Fifth stage orthopedic 26/10/2015
د.يقظان Lec-3Complications of the fractures :
A- general complications .B- local complications .
A – general complications .
1- blood loss and shock .2- cardiopulmonary failure .
3- fat embolism .
4- DVT .
5- tetanus .
6- gas gangrene .
7- crush syndrome .
Fat embolism :
Fat globules larger than 10 micro meter in diameter can enter the circulation after closed fractures of the long bones . It's source is from the bone marrow , it can be deposited in any site in the body mainly in the lung or even in the brain , the condition is more common in patients with multiple fractures .Clinically :
The patient usually with lower limb fracture , early signs (within 72 hours of the injury ) has slight rise in temperature and pulse rate , then the patient develop breathlessness and mild mental confusion or restlessness ; petechiae can be looked for on the chest , back , axilla and conjunctival folds .
In sever cases there will be marked respiratory distress and coma due to hypoxia or brain emboli .
Treatment : there is no infallible test for embolism ; monitoring of the patient is mandatory , oxygen supply and even in sever cases ventilator can be used , but in sever cases recovery is unpredictable and the mortality rate is high … early fixation of the fractures help in decrease its possibility .
Crush syndrome :
the crushed limb is deprived from the blood flow , also in case of interruption of blood supply for the limb for any cause ; tissues begin to die and toxic metabolite accumulate and when reach to the circulation it causing a lot of problems :The resultant hyperkalemia , hypocalcaemia and metabolic acidosis can arrest the heart ; the large molecules of myoglobin which released from dead muscles may lead to acute renal failure .
Treatment :
The most important measure is prevention .
High urine flow must be ensured by giving large volume of intravenous crystalloid ; manitol alkaline diuretic can be given .
Extensive wound excision (remove all the dead muscle if there is wound) is mandatory .
Some time amputation is the resolution to save the life .
Gas gangrene :
This condition is caused by clostridial infection , mainly clos. Welchii ; which are anaerobic organism which can live and multiply in tissues with low oxygen tension ; so the dirt wound with dead muscle that has been closed without adequate debridement is the most suitable media for the growth of this micro organism .The toxin which produced by this m.o. destroy the cell wall and rapidly lead to tissue necrosis and spread of the infection .
Clinically :
Clinical features appear within 24 hours of the injury .
The patient has sever pain and swelling around the wound and brownish discharge may be seen , little or no pyrexia , high pulse rate , gas in the tissue can be detected by x – ray but it is not very marked ; characteristic smell become evident .
Rapidly the patient become toxemic and may pass into coma and death .
Prevention :
Any deep wound in the muscle should be explored , all dead tissue should be totally removed , if there is doubt about tissue validity , then the wound should be left opened .Treatment :
Early diagnosis is the key for success of the treatment which include :
I.V fluid replacement , intravenous antibiotic ( benzyl penicillin in high doze , metronidazole ) .
Hyperbaric oxygen has been used to decrease spread of infection ;
Decompression of the wound and remove the dead tissue .
In advance cases amputation may be essential .
B- local complication of the fractures :
a- early complications .b- late complications .
a- early complications :
1- vascular injuries and compartment syndrome .2- nerves injuries .
3- tendons injuries .
4- visceral injuries .
5- haemoarthrosis .
6- infection .
Compartment syndrome :
Fractures of upper and lower limbs can give rise to sever ischemia even if there is no damage to a major vessels .Bleeding , edema or inflammation may increase the pressure within one of the osteofacial compartment ; there is reduced capillary flow which result in muscle ischemia , further edema , still greater pressure and yet more profound ischemia .
Vicious circle that end after 12 hours or less , in necrosis of nerve and muscle within the compartment .
Nerve is capable of regeneration but muscles once infarcted , can never recover and it replaced by inelastic fibrous tissue (Volkmann's ischemic contracture ) .
A similar events may be caused by swelling of a limb inside a tight plaster cast .
b-Late complications of the fractures :
1- delayed union and non union .
2- malunion .
3- avascular necrosis .
4- growth disturbance of the bone .
5- myositis ossificans .
6- tendons ruptures .
7- nerves compression .
8- bed sore .
9- joint stiffness .
10- joints instability .
11- sudeck dystrophy .
12- osteoarthritis .
1- delayed union and non union :
non union :it is failure of the fracture to unite after double of theexpected time of healing which is determined by perkin`s
table .
Causes of non union :
A- causes related to the type of injury :1- extensive soft tissue damage and loss i.e in compound fractures .
