Complications

of
the
fractures
Submitted by
:-

Amit
Kochhar

Complications From
Fractures
• Fracture is a common event: most of us
will experience at least one during a
lifetime.
• In modern times, with medical and surgical
assistance, the majority heal without
problem or significant loss of function.
• However, complications can pose risk to
limb and even life.

Classification
• Complications of fractures tend to be
classified according to whether they
are local or systemic and when they
occur –
Early
Late

Early complications
• Early complications occur at the time
of the fracture (immediate) or soon
after.
• They are again classified intoLocal
Systemic

• Early local complications tend to
affect mainly the soft tissues.

Local Early complications
• Vascular injury causing haemorrhage,
internal or external
• Visceral injury causing damage to
structures such as brain, lung or bladder
• Damage to surrounding tissue, nerves or
skin
• Haemarthrosis
• Compartment syndrome (or Volkmann's
ischaemia)

• Wound Infection, more common for open
fractures
• Tetanus
• Gas gangrene
• Injury to joints

Vascular injury

Visceral injuries

Nerve and skin tissue
damage

Open Humeral fracture with Radial Nerve
Injury

Haemarthrosis

Bleeding in the joint because of fracture

Compartment syndrome
• Fractures of the limbs can cause severe
ischaemia, even without damage to a major blood
vessel
• . Bleeding or oedema in an osteofascial
compartment increases pressure within the
compartment, reducing capillary flow and causing
muscle ischaemia
• A vicious circle develops of further oedema and
pressure build-up, leading swiftly to muscle and
nerve necrosis.
• Limb amputation may be required if untreated.

• Compartment syndromes can also
result from:
Crush injuries caused by falling debris or
from a patient’s unconscious compression
of their own limb.
Swelling of a limb inside an over-tight cast.

• Compartment syndrome can occur in any
compartment, e.g. the hand, forearm,
upper arm, abdomen, buttock, thigh, and
leg.
• 40% occur following fracture of the shaft
of the tibia (with an incidence of 1-10%)
and about 14% following fracture of a
forearm bone.
• Risk is highest in those under 35 years.

• Compartmental syndrome may lead
to the Volkmann's ischaemia:

• Presentation: Signs of ischaemia (5 P's: Pain,
Paraesthesia, Pallor, Paralysis,
Pulselessness)
 Signs of raised intracompartmental
pressure:
1. Swollen arm or leg
2. Tender muscle - calf or forearm pain on
passive extension of digits
3. Pain out of proportion to injury
4. Redness, mottling and blisters

 Watch for signs of renal failure

• Management
Remove/relieve external pressures
(fasciotomy)
Prompt decompression of threatened
compartments by open fasciotomy
Debride any muscle necrosis
Treat hypovolaemic shock and oliguria
urgently
Renal dialysis may be necessary

Removal of extra
pressure(fasciotomy)

• Complications
Acute renal failure secondary to
rhabdomyolysis
DIC
Volkmann's contracture (where infarcted
muscle is replaced by inelastic fibrous
tissue)

Gas gangrene
• Clostidium welchii ( perfringens )
• Clinical presentation
 Subcutaneous crepitation
 Myonecrosis

• Treatment
Debridement
 Penicillin

tetanus
• Causative agent
Clostidium tetani
Release exotoxin

• Symptoms
TRISMUS
DYSPHAGIA
RISUS SARDONICUS
OPIS THOTONAS

• Treatment
Immunoglobulin
Bed rest and sedation
 Respiratory support
 Penicillin

Injury to joints

AC joint injury after clavicle and scapular
fracture

Systemic early
complications



Fat embolism
Shock
ARDS
Thromboembolism (pulmonary or
venous)
• Exacerbation of underlying diseases
such as diabetes or CAD
• Pneumonia

