Complications of Fractures 2024 PDF

Semester 7 2024 Complications of Fractures BY Dr. WAIL LOTFY ABDELNABY Professor of orthopedic surgery  Complications of fractures Local 1- Viscera...

Semester 7 2024 Complications of Fractures BY Dr. WAIL LOTFY ABDELNABY Professor of orthopedic surgery  Complications of fractures Local 1- Visceral injury 2- Skin 3- Muscles & tendons 4- Blood vessels General 5- Nerve injury 1- Shock 6- Joint complication 2- Haemorrhage. 3- Pulmonary complications 7- Bone complications 4- G.I. complications 5- Crush syndrome. 6- Deep venous thrombosis. 7- Complications of prolonged recumbency.  Complications of Fractures General complications Local complications Early complications Late Complications Urgent Less urgent Urgent local complications 1- Visceral injury. 2- Vascular injury. 3- Nerve injury. 4- Haemarthrosis. 5- Infection. 6- Gas gangrene. Complications of Fractures General occur in major fractures e.g. femur, pelvis and spine. 1- Shock 2- Haemorrhage. 3- Pulmonary complications: pulmonary embolism, fat embolism, adult respiratory distress syndrome (ARDS). 4- G.I. complications: Paralytic illeus and acute gastric dilatation. 5- Crush syndrome. 6- Deep venous thrombosis. 7- Complications of prolonged recumbancy. Local complications Visceral injury a- Fracture ribs causes penetration of the lung and pueumothorax. b- Fracture pelvis causes rupture bladder or urethera. Local complication Skin Injury. Infection. Sores. Muscles & tendons 1- injury 2- Myositis ossificans Traumatic ossification (Traumatic myositis ossificans) Calcification and may be ossification outside the skeleton causing restriction of joint movement. It may involve lacerated muscle (myositis ossificans), torn capsule (capsulitis), fascia, tendon and periosteum. Sites: it is frequent after injuries of the elbow and hip, but may occur at other sites. Traumatic ossification (Traumatic myositis ossificans) Predisposing factors: a-Delay in reduction b- Massage and passive exercises. Pathogenesis: 1- osteoblasts from injured periosteum migrating and forming bone in muscle haematoma. 2- Metaplasia of some fibroblasts to osteoblasts. Traumatic ossification (Traumatic myositis ossificans) Diagnosis (according to the stage) 1- Active stage (few weeks after injury): - There is still pain, swelling and local heat. -The range of movement of the joint decreases. - X-ray: Cloudy shadow of calcification apppear around the joint. 2- Quiescent stage: - Pain and local heat gradually disappear and rarely a swelling is felt. -Joint stiffness persists. - X-ray: Circumscribed and denser shadow of calcification appear around the joint. Traumatic ossification Treatment A- Prophylactic: 1- Early reduction of fracture and dislocation and Immobilisation of injured joint. 2- Avoid massage and passive movement after plaster removal. B- Curative : 1- Active stage: Encourage graduated active exercises after a period of rest. 2- Quiescent stage: excision (be aware of the tendency to recurrence). Vascular injuries Acute ischemia. Compartment syndrome. Diagnosis of acute iscaemia Clinical picture. Dopplar US. MRA. Management of acute Ischemia Treatment: surgical emergency The following measures are done one after the other until blood flow to the limb is restored #Remove any tight bandage or plaster. #Reduce the fracture if x-ray suggests that the artery is being compressed or kinked by bone. #If there is no improvement within 30 minutes, the vessels is explored by urgent operation. Management of acute Ischemia a- If the occlusion is due to kinking or spasm of the artery an attempt is made to relieve it by freeing the vessel, bathing the vessel in warm solution of papaverine sulphate. b- If pulsations do not return, forcible intra-arterial injections of saline may relieve the spasm. c-If the vessel is thrombosed, endartrectomy may restore the blood flow. d- A torn vessel can be sutured or a damaged or contused segment may need excision and repair with a vein graft. Compartment syndrome A condition characterized by raised pressure within a closed space with a potential to cause irreversible damage to soft tissues.  Compartment syndrome Diagnosis: 1- A tense compartment (is the earliest and most objective sign). 2- The 5Ps of compartment syndrome are Pain, Parathesia, Pallor, Paralysis, and Pulselessness. Compartment syndrome 3-Sever pain out of proportion to what would be expected, particularly pain on passive extension of the fingers or toes (is the classical clinical finding)  Compartment syndrome Measurement of pressure in the compartment (if the patient is unconscious or un cooperative)  Compartment syndrome Early detection & treatment is important 1. Remove all constrictive dressings and casts and avoid joint flexion 2. Reduce the fracture and elevate the limb. 3.Operative treatment: Fasciotomy (decompression by opening of the threatened compartments) Volkmann’s ischaemic contracture  Volkmann’s ischaemic contracture of the forearm Massive infarction of the musle of forearm lead to fibrosis then permenant shortening of the muscle. Clinically: 1- Deformity:There is flexion of the wrist ,interphalangeal joints, and extension of the metacarpo-phalangeal joints. 