Orthopaedics - complications of fratures

1. Dr. Krishna, PGIMS, Rohtak
COMPLICATIONS OF FRACTURE
General Local
Early Late

2. Dr. Krishna, PGIMS, Rohtak
General Complications
Bed sore & other complications of recumbency
Crush Syndrome (rhabdomyolysis)
Diffuse Coagulopathy
Embolism – Pulmonary & Venous Thrombosis & Electrolyte Imbalance
Fat Embolism
Gas gangrene
Hospital related - Complications of anaesthesia & Surgery
Infections incl Tetanus
Jolt (Shock)

3. Dr. Krishna, PGIMS, Rohtak

4. Dr. Krishna, PGIMS, Rohtak
SHOCK
*A generalized state of decreased tissue perfusion
*If prolonged it may lead to irreversible damage of the life
supporting organs
Causes:
I. Cardiogenic
II. Neurogenic
III. Hypovolaemic

5. Dr. Krishna, PGIMS, Rohtak
Low cardiac
output
Low B.P
Decreased
tissue
perfusion
Hypoxia &
acidosis
Progressive
cell damage
ORGAN
FAILURE
SHOCK

6. Dr. Krishna, PGIMS, Rohtak
Crush syndrome
 Occurs when
 Large bulk of muscle is crushed
 Tourniquet left for too long

7. Dr. Krishna, PGIMS, Rohtak
What happens?
 1st Theory
Compression
released
Acid
myohaematin
enters
circulation
Blocks the
tubules In
kidney
SHOCK

8. Dr. Krishna, PGIMS, Rohtak
SHOCK
 Limb
 Pulseless
 pallor
 Swollen
 Renal
 Low output uremia
 Acidosis
 Neurologically
 Drowsy → not treated → DEATH

9. Dr. Krishna, PGIMS, Rohtak
1st rule = Limb crushed severely (>6hrs)
= Amputation
-Above the compression or crushed injury
-Before compression is released
Dialysis

10. Dr. Krishna, PGIMS, Rohtak
Venous thrombosis & Pulmonary
Embolism
 Commonest complication of Trauma & Surgery
 Most frequently
 Calf veins
 Less frequent in proximal thigh & pelvic veins
 Pulmonary Embolism
 From Proximal thigh & pelvis
 Incidence = 5% & Fatal = 0.5%

11. Dr. Krishna, PGIMS, Rohtak
VTE
 The primary cause in surgical
 HYPERCOAGULABILITY of the Blood
 due to activation of Factor X by Thromboplastin from
damaged tissues
 Thrombosis occurs → secondary factors involved
 Stasis
 Pressure
 Prolonged immobility
 Endothelial damage
 Increase in No. & stickiness of platelets

12. Dr. Krishna, PGIMS, Rohtak
c

13. Dr. Krishna, PGIMS, Rohtak
VTE - high risk group
 Old age
 Cardiovascular Disease
 Bedridden patient
 Patients undergoing hip arthroplasty

14. Dr. Krishna, PGIMS, Rohtak
VTE symptoms
 Pain the calf or thigh
 Soft tissue tenderness
 Sudden slight increase in
temperature
 Sudden increase in pulse rate
 Homann’s Sign
positive

15. Dr. Krishna, PGIMS, Rohtak

16. Dr. Krishna, PGIMS, Rohtak
Diagnosis of DVT
 USG
 Doppler technique (measure blood
flow)
 Ascending venography (bilaterally)
 Radioactive iodine labelled
fibrinogen(clot)

17. Dr. Krishna, PGIMS, Rohtak
Pulmonary Embolism
 Difficult to diagnose =only minority have symptoms (chest pain,
dyspnea, hemoptysis)
• So high risk patients should be
examined for pulmonary consolidation
• X-ray
• Lung scintigraphy
• Pulmonary angiography
• Normal D-dimer has almost 100%
negative predictive value (virtually
excludes PE)
• CT

18. Dr. Krishna, PGIMS, Rohtak
H
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P
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H
U
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19. Dr. Krishna, PGIMS, Rohtak
Prevention
 Prophylactic treatment
 Foot elevation
 Graduated compression stockings
 Exercise
 Anticoagulant treatment
 Subcut heparin or LMW heparin

20. Dr. Krishna, PGIMS, Rohtak
Rx of Pulmonary Embolism
 Cardiorespiratory resuscitation
 Vasopressor for shock
 Oxygen
 Large dose heparin (15 000 units)
 Streptokinase (dissolve clot)
 Antibiotics (prevent lung infection)

21. Dr. Krishna, PGIMS, Rohtak
TETANUS
Tetanus organism live only in dead tissue → exotoxin → blood & lymph
to CNS →anterior horn cell
 Will develop
 Tonic clonic contraction
 Jaw & face (trismus & risus sardonicus)
 Neck & trunk
 Diaphragm & Intercostal muscle → spasm → ASPHYXIA
https://www.youtube.com/watch?v=2baVlK5Uvyc

22. Dr. Krishna, PGIMS, Rohtak
Prophylaxis
 Active immunization (tetanus toxoid)
 Booster doses (immunized patients)
 Non Immunized patients
 Wound toilet & antibiotics
 If wound contaminated →antitoxin

