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
• 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
• 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.
• Causes :
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
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
• 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
• 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. Osteotomy
2. Excision of protruding bone
3. Osteoclasis
4. Redoing the fracture surgically
Cross union
• Sometimes radio-ulnar and tibio-
fibular fractures may undergo cross-
union
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.
• 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)
• 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
• 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
• 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
• 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.
• 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)