Presentation on Complications of Fracture. Provides a brief overview on various complications and is useful to present as a seminar as well as to learn quickly. Content is being taken from Standard books as well as online.

1. COMPLICATIONS OF
FRACTURE
DR. URVISH BHANUSHALI
JR1 ORTHOPEDICS GSMC&H,HAPUR

2. FRACTURE
• FRACTURE IS A BREAK IN CONTINUITY OF BONE ALONG WITH PARTIAL
OR COMPLETE DISRUPTION OF BLOOD SUPPLY TO THE
REGION,VISIBLE RADIOLOGICALLY AS A UNI OR BICORTICAL BREAK.
CONVENTIONALLY FRACTURES WERE STABLIZED BY CAST TREATMENT
OR PROLONGED SPLINTING THAT LED TO DEVELOPMENT OF LOCAL
AND SYSTEMIC COMPLICATIONS CALLED AS FRACTURE DISEASE.

3. FRACTURE DISEASE
• STIFFNESS
• MUSCLE ATROPHY
• SKIN ATROPHY
• CIRCULATORY DYSFUNCTION
• OSTEOPENIA

4. COMPLICATIONS OF FRACTURE
• IMMEDIATE:HYPOVOLEMIC SHOCK
EARLY COMPLICATIONS
LOCAL SYSTEMIC
• DELAYED COMPLICATIONS

5. EARLY LOCAL COMPLICATIONS
• VASULAR INJURY
• VISCERAL INJURY
• DAMAGE TO TISSUES,NERVE OR SKIN
• HEMARTHROSIS
• COMPARTMENT SYNDROME
• WOUND INFECTION
• TETANUS
• GAS GANGRENE

6. EARLY SYSTEMIC COMPLICATIONS
• FAT EMBOLISM
• SHOCK
• ARDS
• THROMBOEMBOLISM
• SEPTICEMIA
• CRUSH SYNDROME

7. LATE COMPLICATIONS
• DELAYED UNION
• NON UNION
• MALUNION
• AVN
• STIFFNESS
• RSD
• OSTEOMYELITIS
• VIC
• MYOSITIS OSSIFICANS
• OSTEOARTHRITIS

8. HYPOVOLEMIC SHOCK
• HYPOVOLEMIA DUE TO HEMORRHAGE IS THE MOST COMMON
CAUSE OF SHOCK IN A TRAUMA PATIENT.(HEMORRHAGIC SHOCK)
• IN EARLY HEMORRAGIC SHOCK THERE IS NARROWED PULSE
PRESSURE
• CLINICAL FEATURES DEPEND ENTIRELY ON THE AMOUNT OF BLOOD
LOSS

10. VASCULAR INJURY
• INJURY TO ARTERIAL FLOW IS A SURGICAL EMERGENCY
• WHEN AN EXTREMITY IS PULSELESS DESPITE REDUCTION AND
SPLINTING EMERGENCY REVASCULARIZTION IS ESSENTIAL TO
PRESERVE THE LIMB.
• WITHIN 6 HOURS OF ISCHAEMIA,MYONECROSIS AND LOSS OF
NEUROLOGICAL FUNCTION WILL ENSUE.
• ANKLE BRACHIAL INDICES SHOULD BE OBTAINED IF SIGNS OF
VASCULAR COMPRISE EXIST

11. NERVE INJURY
• CAN LEAD TO NEUROPRAXIA,AXONOTMESIS OR NEUROTMESIS

12. COMPARTMENT SYNDROME
• ACUTE COMPARTMENT SYNDROME IS THE ELEVATION OF
INTRACOMPARTMENTAL PRESSURE TO A LEVEL AND FOR A
DURATION THAT WITHOUT DECOMPRESSION WILL CAUSE TISSUE
ISCHEMIA AND NECROSIS.

