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Complications of fractures
1.
2. •Complications of fractures tend to be
classified according to whether they
are local or systemic and when they
occur –
IMMEDIATE
EARLY
LATE
3. HYPOVOLAEMIC SHOCK
Commonest cause of death following
fractures
Cause- external/internal haemorrhage
Treatment
Iv crystalloids-ringer lactate,followed by
colloids and blood
4. •Early complications occur at the time
of the fracture (immediate) or soon
after.
•They are again classified into-
local
Systemic
•Early local complications tend to
affect mainly the soft tissues
5. •Vascular injury causing haemorrhage,
internal or external
•Visceral injury causing damage to
structures such as brain, lung or bladder
•Damage to surrounding tissue, nerves or
skin
•Haemarthrosis
•Compartment syndrome {volkmanns
ischemia}
6.
•Wound Infection, more common for open
fractures
•Tetanus
•Gas gangrene
•Injury to joints
7.
8. Blood vessels lie close proximity to bones
,hence liable to injured
Popliteal is commonly injured one
Consequences- exercise ischemia-ischemic
contracture-gangrene
Signs-5ps-pain,absent
pulse,pallor,parasthesia,paralysis
13. Radial nerve is commonly injured
Consequences- lead to
neurapraxia,axonotmesis or neurotmesis
Axillary n-dislocatn of shoulder-deltoid
paralysis
Radial n-#shaft of humerus-wrist drop
Median n-supracondylar# of humerus-pointing
index
Ulnar n-#medial epicondyle humerus-claw
hand
Sciatic n- posterior dislocation of hip-foot
drop
15. •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.
Limp amputation may be required if untreated
16. •Compartment syndromes can also
result from ;
Crush injuries caused by falling debris or
from a patient’s unconscious compression
of their own limb
Swelling of a limb inside an over tight cast
17.
•Compartment 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
18.
19.
Presentation:-
Signs of ischaemia (5 P's: Pain,Paraesthesia,
Pallor, Paralysis,Pulselessness)
Signs of raised intracompartmental
pressure:
1.Swollen arm or leg
2.Tender muscle - calf or forearm pain on
passive extension of digits
3.Pain out of proportion to injury
4.Redness, mottling and blisters
Watch for signs of renal failure{low-output
uraemia with acidosis)
20.
21. Remove/relieve external pressures
(fasciotomy)
Prompt decompression of threatened
compartments by open fasciotomy
Debride any muscle necrosis
Treat hypovolaemic shock and oliguria
urgently
Renal dialysis may be necessary
22. •Complications
Acute renal failure secondary to
rhabdomyolysis
DIC
Volkmann's contracture (where infarcted
muscle is replaced by inelastic fibrous
tissue)
24. Causative agent
Clostidium tetani
TRISMUS
DYSPHAGIA
RISUS SARDONICUS
OPIS THOTONUS
Treatment
Bed rest and
sedation
Immunoglobulin
Respiratory
support
pencillin
25. •Fat embolism
•Shock
•ARDS
•Thromboembolism (pulmonary or venous)
•Exacerbation of underlying diseases
such as diabetes or CAD
Pneumonia
Aspectic traumatic fever
Septicemia
Crush syndrome
26. •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
30. Respiratory support
Heparinisation
Intravenous low molecular weight
dextran(lomodex 20) and corticosteroids
Iv 5% dextrose solution with 5% alcohol –helps
in emulsification of fat globules
31. 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 leg
Symptoms
Leg swelling
Calf tenderness
32. 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 fractures
Active mobilization of the extremity
33. •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 of it
34. •Because of trauma a large amount of
bacteria can enter in the blood stream and
may cause septicemia
Symptoms
Rash
Fever and vomiting
Cold extremitis
Rapid breathing
Stomach pain and joint pain
drowsy
35. Initial Resuscitation - ABC
1.Secure airway
2. Support breathing
3.Restore circulation
Fluid therapy
Inotropic Support
Antimicrobial therapy
Respiratory Support
36. •Crushing injury to skeletal muscles
because of the fracture
Cause- crushing of muscles- myohb enters to
circulation-ppt in renal tubules-a/c renal
failure
•Complications
shock
Renal failure
•Management
To avert disaster, a limb crushed severely
and for several hours should be amputated
37. •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.
•They are again classified in to 2 groups
Imperfect union of the fracture
others
39. •They are again classified into four sub
groups:
Delayed union
Non union
Mal-union
Cross-union
40. •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
1.Insufficient splintage
2.excessive traction
41. •Signs:
The fractured site is usually tender
The bone may appear to move in one piece,
if however, it is subjected to stress , pain is
immediately felt and the bone may angulate;
The fracture is not consolidated
X-ray: the fractured site is still clearly
visible,
but the bone ends are not sclerosed
42.
43.
Conservative:
1.Plaster should be sufficiently extensive and
must fit accurately
2.Replace traction by plaster splintage
3.Use of functional bracing
Operative:
Bone grafting with or without IF
44. •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.
