COMPLICATIONS OF FRACTURES &

INDICATIONS FOR OPEN REDUCTION OF FRACTURES

Dr.k.s.n.chenna kesava rao (1st year pg)

COMPLICATIONS OF FRACTURES
Fracture

is a common event: most of us will experience at least one during a lifetime. In modern times, with medical and surgical assistance, the majority heal without problem or significant loss of function. However, complications can pose risk to limb and even life.

CLASSIFICATION

Complications of fractures tend to be classified according to whether they are systemic OR local and when they occur

IMMEDIATE EARLY LATE

IMMEDIATE COMPLICATIONS

OCCURS AT THE TIME OF INJURY SYSTEMIC : HYPOVOLAEMIC SHOCK LOCAL : INJURY TO MAJOR VESSELS,MUSSLES AND TENDONS,PERIPHERAL NERVES,JOINTS AND VISCERA.

HYPOVOLEMIC SHOCK

INADEQUATE PERFUSION AND OXYGENATION OF TISSUES DUE TO FAILURE OF CIRCULATORY SYSTEM WHICH LEADS TO HYPOXIA WHICH MAY DAMAGE VITAL ORGANS OCCURES IN FRACTURES OF LONG BONES AND PELVIC FRACTURES DUE TO HEMMORRAGE.

CRYSTALIODS

COLLIODS

BLOOD

IMMEDIATE LOCAL COMPLICATIONS

VASCULAR INJURY VISCERAL INJURIES NERVE AND SOFT TISSUE INJURIES INJURY TO JOINTS

VASCULAR INJURY

VISCERAL INJURIES
Fractures around the trunk like penetrating injury of the lung with life threatening pneumothorax. Rupture of bladder and urethra in pelvic fractures

NERVE AND SOFT TISSUE DAMAGE

Vascular repair

NERVE REPAIR

VS

TENDON REPAIR

Vascular repair should be done as early as possible before 6 hrs All bandages and splints should be removed Fracture reduction should be done as early as possible and circulation assessed If after reduction, no improvement vessel exploration should be done Torn vessel can be sutured end to end or vein graft may be done

PRIMARY NERVE REPAIR

6-8 hrs 7-18 days

PRIMARY TENDON REPAIR

12 hrs 1-10 days 10-14 days After 4 weeks

Delayed primary secondary Tendon transfer done

Delayed primary

After secondary 18 days After Late 18 secondary months repair of tendon

INJURY TO JOINTS
Fractures near the joint may be associated with subluxation or dislocation of that joint. Early open reduction and stabilization of the fracture to permit early joint movements have good results .

LOCAL EARLY COMPLICATIONS

Haemarthrosis

Compartment syndrome (or Volkmann's ischaemia) Wound Infection, more common for open fractures Tetanus Gas gangrene

HAEMARTHROSIS
Fractures involving a joint may cause acute haemarthrosis.The joint is swollen and tense and the patient resists any attempt at moving it. The blood should be aspirated before deealing with fracture.

COMPARTMENT SYNDROME
Fractures

of the limbs can cause severe ischaemia, even without damage to a major blood vessel . Bleeding or oedema in an osteofascial compartment increases pressure within the compartment, reducing capillary flow and causing muscle ischaemia A vicious circle develops of further oedema and pressure build-up, leading swiftly to muscle and nerve necrosis. Limb amputation may be required if untreated.

syndrome can occur in any compartment, e.g. the hand, forearm, upper arm, abdomen, buttock, thigh, and leg. 40% occur following fracture of the shaft of the tibia (with an incidence of 1-10%) and about 14% following fracture of a forearm bone. Risk is highest in those under 35 years.
Compartment

Presentation:

Signs of ischaemia (5 P's: Pain, Paraesthesia, Pallor, Paralysis, Pulselessness) Signs of raised intracompartmental pressure:
 

 

Swollen arm or leg Tender muscle - calf or forearm pain on passive extension of digits Pain out of proportion to injury Redness, mottling and blisters

Watch for signs of renal failure

GAS GANGRENE
Clostidium welchii ( perfringens ) Clinical presentation



Subcutaneous crepitation Myonecrosis Debridement Penicillin

Treatment
 

TETANUS

Causative agent
 

Clostidium tetani Release exotoxin TRISMUS DYSPHAGIA RISUS SARDONICUS OPIS THOTONAS

Symptoms
   

Treatment
   

Immunoglobulin Bed rest and sedation Respiratory support Penicillin

SYSTEMIC EARLY COMPLICATIONS

Fat

embolism ARDS DVT and Pulmonary embolism Exacerbation of underlying diseases such as diabetes or CAD Pneumonia Aseptic traumatic fever Septicemia Crush syndrome

