Complications of Fractures and Management_hso

8/19/2019 Complications of Fractures and Management_hso

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COMPLICATIONS OFCOMPLICATIONS OF

FRACTURES AND ITSFRACTURES AND ITSMANAGEMENTMANAGEMENT


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INTRODUCTIONINTRODUCTION

Because bones areBecause bones are

surrounded by soft tissue,surrounded by soft tissue,

the physical forces thatthe physical forces that

produce a fracture alwaysproduce a fracture alwaysproduce some degree ofproduce some degree of

soft tissue injury as well.soft tissue injury as well.

The associated soft tissueThe associated soft tissue

injury may assume muchinjury may assume muchgreater clinical significancegreater clinical significance

than the fracture itself.than the fracture itself.


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INTRODUCTIONINTRODUCTION

Radiographs:Radiographs:

• Just provide suchJust provide such

graphic evidence of agraphic evidence of a

fracture.fracture.

• eldom provideeldom provideevidence of the e!tent ofevidence of the e!tent of

the associated softthe associated soft

tissue injury.tissue injury.

Therefore it must beTherefore it must bethought in term of thethought in term of the

fracture: "hat hasfracture: "hat has

happened to thehappened to the

surrounding soft tissue#surrounding soft tissue#


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Genaral

Blood Loss

Shock

Fat Embolism

Cardiorespiratory Failure


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LOCALLOCAL

Urgent Less Urgent LateUrgent Less Urgent Late

$ocal visceral$ocal visceral injuryinjury%ascular injury%ascular injury

&erve injury&erve injury'ompartment'ompartment

yndromeyndrome

(aemarthrosis(aemarthrosis

)nfection)nfection

*as gangrene*as gangrene

+racture blisters+racture blisters

laster soreslaster sores

ressure soresressure sores

&erve entrapment&erve entrapment

-yositis ssificans-yositis ssificans

$igament injury$igament injury

Tendon lesionsTendon lesions

Joint stiffnessJoint stiffness

/lgdystrophy/lgdystrophy

0elayed union0elayed union

-alunion-alunion

&on1union&on1union

/vascular necrosis/vascular necrosis

-uscle contracture-uscle contracture

Joint instabilityJoint instability

steoarthrosissteoarthrosis


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VISCERAL INJURYVISCERAL INJURY

enetration of the lungenetration of the lung

with life threateningwith life threatening

pneumothora! 11pneumothora! 11

following rib fractures.following rib fractures.

Rupture of the bladderRupture of the bladder

or urethra in pelvicor urethra in pelvic

fractures.fractures.

These injuries re2uireThese injuries re2uire

emergency treatment.emergency treatment.


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VASCULAR INJURYVASCULAR INJURY

The artery may be cut,The artery may be cut,

torn, compressed ortorn, compressed or

contused, either by thecontused, either by the

initial injury orinitial injury or

subse2uently by jaggedsubse2uently by jagged

bone fregments.bone fregments.

The effects vary fromThe effects vary from

transient diminution oftransient diminution of

blood flow to profoundblood flow to profoundischaemia, tissue deathischaemia, tissue death

and periphera3 gangrene.and periphera3 gangrene.


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Common vasc!ar "n#r"esCommon vasc!ar "n#r"es

InjuryInjury

+irst rib fracture+irst rib fracture

houlder dislocationhoulder dislocation

(umeral supracondylar fracture(umeral supracondylar fracture4lbow dislocation4lbow dislocation

elvic fractureelvic fracture

+emoral supracondylar fracture+emoral supracondylar fracture

5nee dislocation5nee dislocation

ro!imal tibialro!imal tibial

VesselVessel

ubclavianubclavian

/!illary/!illary

BrachialBrachialBrachialBrachial

resacral and internal iliacresacral and internal iliac

+emoral+emoral

oplitealopliteal

oplitealopliteal


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C!"n"ca! $eatre % Vasc!ar "n#r&C!"n"ca! $eatre % Vasc!ar "n#r&

araesthesia oraraesthesia or

numbness in the toesnumbness in the toes

or fingers.or fingers.

The injured limb isThe injured limb is

cold and pale, orcold and pale, or

slightly cyanosed.slightly cyanosed.

The pulse is wea3 orThe pulse is wea3 or

absentabsent


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Treatment % Vasc!ar "n#r&Treatment % Vasc!ar "n#r&

rompt reduction is necessary.rompt reduction is necessary. The circulation is then reassessed.The circulation is then reassessed. )f there is no improvement the vessels)f there is no improvement the vessels

must be e!plored by operation 6preferablymust be e!plored by operation 6preferablywith the benefit of preoperative orwith the benefit of preoperative orperoperative angiography7.peroperative angiography7.

