A brief overview of fracture complications

1. COMPLICATIONS IN TRAUMATOLOGY
DR. UTKARSH SHAHI
ASSISTANT PROFESSOR IN ORTHOPEDICS
DEPARTMENT OF SURGERY
KING FAISAL UNIVERSITY
AL AHSA, KSA

2. LEARNING QUESTIONS
• What are the immediate complications of a fracture? Describe the diagnosis &
treatment.
• What are the early complications of a fracture? Describe the diagnosis & treatment.
• What are the late complications of a fracture? Describe the diagnosis & treatment.
• What are the advantages, disadvantages and complications of a fracture treatment
using traction, plaster cast, external fixator, plate & screw osteosynthesis, cerclage &
intramedullary pin fixation?

3. COMPLICATIONS
LOCAL
IMMEDIATE
EARLY
DELAYED
SYSTEMIC
IMMEDIATE
EARLY

4. IMMEDIATE COMPLICATIONS EARLY COMPLICATIONS LATE COMPLICATIONS
Systemic
 Hypovolemic shock (Haemorrhage)
Systemic
 Hypovolemic shock
 ARDS (Adult respiratory distress
syndrome)
 Fat embolism syndrome
 Deep vein thrombosis
 Pulmonary Embolism
 Crush syndrome
 DIC: Disseminated Intravascular
Coagulation
 Aseptic traumatic fever
 Septicaemia (in open fracture )
Imperfect union of the fracture
(Deformity)
 Delayed union
 Non union
 Mal union
 Cross union
 Aseptic Necrosis
 Shortening
Others
 Joint stiffness
 Myositis ossificans
 Traumatic Chondromalacia
 Osteomyelitis
 Ischaemic contracture
 Osteoarthritis
 CRPS : Chronic Regional Pain
Syndrome
Local
 Injury to major vessels
 Injury to muscles and tendons
 Injury to joints
 Injury to viscera
Local
 Compartment syndrome
 Infection

5. FRCATURE
SHARP BONE
ENDS CAUSING
DAMAGE TO
BLOOD VESSELS
HYPOVOLAEMIC
SHOCK
HAEMORRHAGE
BLEEDING FROM
BONES
HYPOVOLAEMIC
SHOCK
HAEMORRHAGE

6. HEMORRHAGE: DIAGNOSIS
Complete
Blood Count
Coagulation
studies
Urine and
stool for blood
Radiographic
studies

7. HEMORRHAGE: INTERVENTIONS
Direct pressure
Surgical intervention as indicated
Use of autologous or synthetic clotting material
Vitamin K or clotting replacement factors
Volume replacement and blood transfusion as necessary
Iron supplementation

8. Soft
Tissues
Injury
Periosteum
Blood
vessels
Nerves
Muscles
Tendons
Ligaments

9. BLOOD VESSELS : VASCULAR INJURY
Relatively uncommon event when associated with fractures.
When it occurs, it is always an emergent situation.
Injury to the artery is classically associated with several
specific fractures involving such sites as :
• Clavicle
• Supracondylar region of the elbow (especially in children)
• Femoral shaft
• Around the knee

10. NERVE INJURY
Typically, a nerve is compressed, contused, or
stretched.
Classic examples include:
• Radial nerve injury secondary to fractures of the distal humerus
• Sciatic nerve injury following posterior fracture dislocations of
hip

11. Neuropraxia.
• Death of the axon does not occur.
• The condition is generally caused by pressure or contusion and usually
improves by itself in a few weeks.
• The nerve is anatomically intact and physiologically nonfunctional.
Axonotmesis.
• Is an anatomic disruption of the axon in its sheath.
• Improvement follows regeneration, the axon growing at a slow rate of 1
mm a day along the existing axonal sheath.
Neurotmesis.
• Is an anatomic disruption of the nerve itself.
• Surgical repair is required if recovery is to be anticipated.

13. MUSCLE AND TENDON INJURY
With any fracture or dislocation there is always some associated
muscle damage.
The extent of this damage and the results will vary depending on
the site in consideration.
Myositis ossificans is a specific complication of muscle damage in
which heterotopic bone forms within the damaged muscle.
The quadriceps and brachialis are specifically predisposed to
develop this complication.

14. ADULT RESPIRATORY DISTRESS SYNDROME
Also known as Shock lung or wet lung.
Can follow slight fluid overload and is made worse if:
• There is any damage to the lungs
• Aspiration into the lung or over-transfusion.
Oedema and electrolyte retention secondary to the trauma also contribute to it.
Treatment is by oxygen and ventilation.
Do not over-transfuse with crystalloids!