• Aseptic traumatic fever
• Septicaemia
• Crush syndrome

Fat embolism

• This is a relatively uncommon disorder that occurs
in the first few days following trauma with a
mortality rate of 10-20%
• Fat drops are thought to be released mechanically
from bone marrow following fracture, coalesce and
form emboli in the pulmonary capillary beds and
brain, with a secondary inflammatory cascade and
platelet aggregation
• An alternative theory suggests that free fatty acids
are released as chylomicrons following hormonal
changes due to trauma or sepsis
• 5 Risk of Fat Embolism Syndrome (FES) increases
with number of fractures, but is also seen following
severe burns, CPR, bone marrow transplant and
liposuction.6

• Risk factors
Closed fractures
Multiple fractures
Pulmonary contusion
Long bone/pelvis/rib fractures

• Presentation
• Sudden onset dyspnoea
• Hypoxia
• Fever
• Confusion, coma, convulsions
• Transient red-brown petechial rash
affecting upper body, especially axilla

• Treatment :Respiratory support
Heparinisation
Intravenous low molecular weight
dextran(lomodex 20) and corticosteroids.

Hypovolaemic shock

Bleeding after trauma
Shock

Hypovolaemic

Acute respiratory distress
syndrome

Deep vein thrombosis
• Common complication associated with lower
limb injuries and with spinal injuries
• D.V.T. proximal to the knee
is a common cause of life
threatening complication
of Pulmonary embolism
• Causes:Immobilization following trauma
Fracture of the leg

• Symptoms:Leg swelling
Calf tenderness

Leg swelling

Deep vein thrombosis
Phlebogram:
a. Normal (right calf)
b. Thrombosis (left calf)
c. Femoral vein
thrombosis

• Consequences: pulmonary embolism
Tachypnoea
Dyspnoea
4-5 days after trauma

• Treatment:Elevation of the limb
Anti coagulating therapy
Respiratory support and heparin therapy{
respiratory embolism}
Early internal fixation of flexors
Active mobilization of the extremity

pneumonia
• Bed rest after fracture
and during surgery
can increase the
vulnerability
• Up to half of the patients
with significant chest
injuries develops pneumonia

Aseptic traumatic fever
• Aseptic traumatic fever: This is
supposed to be due to absorption of
fibrin ferment taking place.
• It may, however, be due to some
irritation, as of a badly fitting splint,
and disappears on removal

Septicaemia
• Because of trauma a large amount of
bacteria can enter in the blood stream
and may cause septicemia

Symptoms

• Management
 Initial Resuscitation - ABC
1. Secure airway
2. Support breathing
3. Restore circulation
 Fluid therapy
 Inotropic Support
 Antimicrobial therapy
 Respiratory Support

Crush syndrome
• Crushing injury to skeletal muscles
because of the fracture
• Complications
Shock
Renal failure

• Management
To avert disaster, a limb crushed severely
and for several hours should be amputated

Crush injury

Late complications
• Late complications are those which occur
after a substantial time has passed and
are as a result of defective healing
process or because of the treatment itself.
• They are again classified into two groups:
Imperfect union of the fracture

others

Imperfect union of the
fracture
• They are again classified into four sub
groups:
 Delayed

union
 Non-union
 Mal-union
 Cross-union

Delayed union
• When a fracture takes more than the
usual time to unite, it is said to have
gone in delayed union
• Causes:
 Inadequate blood supply
 Infection
 Incorrect splintage
1. Insufficient splintage
2. Excessive traction

Intact fellow bone: if one bone in the
forearm or leg is unbroken, the fractured
ends of the other may be held apart, end
some delay then follows
Internal fixation: open reduction with internal
fixation of a fracture delays union

• Signs:
The fractured site is usually tender
The bone may appear to move in one piece,
if however, it is subjected to stress , pain is
immediately felt and the bone may angulate;
The fracture is not consolidated
X-ray: the fractured site is still clearly visible,
but the bone ends are not sclerosed

Treatment:
 Conservative:
1. Plaster should be sufficiently extensive and
must fit accurately
2. Replace traction by plaster splintage
3. Use of functional bracing

 Operative:
1. If a fractured tibia is being held apart by a fibula
which was not fractured or which has united
quickly, it is worth while excising 2.5 cm of fibula
and reapplying plaster

Non-union
• When the process of fracture healing
comes to a stand before its
completion, the fracture is said to
have gone in non –union.
• It is not before six months that a
fracture can be so labelled.