/ torn vessel can be sutured, or a/ torn vessel can be sutured, or a

segment may be replaced by a vein graft.segment may be replaced by a vein graft. )f it is thrombosed, endarterectomy may)f it is thrombosed, endarterectomy may

restore the blood flow.restore the blood flow.


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NERVE INJURYNERVE INJURY

'omplaints of'omplaints of

numbness ornumbness or

paraesthesia in theparaesthesia in the

nerve distribution.nerve distribution.

)n close injury the nerve)n close injury the nerve

is seldom severed, andis seldom severed, and

spontaneous recoveryspontaneous recovery

should be awaited 8 itshould be awaited 8 itoccurs in 9; of casesoccurs in 9; of cases

within < months.within < months.


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Common nerve "n#r"esCommon nerve "n#r"es

InjuryInjury NerveNerve

houlder dislocationhoulder dislocation /!illary/!illary

(umeral shaft fracture(umeral shaft fracture RadialRadial

(umeral supracondylar fracture(umeral supracondylar fracture Radial or medianRadial or median

4lbow medial condyle4lbow medial condyle =lnar=lnar

-onteggia fracture1dislocation-onteggia fracture1dislocation osterior interosseousosterior interosseous

(ip dislocation(ip dislocation ciaticciatic

5nee dislocation5nee dislocation eronealeroneal


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If recovery has notIf recovery has not

occurred by theoccurred by theexpected time, and ifexpected time, and if

nerve conductionnerve conduction

studies fail to showstudies fail to show

evidence of recovery,evidence of recovery,

the nerve should bethe nerve should be

explored.explored.

Early exploration shouldEarly exploration should

also be considered ifalso be considered if

signs of a nerve injurysigns of a nerve injury

appear afterappear after

manipulation of themanipulation of thefracture. ( iegel andfracture. ( iegel and

!elberman, "##"$!elberman, "##"$


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)n open fracture any)n open fracture any

nerve lesion is morenerve lesion is more

li3ely to beli3ely to be

complete> the nervecomplete> the nerveis e!plored duringis e!plored during

wound debridementwound debridement

and repair, eitherand repair, either

then or as athen or as asecondary proceduresecondary procedure

? wee3 later? wee3 later


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COMPARTMENT SYNDROMECOMPARTMENT SYNDROME

Bleeding, oedema orBleeding, oedema or

inflamation may increaseinflamation may increase

the pressure within one ofthe pressure within one of

the osteofascialthe osteofascial

compartment.compartment.

There is reduced capillaryThere is reduced capillary

flow which result in muscleflow which result in muscle

ischaemia, furtherischaemia, further

oedema, still greateroedema, still greaterpressure and yet morepressure and yet more

profound ischaemia.profound ischaemia.


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/ %icious circle that ends, after @A hours or less, in necrosis of/ %icious circle that ends, after @A hours or less, in necrosis ofnerve and muscle within compartment.nerve and muscle within compartment.

&erve is capable of regeneration but muscle, once infarcted,&erve is capable of regeneration but muscle, once infarcted,

can never recover and is replaced by inelastic fibrous tissuecan never recover and is replaced by inelastic fibrous tissue

6 %$5-/&& )'(/4-)' '&TR/'T=R4 76 %$5-/&& )'(/4-)' '&TR/'T=R4 7

Reduced

Blood flow

Oedema

Ischaemia

Increase

Compartment

pressure

ainful

ale

ulseless

araesthetic

aralysed

Fasciotomy


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C!"n"ca! Featres % Com'artment S&n(romeC!"n"ca! Featres % Com'artment S&n(rome

)schaemic muscle is highly)schaemic muscle is highly

sensitive to stretch, it shouldsensitive to stretch, it should

be tested by stretching thembe tested by stretching them

8 when the toes or fingers8 when the toes or fingers

are passively hypere!tendedare passively hypere!tended

there is increase pain in thethere is increase pain in thecalf or forearm.calf or forearm.

The presence of a pulse doesThe presence of a pulse does

not e!clude the diagnosis.not e!clude the diagnosis.

)n doubtful cases the)n doubtful cases the

diagnosis can be confirmeddiagnosis can be confirmedby measuring theby measuring the

intracompartmentalintracompartmental

pressure.pressure.


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Treatment % Com'artment S&n(romeTreatment % Com'artment S&n(rome

The threatened compartmentThe threatened compartmentmust be promptlymust be promptly

decompressed. 'ast, bandagedecompressed. 'ast, bandage

and dressing must beand dressing must be

completely removed.completely removed.

