Transcript 5-6._General_Principles_of_Fracture_

Complications of Fractures
COMPLICATION OF
FRACTURE
General
Local
Early
Late

General complications








Shock
 Hypovolemic or hemorrhagic shock.
 Septic shock.
 Neurogenic shock.
Fat embolism.
Pulmonary embolism.
Crush syndrome.
Multiple organs failure syndrome (MOFS).
Thrombo-embolism.
Tetanus.
Gas gangrene.

Local complications

Early
1.
2.
3.
4.
5.
6.
7.
8.
9.
Visceral injury (the lung, the bladder, the urethra,
and the rectum).
Vascular injury.
Nerve injury.
Compartment syndrome.
Haemoarthrosis.
Infection.
Gas gangrene.
Fracture blisters.
Plaster and pressure sores.
Late
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
Delayed union.
Non-union.
Malunion.
Avascular necrosis.
Growth disturbance.
Bed sore.
Myositis ossificans.
Muscle contracture.
Tendon lesions.
Nerve compression and entrapment.
Joint instability.
Joint stiffness.
Complex regional pain syndrome. ( algodystrophy).
Osteoarthritis.
General complications
Shock
 Three types of shock may complicate
fractures
 Hypovolemic or hemorrhagic shock
 This type of shock is due to blood loss due
to vascular injury. The vessels may be
injured by the fracture pieces or in open
fractures the vessels are injured by the
same cause like in missile or bullet

injury.In hypovolemic shock there will be
reduction in the circulating volume causing
reduction in venous return and cardiac
output.
 The patient usually; severely pallor,
shivering, rigor, hypotensive and
sometimes comatose.
 Treatment by 1) control of hemorrhage
(may require surgery).
 restoration of circulating volume (fluid and
blood products).

Crush syndrome

Occur in
Large bulk of muscle crushed
 Tourniquet left for TOO long


What happened?

1st theory =Compression releasedacid
myohaematin enter the
circulationkidneyblocks the tubules
Renal failure and death.
What we can see?

Limb




Renal




Pulseless
Red
Swollen
Secretion diminished
Low output uraemia
Acidosis
Neurologically

Drowsynot treated  DEATH
How to treat it?

1st rule = Limb crushed severely(>6hrs)

How the amputation done?
Above the compression or crushed injury
 Before compression is released

Venous thrombosis & Pulmonary
Embolism
 Commonest Complications of Trauma
& Surgery
 Most frequently
Calf
 Less frequent in proximal of thigh & pelvis


Pulmonary Embolism
From Proximal of thigh & pelvis
 Incidence=5% & Fatal = 0.5%

What cause DVT?

The primary cause in surgical

HYPERCOAGULABILITY of the Blood
 due
to activation of Factor X by Thromboplastin from
damaged tissues

Thrombosis occurssecondary factors are
 Stasis
 Pressure
 Prolonged
immobility
 Endothelial damage
 Increase in no & stickiness of platelet
What are the high risk group?
Old people
 Cardiovascular Disease
 Bedridden patient
 Patients undergoing hip arthroplasty

What we can see in DVT?
Pain the calf or thigh
 Soft tissue tenderness
 Sudden slight increase in temperature
 Sudden increase in pulse rate

 Homann’s
Sign positive
How to diagnose DVT?
Ascending venography (bilaterally)
 US scanning (detecting prox DVT)
 Radioactive iodine labelled fibrinogen(clot)
 Doppler technique (measure blood flow)

How about pulmonary embolism?
Difficult to diagnose =only minority have
symptoms (chest pain, dyspnoe,
heamoptysis)
 So high risk patients should be examine
for pulmonary consolidation

X-ray
 Pulmonary angiography

How to prevent it?

Prophylactic treatment
Foot elevation
 Graduated compression stockings
 Exercise
 Anticoagulant treatment

 Subcut
low dose heparin 5000 units preops & 3/7
postops (but CI in older patientbleeding)
 Change to low molecular weight heparin (less
likely to cause bleeding)
What is the treatment?

