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Complication of Fracture

Definition Complications
People do not usually die of broken bone Fracture Treatment
Airway Obstruction Type Conservative
Blood Loss Age Surgery
Brain Injury Site Post Surgery
Complications of Fractures Underlying Disease
Hypovolaemia
Sepsis Common Orthopaedic Fracture, Complications
Bleeding
Typical Bone Fractures • Pelvic Fracture
• Arterial Injury
Open Fracture
Long Bone Fracture
Dislocation
Compartment Syndrome
Deep Vein Thrombosis (DVT)

Orthopaedic Emergencies come 2nd After

Airway
Breathing
Circulation

Classification
Acute (Early) Delay (Late)
Occur at the time of fracture (immediate) or soon after Later
Affect mainly Soft Tissues Affect mainly Bone, Joint
Local Systemic Local Systemic
Compartment Syndrome Fat Embolism Bone Healing Problems Gangrene
Infection Shock • Delayed Union Tetanus
DVT Pulmonary Embolism/ ARDS • Non-Union Septicaemia
Neurovascular Exacerbation of underlying diseases • Malunion DVT, PE
(depend on site of fracture) (eg. Diabetes, CAD) Joint Stiffness
• Spine Pneumonia Contractures
• Pelvic Myositis Ossificans
• Long Bones Avascular Necrosis
• Shoulder Clavicle Algodystrophy (Sudeck’s Atrophy)
• Elbow, Wrist Osteomyelitis
• Hip, Neck of Femur Growth Disturbance, Deformity
• Knee, Head of Fibula

Complications of Fractures Iatrogenic

Early Late Cast
General Other Injuries Chest Infection Pressure Ulcers
PE UTI Thermal Burns
FES/ ARDS Bed Sores Thrombophlebitis
Bone Infection Non-Union Compartment Syndrome
Malunion Prolonged Cast Immobilization, Cast Disease
AVN • Circulatory Disturbances, Inflammation, Bone Disease
Soft-Tissues Plaster Sores/ WI Tendon Rupture • Results - Osteoporosis, Chronic Edema, Soft-Tissue Atrophy, Joint Stiffness
N/V Injury Nerve Compression Good Physiotherapy should avoid these problems
Compartment Syndrome Volkmann Contracture Traction
Prevents patients mobilising causing additional Muscle Wasting, Weakness
Complications
• Pressure Ulcers
• Pneumonia, UTIs
• Footdrop Contractures (Permanent)
• Peroneal Nerve Palsy
• Pin Tract Infection
• Thromboemb olism
Surgery
External Fixator Internal Fixator
Pin Tract Infection Infection
Pin Loosening, Breakage Implant Failure
Interference with Movement of Joint
Neurovascular damage
(Pin Placement)
Misalignment
(Poor Placement of Fixator)
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Acute Local Complication