/ differential pressure/ differential pressure

between diastolic andbetween diastolic and

compartment should becompartment should bemonitored, if it falls below ?monitored, if it falls below ?

mm(g, immediate openmm(g, immediate open

fasciotomy is performedfasciotomy is performed


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)AEMART)ROSIS)AEMART)ROSIS

+ractures involving a joint may cause+ractures involving a joint may cause

acute haemarthrosis.acute haemarthrosis.

The joint is swollen and tense andThe joint is swollen and tense and

the patient resist any attempt atthe patient resist any attempt at

moving it.moving it.

The blood should be aspirated beforeThe blood should be aspirated before

dealing with the fracture.dealing with the fracture.


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INFECTIONINFECTION

pen fracture may becomepen fracture may become

infected.infected. 'losed fractures hardly ever'losed fractures hardly ever

do unless they are opened bydo unless they are opened by

operation.operation.

ost1traumatic woundost1traumatic wound

infection is now the mostinfection is now the mostcommon cause of chroniccommon cause of chronic

osteitis.osteitis.

This does not prevent theThis does not prevent the

fracture from uniting, butfracture from uniting, butunion will be slow and chanceunion will be slow and chance

of refracturing is increase.of refracturing is increase.


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C!"n"ca! $eatres * In$ect"onC!"n"ca! $eatres * In$ect"on The history is of anThe history is of an

open fracture or anopen fracture or anoperation on a closedoperation on a closed

fracture.fracture.

The wound becomesThe wound becomesinflamed and startsinflamed and starts

draining seropurulentdraining seropurulent

fluid, a sample of whichfluid, a sample of which

may yield a growth ofmay yield a growth of

staphylococci or mi!edstaphylococci or mi!edbacteria.bacteria.


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Treatment * In$ect"onTreatment * In$ect"on /ll open fractures should/ll open fractures should

be regarded asbe regarded aspotentially infected 8potentially infected 8

antibiotics andantibiotics and

meticulously e!cising allmeticulously e!cising all

devitaliCed tissue.devitaliCed tissue.

igns of acute infectionigns of acute infectionand pus formation, theand pus formation, the

tissue around thetissue around the

fracture should befracture should be

opened and drained.opened and drained.

4!ternal fi!ation is useful4!ternal fi!ation is useful

in such casesin such cases


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GAS GANGRENEGAS GANGRENE

roduced by 'lostridial infection ,especially 'lostridiumroduced by 'lostridial infection ,especially 'lostridium

welchii 8 anaerobic organism that can survive and multiplywelchii 8 anaerobic organism that can survive and multiply

only in tissues with low o!ygen tension.only in tissues with low o!ygen tension.

The prime site is a dirty wound with dead muscle that hasThe prime site is a dirty wound with dead muscle that hasbeen closed without ade2uate debridementbeen closed without ade2uate debridement..

To!ins produced by the organisms destroy the cell wall andTo!ins produced by the organisms destroy the cell wall and

rapidly lead to tissue necrosis, thus promoting the spreadrapidly lead to tissue necrosis, thus promoting the spreadof the disease.of the disease.


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C!"n"ca! $eatre % Gas gangreneC!"n"ca! $eatre % Gas gangrene

/ppear within A< hours of injury./ppear within A< hours of injury.

)ntense pain, swelling around the wound and a)ntense pain, swelling around the wound and a

brownish discharge may be seen. *as formationbrownish discharge may be seen. *as formation

is usually not very mar3ed.is usually not very mar3ed.

ulse rate is increase and a characteristic smellulse rate is increase and a characteristic smell

becomes evident. Rapidly the patient becomesbecomes evident. Rapidly the patient becomes

to!aemic and may lapse into coma and death.to!aemic and may lapse into coma and death.


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C!"n"ca! $eatre % Gas gangreneC!"n"ca! $eatre % Gas gangrene

)t is essential to distinguish gas gangrene, which)t is essential to distinguish gas gangrene, which

is characteriCed by myonecrosis, from anaerobicis characteriCed by myonecrosis, from anaerobic

cellulitis, in which superficial gas formation iscellulitis, in which superficial gas formation is

abundant but to!aemia usually slight.abundant but to!aemia usually slight.

+ailure to recogniCe the difference may lead to+ailure to recogniCe the difference may lead to

unnecessary amputation for the nonlethalunnecessary amputation for the nonlethal

cellulitis.cellulitis.


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Prevent"on % Gas gangrenePrevent"on % Gas gangrene

0eep, penetrating wound in muscular tissue are0eep, penetrating wound in muscular tissue are

dangerous> they should be e!plored, all deaddangerous> they should be e!plored, all dead

tissue should be completely e!cised.tissue should be completely e!cised.