15. FAT EMBOLI SYNDROME (FES)
Mechanical blockage of blood
vessels by circulating fat particles
Occurs following
• Long bone fracture
• Pelvic fracture
• Total hip arthroplasty

16. FES: CLINICAL MANIFESTATIONS
Signs and symptoms can appear 12-
72 hours post injury
• Change in mental status
• Increased respiratory distress
• Petechial of skin & mucosa (appear
above nipple line and blanch)

17. FES: DIAGNOSTICS
No specific labs
Fat globules may be detected in blood, urine or sputum
PO2 drops to < 50 mm HG
Chest X Ray with diffuse “snowstorm” effect
VQ scan to r/o PE

18. FES: INTERVENTIONS
Early recognition to prevent morbidity and mortality
Minimize movement of long bone fractures
Respiratory support
• Intubation
• Ventilator management
• ICU monitoring

19. DEEP VEIN THROMBOSIS (DVT)
AND PULMONARY EMBOLISM (PE)
Formation of fibrin leads to development of a thrombus (fibrin clot)
Clinical symptoms appear when thrombus is large enough to
impede blood flow in a large vessel
When venous thrombosis or part of a thrombus dislodges from its
primary site, it becomes an embolus
Embolus can enter pulmonary circulation and perfusion distal to the
embolus can be partially or completely occluded

20. DVT: CLINICAL MANIFESTATIONS
Unilateral swelling of thigh/lower leg
Discomfort in leg
Erythema
Warmth
Tenderness
Palpable, tender venous cord in popliteal space

21. DVT: DIAGNOSTICS
Contrast venography
Doppler ultrasonography
Magnetic Resonance Imaging (MRI)
Radionuclide venography

22. PE: DIAGNOSTICS
Arterial blood gas (ABG)
Chest x-ray (CXR)
Electrocardiogram (EKG)
Ventilation-perfusion scan (VQ scan)
Pulmonary angiography
CT scan

23. DVT & PE: PREVENTION
External pneumatic compression
Graduated compression stockings
Early ambulation and range of motion
Elevation of lower extremities

24. DVT & PE: PREVENTION
Prophylactic inferior vena cava filter
Anticoagulation
• Heparin
• LMWH (low molecular weight heparin)
• Warfarin (Coumadin)

25. DVT & PE: PREVENTION
Full dose anticoagulation with heparin/warfarin
Oxygen therapy for PE
Thrombolytic therapy
• Urokinase
• streptokinase
Surgical embolectomy
Inferior vena cava filter

26. CRUSH SYNDROME
Also known as traumatic rhabdomyolysis or Bywaters' syndrome
It is characterized by major shock and renal failure after a crushing injury to skeletal
muscle.
It is compression of extremities or other parts of the body that causes muscle swelling
and/or neurological disturbances in the affected areas of the body.
Cases occur commonly in catastrophes such as earthquakes, to victims that have been
trapped under fallen masonry.
Treatment is complex & it should be started at the earliest to avoid irreversible damage

27. DISSEMINATED INTRAVASCULAR COAGULATION
Also known as Diffuse intravascular coagulation (DIC)
Can follow any injury and is due to a disturbance of the
clotting mechanism.
Treatment is done with:
• Fresh frozen plasma
• Platelets
• Heparin.

28. COMPARTMENT SYNDROME
“A condition in which the circulation and function
of tissues within a closed space compromised by
an increased pressure within that space”
The muscles and nerves of the extremity are
enclosed in fascial spaces or compartments and are
therefore susceptible to this condition

29. COMPARTMENT SYNDROME
RISK FACTORS
External
Compression Force
• Tight cast
• Tight dressing
• Prolonged
compression
• Crush injuries
Internal Factors
• Bleeding
• Swelling/edema
• Exertional
Miscellaneous Factors
• Acute trauma
• Fracture
• Infection
• Skin traction
• Tibial nailing
• Exercise
• Insensate extremity

30. COMPARTMENT SYNDROME: 5 PS
Pain on passive stretch
Pallor
Pulselessness
Paresthesia
Paralysis

31. PERIPHERAL VASCULAR ASSESSMENT
Color
• Pale
• White
• Pink
• Dusky
• Cyanotic
• Mottled
Edema
• Pitting
Temperature
• Cold
• Warm
• Hot
Capillary
refill
• normal < 3
seconds
Peripheral
pulses
• Distal to
injury
• Bilateral
• If non-
palpable:
doppler

