1. Fractures – Complications &
Management

2. Complication of Fractures
 Immediate Complication (at the time of
fracture)
 Early complication (initial few days)
 Late Complication

3. Immediate Complications
Systemic
 Hypovolaemic Shock
Local
 Injury to major vessels
 Injury to muscles & tendons
 Injury to joints
 Injury to viscera

4. Early complications
Systemic
 Hypovolaemic shock
 ARDS
 Fat Embolism Syndrome
 DVT & Pulmonary embolism
 Aseptic traumatic fever
 Septicemia (Open fractures)
 Crush syndrome

5. Early Complications
Local
 Infection
 Compartmental Syndrome

6. Late complications
Bone Union related
 Delayed-Union
 Non-union
 Mal-union
 Cross-union

7. Late complications
Others
 Avascular Necrosis
 Shortening
 Joint Stiffness
 Sudeck’s dystrophy
(Reflex Sympathetic
dystrophy)
 Osteomyelitis
 Ischaemic
contracture
 Myossitis Ossificans
 Osteoarthritis

8. Hypovolaemic Shock
 Commonest cause for death
 Pelvis(2 lts) & Long Bone(1.5lts) #’s
 External Hemorrhage
eg: Open fracture, vascular Injury
 Internal Hemorrhage
eg: Chest/Abdominal bleeding

9. Hypovolaemic shock-Management
 Follow the BLS/ATLS protocols
Eg: No 14 IV cannula + 2lts of
crystalloids/colloids/blood, Localize the site of
bleeding, needle aspiration, Inv - X-ray,
Ultrasound
 Avoid movements at the Fracture
 Stabilize the fracture eg : External
Fixator for Pelvis, Splints for long bones

10. ARDS –Adult Respiratory Distress
Syndrome
 Cause – Trauma & Shock
 Release of Inflammatory mediators
 Disruption of Pulmonary
microvasculature
 Onset in 24 hrs
 Tachypnoea & laboured breathing

11. ARDS - Management
 Chest X-ray: diffuse Pulm infiltrate
 Arterial PO2 <50
 100% Oxygen
 Assisted ventilation
 Chest clears in 4 to 7 days
 Not treated – CardioPulmonary failure -
Death

12. Fat Embolism
 Occlusion of Small vessels by fat globules
 Bone Marrow/Adipose tissue
 Polytrauma of long major bones
 Release of free fatty acids(Lipases action) –
toxic vasculitis – Platelet fibrin thrombosis
 Obstruction of Pulm vessels by fat

13. Fat Embolism – clinical features
 Develops in 24 to 72hrs
 Cerebral type – drowsy, restless,
disoriented, coma
 Pulmonary type – tachypnoea, tachycardia
 Patechial rash- neck, axillary fold, chest,
conjunctiva
 Respiratory failure - Death

14. Fat Embolism - Diagnosis
 Strong suspicion
 Retinal artery emboli (Striate haemorrhages)
 Fat globules in sputum & Urine
 X-ray – Patchy pulm Infiltrate (snow storm)
 Blood PO2 <50

15. Fat Embolism - treatment
 Respiratory support
 Heparinisation, IV Low molecular wt
dextran, corticosteriods

16. Deep Vein Thrombosis (DVT)
& Pulmonary Embolism (PE)
 Lower limb & Spinal Injuries
 Cause: Immobilization – venous stasis –
thrombosis of veins
 DVT proximal to knee is Dangerous
 DVT in 48 hrs – PE in 4 to 5 days

17. DVT & PE – Clinical Feature
 High index of suspicion
 Elderly & Obese pts
 Leg swelling & calf tenderness
 Calf tenderness on passive dorsiflexion
of Ankle ( Homan’s sign)
 Venography/Doppler Ultrasound
 PE – tachypnoea, dyspnoea, chest
pain, hemoptysis

18. DVT & PE - treatment
 DVT : Elevation of limb, Elastic
bandage, active mobilization after early
fracture stabilization, anticoagulation
 PE : Respiratory support,
Anticoagulation therapy

19. Crush syndrome
 Massive crushing of Muscles
 Release of Myohaemoglobin
 Precipitates in Renal tubules
 Acute renal tubular necrosis
 Treated as for Acute renal failure

20. Injury to the blood vessels
 Femoral - # L/3rd
Femur
 Popliteal – Supracondylar # Femur(commenest)
 Post Tibial – Dislocation Knee, # Tibia
 Subclavian – Clavicle #
 Axillary – Fracture dislocation shoulder
 Brachial – Supracondylar # Humerus

21. Injury to the blood vessels
 No effect – collateral circulation is good
 Exercise Ischemia – vascular
claudiction
 Ischemic contracture – Ischemic muscle
necrosis – contracture/fibrosis –
volkmann’s ischemic contracture
 Gangrene

22. Injury to the blood vessels
 Pain – cramp like
 Pulse – absent
 Pallor
 Paraesthesia
 Paralysis
Doppler study / Angiogram
Repair of vessel