)f there is the slightest doubt about tissue)f there is the slightest doubt about tissue

viability, the wound should be left open.viability, the wound should be left open.

=nhappily there is no effective antito!in against=nhappily there is no effective antito!in against

'.welchii.'.welchii.


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Treatment % Gas gangreneTreatment % Gas gangrene

The 3ey to life1saving treatment is earlyThe 3ey to life1saving treatment is early

diagnosis.diagnosis.

+luid replacement and intravenous antibiotic are+luid replacement and intravenous antibiotic are

started immediately.started immediately.

(yperbaric o!ygen has been used as a means of(yperbaric o!ygen has been used as a means of

limiting the spread of gangrene.limiting the spread of gangrene.

The mainstay of treatment is promptThe mainstay of treatment is prompt

decompression of the wound and removal of alldecompression of the wound and removal of all

dead tissue.dead tissue.

)n advanced cases, amputation may be essential.)n advanced cases, amputation may be essential.


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FRACTURE +LISTERSFRACTURE +LISTERS

These are due to elevation of the superficialThese are due to elevation of the superficial

layers of s3in by oedema, and can sometime belayers of s3in by oedema, and can sometime be

prevented by firm bandaging.prevented by firm bandaging.

They should be covered with a sterile dryThey should be covered with a sterile dry

dressing.dressing.


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PLASTER SORESPLASTER SORES AND AND PRESSURE SORESPRESSURE SORES

laster sores occur where s3in presses directlylaster sores occur where s3in presses directly

onto bone. They should be prevented by paddingonto bone. They should be prevented by padding

the bony points and by moulding the wet plasterthe bony points and by moulding the wet plaster

so that pressure is distributed to the soft tissueso that pressure is distributed to the soft tissue

around the bony points.around the bony points.

"hile a plaster sore is developing the patient"hile a plaster sore is developing the patient

feels localiCed burning pain. / window mustfeels localiCed burning pain. / window must

immediately be cut in the plaster, or warning painimmediately be cut in the plaster, or warning pain2uic3ly abates and s3in necrosis proceeds2uic3ly abates and s3in necrosis proceeds

unnoticed.unnoticed.


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DELAYED UNIONDELAYED UNION

)f the time is unduly)f the time is unduly

prolonged, the termprolonged, the term

Ddelayed union is used. Ddelayed union is used.

+actors causing delayed+actors causing delayed

union can be summariCedunion can be summariCed

as :as :

• BiologicalBiological

• BiomechanicalBiomechanical

• atient relatedatient related


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+IOLOGICAL FACTORS+IOLOGICAL FACTORS

)&/04E=/T4 B$0 =$F)&/04E=/T4 B$0 =$F

/ badly displaced fracture of a long bone will/ badly displaced fracture of a long bone will

cause tearing of both the periosteum andcause tearing of both the periosteum and

interruption of the intramedullary blood supply.interruption of the intramedullary blood supply.

.. 4%4R4 +T T)=4 0/-/*44%4R4 +T T)=4 0/-/*4

1 Reducing the effect of muscle splintage.1 Reducing the effect of muscle splintage.

1 0amaging blood supply.1 0amaging blood supply.

1 0iminishing the osteogenic stimulus.1 0iminishing the osteogenic stimulus... 4R)T4/$ TR))&*4R)T4/$ TR))&*


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+IOMEC)ANICAL FACTORS+IOMEC)ANICAL FACTORS

.. )-4R+4'T $)&T/*4)-4R+4'T $)&T/*44!cessive traction, e!cessive movement or4!cessive traction, e!cessive movement orisolated fracture of forearm or leg will delayisolated fracture of forearm or leg will delayossification in the callus.ossification in the callus.

.. %4R1R)*)0 +)G/T)&%4R1R)*)0 +)G/T)&

'ontrary to popular belief, rigid fi!ation delays'ontrary to popular belief, rigid fi!ation delaysrather than promotes fracture union. =nion byrather than promotes fracture union. =nion byprimary bone healing is slow.primary bone healing is slow.

.. )&+4'T)&)&+4'T)&There is bone lysis, necrosis and pus formationThere is bone lysis, necrosis and pus formationbut also implants which are used to hold thebut also implants which are used to hold thefracture tend to loosen.fracture tend to loosen.


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C!"n"ca! $eatres % De!a&e( Un"onC!"n"ca! $eatres % De!a&e( Un"on

+racture tenderness persists and if the bone is+racture tenderness persists and if the bone is

subjected to stress, pain may be acute.subjected to stress, pain may be acute.

