Complications of fractures.

General complications related to the fracture

it self.
Specific complications attributed to
associated injury.
COMPLICATIONS OF
FRACTURE

General Local

Early Late
Shock
Hypovolemic or hemorrhagic shock.
Septic shock.
Neurogenic shock.
Crush syndrome.
Thrombo-embolism-Pulmonary embolism.
Fat embolism.
Tetanus.
Gas gangrene.
Hypovolaemic shock
Neurogenic shock
Septic shock
Spinal shock
Cardiogenic 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.
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).
2)restoration of circulating volume (fluid and blood products).
Cardiogenic shock can mimic many of the signs
of hypovolaemic shock. The history will give a good
indication of the likely cause. The veins tend to be full in
cardiogenic shock, and cyanosis more profound. There may be
other diagnostic signs present such as pulmonary oedema.

Septic, neurogenic shock are characterized by

vasodilatation as opposed to vasoconstriction.
Neurogenic shock result in low blood pressure and slow heart rate.
Septic shock maifested by tachycardia, tachypnea and altered
sensorium.
Spinal shock, due to spinal cord injury.
abscence all voluntry and reflex neurological
activity below level of injury – decreased
reflexes, loss of sensation and flaccid
paralysis below injury.
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
Pulseless
Red
Swollen
Renal
Secretion diminished
Low output uraemia
Acidosis
Neurologically
Drowsynot treated  DEATH
How to treat it?
1st rule = Limb crushed severely(>6hrs)

AMPUTATION
How the amputation done?
Above the compression or crushed injury
Before compression is released
Commonest Complications of Trauma &
Surgery
Most frequently
Calf
Less frequent in proximal of thigh & pelvis
Pulmonary Embolism
From Proximal of thigh & pelvis
Old people
Cardiovascular Disease
Bedridden patient
Patients undergoing hip arthroplasty
Pain the calf or thigh
Soft tissue tenderness
Sudden slight increase in temperature
Sudden increase in pulse rate
Ascending venography (bilaterally)
US scanning (detecting prox DVT)
Radioactive iodine labelled fibrinogen(clot)
Doppler technique (measure blood flow)
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
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
Cardiorespiratory resuscitation
Oxygen
Large dose heparin (15 000 units)
Streptokinase (dissolve clot)
Antibiotics (prevent lung infection)
Only minority patients with circulating fat
globules will develop POST TRAUMATIC
RESPIRATORY DYSFUNCTION
Source of fat emboli=bone marrow
Usually in MULTIPLE CLOSED FRACTURE
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
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
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
By clostridial infection (esp C.welchii)
Anaerobic with low oxygen tension
Produce toxinsdestroy cell walltissue
necrosis Spreading
Within 24 hours
Intense pain
Swelling
Brownish discharge
Pulse rate increased
Charasteristis smell
Little or no pyrexia
Gas formation
ToxaemiccomaDEATH
 swelling around the wound,
brownish discharge

gas
formation
How to prevent it?
Deep penetrating wound should be EXPLORED
ALL dead tissue completely EXCISED
Doubt about tissue viability left it OPEN
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)
Early complication : may present as part of the
primary injury or may appear only after a few
days or weeks.
FRACTURE BLISTERS
Two distinct blister types are
sometimes seen after fractures:
clear fluid-filled vesicles and blood-
stained ones.
Both occur during limb swelling and
are due to elevation of the
epidermal layer of skin from the
dermis.
 The skin over the
sacrum and heels
is especially vulnerable.
Careful nursing and
early activity can
usually prevent bed
sores.
Tendinitis may affect the tibialis posterior tendon
following medial malleolar fractures.

Rupture of the extensor pollicis longus tendon may

occur 6–12 weeks after a fracture of the lower
radius.
Fracture around the trunk are often Cx by
injury to the adjacent viscera :

Pelvic fracture Bladder and urethral

rupture
Rib fracture penetration to the lungs

Pneumothorax
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
1.First rib or clavicle fracture (subclavian artery).
2.Shoulder dislocation (Axillary artery).
3.Humeral supracondylar fracture (brachial artery).
4.Elbow dislocation (Brachial artery).
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).
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 Deltoid paralysis

Radial # of humerus Wrist drop

Median Supracondylar # of humerus Pointing index

Ulnar # medial epicondyl humerus Claw hand

Sciatic Post dislocation of hip Foot drop

Common Knee dislocation # neck of fibula Foot drop

peroneal
Bone or joint deformity may result in local
nerve entrapment the ulnar nerve, due to a
valgus elbow following a malunited lateral
condyle or supracondylar fracture
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.
 5P’s
Arterial ischaemia blood flow
Pain
Damage Paraesthesia
Pallor
Pulseless
Paralysis

Direct ………….....
oedema .…………….Fasciotomy
injury

Compartment
pressure
Dx : confirmed by direct
intracompartmental pressure
measuring
> 40mmHg is an indication of
compartment decompression and
fasciotomy.
A differential pressure (ΔP) – the
difference between diastolic
pressure and compartment
pressure – of less than 30 mmHg
(4.00 kilopascals) is an indication for
immediate compartment
decompression.
Fracture takes more than the usual time
to unite.

Causes
 Inadequate blood supply
 Severe soft tissue damage
 Periosteal stripping
 Excessive traction
 Insufficient splintage
 Infection
 Clinical features
 Fracture tenderness
(Esp. when subjected to stress)

 X-Ray
 Visible fracture line
 Very little callus formation or

periosteal reaction
 Severe soft Infectio Excessive Intact fibula
tissue damage n traction
Conservative
- To eliminate any possible cause
- Immobilization
- Exercise
 Operative
- Indication :
Union is delayed > 6 mths
No signs of callus formation
- Internal fixation & bone grafting
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

Osteotomy & internal fixation

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
  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
Circumscribed bone
necrosis Common site :
 Femoral head
Causes  Femoral condyls
 Interruption of the  Humeral head
arterial blood flow  Capitulum of humerus
 Slowing of the venous  Scaphoid (proximal
outflow leading to part)
inadequate perfusion  Talus (body)
 Lunate
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)

Osteoporosi Algodystroph
s y
 Treatment
 Physiotherapy (elevation & active exercises)
 Drugs

- Anti-inflammatory drugs
- Sympathetic block or sympatholytic drugs
(Guanethidine)
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
 Heterotopic ossification in the muscles after an
injury

Usually occurs in
 Dislocation of the elbow
 A blow to the brachialis / deltoid / quadriceps

 Causes
 muscle damage
 w/o a local injury: (unconscious / paraplegic patient)
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
Following injury, a joint may give way. Causes include
the following:
• LIGAMENTOUS LAXITY – especially at the knee, ankle
and metacarpophalangeal joint of the thumb
• MUSCLE WEAKNESS – especially if splintage has been
excessive or prolonged, and exercises have been
inadequate – again the knee and ankle are most
often affected
• BONE LOSS – especially after a gunshot fracture or
severe compound injury, or from crushing of metaphyseal bone in joint
depression fractures.
ALTERATION OF
GRWTH
Physeal injuries
Q1- HOW WOULD YOU DIAGNOSE
COMPARTMENTAL SYNDROME?

Q2-LIST
A-THE GENERAL COMPLICATIONS OF
FRACTURE.
B- THE BONY COMPLICATIONS OF
FRACTURES.