Fractures – Complications & Management

Complication of Fractures Immediate Complication (at the

time of fracture) Early complication (initial few

days) Late Complication

Immediate Complications

Systemic Hypovolaemic ShockLocal Injury to major vessels Injury to muscles & tendons Injury to joints Injury to viscera

Early complications

Systemic Hypovolaemic shock ARDS Fat Embolism Syndrome DVT & Pulmonary embolism Aseptic traumatic fever Septicemia (Open fractures) Crush syndrome

Early Complications

Local Infection Compartmental Syndrome

Late complications

Bone Union related Delayed-Union Non-union Mal-union Cross-union

Late complications

Others Avascular

Necrosis Shortening Joint Stiffness Sudeck’s

dystrophy (Reflex Sympathetic dystrophy)

Osteomyelitis Ischaemic

contracture Myossitis

Ossificans Osteoarthritis

Hypovolaemic Shock Commonest cause for death Pelvis(2 lts) & Long Bone(1.5lts)

#’s External Hemorrhage eg: Open fracture, vascular Injury Internal Hemorrhage eg: Chest/Abdominal bleeding

Hypovolaemic shock-Management Follow the BLS/ATLS protocolsEg: No 14 IV cannula + 2lts of

crystalloids/colloids/blood, Localize the site of bleeding, needle aspiration, Inv - X-ray, Ultrasound

Avoid movements at the Fracture Stabilize the fracture eg : External

Fixator for Pelvis, Splints for long bones

ARDS –Adult Respiratory Distress Syndrome

Cause – Trauma & Shock Release of Inflammatory mediators Disruption of Pulmonary

microvasculature Onset in 24 hrs Tachypnoea & laboured breathing

ARDS - Management Chest X-ray: diffuse Pulm infiltrate Arterial PO2 <50 100% Oxygen Assisted ventilation Chest clears in 4 to 7 days Not treated – CardioPulmonary

failure - Death

Fat Embolism Occlusion of Small vessels by fat

globules Bone Marrow/Adipose tissue Polytrauma of long major bones Release of free fatty acids(Lipases

action) – toxic vasculitis – Platelet fibrin thrombosis

Obstruction of Pulm vessels by fat

Fat Embolism – clinical features

Develops in 24 to 72hrs Cerebral type – drowsy, restless,

disoriented, coma Pulmonary type – tachypnoea,

tachycardia Patechial rash- neck, axillary fold, chest,

conjunctiva

Respiratory failure - Death

Fat Embolism - Diagnosis Strong suspicion Retinal artery emboli (Striate

haemorrhages)

Fat globules in sputum & Urine X-ray – Patchy pulm Infiltrate (snow

storm)

Blood PO2 <50

Fat Embolism - treatment Respiratory support Heparinisation, IV Low molecular

wt dextran, corticosteriods

Deep Vein Thrombosis (DVT)& Pulmonary Embolism (PE)

Lower limb & Spinal Injuries Cause: Immobilization – venous

stasis – thrombosis of veins DVT proximal to knee is Dangerous DVT in 48 hrs – PE in 4 to 5 days

DVT & PE – Clinical Feature High index of suspicion Elderly & Obese pts Leg swelling & calf tenderness Calf tenderness on passive

dorsiflexion of Ankle ( Homan’s sign) Venography/Doppler Ultrasound PE – tachypnoea, dyspnoea, chest

pain, hemoptysis

DVT & PE - treatment DVT : Elevation of limb, Elastic

bandage, active mobilization after early fracture stabilization, anticoagulation

PE : Respiratory support, Anticoagulation therapy

Crush syndrome Massive crushing of Muscles Release of Myohaemoglobin Precipitates in Renal tubules Acute renal tubular necrosis Treated as for Acute renal failure

Injury to the blood vessels Femoral - # L/3rd Femur Popliteal – Supracondylar # Femur(commenest)

Post Tibial – Dislocation Knee, # Tibia Subclavian – Clavicle # Axillary – Fracture dislocation shoulder Brachial – Supracondylar # Humerus

Injury to the blood vessels No effect – collateral circulation is

good Exercise Ischemia – vascular

claudiction Ischemic contracture – Ischemic

muscle necrosis – contracture/fibrosis – volkmann’s ischemic contracture

Gangrene

Injury to the blood vessels Pain – cramp like Pulse – absent Pallor Paraesthesia ParalysisDoppler study / AngiogramRepair of vessel

