This document discusses various complications that can arise from fractures. It classifies complications as immediate, early, or late. Immediate complications include hypovolaemic shock, injuries to major vessels or internal organs. Early complications include hypovolaemic shock, ARDS, fat embolism, DVT, and infections. Late complications are related to imperfect union like delayed union, non-union, or malunion. Other late complications include avascular necrosis, joint stiffness, osteomyelitis, and osteoarthritis. The document provides details on pathogenesis, clinical features, diagnosis, and management of various common complications like hypovolaemic shock, fat embolism, DVT, crush syndrome, compartment syndrome, and
Fat Embolism Syndrome (FES) is a Syndrome characterized by: Hypoxia, Confusion and Petechiae. Presenting soon after long bone fracture and soft tissue injury. Diagnosed by exclusion of other causes 0f (Hypoxia & Confusion). It occurs in 0.9 – 8.5% of all fracture patients. Up to 35% of the multiply injured. Mortality 2.5 – 15 - 20%. Rare in upper limb injury and children.
Treatment includes prompt stabilization of long bone fractures and supportive measures which includes: 1- Oxygen Therapy to maintain PaO2. 2- Mechanical Ventilation. 3- Adequate Hydration.
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Fat Embolism Syndrome (FES) is a Syndrome characterized by: Hypoxia, Confusion and Petechiae. Presenting soon after long bone fracture and soft tissue injury. Diagnosed by exclusion of other causes 0f (Hypoxia & Confusion). It occurs in 0.9 – 8.5% of all fracture patients. Up to 35% of the multiply injured. Mortality 2.5 – 15 - 20%. Rare in upper limb injury and children.
Treatment includes prompt stabilization of long bone fractures and supportive measures which includes: 1- Oxygen Therapy to maintain PaO2. 2- Mechanical Ventilation. 3- Adequate Hydration.
Operation “Blue Star” is the only event in the history of Independent India where the state went into war with its own people. Even after about 40 years it is not clear if it was culmination of states anger over people of the region, a political game of power or start of dictatorial chapter in the democratic setup.
The people of Punjab felt alienated from main stream due to denial of their just demands during a long democratic struggle since independence. As it happen all over the word, it led to militant struggle with great loss of lives of military, police and civilian personnel. Killing of Indira Gandhi and massacre of innocent Sikhs in Delhi and other India cities was also associated with this movement.
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2. Introduction
These are the associated pathologies other than the loss
of bone continuity which either co exist or originate
due to the fracture.
early diagnosis and aggressive treatment is necessary
to minimize disabilities.
5. III. LATE COMPLICATIONS
A. Related to imperfect union
1. Delayed union
2. Non union
3. Mal union
4. Cross union
B.Others
1. Avascular necrosis
2. Shortening
3. Joint stiffness
4. Sudeck’s dystrophy
5. Osteomyelitis
6. Ischemic contracture
7. Myositis ossificans
8. OA
7. cause
External or internal haemorrhage.
External: compound fractures injuring major vessels of
the LIMB
Internal: injury to body cavities- chest or pelvis
Internal is more difficult to diagnose.
# pelvis (1.5-2 litres) # femur (1-1.5 litres) produces
major haemorrhage.
8. Prevention
Early stopping of bleeding
Avoiding shifting of the patients
For # pelvis- temporary stabilization with external
fixator
Emergency angiography and embolisation of bleeding
vessels for deeper vessels.
9. Management
Starts even before the cause is established
Two large bore iv cannulas put
Infuse 2000 ml of crystalloids (ringer lactate) followed
by colloid (haemaccel) and blood if needed
Cut down if peripheral vasoconstriction is present
Localise the site of lesion- if in body cavities, perform
chest aspiration or diagnostic peritonial lewage.
Sometimes a simple x ray is enough.
Chest bleeding-ICDT
Abdominal bleeding- laperotomy
10. ARDS
Respiratory distress following a trauma
Cause- not definite. Hypothesized to be by release of
Inflammatory cells and proteinaceous fluid that
accumulate in the alveolar spaces leading to a decrease
in diffusing capacity and hypoxemia. The
microvasculature in dysrupted.
Onset- 24 hours after injury
12. management
100% O2 and assisted ventilation
It takes upto 7 days to get the chest clear
If not detected early death occurs by multiorgan
failure or cardiorespiratory failure.
13. Fat Embolism
It is a life threatening complication of fracture where fat
globules occlude the small blood vessels.
Embolism is the process of occlusion of blood vessel by
any material which is brought to the site from
elsewhere by bloodstream.
14. Pathogenesis
Injury to large bones (e.g. femur) release fat globule
from bone marrow to blood stream. Alternatively fat
can also be released from the adipose tissue.
The fat globules obstruct capillary vasculature of the
lungs.
Also, fat is converted to free fatty acid, which induces
toxic vasculitis followed by thrombosis which obstruct
the microvasculature.
15. Clinical features
COMMON
Patechial rash of anterior
neck, anterior axillary
fold or conjunctiva
CEREBRAL TYPE
Drowsiness
Restlessness
Disorientation
Coma
PULMONARY TYPE
Tachypnoea
Tachycardia
Respiratory failure
17. management
Respitarory support
Heparinisation
i.v. low mol wt dextran
Corticosteroid
Dextrose and alcohol infusion to emulsify fat.