13. SIGNS AND SYMPTOMS
• PAIN:MOST SENSITIVE AND EARLIEST SYMPTOM.OUT OF
PROPORTION.INCREASES WITH PASSIVE STRETCH.
• PARESTHESIA:FIRST SIGN OF NERVE ISCHAEMIA.DECREASED LIGHT
TOUCH BETTER THAN 2 POINT DISCRIMINATION.LOW SENSITIVITY
BUT HIGH SPECIFICITY
• PARALYISIS:WORST CLINICAL SYMPTOM OR SIGN IN TERMS OF
COMBINED SENSITIVITY AND SPECIFICITY.DIFFICULT TO INTERPRET
UNDERLYING CAUSE OF WEAKNESS
• PULSELESSNESS:NOT RELIABLE.
• PALLOR:REFLECTS LOSS OF ARTERIAL FLOW AND IS RARELY PRESENT

14. PRESSURE
• VISIBLE SWELLING IS SEEN
• PALPABLE SWELLING IN THE COMPARTMENT AFFECTED
• NORMAL INTRACOMPARTMENTAL PRESSURE IS 0-8MM HG
• DELTA PRESSURE OF ≤30MM HG IS THE THRESHOLD USED
COMMONLY FOR DIAGNOSING ACS
• INDIRECT TECHNIQUES:WICK CATHETER,SLIT
CATHETHER,NEEDLE MANOMETER
• DIRECT METHODS:TRANSDUCER TIP INTRACOMPARTMENTAL
CATHETER

15. • INTRAMUSCULAR pH IS A RECENT BETTER MEASURE FOR
DIAGNOSING ACS THAN MEASURING PRESSURE DIFFERENCE.
• INTRAMUSCULAR pH OF LESS THAN 6.38 IS 80% SPECIFIC AND 95%
SENSITIVE WHEREAS PRESSURE DIFFERENCE LESS THAN 33MM HG
HAD 27% SPECIFICITY AND 95% SENSITIVITY.

16. FAT EMBOLISM
CAUSES
FRACTURE OF LONG BONES-CLOSED AND MULTIPLE FRACTURES PRODUCES
MORE EMBOLI THAN OPEN FRACTURES
PRINCIPLE CLINICAL FEATURES-RESPIRATORY FAILURE,CEREBRAL
DYSFUNCTION AND SKIN PETECHIAE GENERALLY DEVELOP 24-72 HOURS
AFTER TRAUMA
PRESENTATON:
CARDIOPUMONARY:PERSISTENT TACHYCARDIA,TACHYPNEA,DYSPNEA AND
HYPOXEMIA EARLIEST TO MANIFEST.
PETECHIAL RASH:WITHIN FIRST 36 HOURS AND DISAPPEARS WITHIN 7 DAYS
NEUROLOGICAL:ACUTE CONFUSIONAL STATE IS M.C. PRESENTATION

17. INVESTIGATIONS
• ARTERIAL BLOOD GAS-REDUCED PARTIAL PRESSURE OF OXYGEN
• HEMATOCRIT-DECREASES WITHIN 24-48 HOURS
• PLATELET COUNT-THROMBOCYTOPENIA
• FIBRINOGEN-DECREASES
• CHEST X-RAY-SNOW STORM APPEARANCE OF FLECK-LIKE
PULMONARY SHADOWS.
• SPUTUM AND URINE-SHOWING FAT GLOBULES

18. TREATMENT
• NO SPECIFIC TREATMENT
• RESPIRATORY SUPPORT TO MAINTAIN TISSUE OXYGENATION AND
PULMONARY VENTILATION
• RESTRICT FLUID INTAKE AND USE OF DIURETICS TO MINIMIZE FLUID
ACCUMULATION IN LUNGS PROVIDED CIRCULATION IS NOT
COMPROMISED.
• STEROID CAN BE USED.

19. DEEP VENOUS THROMBOSIS
• ASSOCIATED WITH LOWER LIMB AND SPINAL INJURIES
• CAUSES:FRACTURE OF LEG,IMMOBILIZATION FOLLOWING TRAUMA
• SYMPTOMS:LEG SWELLING,CALF TENDERNESS
• CONSEQUENCES:
PULMONARY EMBOLISM
TACHYPNEA/DYSPNEA
TREATMENT:
LIMB ELEVATION.
ANTICOUGALANT THREAPY.
EARLY FIXATION OF FRACTURE

20. SEPTICEMIA
• RASH
• FEVER
• TACHYPNEA
• DROWSY
• ABDOMINAL PAIN
• VOMITING
• MANAGEMENT:SUPPORTIVE TREATMENT ALONG WITH ANTIBIOTICS

21. CRUSH SYNDROME
• CRUSHING OF MUSCLES-MYOGLOBIN PRECIPIATES IN RENAL
TUBULES.
• RENAL FAILURE CAN OCCUR
• LIMB CRUSHED SEVERELY AND FOR SEVERAL HOURS SHOULD BE
AMPUTATED TO PREVENT DISASTER.