Localized DVT
Elastic stockings
 Low dose subcut heparin (5000 unit)


More extensive DVT
Bed rest
 Elastic stockings
 Full anticoagulation

 Heparin
IV (10000 units 6 hourly)
 Continue for 5-7/7 with last 2/7 warfarin introduce
How to treat Pulmonary Embolism?
Cardiorespiratory resuscitation
 Oxygen
 Large dose heparin (15 000 units)
 Streptokinase (dissolve clot)
 Antibiotics (prevent lung infection)

TETANUS

What is Tetanus?
Tetanus organism live only in dead
tissueexotoxin blood & lymph to CNS
anterior horn cell
 Will develop

 Tonic



clonic contraction
Jaw and face (trismus and risus sardonicus)
Neck and trunk
Diaphragm and Intercostal muscle spasmASPHYXIA
What is the prophylaxis?
Active immunization (tetanus toxoid)
 Booster doses (immunized patients)
 Non Immunized patients

Wound toilet & antibiotics
 If wound contaminated antitoxin

Treatment for Tetanus
IV antitoxin
 Heavy Sedation
 Muscle Relaxant drug
 Tracheal Intubation
 Controlled respiration

GAS GANGRENE
By clostridial infection (esp C.welchii)
 Anaerobic with low oxygen tension
 Produce toxinsdestroy cell walltissue
necrosis Spreading

The clinical features

Within 24 hours
Intense pain
 Swelling
 Brownish discharge
 Pulse rate increased
 Charasteristis smell
 Little or no pyrexia
 Gas formation not marked
 ToxaemiccomaDEATH

How to prevent it?
Deep penetrating wound should be
EXPLORED
 ALL dead tissue completely EXCISED
 Doubt about tissue viabilityleft it OPEN
 No antitoxin

Treatment for gas gangrene
The key = EARLY DIAGNOSIS
 General measures (fluid, IV antibiotics)
 Hyperbaric oxygen (limiting spread)
 Decompression of wound
 Removal of all dead tissue
 Amputation (advanced case)

FAT EMBOLISM
Only minority patients with circulating fat
globules will develop POST TRAUMATIC
RESPIRATORY DYSFUNCTION
 Source of fat emboli=bone marrow
 Usually in MULTIPLE CLOSED
FRACTURE
 But other condition also reported (burns,
renal infarction, cardiopulmonary
operation)

How can we detect it?
Usually young adults with LL fracture
 Early warning signs (72 hrs. of injury)



Rise in temperature and pulse rate
More pronounced case
Breathlessness
 Mild mental confusion
 Petechia (chest & conjuntival fold)


Most severe case

Marked respiratory distress coma ARDS
How to treat it?

Mild case


Monitoring of blood PO2
Signs of hypoxia
Oxygen
 If severe

 Intensive
care with sedation and assisted ventilation
 Swan ganz Catheterization (monitor cardiac Fx)
 Fluid balance
 Supportive



Heparin-thromboembolism
Steroids-pulmonary oedema
Aprotinin-prevent aggregation of chylomicrons
COMPLICATION OF
FRACTURE
General
Local
Early
Late
* Early complication : those that arise during the first few weeks
following injury.
Early Complication
Local Visceral Injury
 Vascular Injury
 Nerve Injury
 Compartment Syndrome
 Haemarthrosis
 Infection
 Gas gangrene

Local visceral Injury



Fracture around the trunk are often Cx by
injury to the adjacent viscera :
Pelvic fracture
Rib fracture
Bladder and urethral
rupture
penetration to the lungs
Pneumothorax
Vascular injury
Most commonly – knee, femoral shaft,
elbow, and humerus.
 Artery may be cut, torn, compressed or
contused.
 Intima may be detached, thrombus block,
artery spasm
 Effect ?? ↓↓ bld flow coz Ischemia leads to
tissue death & peripheral gangrene

Common vascular injuries may associate with
the following fractures.