FAT EMBOLISM

This is a relatively uncommon disorder that occurs in the first few days following trauma with a mortality rate of 10-20% Fat drops are thought to be released mechanically from bone marrow following fracture, coalesce and form emboli in the pulmonary capillary beds and brain, with a secondary inflammatory cascade and platelet aggregation An alternative theory suggests that free fatty acids are released as chylomicrons following hormonal changes due to trauma or sepsis 5 Risk of Fat Embolism Syndrome (FES) increases with number of fractures, but is also seen following severe burns, CPR, bone marrow transplant and liposuction.6

 Risk


factors

Closed fractures Multiple fractures Pulmonary contusion Long bone/pelvis/rib fractures

Presentation

Sudden onset dyspnoea Hypoxia Fever Confusion, coma, convulsions Transient red-brown petechial rash affecting upper body, especially axilla

Treatment :  

Respiratory support Heparinisation Intravenous low molecular weight dextran(lomodex 20) and corticosteroids.

ACUTE RESPIRATORY DISTRESS

SYNDROME
It is an increased permeability pulmonary oedema syndrome associated with direct pulmonary injury such as occurs in aspiration of gastric contents or as a consequence of thoracic trauma or indirect result of sepsis. Increased vascular permeability to proteins and fluids leads to alveolar damage Alveolar damage further exaggerated by reduction in surfactant synthesis leading to alveolar collapse.

DEEP VEIN THROMBOSIS

Common complication associated with lower limb injuries and with spinal injuries D.V.T. proximal to the knee is a common cause of life threatening complication of Pulmonary embolism Causes: 

Immobilization following trauma Fracture of the leg

Symptoms: 

Leg swelling Calf tenderness

SIGNS:  

homans sign mosses sign Pratts sign

Leg swelling

Deep vein thrombosis Phlebogram:

a. b. c. Normal (right calf) Thrombosis (left calf) Femoral vein thrombosis

Consequences:

pulmonary embolism

Tachypnoea Dyspnoea 4-5 days after trauma



Treatment:    

Elevation of the limb Anti coagulating therapy Respiratory support and heparin therapy{ respiratory embolism} Early internal fixation of flexors Active mobilization of the extremity

PNEUMONIA
Bed

rest after fracture and during surgery can increase the vulnerability Up to half of the patients with significant chest injuries develops pneumonia

ASEPTIC TRAUMATIC FEVER

Aseptic traumatic fever: This is supposed to be due to absorption of fibrin ferment taking place. It may, however, be due to some irritation, as of a badly fitting splint, and disappears on removal

SEPTICAEMIA

Because of trauma a large amount of bacteria can enter in the blood stream and may cause septicemia

SYMPTOMS

Management


Initial Resuscitation - ABC

1. 2. 3.

Secure airway Support breathing Restore circulation

   

Fluid therapy Inotropic Support Antimicrobial therapy Respiratory Support

CRUSH SYNDROME
Crushing injury to skeletal muscles because of the fracture Complications

 

Shock Renal failure

 Management  To

avert disaster, a limb crushed severely and for several hours should be amputated

Crush injury

LATE COMPLICATIONS
Late

complications are those which occur after a substantial time has passed and are as a result of defective healing process or because of the treatment itself.

LATE COMPLICATIONS
Imperfect

union of the fracture Avascular necrosis Shortening Osteomyelitis Myositis ossificans Osteoarthritis Delayed rupture of tendons Volkmann s Ischaemic contracture Joint stiffness Sudeck s dystrophy

IMPERFECT UNION OF THE FRACTURE

They are again classified into four sub groups:

Delayed union  Non-union  Mal-union  Cross-union



DELAYED UNION

When a fracture takes more than the usual time to unite, it is said to have gone in delayed union Causes:


 

Inadequate blood supply Infection Incorrect splintage Insufficient splintage Excessive traction

NON-UNION
When the process of fracture healing comes to a stand before its completion, the fracture is said to have gone in non union. It is not before six months that a fracture can be so labelled.

DIFFERENT TYPES OF NON UNION

HYPERTROPHIC ATROPHIC

MAL-UNION
IS FRACTURE HEALING WITH FRAGMENTS IN NON-ANATOMICAL POSITION OR UNACCEPTABLE POSITION. FRACTURE UNITED WITH ANGULATION ,ROTATION,LOSS OF END TO END APPOSITION OR OVERLAP AND SHORTENING.

CROSS UNION

Sometimes radio-ulnar and tibio-fibular fractures may undergo cross-union

AVASCULAR NECROSIS

Blood supply of some bones is such that the vascularity of a part of it is seriously jeopardized following fracture, resulting in necrosis of the part.

