1. Complications of Fractures

2. COMPLICATION OF FRACTURE
General
Local
Early
Late

3. 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.

4. Local complications Early
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.

5. Late
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.

6. General complications

7. 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

8. 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).

9. Crush syndrome Occur in What happened? 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.

10. What we can see? Limb Renal Neurologically Pulseless Red Swollen
Secretion diminished
Low output uraemia
Acidosis
Neurologically
Drowsynot treated  DEATH

11. How to treat it? AMPUTATION 1st rule = Limb crushed severely(>6hrs)
How the amputation done?
Above the compression or crushed injury
Before compression is released
AMPUTATION

12. 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%

13. 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

14. What are the high risk group?
Old people
Cardiovascular Disease
Bedridden patient
Patients undergoing hip arthroplasty

15. What we can see in DVT? Homann’s Sign positive Pain the calf or thigh
Soft tissue tenderness
Sudden slight increase in temperature
Sudden increase in pulse rate
Homann’s Sign positive

16. How to diagnose DVT? Ascending venography (bilaterally)
US scanning (detecting prox DVT)
Radioactive iodine labelled fibrinogen(clot)
Doppler technique (measure blood flow)

17. 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

18. 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)

19. What is the treatment? Localized DVT More extensive DVT
Elastic stockings
Low dose subcut heparin (5000 unit)
More extensive DVT
Bed rest
Full anticoagulation
Heparin IV (10000 units 6 hourly)
Continue for 5-7/7 with last 2/7 warfarin introduce

20. How to treat Pulmonary Embolism?
Cardiorespiratory resuscitation
Oxygen
Large dose heparin ( units)
Streptokinase (dissolve clot)
Antibiotics (prevent lung infection)

21. 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

22. What is the prophylaxis?
Active immunization (tetanus toxoid)
Booster doses (immunized patients)
Non Immunized patients
Wound toilet & antibiotics
If wound contaminated antitoxin

23. Treatment for Tetanus IV antitoxin Heavy Sedation Muscle Relaxant drug
Tracheal Intubation
Controlled respiration

24. GAS GANGRENE By clostridial infection (esp C.welchii)
Anaerobic with low oxygen tension
Produce toxinsdestroy cell walltissue necrosis Spreading

25. 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

26. How to prevent it? Deep penetrating wound should be EXPLORED
ALL dead tissue completely EXCISED
Doubt about tissue viabilityleft it OPEN
No antitoxin

27. 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)

28. 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)

29. 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

30. How to treat it? Mild case Signs of hypoxia Monitoring of blood PO2
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

31. COMPLICATION OF FRACTURE
General
Local
Early
Late
* Early complication : those that arise during the first few weeks
following injury.

32. Early Complication Local Visceral Injury Vascular Injury Nerve Injury
Compartment Syndrome
Haemarthrosis
Infection
Gas gangrene

33. Local visceral Injury
Fracture around the trunk are often Cx by injury to the adjacent viscera :
Pelvic fracture
Rib fracture penetration to the lungs
Bladder and urethral
rupture
These require Emergency Treatment…………chest tube insertion
Pneumothorax

34. 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
Most common artery injury is popliteal art
Knee – poppliteal artery, femoral art, brachial art…….cut, torn – by initial inj or jagged by bone fragments

35. Common vascular injuries may associate with the following fractures.
First rib or clavicle fracture (subclavian artery).
Shoulder dislocation (Axillary artery).
Humeral supracondylar fracture (brachial artery).
Elbow dislocation (Brachial artery).

36. 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).

38. Clinical features Pt with ischemia may have 5 P’s:
- paraesthesia/numbness
- pain
- pallor
- pulselessness
- paralysis
Investigate if suspect vascular injury : Angiogram

39. 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
In this operation, the fracture can be fixed internally at the same time

40. 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.
Radial N – Humerus fracture
Neurapraxia-minimal damage, axonotmesis- axon damage but sheath intact, neurotmesis- complete damage

41. Dislocation of shoulder Deltoid paralysis Radial # of humerus
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 peroneal
Knee dislocation # neck of fibula

42. 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.
About 90% cases recover within 4 months

43. 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.
If blood supply is impaired more than 12 hours, coz necrosis of the muscles and nerves within the compartments. Nerve is still capable of regeneration but muscles once infarcted, can never recover n will be replaced by inelastic fibrous tissue.(volkmann’s contracture)

44. 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.

