Complications of Fractures and Their Management by Dr. Jasim Hasan

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By Dr. Jasim Hasan
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COMPLICATION OF FRACTURE
COMPLICATION OF FRACTURE
 
 
General
 
Local
 
Early
 
Late
 
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General  complications
Shock
Hypovolemic or hemorrhagic shock.
Septic shock.
Neurogenic shock.
Fat embolism.
Pulmonary embolism.
Crush syndrome.
Multiple organs failure syndrome (MOFS).
Thrombo-embolism.
Tetanus.
Gas gangrene.
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Local complications
Early
1.
Visceral injury (the lung, the bladder,
the urethra, and the rectum).
2.
Vascular injury.
3.
Nerve injury.
4.
Compartment syndrome.
5.
Haemoarthrosis.
6.
Infection.
7.
Gas gangrene.
8.
Fracture blisters.
9.
Plaster and pressure sores.
                 10. Tendon injury.
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Late
1.
Delayed union.
2.
Non-union.
3.
Malunion.
4.
Avascular necrosis.
5.
Growth disturbance.
6.
Bed sore.
7.
Myositis ossificans.
8.
Muscle contracture.
9.
Tendon lesions.
10.
Nerve compression and entrapment.
11.
Joint instability.
12.
Joint stiffness.
13.
Complex regional pain syndrome. ( algodystrophy).
14.
Osteoarthritis.
 
Local Visceral Injury
Vascular Injury
Nerve Injury
Compartment Syndrome
Haemarthrosis
Infection
Gas gangrene
 
Fracture around the trunk are often Cx by injury
to the adjacent viscera :
 
 Pelvic fracture
 
Rib fracture                 penetration to the lungs
 
Pneumothorax
 
Bladder and urethral
rupture
 
Most commonly – knee, femoral shaft, elbow,
and humerus.
Artery may be cut, torn, compressed or
contused.
Intima may be detached, thrombus block,
artery spasm
Effect ?? ↓↓ bld flow coz Ischemia leads to
tissue death & peripheral gangrene
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Common vascular injuries may associate with the
following fractures.
1.
First rib or clavicle fracture (subclavian artery).
2.
Shoulder dislocation (Axillary artery).
3.
Humeral supracondylar fracture (brachial artery).
4.
Elbow dislocation (Brachial artery).
5. Pelvic fracture (presacral and internal iliac).
6. Femoral supracondylar fracture (Femoral artery).
7. Knee dislocation (Popliteal artery).
8. Proximal tibia (popliteal or its branches).
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Pt with ischemia may have 5 P’s:
 
- paraesthesia/numbness
 
- pain
 
- pallor
 
- pulselessness
 
- paralysis
Investigate if suspect vascular injury :
Angiogram
 
Emergency treatment
All bandages/splints removed
The fracture X-Ray again
Circulation reassessed for next half hour
If no improvement, do vessels exploration
Suture torn vessels, vein grafting, if
thrombosed do endarterectomy
Aim: to restore bld flow
 
Variable degree of motor and sensory loss
along the distribution of the nerve
May be neurapraxia, axonotmesis or
neurotmesis
Radial nerve is most frequently damaged
nerves.
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In closed injuries – nerve is seldom severed and
spontaneous recovery should be awaited.
 
In open fractures – complete lesion(neurotmesis) :
the nerve is explored during wound debridement
and repaired.
 
Definition
 
Compartment syndrome involves the compression of nerves
and blood vessels within an enclosed space, leading to
impaired blood flow and nerve damage.
 
Fascia separate groups of muscles in the arms and legs from
each other. Inside each layer of fascia is a confined space,
called a compartment, that includes the muscle tissue,
nerves, bones and blood vessels.
 
A rise in pressure within these compartments may jeopardize
the blood supply to the muscles & nerves within the
compartment.
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Causes:
 
-any injury/infection leading to edema of
muscle
 
-fracture haematoma within the compartment
 
-ischemia to the compartment leading to
muscle
 
 oedema
 
-Due to tight bandages or casts
 
Hallmark Symptoms:
  
- severe pain that does not respond to
elevation 
 
  or pain medication.
  
- In more advanced cases, there may be
 
   
 
  decreased sensation, weakness, and
paleness 
 
  of the skin.
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Injuries with a high risk of developing
Compartments synd:
# of the elbow
# of the forearm bone
# of the proximal third of the tibia
 
Arterial               
ischaemia                 blood flow
Damage
 
Direct
injury
 
oedema
 
Compartment
pressure
 
5P’s
Pain
Pallor
Paraesthesia
Pulseless
Paralysis
 
………….....
.…………….
 
Fasciotomy
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A vicious cycle cont. until the total vascularity of the
muscles and nerves is jeopardized.
 
This result in ischaemic muscle necrosis and nerve
damage. (within 12 hours)
 
The necrotic muscle undergo healing with fibrosis,
leading to Volkmann’s contracture.
 