G1RayG1Ray

1 The fracture line remains visible and there is1 The fracture line remains visible and there is

very little callus formation or periosteal reaction.very little callus formation or periosteal reaction.

1 The bone ends are not sclerosed or athropic.1 The bone ends are not sclerosed or athropic.


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Conservat"ve Treatment % De!a&e( Un"onConservat"ve Treatment % De!a&e( Un"on

The two important principles are:The two important principles are:

@.@. To eliminate any possible cause of delayedTo eliminate any possible cause of delayed

union.union.

A.A.

To promote healing by providing the mostTo promote healing by providing the most

appropriate biological environment.appropriate biological environment.

+racture loading is an stimulus to union by:+racture loading is an stimulus to union by:

a. By encouraging muscular e!ercisea. By encouraging muscular e!ercise

b. By weightbearing in the cast or braceb. By weightbearing in the cast or brace


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O'erat"ve Treatment % De!a&e( Un"onO'erat"ve Treatment % De!a&e( Un"on

)f union is delayed for more than H months and)f union is delayed for more than H months and

there is no sign of callus formation, fi!ation andthere is no sign of callus formation, fi!ation and

bone grafting are indicated.bone grafting are indicated.

The operation should be planned in such a way asThe operation should be planned in such a way as

to cause the least possible damage to the softto cause the least possible damage to the softtissue.tissue.


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NON*UNIONNON*UNION

The fracture gap become a typeThe fracture gap become a type

of pseudoarthrosis.of pseudoarthrosis.

)n hyperthropic non1union the)n hyperthropic non1union the

bone ends are enlarged,bone ends are enlarged,

suggesting that osteogenesissuggesting that osteogenesis

is still active but not 2uiteis still active but not 2uitecapable of bridging the gap.capable of bridging the gap.

)n athropic non1union)n athropic non1union

osteogenesis semms to haveosteogenesis semms to have

ceased. The bone ends areceased. The bone ends are

often tapered or rounded withoften tapered or rounded withno suggestion of new boneno suggestion of new bone

formation.formation.

C $ "C $ "


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Cases o$ non*n"onCases o$ non*n"on

The )njuryThe )njury

oft tissue lossoft tissue loss

Bone lossBone loss

)ntact fellow bone)ntact fellow bone

oft tissue interpositionoft tissue interposition

The boneThe bone

oor blood supplyoor blood supply

oor haematomaoor haematoma

)nfection)nfection

athologic lesionathologic lesion

The surgeonThe surgeon

0istraction0istraction

oor splintageoor splintage

oor fi!ationoor fi!ation

)mpatience)mpatience

The patientThe patient

)mmense)mmense

)mmoderate)mmoderate

)mmovable)mmovable

)mmpossible)mmpossible


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CONSERVATIVE TREATMENTCONSERVATIVE TREATMENT

"ith hyperthropic non1union,"ith hyperthropic non1union,

1 +unctional bracing may be sufficient to induce1 +unctional bracing may be sufficient to induce

union.union.

1 ulse electromagnetic fields.1 ulse electromagnetic fields.

1 $ow fre2uency pulsed ultrasound can1 $ow fre2uency pulsed ultrasound can


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OPERATIVE TREATMENTOPERATIVE TREATMENT

(ypertrophic non1union,(ypertrophic non1union,

rigid fi!ation alone mayrigid fi!ation alone may

lead to union.lead to union.

/trophic non1union,/trophic non1union,fi!ation alone is notfi!ation alone is not

enough. +ibrous tissue inenough. +ibrous tissue in

the fracture gap, as well asthe fracture gap, as well as

the hard, sclerotic bonethe hard, sclerotic bone

ends, are e!cised and boneends, are e!cised and bone

grafts are pac3ed arroundgrafts are pac3ed arround

the fracture.the fracture.


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MALUNIIONMALUNIION

"hen the fragments join in"hen the fragments join in

an unsatisfactory positionan unsatisfactory position

6unacceptable angulation,6unacceptable angulation,

rotation or shortening7 therotation or shortening7 the

fracture is said to befracture is said to be

malunited.malunited.

'auses are failure to'auses are failure to

reduce a fracturereduce a fracture

ade2uately, failure to holdade2uately, failure to hold

reduction while healingreduction while healing

proceeds or gradual collapsproceeds or gradual collaps

of comminuted orof comminuted or

osteoporotic bone.osteoporotic bone.


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C!"n"ca! $eatres * Ma!n"onC!"n"ca! $eatres * Ma!n"on

The deformity is usuallyThe deformity is usually

obvious, but sometimesobvious, but sometimes

apperent only on G1ray.apperent only on G1ray.