2- Atrophy of muscles. 3-Ischaemic neuritis: Sensory loss along the distribution of the median nerve may be present. Trophic changes in the fingers are often present.  Volkmann’s ischaemic contracture of the forearm Contracture : The flexors of the fingers are short. When the wrist is dorsiflexed, the fingers become flexed and cannot be passively extended ; When the wrist is flexed, the fingers can be passively extended Volkmann’s ischaemic contracture of the forearm Prevention: 1 - Early reduction: of fractures around the elbow to relieve any pressure on the brachial artery. 2- Avoid a- acute flexion of the elbow after reduction of a supracondylar fracture to obviate kinking the brachial artery (this fracture is treated with the elbow in full extension and the forearm supinated). b- Tight bandages and casts. 3- Treatment of ischaemia and fascitomy Volkmann’s ischaemic contracture of the forearm Treatment: A- Non-operative treatment Gradual stretching by a splint or by wedged plaster cast (in recent mild cases). B- Operative treatment Muscle slide operation or Carpectomy. Excision of necrotic muscles and transfer of a tendon of healthy muscle (In selected cases) Nerve injury: Types: Neurapraxia, axontemesis and neurotemesis Common sites: Carpal tunnel syndrome in colles' fracture Treatment: early exploration? Neuroapraxia: Physiologic interruption of nerve function Recovery from minutes to weeks Axonotemesis: It’s cut of nerve axon with intact sheath Complete recovery within 6 months Neurotemesis: It’s cut of nerve axon & sheath Bad prognosis  type Simple fr. Open fr. lesion Neurapraxia or axonotemesis neurotemesis fate Spontaneous recovery repair Nerve Trauma Effect Axillary Dislocation of shoulder Deltoid paralysis Radial # of humerus Wrist drop Median Supracondylar # of Pointing index (anterior humerus in children. interosseu s nerve), Ulnar # medial epicondyl Claw hand humerus Sciatic Post dislocation of hip Foot drop Common Knee dislocation Foot drop peroneal # neck of fibula  Joint complications 1- Sprain,dislocation or sublaxion. 2- Joint stiffness 3- Effusion (traumatic synovitis) 4- Haemoarthrosis 5- Septic arthritis 6- Sudeck’s osteodystrophy 7- Post-traumatic arthritis Post-traumatic joint stiffness a.Adhesions(periarticular and intra-articular) b.Traumatic ossification (myositis ossificans). c. Sudeck’s osteodystrophy. d. Osteoarthritis (late after may years). e. Malunion, and bone block. Reflex sympathetic dystrophy (Sudek's atrophy) pain , swelling , osteoprosis and stiffness of hand and foot in wrist and ankle fracture Etiology Unknown may be * disuse atrophy * over sympathatic activity Reflex sympathetic dystrophy (Sudek's atrophy) Patient is often a neurotic - female. Occur most often after wrist - and ankle fractures. - Is characterized by severe pain and stiffness. - Is associated with local vasomotor symptoms in the form of discolouration of the skin which becomes thin and there is excessive perispiration. - X-ray: Patchy rarefaction of bone. Reflex sympathetic dystrophy (Sudek's atrophy) Treatment : 1- Physiotherapy :graduated exercises and paraffin baths. 2- Analgesics 3- TENS 4- Sympathetic block and sympathectomy. Post-traumatic arthritis Causes : 1) Joint incongruity after intraarticular fracture 2) Avascular bone necrosis. 3) Malunited fractures. Bone complications 1- Avascular necrosis. 2- Non union. 3- Mal union. 4- Delayed union. 5- Growth arrest 6- Bone shortening 7- Epiphyseal injuries. 8- Osteomylitis Avascular bone necrosis (AVN) Definition : Bone necrosis due to interruption of blood supply after fracture or dislocation injury. Site : 1- Head of femur after femoral neck fracture or hip dislocation 2- Scaphoid 3- Talus c/p : late Pain – mal-union Vulnerable sites of AVN Bone healing complications Delayed union : Healing takes longer than average for a given bone injury to heal. Non-union : - An arrest of healing process & formation of sclerosis at the ends of the fracture. - Fracture didn’t and will not unite. - In this case there is a fibrous union and may be a false joint at fracture site (pseudo-arthrosis). WHEN IS THE FRACTURE HEALED? Clinical union Upper limb Lower limb Child 3-4 weeks 6-8 weeks Adult 6-8 weeks 12-16 weeks Radiological union ▪ Bridging callus formation ▪ Remodelling Delayed union and non-union Local causes : Infection Inadequate blood supply Inadequate immobilization Distraction of fragments Interposition of soft tissue Sever soft tissue damage Avascular necrosis Types of Non-union. Atrophic, hypertrophic Delayed union and non-union c/p Pain – swelling – abnormal movement Treatment A- Delayed union: * Prolonged immmobilization * Adequate fixation * Bone graft : high bone loss B- Non union * Internal fixation * Bone graft  Mal-union Fracture that has healed in non-anatomical position It can cause angular deformity, rotation deformity, shortening of limb e.g. cubitus varus after supracondyle fracture in humerus Treatment: Osteotomty