18. Deep Vein Thrombosis
It is a common complication
originating from altered
hemodynamics in lower
limb and spinal injuries.
Pathology:
19. pathology
Virchow's triad
1. decreased flow rate of
the blood
2. damage to the blood
vessel wall
3. hypercoagulability
trauma
immobilisation
Venous stasis
thrombosis
20. Clinical features
Elderly and obese patients are at risk.
Leg swelling
Local redness, warmth
Calf tenderness
Pain in passive dorsiflexion (Homan sign)
Venography shows DVT
21. Sequale
1. The venous thrombosis can get dislodged and
produce embolism elsewhere. If it is pulmonary
embolism the condition is life threatening.
Embolism usually occurs within 4-5 days after injury.
2. A late complication of DVT is the post-phlebitic
syndrome, which can manifest itself as edema, pain
or discomfort and skin problems.
22. Other causes
compression of the veins
physical trauma
cancer
infections
inflammatory diseases
stroke
heart failure
nephrotic syndrome
Risk factor:
Surgery
hospitalization
immobilization
orthopedic casts
economy class syndrome
smoking
Obesity
age
certain drugs (such as estrogen
or erythropoietin)
thrombophilia
pregnancy
postnatal period.
24. treatment
Prophylaxis
Active/ passive calf pump
and toe movement
Elevation
Deep breathing exercise
Elastic TED stockings
Early internal fixation to
provide early mobility.
Management
Complete rest with elevation
thrombolysis
Anticoagulant therapy
graduated compression
stockings (
thromboembolic deterrent
stockings) or
intermittent pneumatic
compression devices.
Respiratory support in case
of pulmonary embolism
25. Crush syndrome
It is renal failure following
extensive crushing injury
of muscles.
Pathogenesis:
Crushing of muscles causes
entry of myoglobin into
circulation. Myoglobin
precipitates in renal
tubules causing acute
tubular necrosis,
metabolic acidosis &
hperkalemia
Clinical features
(appear within 2-3 days of injury)
Signs of deficient renal function:
Oliguria (Scanty urine)
Apathy
Restlessness
Delirium
Cardiac arrhythmia & failure
Hypothermia
Shock
27. An increased pressure within enclosed
osteofascial space that reduces capillary per-
fusion below level necessary for tissue
viability; the underlying mechanism is:
- increased volume within space
- decreased space for contents
- combination of both
Compartment syndrome
32. Clinical features
The six ‘Ps’:
Pressure: palpation of compartment and its tension or
firmness
Pain: Exaggerated with passive stretch of the involved
muscles in compartment
Earliest symptom but inconsistent
Paresthesia:Peripheral nerve tissue is more sensitive than
muscle to ischemia
Will progress to anesthesia if pressure not relieved
Paralysis: late finding
Pallor
Pulselessness
33. Treatment
Lower leg to level of the heart
Remove cast
Split all dressings down to skin
Fasciotomy if continued clinical findings and/or
elevated compartment pressure
40. Delayed/ Non union
When a fracture takes more than the usual time to unite
it is said to have gone in delayed union.
When the process of healing stops before completion
the fracture is said to have gone for non union. To
diagnose non union the fracture has to be minimum
six months old.
41. causes
I. Related to patient
Old age
Associated systemic illness: ex. Malignancy
II. Related to fracture
Distraction at fracture site
Muscle pulling the fragments: ex. # patella
Gravity: ex. # shaft of humerus
Soft tissue interposition: ex. # shaft of humerus
Bone loss during fracture: ex. # tibia open type
Infection from open fracture: ex. # tibia
Damage to blood supply of # fragment: ex. # scaphoid
Pathological fracture: ex. # osteomyelitic tibia
42. III causes related to treatment:
Inadequate reduction: # shaft of long bones
Inadequate immobilisation:# shaft of long bones
Distraction (excessive) during treatment::# shaft of
femur.
43. types
1. Atrophic: no or minimal callus formation
2. Hypertrophic: callus is present but it does not bridge
the fracture site.
44. Common sites
Neck of femur
Scaphoid
Lower third of tibia
Lower third of ulna
Lateral condyle of humerus
45. Clinical features
Pain
Deformity
Abnormal mobility
Refracture
Radiological findings
Delayed union: inadequate callus, visible fracture line
Non union: ends are rounded, smooth sclerotic.
Medullary cavity may be obliterated. visible fracture
line.
46. Treatment: Delayed union
1. Most commonly prolonged conservative
management
2. Surgical intervention: bone grafting with or without
internal fixation.
47. Treatment: non union
Depends upon site and resulting disability. Following are
the options.
1. Bone grafting: commonest.
2. Excision of fragments: when it can be done with
minimal loss of function. A prosthesis may be used
to replace the lost part, eg. In # neck of femur the
head can be replaced with an austin moore
prosthesis.
3. Illizarov menthod
4. No treatment: when there is no disability, eg. #
scaphoid.
48. Mal union
When a fracture does not unite in proper position it is
said to have malunited.
Causes:
1. Improper reduction
2. Unchecked muscle pull
3. Excessive communication
50. treatment
1. osteoclasis: refracture, done in children to correct
mild to moderate angular deformities under GA.
2. Redoing the fracture surgically: most common. ORIF
is generally done along with bone grafting.
3. Corrective osteotomy: performed at a site away from
the fracture. Eg. Supracondyle # of humerus.
4. Excision of protruding bone.