Complications of Fractures

Complications of Fractures. DR. Ahmad AboSalem Lecturer of orthopedic surgery M.B.b.Ch., m.sc.

Definition:. Fracture: break in the normal continuity of bone.

Complications of fractures. General : CVS: Shock, crush syndrome Respiratory: pulmonary embolism ( DVT→embolus , Fat embolism) Aspiration pneumonia Renal: ARF, renal caliculi, UTI GIT: Constipation Infection: Tetanus, gas gangrene Prolonged recumbency : DVT→pulmonary embolism Bed sores Osteoporosis Renal stones constipation.

Skin (loss, infection, sores→ pressure, cast). Muscles (Myositis ossificans, tendon injury).

Shock. Types Causes Management (c/p, investigations, treatment).

Shock. Definition : Altered physiologic status with generalized inadequate tissue perfusion relative to metabolic requirements.  irreversible damage to vital organs. Types.

Shock. Management (c/p, investigations, treatment).

Diffuse coagulopathy. Consumptive Coagulopathy • activation by tissue thromboplastin • endothelial injury activating platelets • massive blood transfusion Management • Stop the bleeding • Fresh Frozen Plasma (FFP) • Cryoprecipitate • Platelet transfusion • Heparin.

Respiratory Dysfunction. Pathophysiology • Alveolar edema • endothelial injury • capillary permeability • Poor lung compliance • inactivated surfactant • Arterial hypoxemia Management • Oxygenation • Ventilation • positive end expiratory pressure (PEEP).

Crush Syndrome.

Crush Syndrome. Clinically • Shock • Pulseless limb redness swelling • Loss of muscle sensation and power • Decrease renal secretion • Uremia, acidosis • Prognosis • If renal secretion return within I week the patient survive • But most of them die within 4 days Management • PREVENTION • Strict tourniquet timing • Amputation • limb crushed severely • tourniquet left on > 6 hrs • above site of compression & before compression released • Monitor intake & output • Dialysis • Correct electrolytes & acidosis • Antibiotics.

Crush syndrome→ ARF.

Pulmonary embolism. DVT→ Embolus Fat Definition- mechanism- c/p- investigations-TTT.

DVT and Pulmonary embolism.

Management of DVT and Pulmonary embolism.

Fat Embolism.

Fat Embolism.

Fat Embolism. SKIN: Fat droplets obstruct alveolar capabaries -+ thrornboplastin consurnption or bc & platelets DIVC/Skü1 necrosis Petechia LUNG: droplets —Y obstruct alveolar capillaries thrornboplastül —Y dter rnern&ane perrneabiEty / lung -5 æderna re*frafioc-y fcih-rre [V JQ MÉrnatchJ BRAIN: Fat droplets obstruct capilkries confusion -5 corna/füs death.

Gas Gangrene. Rapid and extensive necrosis of the muscle accompanied by gas formation and systemic due to clostridium perfringens infection Clinical Features •sudden onset of pah socaüea to me irfectea area. •sweling „ eaemaz pyrexia •profuse serous aiscno•ge W'itn• sweetin ono mousy odor. •Gas production, Management •earty diagnosis. •surgical intervention ane debridement are me mainstay of treatment- •IV antibiotics, •fluid replacement: • 'hyperbaric Oxygen.

Gas Gangrene. Prevenfion: ALL DEAD TISSUE SHOULD BE COMPLETELY EXCISED*.

Tetanus. A condition affer clostridium tetani infection that passes to anterior horn cells where it fixed and cant be neutralized later ryoduces hyper-excitabifity and reflex muscle spasrn CEnical Features and clonie confracfionS of esp. face, around the wound iiseø eneck ,frunkv finoIlV spasm of fhe diaphragm and intercostal muscles leads to asphyxia and death. Management • Prophylaxis •Treatmentt • Antitoxü•v C. antöotic: • MuscE relaxant •Tracheal ültubation • Respiration contrail.

Early Complications 1. 2. 3. 4. 5. 6. Visceral Injury Vascular Injury Compartment Syndromes Nerve injury Haemarthrosis Infection.

Blood vessels. Acute Ischemia Compartmental syndrome Volkmann ischemic contracture.

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Early I : Visceral injury o Fractures around the trunk are often complicated by visceral o E.g. Rib fractures -5 pneumothorax / spleen trauma / liver injuries. o E.g. Pelvic injuries -5 bladder or urethral rupture / severe hematoma in the retro- peritoneum . o Rx: Surgery of visceral injuries.

Early 2: Vascular injury o Commonly associated with high- energy open fractures. They are rare but well-recognized. o Mechanism of injuries: o The artery may be cut or torn. o Compressed by the fragment of bone. o normal appearance, with intimal detachment that lead to thrombus formation. o segment of artery may be in spasm. o It may cause o Transient diminution of blood flow o Profound ischaemia o Tissue death and gangrene a].

Early 2: Vascular injury Pain Pallor Pulseless Paral sis Paraesthesi (C).

Early 2: Vascular injury o muscle ischaemic is irrevesible after 6 hours. o Remove all bandages and splint & assess circulation o Skeletal stabilization — temporary external fixation. o Definitive vascular repair. o Vessel sutured o endarterectomy.

