Complications Of Fractures

Complications of the fractures Submitted by :-

Amit Kochhar

Complications From 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 local or systemic and when they occur – Early Late

Early complications • 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.

Local Early complications • 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 (or Volkmann's ischaemia)

• Wound Infection, more common for open fractures • Tetanus • Gas gangrene • Injury to joints

Vascular injury

Visceral injuries

Nerve and skin tissue damage

Open Humeral fracture with Radial Nerve Injury

Haemarthrosis

Bleeding in the joint because of 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.

• 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.

• 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.

• Compartmental syndrome may lead to the Volkmann's ischaemia:

• 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

• Management 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

Removal of extra pressure(fasciotomy)

• Complications Acute renal failure secondary to rhabdomyolysis DIC Volkmann's contracture (where infarcted muscle is replaced by inelastic fibrous tissue)

Gas gangrene • Clostidium welchii ( perfringens ) • Clinical presentation  Subcutaneous crepitation  Myonecrosis

• Treatment Debridement  Penicillin

tetanus • Causative agent Clostidium tetani Release exotoxin

• Symptoms TRISMUS DYSPHAGIA RISUS SARDONICUS OPIS THOTONAS

• Treatment Immunoglobulin Bed rest and sedation  Respiratory support  Penicillin

Injury to joints

AC joint injury after clavicle and scapular fracture

Systemic early complications • • • •

Fat embolism Shock ARDS Thromboembolism (pulmonary or venous) • Exacerbation of underlying diseases such as diabetes or CAD • Pneumonia

• Aseptic traumatic fever • Septicaemia • 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.

Hypovolaemic shock

Bleeding after trauma Shock

Hypovolaemic

Acute respiratory distress syndrome

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

Leg swelling

Deep vein thrombosis Phlebogram: a. Normal (right calf) b. Thrombosis (left calf) c. 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. Secure airway 2. Support breathing 3. 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. • They are again classified into two groups: Imperfect union of the fracture

others

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 1. Insufficient splintage 2. Excessive traction

Intact fellow bone: if one bone in the forearm or leg is unbroken, the fractured ends of the other may be held apart, end some delay then follows Internal fixation: open reduction with internal fixation of a fracture delays union

• 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

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Treatment:  Conservative: 1. Plaster should be sufficiently extensive and must fit accurately 2. Replace traction by plaster splintage 3. Use of functional bracing

 Operative: 1. If a fractured tibia is being held apart by a fibula which was not fractured or which has united quickly, it is worth while excising 2.5 cm of fibula and reapplying plaster

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.

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Causes :  The injury 1. 2. 3. 4.

Soft tissue loss Bone loss Intact fellow bone Soft tissue inter position

 The bone 1. 2. 3. 4.

Poor blood supply Poor haematoma Infection Pathological lesion

The surgeon 1.Distraction 2.Poor splintage 3.Poor fixation 4.Impatience

The patient 1.Immense 2.Immoderate 3.Immovable 4.impossible

• Signs Movement can be elicited at the fracture site, and this movement (unless excessive) is painless; such painless movement is diagnostic of non-union as distinct from delayed union

X-ray:

 1.

The fracture is visible and the bone on each side of it may be sclerosed. 2. Two varieties of non-union can be distinguished : I. Hypertrophic, with bulbous bone ends, indicating estrogenic activity (as if in the attempt to form bridging callus). II. atrophic, with no calcification around the bone ends

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Treatment  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

Mal-union •

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. Redisplacement may occur during the first week, and a check x-ray at 1 week is advisable.

• Signs: The deformity is usually obvious. There may be painful limitation of joint movements At elbow, valgus deformity may present with delayed ulnar palsy

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Treatment:  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. 2. 3. 4.

Osteotomy Excision of protruding bone Osteoclasis Redoing the fracture surgically

Cross union • Sometimes radio-ulnar and tibiofibular fractures may undergo crossunion

Other late complications • • • • • • • •

Avascular necrosis Shortening Joint stiffness Sudeck’s dystrophy Osteomyelitis Volkmann’s Ischaemic contracture Myositis ossificans Osteoarthritis

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.

Site

Cause

Fracture neck of the Head of the femur femur. Posterior dislocation of the hip Proximal pole of Fracture through the scaphoid waist of the scaphoid Body of the talus

Fracture through neck of the talus

• Consequences:Avascular necrosis causes deformation of the bone. This leads, a few years later, to secondary osteoarthritis and causes painful limitation of joint movement.

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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

Avascular necrosis of the head of the femur (Bone scan)

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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

Shortening •

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

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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

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

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Causes: Intra-articular or Para-articular adhesions secondary to immobilizations  Contracture of the muscles around a joint because of prolonged immobilizations  Tethering of muscles at fracture site  Myositis ossificans

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Consequences: Hampers the normal physical activity  Results in late osteoarthritis

• Treatment: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

Sudeck’s dystrophy • Also known as Reflex Sympathetic Dystrophy. • Involves a disturbance in the sympathetic nervous system. • Consequences:Pain Hyperaesthesia Tenderness Swelling

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 rarefaction

Bone scan

• Treatment:Occupational therapy and physiotherapy constitutes the principle modality of treatment. Further trauma in the form of an operation or forceful mobilizations is injurious. Use of β-blocker. In resistant cases, sympathetic blocks have been shown to aid in recovery.

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.

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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

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

• Clinical features:Marked atrophy Skin becomes dry and scaly Flexion deformity Nails shows atrophic changes

• Treatment: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

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.

• Clinical features: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

In late stages Occupational and Physiotherapy is prescribed to regain movements Ultra sound In some cases surgical excision of myositic mass is done

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

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Treatment: 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

Cortisone Injections Occupational and physiotherapy Weight Loss Activity Modification Diet: obesity is a risk factor for developing osteoarthritis

References • Apley’s system of orthopaedics and fracturesA. Graham Apley Louis Solomon • Essential orthopaedics- J. Maheshwari • Adam’s outline of orthopaedics • http://www.patient.co.uk/showdoc/40001214/ • Google search