Causes :
 The injury
1.
2.
3.
4.

Soft tissue loss
Bone loss
Intact fellow bone
Soft tissue inter position

 The bone
1.
2.
3.
4.

Poor blood supply
Poor haematoma
Infection
Pathological lesion

The surgeon
1.Distraction
2.Poor splintage
3.Poor fixation
4.Impatience

The patient
1.Immense
2.Immoderate
3.Immovable
4.impossible

• Signs
Movement can be elicited at the fracture site,
and this movement (unless excessive) is
painless; such painless movement is diagnostic
of non-union as distinct from delayed union

X-ray:


1.

The fracture is visible and the bone on each side of
it may be sclerosed.
2. Two varieties of non-union can be distinguished :
I. Hypertrophic, with bulbous bone ends,
indicating estrogenic activity (as if in the attempt
to form bridging callus).
II. atrophic, with no calcification around the bone
ends

Treatment
 Conservative:
1. Occasionally symptom less, needing no
treatment
2. Functional bracing may be sufficient to induce
union
3. Electrical stimulation promotes osteogenesis

 Operative
1. Very rigid internal fixation with hypertrophic
non-union
2. Fixation with bone graft is needed in case of
atrophic non union

Mal-union

Causes
 Primary
1. The fracture was never reduced and has united
in a deformed position.
2. Shortening is, of course, one type of deformity.

 Secondary
1. The fracture was reduced but the reduction was
not held.
2. Redisplacement may occur during the first
week, and a check x-ray at 1 week is advisable.

• Signs:
The deformity is usually obvious.
There may be painful limitation of joint
movements
At elbow, valgus deformity may present
with delayed ulnar palsy

Treatment:
 Conservative
1. If shortening is the main feature a raised shoe
is usually sufficient
2. In child usually no treatment is required
because it is expected to correct by
remodelling

 Operative
1.
2.
3.
4.

Osteotomy
Excision of protruding bone
Osteoclasis
Redoing the fracture surgically

Cross union
• Sometimes radio-ulnar and tibiofibular fractures may undergo crossunion

Other late complications







Avascular necrosis
Shortening
Joint stiffness
Sudeck’s dystrophy
Osteomyelitis
Volkmann’s Ischaemic contracture
Myositis ossificans
Osteoarthritis

Avascular necrosis
• Blood supply of some bones is such
that the vascularity of a part of it is
seriously jeopardized following
fracture, resulting in necrosis of the
part.

Site

Cause

Fracture neck of the
Head of the femur femur.
Posterior dislocation of
the hip
Proximal pole of
Fracture through the
scaphoid
waist of the scaphoid
Body of the talus

Fracture through neck of
the talus

• Consequences:Avascular necrosis causes
deformation of the bone. This leads, a
few years later, to secondary
osteoarthritis and causes painful
limitation of joint movement.

Diagnosis: X-ray changes:1. Sclerosis of the necrotic area
2. Deformity of the bone
3. Osteoarthritis

 Bone scan:- changes can be seen
before X-ray changes:
1. Visible as cold area on the bone

Avascular necrosis of the head of the femur
(Bone scan)

Treatment:- Avascular necrosis can
be prevented by early, energetic
reduction of susceptible fractures
and dislocations. Treatment options:
1. Delay weight bearing till revascularization
to prevent collapse
2. Revascularization
3. Excision of the avascular segment
4. Total joint replacement

Shortening

It is a common complications of
fractures and results from:1. Mal union of the long bones
2. Crushing: Actual bone loss
3. Growth defects: growth plate
or epiphyseal injuries

Treatment: Shortening of upper limbs goes unnoticed
 For lower limb treatment depends upon the
amount of shortening:
1. Shortening less than 2 cm: compensated by
shoe raise
2. Shortening more than 2 cm: limb length
equalization procedures