Compartment Syndrome Deep Vein Thrombosis

Definition ↑ Risk Patients
↑ Osteofascial Compartment Pressure History of Blood Clots (Self, Family)
↓ Blood Flow Fracture
Leads to Ischaemia Immobilization
Vicious Cycle Cancer
Causes Obesity
↑ in Pressure Thromboprophylaxis in all patients
• Bleeding (Vessel Damage, Muscle Tear, Fracture Ends) Pharmacological
• Edema (Swelling due to Trauma, Vascular Deprivation Revascularization) Non-Pharma cological
• Fluid (Iatrogenic) Diagnosis
Constriction DVT PE
• Bandage Limb Swelling, Pain Hypoxemia, Tachcardia (S1Q3T3)
• Cast Ultrasound Limb Spiral CT Scan
Involve any Compartment
Hand Acute Systemic Complication
Forearm
Upper Arm Fat Embolism
Abdomen Definition
Buttock Common Long Bone complication
Thigh Young Adolescents
Leg ↑ Mortality Rate - 10 – 20%
Symptoms (5P’s) Signs 1st Few Days following Trauma (48 – 72h)
Pain Tight Swelling 2 Theory
Paralysis Loss of Strength • Mechanical Theory
Paraesthesia Loss of Sensation • Immunological Theory
Pallor Blisters Risk Factors
Pulselessness Closed Fractures
Susceptible Patients Patients are Unable to tell Pain Multiple Fractures
Tibia Fractures Overnarcotized Pulmonary Contusion
Tibial Plateau Fractures Sedated Fractures
Patients Casted after Injury Drug Overdose • Long Bone
Polytrauma Patients Mental Illness • Pelvis
Drug Overdose, Unconsciou s Patients • Rib
Complications Clinical
Death of Muscles Ill Looking
Death of Nerves Dyspnoea (sudden on set)
Contracture Hypoxia
Paralysis Fever
Chronic Pain Confusi on, Coma, Convulsions
Numbness Transient Red-Brown Petechial Rash (Affe ct Upper Body – especially Axilla)
Amputation Management
Sequele Supportive Treatment
Acute Renal Failure 2° to Rhabdomyolysis Corticosteroid Drugs
DIC Surgical Stabilization of Fracture
Volkmann’s Contracture
(Infracted Muscle is Replaced by Inelastic Fibrous Tissue)
Amputation

Treatment
Remove, Relief External Pressures
Decompression of Threatened Compartments by Open Fasciotomy
Debride Muscle Necrosis
Treat Hypovolaemic Shock, Oliguria
Renal Dialysis
Caution
Well Leg Compartment Syndrome
During Surgical Procedure
Lithotomy Position
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Late Local Complication

Bone Healing Problems Myositis Ossificans

Non-Union Malunion Delayed Union Definition
No Signs of Healing Bone Fragments join in Causes Calcification, Bony Masses develop within Muscle
(after 3 – 6 months) Unsatisfactory Position Soft Tissue Damage Occur as a Complication of Fractures
One Endpoint of (Insufficient Redu ction) ↓ Blood Supply Site
Delayed Union Infection Elbow
Causes Insuffi cient Splintage Hip
Soft Tissue Damage Excessive Traction Clinically
↓ Blood Supply Pain
Infection Tenderness
Insuffi cient Splintage Focal Swelling
Excessive Traction Joint, Muscle Contraction
Too Large Space Management
(for bony remodelling Avoid Excessive Physiotherapy (continue Active)
to bridge) Rest Joint (until Pain Subsides)
Interposition of NSAIDs
• Periosteum Excision (after Lesion has Mature)
• Muscle
• Cartilage Algodystrophy (Sudeck’s Atrophy)
Occurs in approx. 1% Definition
of all fractures Reflex Sympathetic Dystrophy (RSD)
↑ Common (Complex Regional Pain Syndrome Type 1)
Lower Leg Fractures Common in
(19% Non-Union) • Hand
(motion at fracture • Foot
site) Clinical
Presentation Pain (Continuous, Burning)
Pain at Fracture Site Local Swelling
Non-use of Extremity Warmth
Tenderness, Swelling Swelling
Joint Stiffness (Prolonged > 3 months) Redness
Movement around Fracture Site (Pseudoarthrosis) Pallor
Atrophy
Restricted Movement (of affe cted limb)
Management
Rehabilitation
• Physio and Occupational Therapy
• Psychological Therapy
Pain Management

Investigations
Absence of Callous (Lack of progressive change in Callus – Delayed Union)
Closed Medullary Cavities (Non-Union )
(Radiologically) Inactive Bone (Avascular) (Atrophic Non-U nion)
Excessive Bone Formation on either side of gap (Hypertrophic Non-Uni on)
Management
Non-Surgical Surgical
Early Weight Bearing Debridement (establish healthy
Casting infection-free vascularity)
Internal Fixation
(Redu ce, Stabilize Fracture)
Bone Grafting
(Stimulate new Callous formation)