Rotational deformity of theRotational deformity of the

femur, tibia, humerus orfemur, tibia, humerus or

forearm may be missedforearm may be missed

unless the limb isunless the limb is

compared with its oppositecompared with its opposite

fellow.fellow.


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C!"n"ca! $eatres * Ma!n"onC!"n"ca! $eatres * Ma!n"on

Rotational deformity of aRotational deformity of a

metacarpal fracture ismetacarpal fracture is

detected by as3ing thedetected by as3ing the

patient to flatten thepatient to flatten the

fingers onto the palm andfingers onto the palm and

seeing whether the normalseeing whether the normalregular fan1shapedregular fan1shaped

appearance is reproduced.appearance is reproduced.


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Treatment % Ma!n"onTreatment % Ma!n"on

A $e, g"(e!"nes are o$$ere( A $e, g"(e!"nes are o$$ere(

@.@. )n adults, angulation of more than @ 8 @I)n adults, angulation of more than @ 8 @I%% in a longin a long

bone, or a noticeable rotational deformity, may needbone, or a noticeable rotational deformity, may need

correction by remanipulation, or by osteotomy andcorrection by remanipulation, or by osteotomy and

internal fi!ation.internal fi!ation.

A.A. )n children, angular deformities near the bone ends will)n children, angular deformities near the bone ends will

usually remodel with time> rotational deformity will not.usually remodel with time> rotational deformity will not.

?.?. )n the lower limb, shortening of more then A.cm is)n the lower limb, shortening of more then A.cm is

seldom acceptable to the patient and a limb lengtheningseldom acceptable to the patient and a limb lengthening

procedure may be indicated.procedure may be indicated.

they are not

to be ignored.to be ignored.


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Treatment % Ma!n"onTreatment % Ma!n"on

A $e, g"(e!"nes are o$$ere( A $e, g"(e!"nes are o$$ere(

I. 4arly discussion with the patient, and a guided view of theI. 4arly discussion with the patient, and a guided view of the

G1rays, will help in deciding on the need for treatment andG1rays, will help in deciding on the need for treatment and

may prevent later misunderstanding.may prevent later misunderstanding.

H. -alalignment of more than @IH. -alalignment of more than @I%% in any plane may causein any plane may cause

asymmetrical loading of the joint above or below and theasymmetrical loading of the joint above or below and the

late development of secondary osteoarthritis> this applieslate development of secondary osteoarthritis> this applies

particularly to the large weightbearing joints.particularly to the large weightbearing joints.


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AVASCULAR NECROSIS AVASCULAR NECROSIS

'ertain regions are notorious for'ertain regions are notorious for

their propensity to developtheir propensity to develop

ischaemia and bone necrosisischaemia and bone necrosis

after injury:after injury:

@. The head of the femur@. The head of the femur

6after fracture of femoral nec36after fracture of femoral nec3or dislocation of the hip7.or dislocation of the hip7.

A. The pro!imal part of theA. The pro!imal part of the

scaphoid 6after fracturescaphoid 6after fracture

through its waist7.through its waist7.

?. The lunate 6following?. The lunate 6following

dislocation7.dislocation7.


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AVASCULAR NECROSIS AVASCULAR NECROSIS

)schaemia occurs during the first few)schaemia occurs during the first few

hours following fracture orhours following fracture or

dislocation.dislocation.

(owever, the clinical and radiological(owever, the clinical and radiological

effects are not seen until wee3s oreffects are not seen until wee3s or

even months later.even months later.


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C!"n"ca! $eatre % Avasc!ar Necros"sC!"n"ca! $eatre % Avasc!ar Necros"s

ThereThere are no symptomsare no symptomsassociated with avascularassociated with avascular

necrosis, but if the fracture failsnecrosis, but if the fracture fails

to unite or if the bone collaps theto unite or if the bone collaps the

patient may complain of pain.patient may complain of pain.

The G1ray shows:The G1ray shows:

11 )ncrease in bone density.)ncrease in bone density.1 &ew bone ingrowth in the1 &ew bone ingrowth in the

necrotic segment.necrotic segment.1 0isuse osteoporosis in the1 0isuse osteoporosis in the

surrounding partssurrounding parts


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Treatment % Avasc!ar Necros"sTreatment % Avasc!ar Necros"s

)n old people with necrosis)n old people with necrosisof the femoral head anof the femoral head an

arthroplasty is the obviousarthroplasty is the obvious

choice, in younger people,choice, in younger people,

realignment osteotomy 6orrealignment osteotomy 6or

even arthrodesis7 may beeven arthrodesis7 may be

wiser.wiser.