23. Dr. Krishna, PGIMS, Rohtak
Treatment for Tetanus
 IV antitoxin
 Heavy Sedation
 Muscle Relaxant drug
 Tracheal Intubation
 Controlled respiration

24. Dr. Krishna, PGIMS, Rohtak
GAS GANGRENE
 By clostridial infection (esp C. perfringens)
 Anaerobic with low oxygen tension
 Produce toxins → destroy cell wall → tissue necrosis → Spreading

25. Dr. Krishna, PGIMS, Rohtak
Clinical Features
 Within 24 hours
 Intense pain
 Swelling
 Brownish discharge
 Pulse rate increased
 Characteristic smell sweetish & mousy odor
 Little or no pyrexia
 Gas formation not marked
 Toxaemic → coma → DEATH

26. Dr. Krishna, PGIMS, Rohtak
Prevention
 Deep penetrating wound should be EXPLORED
 ALL dead tissue → completely EXCISED
 Doubt about tissue viability → leave it OPEN
 No antitoxin

27. Dr. Krishna, PGIMS, Rohtak
Treatment for gas gangrene
 The key = EARLY DIAGNOSIS
 General measures (fluid, IV antibiotics)
 Hyperbaric oxygen (limiting spread)
 Decompression of wound
 Removal of all dead tissue
 Amputation (advanced case)

28. Dr. Krishna, PGIMS, Rohtak
FAT EMBOLISM
 Only minority patients with
circulating fat globules will develop
POST TRAUMATIC RESPIRATORY
DYSFUNCTION
 Source of fat emboli = bone
marrow
 Usually in MULTIPLE CLOSED
FRACTURE
 But other condition also reported
(burns, renal infarction,
cardiopulmonary operation)

29. Dr. Krishna, PGIMS, Rohtak
Closed/open
Fracture
Fat in bone
marrow
escapes
Formation of
fat globules in
vessels
Fat embolus
Stick in
pulmonary
bed
Trigger
clotting
cascade

30. Dr. Krishna, PGIMS, Rohtak
Features
 After 1-2 days of trauma
 Usually young adults with LL fracture
 Early warning signs
 Rise in temperature & pulse rate
 More pronounced case(classical triad)
 Breathlessness
 Mild mental confusion
 Petechia (chest & conjuntival fold)

31. Dr. Krishna, PGIMS, Rohtak
 Most severe case
 Marked respiratory distress →coma →ARDS
no definitive test, but hypoxia <60mmHg after major trauma is
suspicious

32. Dr. Krishna, PGIMS, Rohtak
Gurd’s Criteria
Major Features
(at least 1)
Minor Features
(at least 4)
Lab Features
(at least 1)
-Respiratory Insufficiency
-Cerebral involvement
-Petechiae Rash
-Pyrexia
-Tachycardia
-Retinal changes
-Jaundice
-Renal changes
-Fat macroglobulinemia
-Anaemia
-Thrombocytopenia
-High ESR

33. Dr. Krishna, PGIMS, Rohtak

34. Dr. Krishna, PGIMS, Rohtak
Treatment
 Mild case
 Monitoring of blood PO2
 Signs of hypoxia (<8kPa @ 60mmHg)
 Oxygen
 If severe
 ICU with sedation & assisted ventilation
 Swan ganz Catheterization (monitor cardiac Fx)
 Fluid balance
 Supportive
 Heparin-thromboembolism
 Steroids-pulmonary oedema
 Aprotinin - prevent aggregation of chylomicrons

35. Dr. Krishna, PGIMS, Rohtak
Early (& immediate) Complications
 Local Visceral Injury
 Vascular Injury
 Nerve Injury
 Compartment Syndrome
 Hemarthrosis
 Infection
 Gas gangrene

36. Dr. Krishna, PGIMS, Rohtak
Local visceral Injury
 Fracture around the trunk are often Complication by injury to the
adjacent viscera:
 Etc: Pelvic fracture
 Etc : Rib fracture → penetration to the lungs → Pneumothorax
Bladder & urethral rupture
This requires Emergency Rx → chest tube insertion

37. Dr. Krishna, PGIMS, Rohtak

38. Dr. Krishna, PGIMS, Rohtak
Vascular injury
 commonly – knee, femoral shaft, elbow
& 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

39. Dr. Krishna, PGIMS, Rohtak
Vascular Injury - Clinical features
 Pt with ischemia may have 5 P’s:
- paraesthesia/numbness
- pain
- pallor
- pulselessness
- paralysis
 Investigate if suspect vascular injury : CT Angiogram

40. Dr. Krishna, PGIMS, Rohtak
Treatment
 Emergency treatment
 All bandages/splints removed
 X-Ray The fracture 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

41. Dr. Krishna, PGIMS, Rohtak
Nerve Injury
 Variable degree of motor & sensory loss along the distribution of
the nerve
 May be neurapraxia, axonotmesis or neurotmesis

42. Dr. Krishna, PGIMS, Rohtak

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

44. Dr. Krishna, PGIMS, Rohtak
 In closed injuries – nerve is seldom severed &
spontaneous recovery should be awaited
 In open fractures – complete lesion (neurotmesis): the
nerve is explored during wound debridement &
repaired
 Acute nerve compression – occur with fracture or
dislocation around the wrist. C/o numbness in median
& ulnar dist. If no improvement >48 hours → after
fracture reduction, do nerve exploration &
decompression