22. UNION COMPLICATIONS
• DELAYED UNION:TEMPORARY FAILURE OF A FRACTURE TO HEAL IN USUAL
PERIOD OF TIME DEPENDING ON TYPE AND SITE OF FRACTURE AND ON THE
BONE AND SOFT TISSUE DAMAGE.
• WARNING SIGNS:PERSISTENT TENDERNESS AT # SITE
PRESENCE OF PERSISTENT NON RESOLVING EDEMA
DISCOMFORT AND PAIN ON USING LIMB FOR MODERATE ACTIVITIES
RADIOLOGICAL SIGNS:
PERSISTENT RADIOLUCENT LINE
DIMINISHING CORTICAL THICKNESS
BEGINNING OF MARGINAL ROUNDING OF FRACTURE ENDS.WOOLLY BONE
ENDS.

23. NON UNION
• NON UNION OF # IS SAID TO EXIST WHEN # SHOWS
CLINICALLY,RADIOLOGICALLY AND BIOLOGICALLY NO SIGNS OF
PROGRESSION TO REPAIR ITSELF AFTER PROLONGED DURATION FOR
TYPE,SITE AND PATTERN OF # AND WILL NOT UNITE UNLESS RADICAL
ALTERATION IN MANAGEMENT IS UNDERTAKEN.

25. MALUNION
• OCCURS WHEN BONE FRAGMENTS JOIN IN AN UNSATISFACTORY
POSITION
• CAUSE:# NOT REDUCED OR REDUCTION NOT HELD
• DEFORMITY IS USUALLY OBVIOUS
• PAINFUL LIMITATION OF MOVEMENT
• SHORTENING CAN OCCUR

26. AVASCULAR NECROSIS
• COMPROMISED BLOOD SUPPLY LEADING TO NECROSIS OF AFFECTED
PART.
• NECROSIS CAUSES DEFORMATION OF BONE AND LATER LEADS TO
SECONDARY OSTEOARTHRITIS AND CAUSE PAINFUL RESTRICTED
MOVEMENT OF JOINT.
• X RAY CHANGES:
SCLEROSIS OF NECROTIC AREA
DEFORMITY OF BONE

27. STIFFNESS
• SHOULDER,ELBOW AND KNEE JOINTS PRONE TO STIFFNESS
• CAUSES:MUSCLE CONTRACTURE,PROLONGED
IMMOBILIZATION,MYOSITIS OSSFICANS
• CONSEQUENCES:RESULTS IN LATE OSTEOARTHRITIS
• TREATMENT:HEAT THERAPY,EXERCISE

28. REFLEX SYMPATHETIC DYSTROPHY
• COMPLEX REGIONAL PAIN SYNDROME A.K.A. RSD IS AN IDIOPATHIC
CONDITION CAUSED BY AN ABERRANT INFLAMMATORY RESPONSE
THAT LEADS TO SUSTAINED SYMPATHETIC ACTIVITY IN A
PERPETUATED REFLEX ARC.
• CARDINAL SIGNS:
EXAGGERATED PAIN
SWELLING
STIFFNESS
SKIN DISCOLOURATION

29. • BUDAPEST DIAGNOSTIC CRITERIA IS USED
• SKIN CHANGES IN EARLY STAGES
• ATROPHY OF SKIN,MUSCLE AND NERVES IN LATER STAGES
• TREATMENT:OCCUPATIONAL THERAPY IS THE PRIMARY TREATMENT
• PHARMACOLOGICAL:NSAIDS,BETA BLOCKERS,ALPHA BLOCKERS
• NERVE BLOCKADE,SURGICAL SYMPATHECTOMY

30. MYOSITIS OSSIFICANS
• CALCIFICATION AND BONY MASSES DEVELOP WITHIN MUSCLE.
• MOST COMMON IN DIAPHYSIS OF LONG BONES
• FEATURES:PAIN,TENDERNESS,FOCAL SWELLING AND DEECREASED
ROM
• TREATMENT:REST,ROM EXERCISES
• PASSIVE STRETCHING IS CONTRAINDICATED
• SURGICAL EXCISION:IF EXCISED EARLY WITHIN 6-12 MONTHS
PREDISPOSES TO RECURRENCE
• USUALLY SELF LIMITING.MASS BEGINS TO DECREASE IN SIZE AFTER 1
YEAR

31. THANK YOU