Injury to NervesInjury to Tendons

Injury to Joints Subluxation or Dislocation Early reduction & stabilization Early Joint movement Secondary Osteoarthritis/stiffness

Infection - Osteomyelitis Open #’s (Common)

Compartment syndrome Rise in Pressure in closed

compartment of the limb Jeopardize the Muscle & nerve

blood supplyInjury & oedma to musclesFracture hematomaIschemia leading to muscle oedema

Compartment syndrome- Vicious cycle

swelling

Blood supply Muscle Ischemia

Injury

Compartment syndrome - Results

Ischemic Muscle necrosis Muscle fibrosis – Contractures Nerve damage Motor sensory loss Gangrene

Compartmental syndrome - Diagnosis

Excessive Pain High risk injuries eg:Supracondylar # humerus, Forearm bones #, Closed Tibial #, Crush injuries to leg & forearm

Compartmental syndrome - Diagnosis

Stretch test – earliest sign Tense compartment Hypoaesthesia of involved nerves Muscle weakness Compartmental pressure of >40

mm of H2O

Compartmental syndrome - Treatment

Early prevention – limb elevation, active finger mobilization

Early surgical decompression eg: fasciotomy

Delayed & Non-union More than the usual time to unite Fracture healing has stopped (not

before six months)

Delayed & Non-union Causes related to the patients Age – common in old age Asso Systemic illness

eg:Malignancy, Osteomalacia

Delayed & Non-union Causes related to fracture Distraction at fracture site Muscle pulling eg:Patella &

Olecranon #Gravity eg: # shaft of humerus Soft tissue interposition eg: # shaft

humerus, femur Bone loss at the # site

Non-union

Delayed & Non-union Causes related to fracture Infection from open # Damage/Poor blood supply eg:#

neck of femur, L/3rd Tibia Pathological #

Delayed & Non-union Causes related to Treatment Inadequate redution Inadequate immobilization Distration during treatment

Types of Nonunion Atrophic Hypertrophic

Common sitesNeck of femur, Scaphoid, L/3rd Tibia,

Lateral condyle Humerus

Delayed & Non-union : C/f Persistant Pain Pain on stressing the # Mobility (Nonunion) Increasing deformity

Delayed & Non-union – X-ray Fracture line is visible Inadequate bridging callus

(Delayed) No bridging callus (Non-union)

TomogramMedullary venography

Infected Nonunion

Delayed & Non-union- Treatment Bone Grafting BG + Internal Fixation Excision of fragment eg: # neck of

femur in elderly(hemiarthroplasty) Ilizarov’s method

Malunion # unites in improper position Disability of clinical significance eg:

deformity, shortening, limitation of motion

Improper treatment Commonest eg: colles #, Clavicle

#

Malunion

Malunion - Treatment Osteoclasis Corrective osteotomy No treatment – RemodellingChildren, 5 to 10 deg of Angulation, Angulation in the plane of movement, #’s near joints

Avascular Necrosis Blood supply is jeopardized Head of Femur eg: # neck of

femur, dislocation hip Proximal pole of scaphoid, Body of

Talus

Avascular Necrosis Sclerosis of necrotic bone Deformity due to collapse Osteoarthritis

Avascular Necrosis- Treatment Delayed wt bearing Vascularised bone graft Excision of avascular segment Excision & Arthroplasty

Reflex sympathetic Dystrophy (sudeck’s Dystrophy) Following Trauma Pain Hyperaesthesia Tenderness & Swelling Skin is red, shiny, warm Atrophy of skin, muscle, nail Joint deformity & stiffness

Reflex sympathetic Dystrophy (sudeck’s Dystrophy) X-ray – Spotty rarefaction Physiotherapy Avoid surgery or forceful

mobilization Sympathetic blocks

Myossitis Ossificans (post-traumatic ossification) Ossification of the hematoma Joint stiffness Head injury Children around elbow Massage

Myossitis Ossificans (post-traumatic ossification) X-ray-active myositis – margins are

fluffy Mature myositis – bone

trabeculated, well defined margins

Myossitis Ossificans (post-traumatic ossification) Avoid Massage Rest to the limb Surgical excision of mature

myositis

Thankyou

Dr Jai Thilak

Orthopaedics