Fracture compli & mx

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Fracture compli & mx

  1. 1. Fractures – Complications &Management
  2. 2. Complication of Fractures Immediate Complication (at the time offracture) Early complication (initial few days) Late Complication
  3. 3. Immediate ComplicationsSystemic Hypovolaemic ShockLocal Injury to major vessels Injury to muscles & tendons Injury to joints Injury to viscera
  4. 4. Early complicationsSystemic Hypovolaemic shock ARDS Fat Embolism Syndrome DVT & Pulmonary embolism Aseptic traumatic fever Septicemia (Open fractures) Crush syndrome
  5. 5. Early ComplicationsLocal Infection Compartmental Syndrome
  6. 6. Late complicationsBone Union related Delayed-Union Non-union Mal-union Cross-union
  7. 7. Late complicationsOthers Avascular Necrosis Shortening Joint Stiffness Sudeck’s dystrophy(Reflex Sympatheticdystrophy) Osteomyelitis Ischaemiccontracture Myossitis Ossificans Osteoarthritis
  8. 8. Hypovolaemic Shock Commonest cause for death Pelvis(2 lts) & Long Bone(1.5lts) #’s External Hemorrhageeg: Open fracture, vascular Injury Internal Hemorrhageeg: Chest/Abdominal bleeding
  9. 9. Hypovolaemic shock-Management Follow the BLS/ATLS protocolsEg: No 14 IV cannula + 2lts ofcrystalloids/colloids/blood, Localize the site ofbleeding, needle aspiration, Inv - X-ray,Ultrasound Avoid movements at the Fracture Stabilize the fracture eg : ExternalFixator for Pelvis, Splints for long bones
  10. 10. ARDS –Adult Respiratory DistressSyndrome Cause – Trauma & Shock Release of Inflammatory mediators Disruption of Pulmonarymicrovasculature Onset in 24 hrs Tachypnoea & laboured breathing
  11. 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. 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. 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. 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. 15. Fat Embolism - treatment Respiratory support Heparinisation, IV Low molecular wtdextran, corticosteriods
  16. 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. 17. DVT & PE – Clinical Feature High index of suspicion Elderly & Obese pts Leg swelling & calf tenderness Calf tenderness on passive dorsiflexionof Ankle ( Homan’s sign) Venography/Doppler Ultrasound PE – tachypnoea, dyspnoea, chestpain, hemoptysis
  18. 18. DVT & PE - treatment DVT : Elevation of limb, Elasticbandage, active mobilization after earlyfracture stabilization, anticoagulation PE : Respiratory support,Anticoagulation therapy
  19. 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. 20. Injury to the blood vessels Femoral - # L/3rdFemur Popliteal – Supracondylar # Femur(commenest) Post Tibial – Dislocation Knee, # Tibia Subclavian – Clavicle # Axillary – Fracture dislocation shoulder Brachial – Supracondylar # Humerus
  21. 21. Injury to the blood vessels No effect – collateral circulation is good Exercise Ischemia – vascularclaudiction Ischemic contracture – Ischemic musclenecrosis – contracture/fibrosis –volkmann’s ischemic contracture Gangrene
  22. 22. Injury to the blood vessels Pain – cramp like Pulse – absent Pallor Paraesthesia ParalysisDoppler study / AngiogramRepair of vessel
  23. 23. Injury to NervesInjury to Tendons
  24. 24. Injury to Joints Subluxation or Dislocation Early reduction & stabilization Early Joint movement Secondary Osteoarthritis/stiffness
  25. 25. Infection - Osteomyelitis Open #’s (Common)
  26. 26. Compartment syndrome Rise in Pressure in closed compartmentof the limb Jeopardize the Muscle & nerve bloodsupplyInjury & oedma to musclesFracture hematomaIschemia leading to muscle oedema
  27. 27. Compartment syndrome- Vicious cycleswellingBlood supply Muscle IschemiaInjury
  28. 28. Compartment syndrome - Results Ischemic Muscle necrosis Muscle fibrosis – Contractures Nerve damage Motor sensory loss Gangrene
  29. 29. Compartmental syndrome -Diagnosis Excessive Pain High risk injurieseg:Supracondylar # humerus,Forearm bones #,Closed Tibial #,Crush injuries to leg & forearm
  30. 30. Compartmental syndrome -Diagnosis Stretch test – earliest sign Tense compartment Hypoaesthesia of involved nerves Muscle weakness Compartmental pressure of >40 mm ofH2O
  31. 31. Compartmental syndrome - Treatment Early prevention – limb elevation, activefinger mobilization Early surgical decompression eg:fasciotomy
  32. 32. Delayed & Non-union More than the usual time to unite Fracture healing has stopped (notbefore six months)
  33. 33. Delayed & Non-unionCauses related to the patients Age – common in old age Asso Systemic illness eg:Malignancy,Osteomalacia
  34. 34. Delayed & Non-unionCauses related to fracture Distraction at fracture siteMuscle pulling eg:Patella & Olecranon #Gravity eg: # shaft of humerus Soft tissue interposition eg: # shafthumerus, femur Bone loss at the # site
  35. 35. Non-union
  36. 36. Delayed & Non-unionCauses related to fracture Infection from open # Damage/Poor blood supply eg:# neckof femur, L/3rdTibia Pathological #
  37. 37. Delayed & Non-unionCauses related to Treatment Inadequate redution Inadequate immobilization Distration during treatment
  38. 38. Types of Nonunion Atrophic HypertrophicCommon sitesNeck of femur, Scaphoid, L/3rdTibia,Lateral condyle Humerus
  39. 39. Delayed & Non-union : C/f Persistant Pain Pain on stressing the # Mobility (Nonunion) Increasing deformity
  40. 40. Delayed & Non-union – X-ray Fracture line is visible Inadequate bridging callus (Delayed) No bridging callus (Non-union)TomogramMedullary venography
  41. 41. Infected Nonunion
  42. 42. Delayed & Non-union- Treatment Bone Grafting BG + Internal Fixation Excision of fragment eg: # neck offemur in elderly(hemiarthroplasty) Ilizarov’s method
  43. 43. Malunion # unites in improper position Disability of clinical significance eg:deformity, shortening, limitation of motion Improper treatment Commonest eg: colles #, Clavicle #
  44. 44. Malunion
  45. 45. Malunion - Treatment Osteoclasis Corrective osteotomy No treatment – RemodellingChildren,5 to 10 deg of Angulation,Angulation in the plane of movement,#’s near joints
  46. 46. Avascular Necrosis Blood supply is jeopardized Head of Femur eg: # neck of femur,dislocation hip Proximal pole of scaphoid, Body ofTalus
  47. 47. Avascular Necrosis Sclerosis of necrotic bone Deformity due to collapse Osteoarthritis
  48. 48. Avascular Necrosis-Treatment Delayed wt bearing Vascularised bone graft Excision of avascular segment Excision & Arthroplasty
  49. 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. 50. Reflex sympathetic Dystrophy(sudeck’s Dystrophy) X-ray – Spotty rarefaction Physiotherapy Avoid surgery or forceful mobilization Sympathetic blocks
  51. 51. Myossitis Ossificans(post-traumatic ossification) Ossification of the hematoma Joint stiffness Head injury Children around elbow Massage
  52. 52. Myossitis Ossificans(post-traumatic ossification) X-ray-active myositis – margins arefluffy Mature myositis – bone trabeculated,well defined margins
  53. 53. Myossitis Ossificans(post-traumatic ossification) Avoid Massage Rest to the limb Surgical excision of mature myositis
  54. 54. ThankyouDr Jai ThilakOrthopaedics

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