/vascular necrosis in the/vascular necrosis in the

scaphoid or talus may needscaphoid or talus may need

no more than symptomaticno more than symptomatic

treatment, but vascular bonetreatment, but vascular bonegrafting, or arthrodesis ofgrafting, or arthrodesis of

the wrist or an3le, isthe wrist or an3le, is

sometime needed.sometime needed.


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GRO-T) DISTUR+ANCEGRO-T) DISTUR+ANCE

)n children, damage to the physis may lead to)n children, damage to the physis may lead to

abnormal or arrested growth.abnormal or arrested growth.

+ractures that split the epiphysis inevitably+ractures that split the epiphysis inevitably

traverse the growing portion of the physis, and sotraverse the growing portion of the physis, and so

further growth may be asymmetrical and thefurther growth may be asymmetrical and the

bone end characteristically angulated.bone end characteristically angulated.


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TENDON LESIONSTENDON LESIONS

Rupture of the e!tensorRupture of the e!tensor

pollicis tendon may occur Hpollicis tendon may occur H

8 @A wee3s after a fracture8 @A wee3s after a fracture

of the lower radius.of the lower radius.

0irect suture is seldom0irect suture is seldom

possible and the resultingpossible and the resulting

disability is treated bydisability is treated by

transferring the e!tensortransferring the e!tensor

indicis proprius tendon toindicis proprius tendon to

the distal stump of thethe distal stump of the

ruptured thumb tendon.ruptured thumb tendon.

TENDON LESIONS


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TENDON LESIONSTENDON LESIONS


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NERVE COMPRESSIONNERVE COMPRESSION

eroneal nerve mayeroneal nerve may

damage if an elderlydamage if an elderly

patient lies with the legpatient lies with the leg

in full e!ternal rotation.in full e!ternal rotation.

Radial palsy may followRadial palsy may follow

the faulty use ofthe faulty use of

crutches.crutches.

NERVE COMPRESSION


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NERVE COMPRESSIONNERVE COMPRESSION Bone or joint deformity may resultBone or joint deformity may result

in local nerve entrapment within local nerve entrapment with

typical feature such as numbnesstypical feature such as numbnessor paraesthesia, loss of power andor paraesthesia, loss of power and

muscle wasting in the distributionmuscle wasting in the distribution

of the affected nerve.of the affected nerve.

'ommon site are :'ommon site are :

@. the ulnar nerve, due to a@. the ulnar nerve, due to avalgus elbow following an un1valgus elbow following an un1

united lateral condyle fracture.united lateral condyle fracture.

A. the median nerve, followingA. the median nerve, following

injuries around the wrist.injuries around the wrist.

?. the posterior tibial nerve,?. the posterior tibial nerve,

following fractures around thefollowing fractures around thean3le.an3le.

TREATMENT NERVE COMPRESSION


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TREATMENT % NERVE COMPRESSIONTREATMENT % NERVE COMPRESSION

Treatment is by earlyTreatment is by earlydecompression of thedecompression of the

nerve.nerve.

)n the case of the ulnar)n the case of the ulnarnerve this may re2uirenerve this may re2uire

anterior transposition.anterior transposition.

MUSCLE CONTRACTUREMUSCLE CONTRACTURE


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MUSCLE CONTRACTUREMUSCLE CONTRACTURE

+ollowing arterial injury or+ollowing arterial injury or

a compartment syndrome,a compartment syndrome,

the patient may developthe patient may develop

ischaemic contractures ofischaemic contractures of

the affected musclesthe affected muscles

66Volkmann’s ischaemicVolkmann’s ischaemiccontracturecontracture7.7.

The sites most commonlyThe sites most commonly

affected are the forearmaffected are the forearm

and hand, the leg and theand hand, the leg and thefoot.foot.


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JOINT INSTA+ILITYJOINT INSTA+ILITY

+ollowing injury a joint+ollowing injury a joint

may give way. 'ausesmay give way. 'auses

include :include :

@. $igamentous la!ity@. $igamentous la!ity

A. -uscle wea3nessA. -uscle wea3ness

?. Bone loss?. Bone loss

)njury may also lead to)njury may also lead to

recurrent dislocation. Therecurrent dislocation. The

commonest sites are thecommonest sites are theshoulder and the patella.shoulder and the patella.

JOINT STIFFNESSJOINT STIFFNESS


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JOINT STIFFNESSJOINT STIFFNESS

/ haemarthrosis forms and/ haemarthrosis forms and

leads to synovial adhesions.leads to synovial adhesions. edema and fibrosis of theedema and fibrosis of the

capsule, the ligaments andcapsule, the ligaments and

the muscles around thethe muscles around the

joint. joint.