Nerve damage may result in motor and sensory
loss. In extreme case 
 gangrene
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clinically:
 
- should be tested by stretching the
 
  muscles 
 when the toes or fingers are
 
  passively hyperextended there is ↑ pain
 
  in the calf or forearm.
Early preventing : limb elevation
Dx : confirmed by direct intracompartmental
pressure measuring > 40mmHg is an indication of
compartment decompression and fasciotomy.
undefined
 
Treatment
 
First removed all the bandages & dressing.
   Fasciotomy is performed.
The wound should be left open and inspected 2
days later.
If there is muscle necrosis 
 debridement
If muscle is healthy
 suture (w/o tension)/ skin
grafted / simply heal by 2˚ intention.
 
 
Fractures involve joints, leads to acc. of blood
within the joints.
C/Feature :The joint is swollen and tense and
patient will resists any movement.
Tx : the blood should be aspirated before
dealing with the fracture.
 
 
Causes:
Open fracture (common)
Use of operative method in the Tx of 
#
Wound becomes inflamed and starts draining
seropurulent fluid.
Infection may be superficial, moderate (osteomyelitis),
severe (gas gangrene).
Post-traumatic wound infx is most common cause of
chronic osteomyelitis 
union will be slow and ↑
chance of refracturing.
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Treatment:
Antibiotic
Excising all devitalised tissue
If Sx of acute infx and pus formation : tissue around
the fracture should be opened & drained
 
Produced by anaerobic orgs : 
Clostridium sp 
infections.
These orgs can survive in ↓ O
2
 tension
Toxins produced will destroy the cell wall and leads to tissue
necrosis
C/feature: within 24hr. Pt complains:
    
- intense pain
    
- swelling around the wound
    
- brownish discharge
    
- gas formation
    
- pyrexia
    
- characteristic smelling
    
- PR ↑
    
- toxaemic 
 coma 
 death
Inability to recognize may lead to unnecessary amputation for
the non-lethal cellulitis.
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swelling around the wound,
swelling around the wound,
brownish discharge
brownish discharge
 
gas formation
gas formation
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Prevention:
deep penetrating wound in muscular tissue are
dangerous;should be explored, all dead tissue should be
completely excised, and if there doubt about the tissue
viability should left open the wound
 
Treatment:
Early Dx is life saving
General measures:
Fluid replacement & IV Antibiotic (immediate)
Hyperbaric O
2 
(limiting the spread of gangrene)
Mainstay : prompt decompression & remove dead tissue
 
undefined
 
       Thank  You
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This detailed presentation by Dr. Jasim Hasan covers the complications of fractures, including general and local complications, early and late complications, and specific issues such as shock, vascular injuries, nerve damage, and more. The information highlights the importance of recognizing and addressing these potential complications to ensure optimal healing and recovery for patients with fractures.


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  1. COMPLICATIONS OF FRACTURES By Dr. Jasim Hasan By Dr. Jasim Hasan

  2. COMPLICATION OF FRACTURE General Local Early Late

  3. General complications Shock Hypovolemic or hemorrhagic shock. Septic shock. Neurogenic shock. Fat embolism. Pulmonary embolism. Crush syndrome. Multiple organs failure syndrome (MOFS). Thrombo-embolism. Tetanus. Gas gangrene.

  4. Local complications Early 1. Visceral injury (the lung, the bladder, the urethra, and the rectum). 2. Vascular injury. 3. Nerve injury. 4. Compartment syndrome. 5. Haemoarthrosis. 6. Infection. 7. Gas gangrene. 8. Fracture blisters. 9. Plaster and pressure sores. 10. Tendon injury.

  5. Late 1. Delayed union. 2. Non-union. 3. Malunion. 4. Avascular necrosis. 5. Growth disturbance. 6. Bed sore. 7. Myositis ossificans. 8. Muscle contracture. 9. Tendon lesions. 10.Nerve compression and entrapment. 11.Joint instability. 12.Joint stiffness. 13.Complex regional pain syndrome. ( algodystrophy). 14.Osteoarthritis.

  6. EARLY COMPLICATION Local Visceral Injury Vascular Injury Nerve Injury Compartment Syndrome Haemarthrosis Infection Gas gangrene

  7. LOCAL VISCERAL INJURY Fracture around the trunk are often Cx by injury to the adjacent viscera : Bladder and urethral rupture Pelvic fracture Rib fracture penetration to the lungs Pneumothorax

  8. VASCULAR INJURY Most commonly knee, femoral shaft, elbow, and humerus. Artery may be cut, torn, compressed or contused. Intima may be detached, thrombus block, artery spasm Effect ?? bld flow coz Ischemia leads to tissue death & peripheral gangrene

  9. Common vascular injuries may associate with the following fractures. 1.First rib or clavicle fracture (subclavian artery). 2.Shoulder dislocation (Axillary artery). 3.Humeral supracondylar fracture (brachial artery). 4.Elbow dislocation (Brachial artery). 5. Pelvic fracture (presacral and internal iliac). 6. Femoral supracondylar fracture (Femoral artery). 7. Knee dislocation (Popliteal artery). 8. Proximal tibia (popliteal or its branches).

