This website anonymously collects information about critical incidents and complications in anaesthesia and how to avoid and manage them.
Critical Incidents Reporting System CIRS

Authors: Peter B. Rauh, FRCS, Matthew C. Solan, FRCS, and Riyaz H. Jinnah, M.D. Orthopaedic patients undergoing lower limb surgery are recognized as a group at especially high risk of DVT/PE. Prevention is therefore of great importance. Treatment of established DVT or PE is beyond the scope of this text. This chapter will consider prophylactic measures only.

Clinical Signs for DVT:
- exam may be unreliable but positive findings should not be ignored;
- calf tenderness, swelling, fever, & increased pulse rate may be present
- suggestive exam features for pulmonary embolism:
- sudden decrease in O2 saturation;
- tachypnea, cyanosis, and hypoxia;
- pulmonary consolidation, pleural effusion, wheeze, and cor pulmonale;
- new onset tachydysrhythmia (usually a. fib);

A simple technique for cutting the suture if a drain has been sewn into the wound. For use when the suture penetrates the drain.

Exertional Compartment Syndrome of the Leg: Steps for Expedient Return to Activity Peter Edwards, MD; Mark S. Myerson, MD THE PHYSICIAN AND SPORTSMEDICINE - VOL 24 - NO. 4 - APRIL 96 In Brief: The pain and swelling associated with exertional compartment syndrome is caused by raised intracompartmental pressures possibly induced by muscle swelling or increased osmotic pressure. Although either the acute or chronic form of exertional compartment syndrome may occur, chronic is more common. Patients typically experience pain and swelling and may also have sensory deficits or paresthesias, and motor loss or weakness. Diagnosis is confirmed by intracompartmental pressure measurements before and after exercise. Although activity modification may alleviate symptoms, fasciotomy may be required.

eMedicine 2005 Compartment syndrome (CS) is a limb-threatening and life-threatening condition observed when perfusion pressure falls below tissue pressure in a closed anatomic space. The current body of knowledge unequivocally reflects that untreated CS leads to tissue necrosis, permanent functional impairment, and, if severe, renal failure and death.

Mr Gurd Shergill and Mr Harish Parmar Archive copy from fractures.com
Fat embolism and the associated fat embolism syndrome is a serious and potentially life threatening complication of long bone trauma, blunt trauma and intramedullary manipulation. However, some seemingly unrelated conditions have also resulting in fat embolism, such as diabetes, burns, severe infections, sickle cell anaemia, cardio pulmonary by pass, SLE and pancreatitis.

eMedicine Article (2004) by Lisa Kirkland MD (Internist)
Synonyms and related keywords: fat embolism syndrome, FES, fat emboli, fat embolus, fat droplet in venous system, blunt trauma, fracture complication, blunt trauma complication, altered mental status

Wheeless' Textbook of Orthopaedics
FES results when embolic marrow fat macroglobules damage small vessel perfusion leading to endothelial damage in pulmonary capillary beds leading to respiratory failure and ARDS like picture;

Fat Embolism syndrome: A review giving most importance on its clinical manifestations, diagnosis and therapy.

Case Report Four Recurrent Periprosthetic Knee Fractures from Medscape Orthopaedics & Sports Medicine eJournal[TM] 2001 Arne-Lembit Kööp, MD, Andres Kööp, MD, Irja Kiisküla, MD Introduction Periprosthetic fractures of the knee are challenging for the orthopaedist, but recurrent periprosthetic fractures are even more challenging. In this case, a 61-year-old female patient with a diagnosis of gonarthrosis deformans suffered 4 ipsilateral periprosthetic fractures during the 4.5-year period following her primary total-knee arthroplasty. A detailed case report is presented here and the classification systems, risk factors, and treatment strategies for periprosthetic fractures are discussed.

The British Medical Association undertook a wide-ranging consultation exercise, which confirmed the need for guidance on decisions to withhold or withdraw artificial nutrition and hydration. The British Medical Asociation Medical Ethics Committee has now published guidelines in this area.

Prophylaxis using heparin and low molecular weight heparin
Heparins and some mechanical pumping devices may help prevent blood clots forming in the legs after surgery for hip fracture
Patients with hip fracture may develop blood clots (thrombosis) in their legs. Some of these blood clots may travel to the lungs and cause a blockage (embolism), which can be fatal. Various drugs and physical devices are sometimes used to try and prevent these complications. This review of randomised trials found that both heparins and mechanical pumping devices significantly decrease the incidence of deep vein thrombosis. There was not enough evidence to conclude about the effect on lung (pulmonary) embolism, mortality or possible side effects for either heparin or mechanical methods.
Handoll HHG, Farrar MJ, McBirnie J, Tytherleigh-Strong G, Milne AA, Gillespie WJ

Wheeless' Textbook of Orthopaedics
may present w/ signs of localized inflammation or pain, elevated skin temp, etc.
- tends to occur after thr, spinal injury, head injury (11%), burns, bruises;

Archive copy
Implant Wear in Total Joint Replacement: Clinical and Biologic Issues, Material and Design Considerations Edited by Timothy M. Wright, PhD and Stuart B. Goodman, MD, PhD A symposium held in October 2000 Table of Contents Clinical Issues Chapter 1 What is the clinical scope of implant wear in the hip and how has it changed since 1995? Chapter 2 What is the clinical scope of implant wear in the knee and how has it changed since 1995? Chapter 3 What patient-related factors contribute to implant wear? Chapter 4 What surgical-related factors contribute to implant wear? Chapter 5 How should wear-related implant surveillance be carried out and what methods are indicated to diagnose wear-related problems? Chapter 6 What are the systemic consequences of wear debris clinically? Chapter 7 What guidelines/algorithms (both operative and nonoperative) are there for the treatment of osteolysis? Chapter 8 What are the best outcome measures for wear? Chapter 9 What is the outcome of the treatment of osteolysis? Biologic Issues Chapter 10 What are the local and systemic biologic reactions to wear debris? Chapter 11 What are the mediators (cellular, molecular, etc) of the local and systemic biologic reactions to wear debris? Chapter 12 Are there host factors that determine/modulate the biologic response to wear particles? Chapter 13 What specific features of wear particles are most important in determining the adverse biologic reactions? Chapter 14 What is the role of endotoxin and fluid pressure in osteolysis? Chapter 15 What experimental approaches (tissue retrieval, in vivo, in vitro, etc) have been used to investigate the biologic effects of particles? Chapter 16 Are there biologic markers of wear? Chapter 17 What potential biologic treatments are there for osteolysis? Material and Design Considerations Chapter 18 What design and material factors influence wear in total joint replacement? Chapter 19 What is the role of wear testing and joint simulator studies in discriminating among materials and designs? Chapter 20 What design factors influence wear behavior in total knee replacement? Chapter 21 What design factors influence wear behavior at the articulating surfaces in total hip replacement? Chapter 22 What are the wear mechanisms and what controls them? Chapter 23 What material properties and manufacturing procedures influence wear mechanisms? Chapter 24 What modifications can be made to materials to improve wear behavior? Chapter 25 What evidence is there for using alternative bearing materials?