COMPLICATIONS OF FRACTURE

Complications of fractures:

Complications of fractures can be divided into:
A. Systemic

B. Local
Immediate
Delayed.

-Immediate complications are life threatening
-And delayed complications are more morbid
A . Systemic complications.

1. Bleeding and Hypovolemic Shock.
2. Fat embolism.
3. Adult respiratory distress syndrome
4. Deep vein thrombosis.
B. Local complication

Early complications.
- Compartment syndrome.
- Infection.
- vascular injuries.
- Nerve injury.
Late complications.
- Delayed Union/ Non union.
- Mal union.
- Reflex sympathetic Dystrophy/ Sudecks atrophy.
- Avascular Necrosis.
- Heterotrophic ossification(Myositis ossificans)
- Joint stiffness.
- Post traumatic osteoarthritis.

1. Hypovolemic shock:
Major long bone fracture, pelvic fracture, multiple fracture.
Inadequate perfusion and oxygenation.
Source: Internal External.
<40% loss Signs of hypovolemia appears.
> 40% loss- Confused or unconscious, low Urine output, Tachycardia, low BP.

Management :
Immediate resuscitation with
Fluids : Ringers lactate, haemaccel.
Blood transfusion.
Oxygen.
( Check for urinary output 0.5ml/kg/hr)



2. Fat Embolism
Post traumatic pulmonary complication within 72 hrs of injury.
Embolism of fat globules in pulmonary circulation.
In long bone fracture in young adults
or in pelvic fracture in elderly.

Clinical features:
Fever, Tachycardia, tachypnoea, cyanosis, confusion, and petechial rashes.

Management :
a. Air way.
b. Oxygen administration.
c. Fluid and electrolyte.
d. ? Heparin/ Steroids.
3. Adult Respiratory Distress Syndrome, ARDS.
Serious Pulmonary complication resulting from diffuse alveolar damage.
Important cause of morbidity and mortality.

Causes :
Lung injury, Shock, Septicemia, poly trauma, co morbidities.

Pathophysiology :
Endothelial cell damage.
Exudation of fluid into the interstitial lung tissue and alveoli.
Diffuse alveolar damage
severe hypoxemia, multi organ failure.



4. Deep Vein Thrombosis.
DVT is a life threatening complication.
Seen after fracture of hip, spine, and lower extremity bones.
Risk Factors:
old age, obesity, malignancy, CCF, smoking, Prolong
immobilization, OC pills,
Clinical Features:
Calf pain, swelling, cramps
Homans sign positive
Management :
Prophylaxis Early ambulation, exercise. Elevation.
Treatment- Anticoagulant therapy.
Early local complications:
1. Compartment syndrome
2. Infection.
3. vascular injuries.
4. Nerve injury.
5. Haemarthrosis
6. Gas gangrene
7. Local visceral injury
Compartment syndrome
An orthopedic Emergency.
Elevation of interstitial pressure in a closed osteofascial
compartment that results in micro vascular compromise.
Ranges from mild ischemia to severe gangrene.
Etiology:
Extra compartmental.
Intra compartmental.
Clinical Features:
5 ps
Acute stage :
Remove bandages, Plaster, Elevation.
Compartment release.

Infection:
Infection are common in open fractures or post
operative cases.
Common organism is staphylococci, and mixed
infection.
Gas Gangrene caused by Clostridial infections.
Common sites: a dirty wound with dead muscle.
It produces gas and toxin.
The toxin produced by this bacteria causes
toxemia, coma and death.

Vascular injuries:
Vascular injury may result in ischemia to gangrene.
Vessels in closed proximity to bones are prone to injure.

Causes of injury :
Reflex vasospasm. - External compression/ Kink.
Tear. - Internal thrombus.
Clinical features: 5 ps
Diagnosis : Doppler, Angiogram.
Treatment :
Removal of all tight bandages.
Prompt reduction of fracture.
Surgery : Vascular repair, Bone fixation, Amputation.




Nerve Injury :
30 40% of bone and joint injuries are associated
with nerve injury.
Nerve injury may be partial or complete
depending upon severity of trauma.
Causes:
Damaged by fracture fragment.
Entrapped between fragments.
Direct injury by external force.
Incidence :
Radial : 45% - Ulnar : 30%
Median 15% - peroneal : 3%
Tibial nerve.< 2% - Other nerves.


Late complications.

1. Delayed Union/ Non union.
2. Mal union.
3. Reflex sympathetic Dystrophy/ Sudecks atrophy.
4. Avascular Necrosis.
5. Heterotrophic ossification(Myositis ossificans)
6. Joint stiffness.
7. Post traumatic osteoarthritis.
Complex Regional Pain Syndromes

Abnormal sympathetic over activity in response to trauma.
Common in wrist injury, ankle/ foot injury.
Predisposing factors: Prolong immobilization, old age.
Clinical features:
Pain, swelling, tenderness, stiffness, hyperesthesia.
Trophic changes in the skin and nail smooth, glistening skin,
atrophic nails, hair loss.
X Ray Regional osteoporosis.
Management :
Early mobilization (Physiotherapy).
Pain management.
Bisphosphonates.
Sympathectomy.


Type I - Reflex sympathetic
dystrophy/Sudecks dystrophy/Algodystrophy
no nerve involvement
Type II Causalgia nerve involvement
obvious
Avascular necrosis:
Devastating complication of fracture.
Common in bones having precarious blood
supply eg. Femoral head, body of Talus,
proximal part of Scaphoid, the lunate
Excessive soft tissue/ Periosteal damage.
End result : Joint damage, osteoarthritis.
Diagnosis : MRI, Bone scan, X- Rays
Prevention :
Early restoration of normal anatomy and rigid
fixation.
Less soft tissue manipulation.

Xray
Increased density
1. Disuse osteoporosis in the surrounding parts
gives impression of increased density in
necrotic segment
2. Collapse of trabeculae compacts the bone
and increases density
Heterotrophic ossification (Myositis ossificans)
In response to trauma ectopic ossification.
Common in children.
Metaplasia of mesenchymal cells into osteoblastic tissue.
Common sites: Elbow, knee, hip, pelvis etc.
Clinical features:
Pain, stiffness, swelling.
Late phase: Bone block
Management:
Biphosphonates, Irradiation.
Early : MUA
Late : Bone block excision.