23. Injury to Nerves
Injury to Tendons

24. Injury to Joints
 Subluxation or Dislocation
 Early reduction & stabilization
 Early Joint movement
 Secondary Osteoarthritis/stiffness

25. Infection - Osteomyelitis
 Open #’s (Common)

26. Compartment syndrome
 Rise in Pressure in closed compartment
of the limb
 Jeopardize the Muscle & nerve blood
supply
Injury & oedma to muscles
Fracture hematoma
Ischemia leading to muscle oedema

27. Compartment syndrome- Vicious cycle
swelling
Blood supply Muscle Ischemia
Injury

28. Compartment syndrome - Results
 Ischemic Muscle necrosis
 Muscle fibrosis – Contractures
 Nerve damage
 Motor sensory loss
 Gangrene

29. Compartmental syndrome -
Diagnosis
 Excessive Pain
 High risk injuries
eg:Supracondylar # humerus,
Forearm bones #,
Closed Tibial #,
Crush injuries to leg & forearm

30. Compartmental syndrome -
Diagnosis
 Stretch test – earliest sign
 Tense compartment
 Hypoaesthesia of involved nerves
 Muscle weakness
 Compartmental pressure of >40 mm of
H2O

31. Compartmental syndrome - Treatment
 Early prevention – limb elevation, active
finger mobilization
 Early surgical decompression eg:
fasciotomy

32. Delayed & Non-union
 More than the usual time to unite
 Fracture healing has stopped (not
before six months)

33. Delayed & Non-union
Causes related to the patients
 Age – common in old age
 Asso Systemic illness eg:Malignancy,
Osteomalacia

34. Delayed & Non-union
Causes related to fracture
 Distraction at fracture site
Muscle pulling eg:Patella & Olecranon #
Gravity eg: # shaft of humerus
 Soft tissue interposition eg: # shaft
humerus, femur
 Bone loss at the # site

35. Non-union

36. Delayed & Non-union
Causes related to fracture
 Infection from open #
 Damage/Poor blood supply eg:# neck
of femur, L/3rd
Tibia
 Pathological #

37. Delayed & Non-union
Causes related to Treatment
 Inadequate redution
 Inadequate immobilization
 Distration during treatment

38. Types of Nonunion
 Atrophic
 Hypertrophic
Common sites
Neck of femur, Scaphoid, L/3rd
Tibia,
Lateral condyle Humerus

39. Delayed & Non-union : C/f
 Persistant Pain
 Pain on stressing the #
 Mobility (Nonunion)
 Increasing deformity

40. Delayed & Non-union – X-ray
 Fracture line is visible
 Inadequate bridging callus (Delayed)
 No bridging callus (Non-union)
Tomogram
Medullary venography

41. Infected Nonunion

42. Delayed & Non-union- Treatment
 Bone Grafting
 BG + Internal Fixation
 Excision of fragment eg: # neck of
femur in elderly(hemiarthroplasty)
 Ilizarov’s method

43. Malunion
 # unites in improper position
 Disability of clinical significance eg:
deformity, shortening, limitation of motion
 Improper treatment
 Commonest eg: colles #, Clavicle #

44. Malunion

45. Malunion - Treatment
 Osteoclasis
 Corrective osteotomy
 No treatment – Remodelling
Children,
5 to 10 deg of Angulation,
Angulation in the plane of movement,
#’s near joints

46. Avascular Necrosis
 Blood supply is jeopardized
 Head of Femur eg: # neck of femur,
dislocation hip
 Proximal pole of scaphoid, Body of
Talus

47. Avascular Necrosis
 Sclerosis of necrotic bone
 Deformity due to collapse
 Osteoarthritis

48. Avascular Necrosis-
Treatment
 Delayed wt bearing
 Vascularised bone graft
 Excision of avascular segment
 Excision & Arthroplasty

49. Reflex sympathetic Dystrophy
(sudeck’s Dystrophy)
 Following Trauma
 Pain
 Hyperaesthesia
 Tenderness & Swelling
 Skin is red, shiny, warm
 Atrophy of skin, muscle, nail
 Joint deformity & stiffness

50. Reflex sympathetic Dystrophy
(sudeck’s Dystrophy)
 X-ray – Spotty rarefaction
 Physiotherapy
 Avoid surgery or forceful mobilization
 Sympathetic blocks

51. Myossitis Ossificans
(post-traumatic ossification)
 Ossification of the hematoma
 Joint stiffness
 Head injury
 Children around elbow
 Massage

52. Myossitis Ossificans
(post-traumatic ossification)
 X-ray-active myositis – margins are
fluffy
 Mature myositis – bone trabeculated,
well defined margins

53. Myossitis Ossificans
(post-traumatic ossification)
 Avoid Massage
 Rest to the limb
 Surgical excision of mature myositis

54. Thankyou
Dr Jai Thilak
Orthopaedics