkward questions over who was to blame. It can also occur if treatment takes some time, or the patient is severely scarred, requires an amputation or is left in continuous pain. The modern limb reconstruction techniques, involving multiple plastic and orthopaedic operations which are so time-consuming and technically demanding, can leave a patient physically capable but a mental invalid. Careful consideration should be given to the possibility that early amputation with rapid return to normal life in a well-fitting prosthesis could give a better result for a patient with a mangled limb than many months spent reconstructing a limb that could and up useless, painful and ugly.

tags:limb,injury,complications