45. Injuries with a high risk of developing Compartments synd:
# of the elbow
# of the forearm bone
# of the proximal third of the tibia

46. The vicious cycle of Volkmann’s ischaemia
5P’s
Pain
Pallor
Paraesthesia
Pulseless
Paralysis
Arterial ischaemia blood flow
Damage
Direct
injury
………….....
.…………….
oedema
Fasciotomy
Compartment
pressure

47. 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
This results in further swelling, a further increase in pressure, and a further reduction in capillary blood flow. Necrosis develops within about 12 hours - nerve function may be recoverable in time but infarcted muscle is damaged permanently. Eventually, the dead muscle fibroses and shortens, and an ischaemic contracture results.

48. - should be tested by stretching the
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.
As ischemic muscles is sensitive to stretch,
Different pressure btwn diastolic pressure and compartment pressure
Within 6 hour in total ischema…muscles necrosis

50. 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.
Fasciotomy :do a long incision to the fascia to release the pressure

53. 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.

54. 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. un

55. Excising all devitalised tissue
Treatment:
Antibiotic
Excising all devitalised tissue
If Sx of acute infx and pus formation : tissue around the fracture should be opened & drained
All open fracture shud be regarded as potentially infecte

56. 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.
C.perfringens, welchii
Cth dead muscle, dirty wound, inadequate debridement
Once experienced this will never be forgotten

57. swelling around the wound,
brownish discharge
gas formation

58. Prevention: Treatment:
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

59. LATE COMPLICATIONS Joint instability Muscle contracture Delayed union
(Volkmann’s contracture)
Tendon lesions
Nerve compression
Growth disturbance
Bed sores
Delayed union
Non-union
Malunion
Joint stiffness
Myoisitis ossificans
Avascular necrosis
Algodystrophy
Osteoarthritis

60. 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

61. PERKINS’ TIME TABLE Upper Limb Lower Limb Callus visible 2-3 wks Union
Consolidation
6-8 wks
12-16 wks

62. Clinical features X-Ray Fracture tenderness
(Esp when subjected to stress)
X-Ray
Visible fracture line
Very little callus formation or
periosteal reaction

63. Severe soft tissue damage
Infection
Excessive traction
Intact fibula

64. 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

65. 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

66. Clinical features X-Ray Painless movement at the fracture site
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

67. Hypertrophic non-union
Atrophic non-union

68. 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

69. 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.

70. Clinical features Treatment Deformity & shortening of the limb
Limitation of movements
Treatment
Angulation in a long bone (> 15 degrees)
→ Osteotomy & internal fixation
Marked rotational deformity
Shortening (> 3cm) in 1 of the lower limbs
→ A raised boot OR
Bone operation

72. 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

73. Treatment Prevention : Joint stiffness has occurred: - 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

74. 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)

75. Clinical features X-Ray 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

76. 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

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

78. Conditions a/w AVN Perthes’ disease Certain fractures
Epiphyseal infection
Sickle cell disease
Caisson disease
Gaucher’s disease
Alcohol abuse
High-dosage corticosteroid

79. Clinical features X-Ray Joint pain, stiffness, swelling
Restricted movement
X-Ray
↑ bone density
Subarticular fracturing
Bone deformity

81. Treatment Avoid weight bearing on the necrotic bone
Revascularisation (using vascularised bone grafts)
Excision of the avascular segment
Replacement by prostheses

82. 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

83. X-Ray Patchy rarefaction of the bones (patchy osteoporosis)
Algodystrophy

84. Treatment Physiotherapy (elevation & active exercises) Drugs
- Anti-inflammatory drugs
- Sympathetic block or sympatholytic drugs
(Guanethidine)

85. OSTEOARTHRITIS Post-traumatic OA 2O 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

86. Clinical features Treatment 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)

87. Thank You