Complications of fractures General complications Hemorrhage and shock. Fat embolism. Venous thrombosis and pulmonary embolism. Crush syndrome. Complications of prolonged bed rest and recumbancy, especially in elderly and aged patients.. e.g. DVT, bedsores, hydrostatic pneumonia and UTI. Local complications Early Infection. Vascular injury. Nerve injury. Visceral injury. Heamarthrosis (bleeding inside a joint). Compartment syndrome.

Late local Delayed union and nonunion, those may need surgical treatment with R efreshment of the bony ends, R e-reduction of the fr. R einforcement by rigid internal fixation and R eplacement by bone graft (the four R principles). Mal-union, if its sever and affect function or show severe deformity it may need surgery in form of Osteotomy at site of deformity, Reduction to normal position, Internal fixation and sometimes Bone graft. Joint stiffness, this needs good physiotherapy and exercises and sometimes manipulation or even surgical soft tissue release. Myositis ossificans around a joint or of the muscles which causes sever stiffness and it’s difficult to treat. Algodystrofy or reflex sympathetic dystrophy where the limb get swollen and painful with excessive loss of bone mass and functional disturbances, this usually treated with physiotherapy and exercises with symptomatic treatment but still it can be sever and very disturbing and difficult to treat. Avascular necrosis of nearby bony end or segment, this occurs in certain regions where the blood supply of a bony end (usually inside a joint) is critical and seriously affected by the fr. this leads to serious changes which may ends in damage to nearby joint and serious functional deficit. Osteoarthritis, it’s a degenerative joint disease associated with pain and limitation of movement.

Special features of fractures in children 1.Green stick (incomplete) fractures: 2.Epiphysial inj SALTER-HARRIS classification into: Type1; the fracture pass through the Epiphysial plate only and there is no displacement. Type 2; fr line pass through most of the epiphysis and cuts partly on the metaphysis displacing the epiphysis and the attached small metapliyesial triangular segment. Type 3; partial epiphysial plate fracture that will continue through the epiphysis separating epiphysial fragment. Type 4; the fracture line cuts through the epiphysis and the metaphysis separating an epiphysial fragment with its opposed epiphysial plate and metaphysis. Type 5; its compression fr of the epiphysis that does not usually seen in x-ray. It carries the worst prognosis, as it’s commonly lead to growth disturbances. Type 1 and 2 are commoner and carry good prognosis, while type 3 and 4 are less common and carry poorer prognosis. OOOOOOOOO uries

JOINT INJURIES Joint dislocation: it’s the condition of complete displacement of articular surfaces. Joint subluxation: it’s the condition of incomplete (partial) displacement of articular surfaces. medical emergency, MUA and rested for 2-3 weeks with pop

Volkman’s ischemia (compartment syndrome) increased soft tissue pressure within enclosed compartment that leads to failure of capillary circulation causing tissue ischemia and damage. Enclosed compartment tight compartments

Pathology and pathogenesis The compartment syndrome is a serious condition because it leads to a VICIOUS CIRCLE where tissue ischemia causes soft tissue swelling and as the swelling occurs and increase in a closed compartment there further increase in local tissue pressure until its more than local capillary pressure causing failure of capillary circulation with hypoxia and lactic acidosis that cause further edema and further increase in tissue pressure with further ischemia... and so on. The ischemia will cause tissue death; the most sensitive tissues affected are the nerves and the muscles that will die. After control of the compartment syndrome the nerves can regenerate and regain some or all of its function but not the muscles that after ischemia and death will heal with fibrous tissue that will contracts later giving a chronically deformed limb with serious functional impairment (the Volkman’s contracture

Clinical features: There are FIVE cardinal clinical features of ischemia are the FIVE Ps: Painful limb (pain is much greater than expected from the injury itself despite good management) or sometimes the limb is tender to stretch because of tender muscles. Pale or plum colored skin, sometimes its cyanosed skin. Parasthesia due to disturbed nerve function. Paralysis or weakness due to muscle ischemia. Pulseless limb, only at late stage after serious pressure increase with impairment of major vessel circulation, PRESENCE OF PULSE DOES NOT EXCLUDE COMPARTMENT SYNDROME, it’s a crime to wait until the pulse is absent.

Diagnosis must be made at earlier stages, and it’s not important to have all the signs and a symptom to say there is a compartment syndrome. For example we must keep it in mind after any possible cause of compartment syndrome and frequently look for it, as limb is in sever unexpected pain with local muscle tenderness on stretch or if skin gets pale or dusky we must check for compartment syndrome and this is done very simply by measuring the local tissue pressure and if its more than 40mm Hg it means there is compartment syndrome that needs management, sometimes we do continues tissue pressure monitoring for expected compartments

Management of compartment syndrome: The primary cause must be removed if possible e.g. removal of tight POP cast, bandages or dressings. Control of main vessel insufficiency, and measure the pressure. If it’s present and there is no relief THE CLOSED COMPARTMENT MUST BE OPENED by surgical FASCIOTOMY by opening of the tight deep fasciae all over the closed compartment to decrease the local pressure and break the circle of progressive tissue death and improve capillary circulation. Fascitomy is an urgent simple surgical procedure that can save a limb from serious consequences as deformity and functional losses.