Early 3: Compartment Syndrome A condition in which increase in Dressure within a closed fascial comoartment leads to decreased tissue Derfusion. Untreated, progresses to tissue ischaemia and eventual necrosis an tenor convtrnent interosæou Leg deep psterior fitnjla taterai cmpartment .4 compartments: anterior, lateral, tibi superficial and deep posterior •NOT interconnected com rtmen Forearm •3 compartments: dorsal, superficial and deep volar •interconnected, hence fasciotomy of 1 compartment may decompress the other 2.

Early 3: Compartment Syndrome o Most common sites (in I freq): leg (after tibial fracture) forearm thigh —+ upper arm. Other sites: hand, foot, abdomen, gluteal and cervical regions. o High risk injuries: o # of elbow, forearm bones, and proximal 3rd of tibia (30-70% after tibial #) o multiple fracture of the foot or hand o crush injuries o circumferential burns.

Early 3: Compartment Syndrome [aetiology] t Compartmental volume (t fluid content) • Trauma — fractures /osteotomies, crush injury • Vascular — haemorrhage, post-ischaemic swelling • Soft tissue injury - burns, prolonged limb compression • Iatrogenic - intraosseous fluid resuscitation in children, intraarterial drug injection • Extreme muscular exertion Compartment volume (constriction of the com artment • Constrictive dressings/plaster casts • Thermal injuries with eschar formation • Pneumatic antishock garments (MAST) • Surgical closure of fascial defects.

Early 3: Compartment Syndrome t fluid content. Early 3: Compartment Syndrome t fluid content.

Direct injury ced Painfut Pale (or plum- coloured) Pulseless Paraesthetic Paralysed.

A vicious circle that ends after 12 hours or less Necrosis of the nerve and muscle within the compartment.

Investigations of compartment sydromes o Intra-compartment Pressure Measurement (ICP) o Use of slit catheter; quick and easy o Indications: o Unconscious patient o Those who are difficult to assess o Concomitant neurovascular injury o Equivocal symptoms o Especially long bone # in lower limb o Perform as soon as dx considered o > 40mmHg — urgent Rx! (normal 0— 10 mmHg).

Investigations of compartment syndromes o Other lx — limited value; +ve only when CS is advanced o Plasma creatinine and CPK o Urinanalysis — myoglobinuria o Nerve conduction studies o lx to establish underlying cause or exclude differentials o X-ray of affected extremity o Doppler US/arteriograms — determine presence of pulses; exclude vascular injuries and DVT o PT/APTT — exclude bleeding disorder.

Management o Prompt DECOMPRESSION of affected compartment o Remove all bandages, casts and dressings o Examination of whole limb o Limb should be maintained at heart level o Elevation may I arterio-venous pressure gradient on which perfusion depends o Ensure patient is normotensive. o Hypotension I tissue perfusion, aggravate the tissue injury..

Management o Measure intra-compartment pressure o If > 40mmHg o Immediate open fasciotomy o If < 40mmHg o Close observation and re-examine over next hour o If condition improve, repeated clinical evaluation until danger has passed.

Fasciotomy o Opening all 4 compartments o Divide skin and deep fascia for the whole length of compartment o Wound left open o Inspect 5 days later o If muscle necrosis, do debridement o If healthy tissue, for delayed closure or skin grafting.

Complications o Volkmann's ischaemic contracture o Motor/sensory deficits o Kidney failure from rhabdomyolysis (if very severe) o Infection — fasciotomy converts closed # to open o Loss of limb o Delay in bone union Prognosis.

Nerves pathological types causes. Trauma tear Compression Stretch Entrapement treatment.

Early 4: Nerve o It's more common than arterial injuries. o The most commonly injured nerve is the radial nerve [in its groove or in the lower third of the upper arm especially in oblique fracture of the humerus] o Common with humerus, elbow and knee fractures o Most nerve injuries are due to tension neuropraxia. Injury Injury I. Shoulder dislocation 2. Humeral shaft fracture 3. Lower end of radius 4. Humeral supracondylar (esp. children) 5. Medial condyle 6. Elbow dislocation 7. Hip dislocation 8. Knee dislocation 9. Fracture of fibular neck nerve Axillary Radial Median Radial or median (ant.inteross eous) Ulnar Ulnar Sciatic Peroneal Peroneal.

Early 4: Nerve Injury o Damaged by laceration, traction, pressure or prolonged ischaemia Neurapraxia • axon remains intact but conduction ceases due to segmental demyelination. Spontaneous recovery in a few days or weeks Axonotmesis • axonal separation with degeneration of distal portions. Sheath remains intact, thus recovery likely but delayed Neurotmesis • nerve completely divided. Spontaneous recovery unlikely..

Early 4: Nerve Injury. Early 4: Nerve Injury. Early 4: Nerve Injury.

Early 4: Nerve Injury • Exploration • Cleanly divided — repair immediately • Torn/crushed — left alone or ends lightly tacked together, re-explore 2— 3 weeks later for scar tissue removal and suturing Usually nerve sheath • intact Rate of axonal • regeneration = I mm/day If no sign of recovery — • re-exploration with excision of scar tissue and suturing of clean-cut ends, nerve grafting if gap too large • Splinting 3-6 weeks then physiotherapy.

Early 5: Haemarthrosis o Bleeding into a joint spaces. o Occurs if a joint is involved in the fracture. o Presentation: o swollen tense joint; the patient resists any attempt to moving it o treatment: o blood aspiration before dealing with the fracture; to prevent the development of synovial adhesions..

Early 6: INFECTION o Closed fractures — hardly ever o Open fractures — may become infected o Post traumatic wound — may lead to chronic osteomyelitis.