2- bone loss in compound fractures .
3- soft tissue inter position .
4- intact fellow bone .
5- infection .
B- causes related to the bone itself .
1- poor blood supply .
2- poor hematoma formation .
3- flimsy periosteum .
4- diseased bone ( pathological fractures )
C- causes related to the surgeon : these includes technical faults like:
1- over traction .2- poor splintage .
3- poor fixation .
4- impatience .
D- cause related to the patient :
1- immense .2- immoderate .
3- immovable .
4- impossible .
Types of non union :
atrophic non union .2- hypertrophic non union .
Treatment of non union :
A- conservative treatment :1- functional brace .
2- pulse electromagnetic fields .
3- low frequency pulsed ultra sound .
B- operative treatment :
1- refreshment of the fracture site . 2- perfect reduction .3- rigid fixation with compression . 4- bone grafting .
2- malunion :
When the fracture is in unsatisfactory position e.g unacceptable angulation , rotation or shortening and unite in this position , so the deformity will persist and it is called malunion .It is caused by , either failure of reduction or failure of holding of the fracture .
3- avascular necrosis :
In certain regions , when fracture occur it may complicated with interruption of blood supply to certain parts of the bone lead to avascular necrosis . e.g of these parts of bones :
1- femoral head necrosis after fracture neck of femur .
2- proximal part of the scaphoid after fracture waist of the scaphoid .
3- body of the talus after fracture neck of talus .
4- growth disturbance :
This complication occur when there is damage to the growth plate of the bone by the fracture .
5- bed sore :
It is pressure sore or ulceration occur in bed ridden patient at the areas which sustained pressure mainly lower back , buttock .It is occur very rapidly and healed very slowly .
The prevention is better than treatment .
6- myositi`s ossificans :
Deposition of calcium in the muscles lead to stiffness of the near joint .Indomethacin is helpful in treatment .
7-Tendons lesions :
a- tendonitis e.g tibialis posterior tendonitis in fracture medial malioli .b- rupture of tendon e.g rupture of extensor pollicis longus tendon in
Cole's fracture .
8- sudeck dystrophy :
It is post traumatic localized reflex sympathetic over activity also known as algodystrophy .The patient has continuous pain , swelling , redness , the skin look shiny , pinkish , decrease in hair distribution warmth , localized tenderness and the near by joints are stiff .
X- ray show localized osteoporosis .
Treatment :
Removal of splintage of the fracture (pop) and start active physiotherapy , analgesic anti inflammatory drugs , sympatholytic drugs e.g guanithidin i. v or even sympathetic block .
9- muscles contracture :
Usually follow arterial injuries with the fractures or compartment syndrome . e.g for it is Volkmann's ischemic contracture in the forearm .
10- nerve compression . By the mal united bone or by the callus .
11- joint instability .12- joint stiffness . It is occur due to immobilization of the limb during
the period of healing of the fracture . It can reduced by avoid prolonging the period of holding of the fracture , using functional orthosis , or by using internal or external fixators which they permit movement of the joints at the time of healing of the fractures .
13- osteoarthritis :
This occur when the fracture involve the articular surface of the joint .It can be minimized by perfect reduction of the articular surface and internal fixation .
Stress fractures :
Stress or fatigue fracture is one occurring in normal bones of healthy patient but it is not caused by a specific traumatic incident , but by repetitive minor trauma or stress .
It affect many bones but the common examples are Marsch fracture
(fracture metatarsal bones , mainly the second one ) in the military people ; and fractures in the lower third of the fibula (runner's people) .
Pathological fracture :
It is fracture that occur in abnormal bone or diseased bone , and it suspected when the force which cause the fracture is less than the ordinary force needed to break the normal bone .Any condition lead to weaken the bone can lead to pathological fracture e.g osteomyelitis , bone tumors , metabolic bone diseases …..etc.
Dislocation and subluxation of the joints :
Dislocation : it mean the joint surfaces are completely displaced and
no longer in contact (complete separation of the two
articular surfaces ) .
Subluxation : it represent a lesser degree of displacement . Such that
articular surfaces are still partly apposed .Injuries of the physis :
Classification : Salter Harris classification :
Type one : transverse fracture through the growth plate .
Type two : it is similar to type one but it contain triangular piece from
the metaphysis .
Type three : the fracture split the epiphysis vertically .
Type four : splitting the epiphysis vertically and extend to the metaphysis.
Type five : compression of the growth plate (crushing) and it result ingrowth disturbance of the bone ( baddest type ) .