  10. CLINICAL FEATURES Pt with ischemia may have 5 P s: - paraesthesia/numbness - pain - pallor - pulselessness - paralysis Investigate if suspect vascular injury : Angiogram

  11. TREATMENT Emergency treatment All bandages/splints removed The fracture X-Ray again Circulation reassessed for next half hour If no improvement, do vessels exploration Suture torn vessels, vein grafting, if thrombosed do endarterectomy Aim: to restore bld flow

  12. NERVE INJURY Variable degree of motor and sensory loss along the distribution of the nerve May be neurapraxia, axonotmesis or neurotmesis Radial nerve is most frequently damaged nerves.

  13. Nerve Trauma Effect Axillary Dislocation of shoulder # of humerus Deltoid paralysis Radial Wrist drop Median Supracondylar # of humerus # medial epicondyl humerus Post dislocation of hip Pointing index Ulnar Claw hand Sciatic Foot drop Common peroneal Knee dislocation # neck of fibula Foot drop

  14. In closed injuries nerve is seldom severed and spontaneous recovery should be awaited. In open fractures complete lesion(neurotmesis) : the nerve is explored during wound debridement and repaired.

  15. COMPARTMENT SYNDROME Definition Definition Compartment syndrome involves the compression of nerves and blood vessels within an enclosed space, leading to impaired blood flow and nerve damage. Fascia separate groups of muscles in the arms and legs from each other. Inside each layer of fascia is a confined space, called a compartment, that includes the muscle tissue, nerves, bones and blood vessels. A rise in pressure within these compartments may jeopardize the blood supply to the muscles & nerves within the compartment.

  16. Causes: muscle muscle -any injury/infection leading to edema of -fracture haematoma within the compartment -ischemia to the compartment leading to oedema -Due to tight bandages or casts Hallmark Symptoms: - severe pain that does not respond to elevation or pain medication. - In more advanced cases, there may be decreased sensation, weakness, and paleness of the skin.

  17. Injuries with a high risk of developing Compartments synd: # of the elbow # of the forearm bone # of the proximal third of the tibia

  18. THE VICIOUS CYCLE OF VOLKMANN S ISCHAEMIA 5P s Pain Pallor Paraesthesia Pulseless Paralysis Arterial ischaemia blood flow Damage ..... . . Fasciotomy Direct injury oedema Compartment pressure

  19. A vicious cycle cont. until the total vascularity of the muscles and nerves is jeopardized. This result in ischaemic muscle necrosis and nerve damage. (within 12 hours) The necrotic muscle undergo healing with fibrosis, leading to Volkmann s contracture. Nerve damage may result in motor and sensory loss. In extreme case gangrene

  20. clinically: Early preventing : limb elevation Dx : confirmed by direct intracompartmental pressure measuring > 40mmHg is an indication of compartment decompression and fasciotomy. - should be tested by stretching the muscles when the toes or fingers are passively hyperextended there is pain in the calf or forearm.

  21. Treatment Treatment First removed all the bandages & dressing. Fasciotomy is performed. The wound should be left open and inspected 2 days later. If there is muscle necrosis debridement If muscle is healthy suture (w/o tension)/ skin grafted / simply heal by 2 intention.

  22. HAEMARTHROSIS Fractures involve joints, leads to acc. of blood within the joints. C/Feature :The joint is swollen and tense and patient will resists any movement. Tx : the blood should be aspirated before dealing with the fracture.

  23. INFECTION Causes: Open fracture (common) Use of operative method in the Tx of # # Wound becomes inflamed and starts draining seropurulent fluid. Infection may be superficial, moderate (osteomyelitis), severe (gas gangrene). Post-traumatic wound infx is most common cause of chronic osteomyelitis union will be slow and chance of refracturing.

  24. Treatment: Antibiotic Excising all devitalised tissue If Sx of acute infx and pus formation : tissue around the fracture should be opened & drained

  25. GAS GANGRENE Produced by anaerobic orgs : Clostridium sp infections. These orgs can survive in O2 tension Toxins produced will destroy the cell wall and leads to tissue necrosis C/feature: within 24hr. Pt complains: - intense pain - swelling around the wound - brownish discharge - gas formation - pyrexia - characteristic smelling - PR - toxaemic coma death Inability to recognize may lead to unnecessary amputation for the non-lethal cellulitis.

  26. swelling around the wound, brownish discharge gas formation

  27. Prevention: Prevention: deep penetrating wound in muscular tissue are dangerous;should be explored, all dead tissue should be completely excised, and if there doubt about the tissue viability should left open the wound Treatment: Treatment: Early Dx is life saving General measures: Fluid replacement & IV Antibiotic (immediate) Hyperbaric O2 (limiting the spread of gangrene) Mainstay : prompt decompression & remove dead tissue

  28. Thank You Thank You

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