First rib or clavicle fracture (subclavian artery).
2. Shoulder dislocation (Axillary artery).
3. Humeral supracondylar fracture (brachial
artery).
4. Elbow dislocation (Brachial artery).
1.
5. Pelvic fracture (presacral and internal iliac).
6. Femoral supracondylar fracture (Femoral
artery).
7. Knee dislocation (Popliteal artery).
8. Proximal tibia (popliteal or its branches).
Clinical features
Pt with ischemia may have 5 P’s:
- paraesthesia/numbness
- pain
- pallor
- pulselessness
- paralysis
 Investigate if suspect vascular injury :
Angiogram

Treatment
Emergency treatment
 All bandages/splints removed
 The fracture X-Ray again
 Circulation reassessed for next half hour
 If no improvement, do vessels exploration
 Suture torn vessels, vein grafting, if
thrombosed do endarterectomy
 Aim: to restore bld flow

Nerve Injury
Variable degree of motor and sensory loss
along the distribution of the nerve
 May be neurapraxia, axonotmesis or
neurotmesis
 Radial nerve is most frequently damaged
nerves.

Nerve
Trauma
Effect
Axillary
Dislocation of
shoulder
# of humerus
Deltoid paralysis
Pointing index
Sciatic
Supracondylar # of
humerus
# medial epicondyl
humerus
Post dislocation of hip
Common
peroneal
Knee dislocation #
neck of fibula
Foot drop
Radial
Median
Ulnar
Wrist drop
Claw hand
Foot drop

In closed injuries – nerve is seldom severed and
spontaneous recovery should be awaited.

In open fractures – complete
lesion(neurotmesis) : the nerve is explored
during wound debridement and repaired.
Compartment Syndrome

Definition
Compartment syndrome involves the compression of
nerves and blood vessels within an enclosed space,
leading to impaired blood flow and nerve damage.

Fascia separate groups of muscles in the arms and legs
from each other. Inside each layer of fascia is a confined
space, called a compartment, that includes the muscle
tissue, nerves, bones and blood vessels.

A rise in pressure within these compartments may
jeopardize the blood supply to the muscles & nerves
within the compartment.

Causes:
-any injury/infection leading to edema of muscle
-fracture haematoma within the compartment
-ischemia to the compartment leading to muscle
oedema
-Due to tight bandages or casts

Hallmark Symptoms:
- severe pain that does not respond to elevation
or pain medication.
- In more advanced cases, there may be
decreased sensation, weakness, and paleness
of the skin.

Injuries with a high risk of developing
Compartments synd:
#
of the elbow
 # of the forearm bone
 # of the proximal third of the tibia
The vicious cycle of
Volkmann’s ischaemia
Arterial
Damage
Direct
injury
ischaemia
oedema
blood flow
………….....
.…………….
5P’s
Pain
Pallor
Paraesthesia
Pulseless
Paralysis
Fasciotomy
Compartment
pressure

A vicious cycle cont. until the total vascularity of
the muscles and nerves is jeopardized.

This result in ischaemic muscle necrosis and
nerve damage. (within 12 hours)

The necrotic muscle undergo healing with
fibrosis, leading to Volkmann’s contracture.

Nerve damage may result in motor and sensory
loss. In extreme case  gangrene



clinically:
- should be tested by stretching the
muscles  when the toes or fingers are
passively hyperextended there is ↑ pain
in the calf or forearm.
Early preventing : limb elevation
Dx : confirmed by direct intracompartmental
pressure measuring > 40mmHg is an indication
of compartment decompression and fasciotomy.
Treatment
First removed all the bandages & dressing.
Fasciotomy is performed.
 The wound should be left open and inspected
2 days later.
 If there is muscle necrosis  debridement
 If muscle is healthy suture (w/o tension)/
skin grafted / simply heal by 2˚ intention.

Haemarthrosis
Fractures involve joints, leads to acc. of
blood within the joints.
 C/Feature :The joint is swollen and tense
and patient will resists any movement.
 Tx : the blood should be aspirated before
dealing with the fracture.