32. PERIPHERAL NEUROLOGICALASSESSMENT
Sensation
Motor function
Both elements evaluate:
• Upper extremity: Radial, Median & Ulnar Nerves
• Lower extremity:Tibial, Peroneal, Femoral & Sciatic
nerves

33. COMPARTMENT SYNDROME: DIAGNOSTICS
Muscle damage indicated by:
• Myoglobin in urine
• Elevated CPK, LDH and SGOT
Intracompartmental pressure monitor
• Pressures of 30-45 mm HG a concern

34. INTRACOMPARTMENTAL PRESSURES (ICP)
Pain can be unreliable especially in the trauma patient.
It can range from being mild to severe, and in the unconscious patient important
clinical symptoms and signs can be difficult to elicit.
Techniques have been developed to measure ICPs.
The normal tissue pressure within closed compartments is 0–10mmHg.
This pressure markedly increases in compartment syndrome

35. COMPARTMENT SYNDROME
PREVENTION
Early recognition is key to preventing or minimizing negative
outcome
Astute nursing intervention to identify pathologic pain in the
presence of good pain control (epidural, PCA)
The key to successful treatment of acute compartment syndrome is
early diagnosis and decompression of the affected compartments

36. COMPARTMENT SYNDROME:
INTERVENTIONS
Relieve pressure source
• Remove constrictive dressing
• Bivalve cast
Initiate pain management
Elevate extremity at heart level
Ongoing neurovascular assessments
Fasciotomy if indicated

38. WOUND/SSI
CLINICAL MANIFESTATIONS
Increased pain
Fever or chills
Foul smell from wound
Edema
Increased temperature around incision or wound
Erythema around wound or incision
Purulent exudate, poor wound healing
Elevated WBC, ESR, C-reactive protein

39. WOUND/SSI: INTERVENTIONS
Wound care
Systemic antibiotics
Adequate perfusion
Adequate oxygenation
Optimal nutritional intake

40. Problems
in Bone
Healing
Delayed
union
Non
union
Malunion
Cross
Union
Avascular
necrosis

41. NON-UNION
• Delayed union  non-union.
• No progression of healing over serial radiographs
• On x-ray :
• Hypertrophic …due to excessive mobility
• Atrophic…due to poor blood supply
• Needs intervention.

43. NON-UNION TREATMENT
• Conservative;
• No symptoms no treatment
or removable splint.
• Symptomatic
• Hypertrophic (functional
Bracing)
• EMG Stimulation
• Pulsed US
• Operative
• Hypertrophic  fixation
• Atrophic excision , bone
graft and fixation

44. MALUNION
• Union in an unsatisfactory position:
• Angulation
• Rotation
• Shortening
• Causes:
• Failure to reduce fracture adequately
• Failure to hold reduction while healing
• Gradual collapse of comminuted or osteoporotic bone

45. MALUNION
• Clinical Features:
• Deformity
• Usually visible in X - ray
• May be not apparent in some cases
• On x-ray:
• Check the position in the 1st 3 weeks

46. MALUNION TREATMENT
• Can be started before the fracture is fully united.
• Adults  reduce to the anatomical position
• More than 10 to15 degrees may need;
• Re-manipulation
• Osteotomy
• Internal fixation

47. MALUNION TREATMENT
• Children
• Angular deformity resolve without treatment
• Rotational deformity needs intervention
• In lower limb shortening ( 2cm or more ) : lengthening

48. AVASCULAR NECROSIS
• Bone death due to interruption of blood supply
• Certain regions more than others include:
• Head of femur
• Proximal part of scaphoid
• Lunate
• Body of talus
• It is an early complication because of ischemia but
radiological findings are seen later

50. COMPLEX REGIONAL PAIN SYNDROME

51. COMPLEX REGIONAL PAIN SYNDROME

52. CHRONIC OSTEOMYELITIS

53. TRAUMATIC OSTEOARTHRITIS

56. SUMMARY
Introduction to posture and factors affecting it.
Ideal versus Normal Posture.
Fundamentals of postural defects.
Growth Variation in lower limbs.
Congenital Telipes Equinovarus.
Developmental disorders of spine.
Syndromes affecting posture:
• Osteogenesis Imperfecta
• Down’s Syndrome
• Marfan’s Syndrome

58. THE END
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