Nonunion is one endpoint of delayed union
45. The injury
1.Soft tissue loss
2. Bone loss
3.Intact fellow bone
4.Soft tissue inter position
The bone
1.Poor blood supply
2. Poor haematoma
3. Infection
4. Pathological lesion
46. Pain at fracture site
Nonuse of extremity
Tenderness and swelling
Joint stiffness (prolonged >3 months)
Movement around the fracture site (pseudarthrosis)
Investigations
Absence of callus (remodelled bone) or lack of
progressive change in the callus suggests delayed
union.
Closed medullary cavities suggest nonunion.
Radiologically, bone can look inactive, suggesting the
area is avascular (known as atrophic nonunion) or
there can be excessive bone formation on either side
of the gap (known as hypertrophic nonunion).
47.
48. Conservative:
1.Occasionally symptom less, needing no
treatment
2.Functional bracing may be sufficient to induce
union
3.Electrical stimulation promotes osteogenesis
Operative
1.Very rigid internal fixation with hypertrophic
non-union
2.Fixation with bone graft is needed in case of
atrophic non union
49. occurs when the bone fragments join in an
unsatisfactory position, usually due to insufficient
reduction.
Causes
primary
1.The fracture was never reduced and has united
in a deformed position.
2.Shortening is, of course, one type of deformity.
Secondary
1.The fracture was reduced but the reduction was
not held
2.Redisplacementmay occur during the first
week, and a check x-ray at 1 week is adviseable
50. .
•Signs:
The deformity is usually obvious
There may be painful limitation of joint
movements
At elbow, valgus deformity may present
with delayed ulnar nerve palsy
51. Conservative
1.If shortening is the main feature a raised shoe
is usually sufficient
2.In child usually no treatment is required
because it is expected to correct by
remodelling
Operative
1. Osteotomy
2.Excision of protruding bone
3. Osteoclasis
4.Redoing the fracture surgical
52. •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.
53.
54. Avascular necrosis causes
deformation of the bone. This leads, a
few years later, to secondary
osteoarthritis and causes painful
limitation of joint movement.
Diagnosis:-
X-ray changes:--
1.Sclerosis of the necrotic area
2.Deformity of the bone
3. Osteoarthritis
Bone scan:- changes can be seen
before X-ray changes:
1.Visible as cold area on the bone
55.
56. •Treatment:- Avascular necrosis can
be prevented by early, energetic
reduction of susceptible fractures
and dislocations. Treatment options:
1.Delay weight bearing till revascularization
to prevent collapse
2. Revascularization
3.Excision of the avascular segment
4.Total joint replacement
57. •It is a common complications of
fractures and results from:-
1.Mal union of the long bones
2.Crushing: Actual bone loss
3.Growth defects: growth plate or epiphyseal
injuries
58. 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
59.
60. •It is a common complications of
fracture treatment.
•Shoulder, elbow and knee joints are
particularly prone to stiffness
following immobilization
61. Intra-articular or Para-articular adhesions
secondary to immobilizations
Contracture ofthe musclesaround a joint
because of prolonged immobilizations
Tethering of muscles at fracture site
Myositis ossificans
•Consequences:-
Hampers the normal physical activity
Results in late osteoarthritis
62. Heat therapy and exercise
Manipulation of the joint under anesthesia
Surgical interventions
1.To excise an extra articular bone block
2.To lengthen contracted muscles
3.Joint replacement, if there is pain due to
secondary arthritis
63. •Also known as Reflex Sympathetic
Dystrophy.
•Involves a disturbance in the
sympathetic nervous system.
•Consequences:-
pain
Hyperaesthesia
Tenderness
Swelling
64. Skin become red, shiny and warm in early
stages
Progressive atrophy of the skin, muscles and
nails in later stages
Joint deformity and stiffness ensues
X-ray shows characteristic spotty rarefraction
65. Occupational therapy and physiotherapy
constitutes the principle modality of
treatment.
Use of β-blocker.
In resistant cases, sympathetic blocks have
been shown to aid in recovery
66. •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
67.
68. •After operative treatment of fracture
bacteria may spread to the bone and
may cause osteomyelitis.
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
69. •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
Clinical features:-
Marked atrophy
Flexion deformity
Nails shows atrophic changes
Skin becomes dry and scaly
70.
71. Mild deformity can be corrected by passive
stretching using a turn-buckle splint
(Volkmann's splint)
For moderate deformities, a soft tissue
sliding
operation, where the flexor muscles are
released from their origin, is performed
For a severe deformity, bone shortening
operations may be required
72. •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 fractures
73.
74. Pain
Tenderness ,
Focal swelling, and
Joint/muscle contractions
•Treatment:-
Massage following injury is strictly
prohibited.
In early stages rest is advised
NSAIDS may help to reduce pain
75. In late stages Occupational and
Physiotherapy is prescribed to regain
movements
Ultra sound
In some cases surgical excision of myositic
mass is done
76. •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
77.
78. Osteoarthritis cannot be cured,
but it can be treated
The goal of every treatment for
arthritis is to:-
1.reduce pain and stiffness,
2.allow for greater movement, and
3.slow the progression of the disease
Anti-Inflammatory Medications
79. Cortisone Injections
Occupational and physiotherapy
Weight Loss
Activity Modification
Diet: obesity is a risk factor for developing
osteoarthritis
82. Problems include:
Pin tract infection
Pin loosening or breakage
Interference with movement of the joint
Neurovascular damage due to pin placement
Misalignment due to poor placement of the
fixator