Post-operative complications in orthopedics
1. Soft tissue swelling;Its common after limb surgery its aggravated by tight dressing or POP it may affect wound healing & delay joint movement sometimes its so serious causing vascular ischemia & compartment syndrome. Prevention is by;
a. Dressing must not be tight.
b. Elevation of the limb.
c. Encourage early joint movement.
d. POP cast must be well padded & not tight.
2. Heamatoma formation;
By post-operative bleeding or ooze sometimes it’s considerable. It’s reduced by using suction drain.3. Delayed wound healing;
Usually due to poor circulation.
4. Infection;
It’s seriously disturbing especially in joint replacement surgery.
5. Thromboembolism;
The incidence of DVT is 20%, only 2% gets pulmonary embolism and only
0.2% will die of it.
Highest incidence in hip surgery especially in old debilitated patient.
The commonest type of DVT is that occurring in calf vein which carry better prognosis than that in proximal thigh vein thrombosis.
Clinical features
DVT usually silent, if it’s manifested it may cause calf or thigh pain sometimes swelling & local tenderness.In calf vein thrombosis there will be positive Homan’s sign i.e. increased calf pain on passive dorsiflexion of the foot. Sudden slight increase in temperature may occur.
If pulmonary embolism occurs patient may have shortness in breath, mild chest pain & sometimes heamoptysis, rarely sudden severe cardiovascular collapse & death.
Investigations:
Doppler U/S can prove the diagnosis. More accurate is ascending veinogreaphy.In pulmonary embolism ECG changes may happen.
Prevention:
• Pre-operative; by decrease smoking, walking exercises, treatment of systemic diseases & calf muscle massage with preoperative Heparin 5000 IU twice daily for high risk patients. Recently we can use low molecular weight heparin.
• Per-operative; avoid trauma to calf veins & frequent massage or use of special elastic stokes.
• Post-operative; calf muscle massage, elastic stokes, early active movement & ambulation, leg elevation together with few days of subcutaneous heparin therapy.
Treatment:
Calf vein DVT treated by heparin 5000 IU s.c. For 10-14 days then change to oral warfarin 5mg once daily for 2-3 months (all under strict supervision by the doctor with frequent PT & PTT check).Thigh or proximal vein thrombosis is more serious it needs full heparin therapy of 5000 IU four times daily intravenously 1-2 weeks followed by 5mg warfarin orally for 3-6 months (all under strict supervision by the doctor with frequent PT & PTT check).
Physiotherapy
It’s used to:
1-Reduce pain.
2-Increase range of motion.
3-Strengthen muscles.
4-Restore function.
All achieved by;
A-Heat; its useful to reduce pain & muscle spasm.
B-Cold; like ice packs it decreases pain & reduces swelling.
C-Transcutaneous nerve stimulation; also relieves pain.
D-Traction; intermittent traction of the spine can relieve neck pain or low back pain.
E-Electrical stimulation & muscle exercises; it builds up muscles & improves weakness.
Occupational therapy
Its used to improve function i.e. teaching the patient to use his skeleton & muscles to perform useful daily activities as feeding, hygiene, walking. .Etc.Functional aids
These are used to decrease stresses on musculoskeletal system during weight bearing like: stick, cane, crutches or frame. During weight bearing these patient uses these to decrease the mechanical stresses passing through his joints & bones.Fractures-general principles
A fracture is an interruption in the bone continuity caused usually by strong trauma in healthy bones (traumatic fracture).
Pathological fracture Stress fr.
Simple or closed fr
Compound or open
complete fr.
Incomplete or partial fr.
Called comminuted fr.
Segmental fr.
Intra-articular fr
Mechanism of fr.:
Direct trauma: the bone usually breaks at point of impact.Indirect trauma: as angulation or rotation or compression of the limb, this can cause fr. Away from the site of injury.
Multiple or complex injury of different forces at the same time that may cause serious complex fracture.
Muscle violence: sudden strong muscle pull on the localized bony attachment may cause (avulsion fr) of the bony fragment with or without displacement, eg. Quadriceps pull on the patella cause transverse fr, triceps pull on the olecranon causes avulsion fr of olecranon.
Fracture displacement:
Fr may be undisplaced or usually displaced according to the; type of injury and the direction of ft line also depends on localized muscle action and gravity, displacement described according to the direction of the distal segment, this can be in form of;Overlap.
Side displacement.
Angulation.
Rotation.
Fracture healing or union
Tissue death and heamatoma formation:
Local bony necrosis will occur about 1 to 2 mm back from the fracture line and capillary bleeding will lead to localized fr heamatoma that bridges the fr and later clots.
Inflammation and cellular proliferation:
Within 8 hours there will be acute inflammatory cell reaction, within few days there is chronic inflammatory cell accumulation. This later will lead to local granulation tissue formation after capillary growth; cellular proliferation will take place as well.
Callus formation:
Proliferating cells will show variable chondrogenic and osteogenic activities with subsequent cartilage and finally bone tissue formation that will later replaces the whole granulation tissue mass leading to a big irregularly laid fusiform bony mass called the CALLUS that bridges the fr and locally fix it, the fr now is united but its not healed yet.
Consolidation stage:
Here the callus is gradually replaced by physiologically normal solid bone that will cross through the fr line and fill the gap, the fusiforrn callus replaced by variable osteoclastic (bone resorbing) and osteoblastic (bone forming) cellular activity, the newly laid solid bone is of near normal shape and can take normal forces and loading.
Remodeling stage
Gradual bone resorbtion and new bone formation will occur where the solid deformed bone is replaced by new normal bone that takes the original bone shape with reformation of the medullary canal, this may take months or even years to occur.