Complication of fractuers
By Ass. Prof. Dr. Zaid W. Al Shahwanii Consultant ortho. surgeonComplication Of Fractures A) General complication
Shock ,, respiratory distress syndrome 3) fat embolism 4) tetanus,, 5) crush syndrome , 6) disseminated intra- vascular coagulationComplications of Fractures
B) Local complication 1) Early complication which happened with in the first few hours ,days (3-7) of injury which include:- A-visceral injury . B-nerve injury. C- vascular injury . D-compartment sy., E-Haemarthosis. F-infection , G-Gas gangrene .2) Late bone complication
Delayunion .Mal-union .Non –union Avascular necrosis. Joint instability.Growth disturbances.Osteoarthritis.3) Late soft tissue complication
1) Joint stiffness, 2)muscl contractuers 3) hetrophic ossification ( Myositis ossifican) 4)nerve entrapment 5)tendon rupture. 6)nerve compressionFat embolism
This is a relatively uncommon disorder that occurs in the first few days following trauma with a mortality rate of 10-20%.,,Fat drops are thought to be released mechanically from bone marrow following fracture, coalesce and form emboli in the pulmonary capillary beds and brain, with a secondary inflammatory reaction and platelet aggregation. …..An alternative theory suggests that free fatty acids are released as chylomicrons following hormonal changes due to trauma or sepsis…Risk of Fat Embolism Syndrome (FES) increases with number of fractures, but is also seen following severe burns, CPR, bone marrow transplant and liposuction.Risk factors :- Closed fractures, Multiple fractures, Pulmonary contusion, Long bone/pelvis/rib fractures..Presentation ;-Sudden onset dyspnoea , Hypoxia , Fever ,Confusion, coma, convulsions ,,Transient red-brown petechial rash affecting upper body, especially axilla ,chest , conjunctivaManagementSupportive treatment oxygen therapy , Corticosteroid drugs (used in treatment, more controversial in prevention) ,,Surgical stabilisation of fracture
2)DVT Deep vein thrombosis
causes due,, to stasis of blood flow, endothelial damage, and hypercoagulabity of blood. It is precipitated by incorrectly applied cast, traction, local pressure on vein, prolonged bed rest, advanced age, and trauma….. usually happened in extensive prolong surgery eg. post- total knee- hip joint replacement ((45 -75 %)) clinical features :- Have redness, tenderness, swelling, pitting edema…. prevention & Treatment by leg pumping, quadriceps exercises, frequent position change & Assessment Of the patient ,,. For prevention Often use Lovenox (enoxaparin) low molecular weight heparin; given deep subcutenouse . in anterolateral abdominal wall post-surgery; require routine monitoring of PT or PTT.Compartment syndromes Fractures of the limbs can cause severe ischaemia, even without damage to a major blood vessel. Bleeding or oedema in an osteofascial compartment increases pressure within the compartment, reducing capillary flow and causing muscle ischaemia. A vicious circle develops of further oedema and pressure build-up, leading swiftly to muscle and nerve necrosis. Limb amputation may be required if untreated.Compartment syndromes can also result from:Crush injuries caused by falling debris or from a patient’s unconscious compression of their own limb. Swelling of a limb inside an over-tight cast. Compartment syndrome can occur in any compartment, e.g. the hand, forearm, upper arm, abdomen, buttock, thigh, and leg. 40% occur following fracture of the shaft of the tibia (with an incidence of 1-10%) and about 14% following fracture of a forearm bone. Risk is highest in those under 35 years.2
PresentationSigns of ischaemia (5 P's: Pain, Paraesthesia, Pallor, Paralysis, Pulselessness) – but diagnosis should be made before all these features are present. The presence of a pulse does not exclude the diagnosis. Signs of raised intracompartmental pressure: Swollen arm or leg Tender muscle - calf or forearm pain on passive extension of digits Pain out of proportion to injury Redness, mottling and blisters Watch for signs of renal failure (low-output uraemia with acidosis)Where the diagnosis is uncertain, measure intracompartmental pressure directly. The pressure at which fasciotomy becomes mandatory is controversial. ManagementRemove/relieve external pressures Prompt decompression of threatened compartments by open fasciotomy Debride any muscle necrosis Treat hypovolaemic shock and oliguria urgently Renal dialysis may be necessary ComplicationsAcute renal failure secondary to rhabdomyolysis DIC Volkmann's contracture (where infarcted muscle is replaced by inelastic fibrous tissue)
Complications of Fractures
1)Non-union (Non-union consider if fracture healing doesn’t occur in 6-9 months) Non-union, delayed union, aseptic necrosis are major complications of fractures as in lower 1/3rd tibia ,# neck femur, # scaphoid bone… CAUSES 1) increased motion at fracture site (in proper fixation) , 2) poor nutrition, lack of approximation of bone ends,& devitalized tissue, 3)infection ,,, 4)presence of foreign boby clinical features there will be motion at the fracture site, called a "pseudoarthrosis". & it’s obvious on X-ray examination Treatment with bone graft, muscle flap. Re-attempt internal fixation, debridement of devitalized tissue and possible use of electrical bone stimulation.Khuder hamid Orthofix external fixator was replacing an ordinary unilateral external fixater.
Bladder Injuries
1) Pelvis is injured. as In a high-speed motor vehicle collision or a fall form height 2) Penetrating wounds. usually from gunshots, high velocity shells 3) Or during surgery of the pelvis or lower abdomen. (such as hysterectomy)Sign& symptoms 1) Blood in the urine . 2) Difficulty in urinating + pain in the pelvis & lower abdomen. 3) Frequent urination or urgency. 4) The diagnosis by cystography.
1)) A 16 years old male patient sustained a high velocity missal injury to the lateral aspect of the upper 1\3rd of the Rt. Thigh.2)) Causing a compound comminuted fracture of the Rt. Femur + a penetrating wound to the U.bladder …3)) Ended with urinary fistula through the pins of the external fixation .