Joint stiffness
• It is a common complications of
fracture treatment.
• Shoulder, elbow and knee joints are
particularly prone to stiffness
following immobilization

Causes: Intra-articular or Para-articular adhesions
secondary to immobilizations
 Contracture of the muscles around a joint
because of prolonged immobilizations
 Tethering of muscles at fracture site
 Myositis ossificans

Consequences: Hampers the normal physical activity
 Results in late osteoarthritis

• Treatment:Heat therapy and exercise

 Manipulation of the joint under anesthesia

 Surgical interventions
1. To excise an extra articular bone block
2. To lengthen contracted muscles
3. Joint replacement, if there is pain due to
secondary arthritis

Sudeck’s dystrophy
• Also known as Reflex Sympathetic
Dystrophy.
• Involves a disturbance in the
sympathetic nervous system.
• Consequences:Pain
Hyperaesthesia
Tenderness
Swelling

Skin become red, shiny and warm in early
stages
Progressive atrophy of the skin, muscles and
nails in later stages
Joint deformity and stiffness ensues
X-ray shows characteristic spotty rarefaction

Bone scan

• Treatment:Occupational therapy and physiotherapy
constitutes the principle modality of
treatment.
Further trauma in the form of an operation
or forceful mobilizations is injurious.
Use of β-blocker.
In resistant cases, sympathetic blocks have
been shown to aid in recovery.

Osteomyelitis
• Osteomyelitis is an infection of a
bone.
• Many different types of bacteria can
cause osteomyelitis.
• However, infection with a bacterium
called Staph. aureus is the most
common cause. Infection with a
fungus is a rare cause.

After operative treatment of fracture
bacteria may spread to the bone and
may cause osteomyelitis.
Treatment: Antibiotics
 Surgery:
1. in case of abscess formation
2. The infection presses on other important
structures
3. The infection has become 'chronic' (persistent)
and some bone has been destroyed.
4. Hyperbaric oxygen

Volkmann’s ischaemic
contracture
• This a sequel to Volkmann's
ischaemia.
• The ischaemic muscles are replaced
by fibrous tissue
• If the peripheral nerves are also
affected, sensory or motor paralysis
may happen

• Clinical features:Marked atrophy
Skin becomes dry and scaly
Flexion deformity
Nails shows atrophic changes

• Treatment:Mild deformity can be corrected by passive
stretching using a turn-buckle splint
(Volkmann's splint)

For moderate deformities, a soft tissue sliding
operation, where the flexor muscles are
released from their origin, is performed
For a severe deformity, bone shortening
operations may be required

Myositis ossificans
• Myositis ossificans is where
calcifications and bony masses
develop within muscle and can occur
as a complication of fractures.
• It may also happens because of the
ossification of the hematoma around
a joint after a compound fracture.

• Clinical features:Pain ,
Tenderness ,
Focal swelling, and
Joint/muscle contractions

• Treatment:Massage following injury is strictly prohibited.
In early stages rest is advised
NSAIDS may help to reduce pain

In late stages Occupational and
Physiotherapy is prescribed to regain
movements
Ultra sound
In some cases surgical excision of myositic
mass is done

osteoarthritis
• Osteoarthritis is liable to follow
malunion and traumatic injuries to the
joints.
• Joint surfaces become incongruent
• Direction of stress transmission is
abnormal
• Increase wear and tear at the joint

Treatment: Osteoarthritis cannot be cured,
but it can be treated
 The goal of every treatment for
arthritis is to:1. reduce pain and stiffness,
2. allow for greater movement, and
3. slow the progression of the disease

 Anti-Inflammatory Medications

Cortisone Injections
Occupational and physiotherapy
Weight Loss
Activity Modification
Diet: obesity is a risk factor for developing
osteoarthritis

References
• Apley’s system of orthopaedics and fracturesA. Graham Apley
Louis Solomon
• Essential orthopaedics- J. Maheshwari
• Adam’s outline of orthopaedics
• http://www.patient.co.uk/showdoc/40001214/
• Google search

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