AVASCULAR NECROSIS OF THE HEAD OF THE

FEMUR (BONE SCAN)

SHORTENING

It is a common complications of fractures and results from:1. 2. 3.

Mal union of the long bones Crushing: Actual bone loss Growth defects: growth plate or epiphyseal injuries

Treatment:Shortening of upper limbs goes unnoticed For lower limb treatment depends upon the amount of shortening: 1. Shortening less than 2 cm: compensated by shoe raise 2. Shortening more than 2 cm: limb length equalization procedures

OSTEOMYELITIS
Osteomyelitis is an infection of a bone. Many different types of bacteria can cause osteomyelitis. However, infection with a bacterium called Staph. aureus is the most common cause. Infection with a fungus is a rare cause.

After operative treatment of fracture bacteria may spread to the bone and may cause osteomyelitis. Treatment: 

Antibiotics Surgery: 1. in case of abscess formation 2. The infection presses on other important structures 3. The infection has become 'chronic' (persistent) and some bone has been destroyed. 4. Hyperbaric oxygen

MYOSITIS OSSIFICANS
Myositis ossificans is where calcifications and bony masses develop within muscle and can occur as a complication of fractures. It may also happens because of the ossification of the hematoma around a joint after a compound fracture.

OSTEOARTHRITIS
Osteoarthritis is liable to follow malunion and traumatic injuries to the joints. Joint surfaces become incongruent Direction of stress transmission is abnormal Increase wear and tear at the joint

DELAYED RUPTURE OF TENDONS

This is uncommon fracture complication seen most frequently after colles fracture. Patient unable to extend the terminal joint of the thumb, this is due to rupture of extensor pollicis longus tendon.

VOLKMANN S ISCHAEMIC
CONTRACTURE
This a sequel to Volkmann's ischaemia. The ischaemic muscles are replaced by fibrous tissue If the peripheral nerves are also affected, sensory or motor paralysis may happen

JOINT STIFFNESS
It is a common complications of fracture treatment. Shoulder, elbow and knee joints are particularly prone to stiffness following immobilization

SUDECK S DYSTROPHY
Also known as Reflex Sympathetic Dystrophy. Involves a disturbance in the sympathetic nervous system. Consequences:
   

Pain Hyperaesthesia Tenderness Swelling

INDICATIONS FOR OPEN REDUCTION OF FRACTURES

1.

2.

3. 4. 5. 6.

THE POSSIBILITY THAT ADEQUATE MANIPULATIVE REDUCTION WILL NOT SUCCEEDED,OR THAT IT HAS BEEN TRIED AND FAILED. THE PROBABILITY THAT MANIPULATION REDUCTION WILL NOT BE MAINTAINED OR THAT REDISPLACEMENT HAS ACTUALLY OCCURRED THE PROBABILITY THAT UNION WILL BE SLOW IN SOME CASES WHERE EXTERNAL FIXATOR IS INADVISABLE IN CASES WHERE VERY ACCURATE REDUCTION IS NECESSARY. IN CASES WHERE ASSOCIATED VASCULAR ,NERVE AND TENDON REPAIR IS REQUIRED

MANIPULATION WILL NOT SUCCEED

Elastic retraction of muscles Eg-fracture patella displaced by quadriceps muscle,olecranon by triceps muscle. Inter position of soft tissue in fractures Eg-fracture shaft of radius with interposition of the pronator teres .

late unreduced fractures and dislocation. Intra -articular fractures:-small fragments may have been chipped from articular surface of a joint and necessitate excision.

MANIPULATIVE REDUCTION WILL NOT

BE MAINTAINED

Certain fractures are so unstable that redisplacement of the fragments is likely to occur despite perfect initial reduction and careful immobilization in plaster. Eg.oblique and spiral fractures of tibia,monteggia and Galeazzi fracturedislocation

UNION OF FRACTURE WILL BE SLOW

Fracture neck of femur fracture can be reduced perfectly,but in which slow union justifies internal fixation . The age of the patient ,interference with the blood supply of femoral head, and the presence of synovial fluid.

WHERE EXTERNAL FIXATION IS INADVISABLE

Traumatic paraplegia, associated gross skin loss and sometimes in fractures complicated by injuries to the main vessels rendering the external fixation difficult or impossible.

WHERE VERY ACCURATE REDUCTION IS NECESSARY

Forearm fractures in adults accurate reduction of angulation and rotatory deformity is required to regain perfect function.

Ankle injuries where even small inaccuracies of reduction may result in progressive deterioration in the joint condition.