Infection

Causes:





Open fracture (common)
Use of operative method in the Tx of #
Wound becomes inflamed and starts draining
seropurulent fluid.
Infection may be superficial, moderate
(osteomyelitis), severe (gas gangrene).
Post-traumatic wound infx is most common
cause of chronic osteomyelitis union will be
slow and ↑ chance of refracturing.
Treatment:
 Antibiotic
 Excising all devitalised tissue
 If Sx of acute infx and pus formation :
tissue around the fracture should be
opened & drained
Gas gangrene





Produced by anaerobic orgs : Clostridium sp infections.
These orgs can survive in ↓ O2 tension
Toxins produced will destroy the cell wall and leads to
tissue necrosis
C/feature: within 24hr. Pt complains:
- intense pain
- swelling around the wound
- brownish discharge
- gas formation
- pyrexia
- characteristic smelling
- PR ↑
- toxaemic  coma  death
Inability to recognize may lead to unnecessary amputation
for the non-lethal cellulitis.
swelling around the wound,
brownish discharge
gas formation
Prevention:

deep penetrating wound in muscular tissue are
dangerous;should be explored, all dead tissue
should be completely excised, and if there doubt
about the tissue viability should left open the wound
Treatment:


Early Dx is life saving
General measures:
 Fluid replacement & IV Antibiotic (immediate)
 Hyperbaric O2 (limiting the spread of gangrene)
 Mainstay : prompt decompression & remove dead
tissue
LATE COMPLICATIONS
•
•
•
•
•
•
•
•
Delayed union
Non-union
Malunion
Joint stiffness
Myoisitis ossificans
Avascular necrosis
Algodystrophy
Osteoarthritis
•
•
•
•
•
•
Joint instability
Muscle contracture
(Volkmann’s contracture)
Tendon lesions
Nerve compression
Growth disturbance
Bed sores
DELAYED UNION

Fracture takes more than the usual time to
unite.

Causes






Inadequate blood supply
Severe soft tissue damage
Periosteal stripping
Excessive traction
Insufficient splintage
Infection
PERKINS’ TIME TABLE
Upper Limb
Lower Limb
Callus visible
2-3 wks
2-3 wks
Union
4-6 wks
8-12 wks
Consolidation
6-8 wks
12-16 wks

Clinical features

Fracture tenderness
(Esp when subjected to stress)
 X-Ray
Visible fracture line
 Very little callus formation or
periosteal reaction

Severe soft tissue
damage
Infection
Excessive
traction
Intact fibula

Treatment


Conservative
- To eliminate any possible cause
- Immobilization
- Exercise
Operative
- Indication :
Union is delayed > 6 mths
No signs of callus formation
- Internal fixation & bone grafting
NON-UNION

Condition when the fracture will never unite w/o
intervention

Healing has stopped.
Fracture gap is filled by fibrous tissue
(pseudoarthrosis)

Causes



Improper Tx of delayed union
Too large a gap
Interposition of periosteum, muscle or cartilage between
the fragments

Clinical features

Painless movement at the fracture site
 X-Ray



Fracture is clearly visible
Fracture ends are rounded, smooth and sclerotic
Atrophic non-union : - Bone looks inactive
(Bone ends are often tapered / rounded)
- Relatively avascular
Hypertrophic non-union : - Excessive bone formation
` - on the side of the gap
- Unable to bridge the gap
Hypertrophic non-union
Atrophic non-union

Treatment
Ununited scaphoid fracture → asymptomatic
 Hypertrophic non-union (Esp long bone)
→ Rigid fixation (internal / external)
sometimes need bone grafting
 Atrophic non-union
→ Fixation & bone grafting

MALUNION

Condition when the fragments join in an
unsatisfactory position (unaccepted angulation,
rotation or shortening)

Causes
Failure to reduce a fracture adequately
 Failure to hold reduction while healing proceeds
 Gradual collapse of comminuted or osteoporotic
bone.


