Complications of Fractures Non-union DVT Damage to Nerves and Blood Vessels Compartment Syndrome Fat Emboli Infection (Osteomyelitis)

Clinical Decisions Bobbie, age 14, was admitted with fx left tibia about 10 hrs age. He has a long leg cast. Report states: “toes warm, pink with good capillary refil, pulses present...pain not controlled with MS.” You note: p. 88,BP 89/66, r.23, t Bobbie reports: ‘toes feel “funny”, left leg hurts at calf.”

Questions n What additional data should you gather? n What is the medical/nursing problem of greatest Priority? n Why did this occur? n What actions should you take?

Compartment Syndrome n Compression of structures within a defined boundry; capillary perfusion decreased. n Self-perpetuating edema-ischemia cycle...inc. capillary permeability...arterial obstruction...muscle and tissue death.

Etiology n Normal compartment pressure=10mm Hg n Above 30mmHg for 8 hrs = Permanent damage n Factors affecting –dec. BP –dec. oncotic pressure –inc. capillary permeability –obs. venous flow –length of time n Causes

Arterial circulation continues; capillary circulation stops!

Events Leading to Compartment Syndrome n Ischemia cycle n Edema with inc. capillary pressure n Capillaries dilate;hydrostatic filtration pressure becomes greater than oncotic pressure of plasma colloid n More fluid leaves capillaries than enters; inc. permeability of capillary walls due to histamine release due to ischemic muscles n Plasma proteins into interstitial fluids n Inc. intramuscular pressure-obstructs venous first, then arterial

Compartment syndrome has many causes. Describe the etiology in these examples. compartment

Compartment Syndrome n Types –Acute –Chronic n Microcirculation ceases when compartment pressure = diastolic BP n Lead to Volksmans ischemic contraction n May develop Crush Syndrome:Rhabdo myolosis=Myoglob inuric renal failure

Volksman’s ischemic contracture may result with compartment syndrome!

Compartments Affected n Forearm –deep volar –superficial volar n Lower leg –deep posterior tibial –anterior with peroneal nerve –lateral with superficial peroneal –posterior with sural Lower leg

Assessment Pain on passive stretch Progressive pain Tenseness of muscle compartment Motor weakness Dec. sensation Loss of pulse

Interventions n Ice and elevate n Early recognition –5 Ps –Pressure monitors n Dec. pressure –Remove what confines –Eval. response to meds

Medical/Surgical Interventions n If compartment syndrome present, elevate limb only to heart level, not above! n Prevent complications associated with myogolbinuria n Monitor for compartment syndrome n Prevent infection n Fasciotomy

Monitor for compartment syndrome Fasciotomy! Treatment for compartment syndrome. Prevent Treatment

Fat Emboli n Fat globules obstruct blood vessels n Causes –Metabolic: biochemical changes, lipids mobilized and embolize, fatty acids toxic –Mechanical: fat is liberated due to inc. pressure n Life-threatening: ARDS Fat emboli

Fat Emboli n Frequency n Recognition –Change in behavior –Respiratory chg –Cardiac chg. –Integumentary system (Late) –Urine fat, dec. platelets n Non-blanching petechiae at these sites; late finding!

Diagnostic Tests Blood gases Lung scan Chest x-rays Laboratory studies: platelets, urine fat Nursing diagnosis Lung changes with fat emboli (ARDS)

Interventions: Fat emboli n Prevent: recognize, immobilize, hydrate n O2 therapy n Steroids n Fluid volume replacement n Plasma expanders n Monitoring