/dhesion of the soft tissues/dhesion of the soft tissuesto each other or to theto each other or to the

underlying bone.underlying bone.

/ll these condition are made/ll these condition are made

worse by prolongedworse by prolongedimmobiliCation.immobiliCation.


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Treatment % Jo"nt St"$$nessTreatment % Jo"nt St"$$ness

The best treatment is prevention:The best treatment is prevention:

1 by e!ercises that 3eep the joints mobile from1 by e!ercises that 3eep the joints mobile from

the outset.the outset.

1 if the joint has to be splinted, ma3e sure that it1 if the joint has to be splinted, ma3e sure that it

is held in the Dposition of safety.is held in the Dposition of safety.


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Treatment % Jo"nt St"$$nessTreatment % Jo"nt St"$$ness

Joints that are already stiff ta3e time to mobiliCe,Joints that are already stiff ta3e time to mobiliCe,

but prolonged and patient physiotherapy canbut prolonged and patient physiotherapy can

wor3 wonders.wor3 wonders.

)f the situation is due to intra1articular adhesions,)f the situation is due to intra1articular adhesions,

gentle manipulation under */ may free the jointgentle manipulation under */ may free the joint

sufficiently to permit a more pliant response tosufficiently to permit a more pliant response to

further e!ercise.further e!ercise.

ccasionally, adherent or contracted tissues needccasionally, adherent or contracted tissues need

to be released by operation.to be released by operation.

ALGODYST)ROP)Y .COMPLE/ALGODYST)ROP)Y .COMPLE/


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ALGODYST)ROP)Y .COMPLE/ ALGODYST)ROP)Y .COMPLE/

REGIONAL PAIN SYNDROME0REGIONAL PAIN SYNDROME0

udec3, in @9, describe a conditionudec3, in @9, describe a condition

characteriCed by painful osteoporosis of the handcharacteriCed by painful osteoporosis of the hand

after fracture, it was calledafter fracture, it was called Sudeck’s atrophy.Sudeck’s atrophy.

&ow recogniCed as the late stage of a post&ow recogniCed as the late stage of a post

traumatictraumatic reflex sympathetic dystrophyreflex sympathetic dystrophy 6also6also

3nown as3nown as algodystrophy algodystrophy 77

ALGODYST)ROP)Y .COMPLE/ALGODYST)ROP)Y .COMPLE/


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ALGODYST)ROP)Y .COMPLE/ ALGODYST)ROP)Y .COMPLE/

REGIONAL PAIN SYNDROME0REGIONAL PAIN SYNDROME0

The patient complains ofThe patient complains ofcontinuous pain.continuous pain.

$ocal swelling, redness and$ocal swelling, redness and

warmth as well aswarmth as well as

tenderness and moderatetenderness and moderate

stiffness of the nearbystiffness of the nearby

joints. joints.

G1ray characteristicallyG1ray characteristicallyshow patchy rarefaction ofshow patchy rarefaction of

the bone.the bone.


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TreatmentTreatment

)n the early stage> anti1inflamatory drugs are)n the early stage> anti1inflamatory drugs are

helpful.helpful.

)f this does not produce improvement,)f this does not produce improvement,

amitriptyline may help to control the pain.amitriptyline may help to control the pain.

ympathetic bloc3 or sympatholytic drugs such asympathetic bloc3 or sympatholytic drugs such as

intravenous guanethidine have been advocatedintravenous guanethidine have been advocated

for this condition.for this condition.

rolonged and dedicated physiotherapy willrolonged and dedicated physiotherapy will

usually be needed.usually be needed.


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OSTEOART)RITISOSTEOART)RITIS

/ fracture involving a joint/ fracture involving a jointmay severely damage themay severely damage the

articular cartilage and givearticular cartilage and give

rise torise to post traumatic post traumatic

osteoarthritisosteoarthritis within awithin a

period of monthsperiod of months

4ven if the cartilage heals,4ven if the cartilage heals,

irregularity of the jointirregularity of the joint

surface may causesurface may cause

localiCed stress and solocaliCed stress and sopredispose topredispose to secondarysecondary

osteoarthritisosteoarthritis years lateryears later

OSTEOART)RITISOSTEOART)RITIS


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OSTEOART)RITIS

-alunion of a metaphyseal-alunion of a metaphysealfracture may radically alterfracture may radically alter

the mechanics of a nearbythe mechanics of a nearby

joint and this, too, can joint and this, too, can

give rise to secondarygive rise to secondary

osteoarthritis.osteoarthritis.


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Complications of Fractures and Management_hso

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