Clinical features


Deformity & shortening of the limb
Limitation of movements
 Treatment



Angulation in a long bone (> 15 degrees)
→ Osteotomy & internal fixation
Marked rotational deformity
→ Osteotomy & internal fixation
Shortening (> 3cm) in 1 of the lower limbs
→ A raised boot
OR
Bone operation
JOINT STIFFNESS

Common complication of fracture Tx following
immobilization

Common site : knee, elbow, shoulder,
small joints of the hand

Causes



Oedema & fibrosis of the capsule, ligaments, muscle
around the joint
Adhesion of the soft tissue to each other or to the
underlying bone (intra & peri-articular adhesions)
Synovial adhesions d/t haemarthrosis

Treatment
 Prevention
:
- Exercise
- If joint has to be splinted → Make sure in correct position
 Joint
stiffness has occurred:
- Prolonged physiotherapy
- Intra-articular adhesions
→ Gentle manipulation under anaesthesia
followed by continuous passive motion
- Adherent or contracted tissues
→ Released by operation
MYOSITIS OSSIFICANS

Heterotopic ossification in the muscles after an injury

Usually occurs in


Dislocation of the elbow
A blow to the brachialis / deltoid / quadriceps
 Causes


(thought to be due to) muscle damage
w/o a local injury (unconscious / paraplegic patient)

Clinical features
 Pain,
soft tissue tenderness
 Local swelling
 Joint stiffness
 Limitation of movements
 Extreme cases: - Bone bridges the joint
- Complete loss of movement
(extra-articular ankylosis)
 X-Ray
 Normal
 Fluffy
calcification in the soft tissue

Treatment
 Early
stage : Joint should be rested
 Then
: Gentle active movements
 When the condition has stabilized :
Excision of the bony mass
 Anti-inflammatory drugs may ↓ joint stiffness
AVASCULAR NECROSIS

Circumscribed bone
necrosis

Common site :


Causes


Interruption of the arterial
blood flow
Slowing of the venous
outflow leading to
inadequate perfusion






Femoral head
Femoral condyls
Humeral head
Capitulum of humerus
Scaphoid (proximal part)
Talus (body)
Lunate

Conditions a/w AVN
 Perthes’
disease
 Certain fractures
 Epiphyseal infection
 Sickle cell disease
 Caisson disease
 Gaucher’s disease
 Alcohol abuse
 High-dosage corticosteroid

Clinical features
 Joint
pain, stiffness, swelling
 Restricted movement
 X-Ray
↑
bone density
 Subarticular fracturing
 Bone deformity

Treatment
 Avoid
weight bearing on the necrotic bone
 Revascularisation (using vascularised bone grafts)
 Excision of the avascular segment
 Replacement by prostheses
ALGODYSTROPHY
(COMPLEX REGIONAL PAIN SYNDROME)
Previosly known as Sudeck’s atrophy
 Post-traumatic reflex sympathetic dystrophy
 Usually seen in the foot / hand
(after relatively trivial injury)
 Clinical features

 Continuous,
burning pain
 Early stage : Local swelling, redness, warmth
 Later
: Atrophy of the skin, muscles
 Movement are grossly restricted

X-Ray
 Patchy
rarefaction of the bones (patchy osteoporosis)
Osteoporosis
Algodystrophy
 Treatment
 Physiotherapy
(elevation & active exercises)
 Drugs
- Anti-inflammatory drugs
- Sympathetic block or sympatholytic drugs
(Guanethidine)
OSTEOARTHRITIS

Post-traumatic OA
 Joint
fracture wt severely damaged articular cartilage
 Within period of months
 2O OA
 Cartilage
heals
 Irregular joint surface may caused localized stress
→ 2O OA
 Years after joint injury

Clinical features





Pain
Stiffness
Swelling
Deformity
Restricted movement

Treatment





Pain relief : Analgesics
Anti-inflam agent
Joint mobility : Physiotherapy
Load reduction : wt reduction
Realignment osteotomy (young pt)
Arthroplasty (pt > 60yr)
Thank You