Complicated fractures

1- Fat embolism:

A- General:

– Observed especially in case of fracture of the femoral shaft (> 2/3 of the causes of fat embolism)

– More frequently observed in case of delayed treatment (immobilization of absence from home beyond 24 hours)

– There is a free interval of several hours to several days.

B- Clinic:

– Clinical signs early high fever; polypnea; petechiae thoracic, cervical and brachial earlier diffuse; neuropsychiatric symptoms (disorientation, abnormal behavior)

– Clinical signs in the status phase

* Acute respiratory failure with constant hypoxemia

* Neurological signs: impaired consciousness, autonomic disorders (hypertension, sweating, loss of urine), sometimes signs of focusing (lobe epilepsy, hemiplegia, aphasia)

* Signs skin (petechiae)

* Ocular signs: nystagmus, subconjunctival hemorrhage, pathognomonic appearance at the fundus (retina banches cottony spots with hemorrhage and macular edema)

– Treatment should involve: osteosynthesis emergency and resuscitation.

2- Open fracture:

A- classification Cauchoix and Duparc:

* TYPE I: wound without peeling or contusion, whose banks are bleeding well after excision and can be sutured without tension. The prognosis of such lesions is similar to that of closed fractures, the risk of infection is minimal.

* TYPE II: risk of secondary skin necrosis. Scraps of dubious vitality, above-aponovrotique peeling, bruising. Suture on after trimming.

* TYPE III: skin defect or another either traumatic or after surgical debridement. Immediate skin closure is impossible.The use of a flap becomes a necessity to cover the bone.

B- To do:

* Evolution: gas gangrene; osteitis; Osteoarthritis (epiphyseal fractures); nonunion suppurative

* Emergency Trauma:

– Preventive treatment: antibiotics (Peni G + Flagyl); tetanus antitoxin

– Treatment of skin lesion: surgical Trimming + disinfection + repair (suture without tension or flap)

– Treatment of open fracture

– The reduction and restraint are urgent

– Type I -> no change; treatment according to the fracture

– Fractures diaphyseal + a contused skin area, intramedullary nailing closed hearth is the ideal treatment

– Fractures epiphyseal -> plate fixation is possible when it can be covered

– III Stadium or large skin damage -> external fixator

– Traction suspension can be used in the queue for healing cutaneous lesions, internal fixation can be connected.

Complicated fractures
Syndrome des Loges

3- Syndrome des Loges:

– Occurs early (early hours). it is an emergency because of the rapid evolution of ischemic lesions, nerve and / or muscle.

– In the upper limb, it follows essentially trauma elbow or both bones of the forearm. It reaches the anterior compartment of the forearm and boxes of hand.

– In the lower limb, it follows essentially a trauma knee or leg. It then reaches the anterolateral lodge and the deep posterior compartment of the leg.

– Wrist and ankle are rarely involved.

– The mechanism is linked to an increase in the pressure of the intratissular pressure inside a box osteo-membranous inextensible compromising the vascularization of tissue in this closed volume.

– Several factors are at the origin: initial trauma; post-traumatic hematoma; Prolonged compression; plaster too tight initially

– Pain is a progressive burning, persistent, undiminished by immobilization and aggravated by passive stretching of the muscle.

It is exceptionally absent and in this case the nerve damage is extensive.

– The neurological deficit associated hyperesthesia then hypoesthesia cutaneous nerve territory through the lodge; a weakening of muscle strength. The altered susceptibility is the earliest sign of nerve ischemia.

– The capillary and peripheral pulse are normal. There are no downstream vascular disorders. There is no fever or biological anomaly.

– The opening of the dressing, removal of the plaster used to feel the painful tension of the box, only clinical sign goal.

– The treatment is extremely urgent: it is the discharge fasciotomy on the full extent of the lodge. This leaving open the skin, allows one to avoid muscle necrosis and ischemic retraction.

– In the upper limb is defined Volkmann syndrome characterized by ischemic retraction of the long finger flexors which is associated with nerve damage to his hand.