BONE HEALING,FRACTURE

COMPLICATIONS,COMPARMENT
SYNDROME
PROF.DR.DENİZ GÜLABİ
MARMARA UNIVERSITY, FACULTY OF MEDICINE, ORTHOPAEDIC AND
TRAUMATOLOGY DEPARTMENT
FRACTURE?

Break in the structural continuity

Of bone.
Fracture; break in the structural continuity of bone
WHY IS IMPORTANT?

► ONE OF THE MOST IMPORTANT CAUSE OF MORBIDITY, MORTALITY.

► Especially age over 65 years old.

 mechanısm

► Dırect trauma (fall from a height)

► Traffıc accident

► Rotational trauma(ankle fracture)

► Muscle contraction
CLASSIFICATION

► COMPLET Fracture
► Fracture of both cortex
Complete Fractures
Comminuted fx
Incomplete Fractures

Fracture of one cortex

Incomplete Fractures
Greenstick fx – fracture of one cortex
Incomplete Fractures
Torus fx – buckling of the cortex
 Location
proximal, middle, distal third of the shaft
head, shaft, base
epiphyseal, metaphyseal, diaphyseal
supracondylar, subtrochanterIc
Open fractures

Exposure of bone and deep tissue to the environment.

► Leads to incresed risk of infection, wound complications and nonunion.
 OPEN FRACTURES

► the fractured bone is in relation

with the exterior enviroment
► it can be totally exposed or there
might be just a small wound over
the skin
 OPEN FRACTURES

► surgical emergency !!!

► unstable fractures should be

immedietaly stabilized and
antibiotic and tetanus
prophylaxis should be started
ASAP !!
OPEN FRACTURES
GUSTILLO ANDERSON
G-A TYPE 1
Gustilo-Anderson tip 2
Gustilo-Anderson TYPE 3

► 3 Subgroups
► 3A: skin lesion(defect) bigger than
10 cm but soft tissue coverage can
be maintained.
► 3B: FLAP coverage is required to
provide soft tissue coverage.
► 3C: Associated with an arterial
injury repiar for limb salvage.
 OPEN FRACTURES

► Orthopaedic emergency.
► Washing the wound with serum isotonic or water.
► If possible do it in sterile conditions at the operating theatre, and also
debritman (dead tissues)
► Tetanus prophylaxis and start antibiotics.
► Closing the wound.
► ANTIBIOTICS are the most important factor of preventing INFECTION.
 G-A TYPE 3 FRACTURES

► FRACTURE THAT HAVE SEGMENTEL PATERN

► DIRTY FRACTURE (farm and agricultural injury)
► GUN SHOT FRACTURE
► ARTERIAL INJURY
► FRACTURES ASSOCIATED WITH COMPARTMENT SYNDROME
► OPEN FRACTURES THAT WERE UNTREATED FOR 24 HOURS
Direction of Fracture Lines
3. Relationship of the fracture fragments to each other

apposition (shift) alignment (tilt)

rotation (twist) altered length

Pathologic Fractures

► Bone related problems or systemic

disease that cause bone fractures
► Bone related (tumors, cysts,
osteomyelitis)
► Systemic disease:rickets,
osteomalacia, osteogenesis
imperfekta, osteoporosis .)
► Neuropathic causes:loss of pain
and proprioseption, the patient can
not balance the weight and bone
fractures can be occured.
► DM is the most common cause of
neuropathy.
 STRESS FRACTURES

► Sports related injuries and also seen in soldiers as a cause of recurent

mictotraumas on the bone.
► Most common at Lower extremity . TIBIA and METATARSAL BONES.
► Pain and swelling.
► No sign of Radiology at onset. BONE SCINTIGRAPHY OR MRI favourable to
diagnosis.
► Treatment: Conservatively, prevent sportive activity.NSAID.
Tibial stress kırığı
CLASSIFICATION

► LOTS OF CLASSIFICATIONS.
► Müller and et all.(AO-OTA) .
► This classification depends on numbers and letters.
► Humerus:1
► Radius and ulna:2
► Femur:3
► Tibia:4
► Vertebra:5
► Pelvis:6
► hand:7
► foot:8
► Anatomical side of the bone:
proximal:1
► Diaphysis:2 distal:3
60 years old, male patient tibia shaft
fracture, AO-OTA type ?
AO/OTA?
DIAGNOSIS

► Anamnesis (trauma, medical history)

► Physical assessment
► Shortness, rotational deformity
► Pain
► Pathological movement
► swelling, ecchymosis
► Functional loss
► Some fractures were seen together;

► VERTEBRA FRACTURE and CALCANEUS FRACTURE

► MOST COMMON CARPAL BONE FRACTURE: SCAPHOİD

► MOST COMMON METACARPAL FRACTURE: 5. METACARPAL FRACTURE;

PUNCHING.BOXER FRACTURE.
RADIOLOGY

► AP/LATERAL graphies of the related

bones also involved adjacent
joints.
► Some times oblique graphies
especially for hand and foot
fractures.
► Some fractures can not be seen at

► acute period under standart Xrays,

► In this condition MRI is a choice..

 Treatment

► Aplly (A,B,C,D,E) emergency PRINCIPLES.

► Firstly norovascular examination, later put the injuried extremity in cast for
► immobilization.
 TREATMENT

► CONSERVATİVE
► CLOSED REDUCTION AND
CAST(PARİS AND SOFT CASTS),
SPLINTS OR BRACE FOR
IMMOBILIZATION.
► SURGERY
► PLATE SCREWS, IM NAILS, EF AND
PROTHESİS.
► First orthopaedic trauma surgery
was done by Scottish surgeon Lister
for open tibia fracture at 1865.
 CAST COMPLICATIONS

► Pressure sores
► Pain
► DVT
► Skin rashes
► Norological problems
► Thermal burns
► Compartment syndrome
 BONE HEALING

► 3 PHASES.
► 1.PHASE: INFLAMMATORY PHASE:
The shortest phase
► 2.PHASE: REPERATİVE : SOFT and
HARD callus.
► 3.PHASE: REMODELLİNG PHASE:
Longest phase.
Stages of Fracture Healing

1. fracture >>> hematoma

2. formation of granulation tissue around
fractured bone ends
3. replacement of granulation tissue by callus
4. replacement of callus by lamellar bone
5. remodeling of bone to normal contour
 1. INFLAMMATORY PHASE
Break in continuity of Injured muscle
bone and periosteum (and other soft tissue)

Hematoma

Cloting of
medullary
capilleries
Dead osteocytes
-necrotic tissue-

Acute intense inflammatory

response vasodilatation

Edema Exudation (PMNL,

macrophages)
2. REPERATIVE PHASE

▪ Clotted hematoma is absorbed

▪ Neovascularization
▪ Intense proliferation of osteoprogenitor cells of endosteum and
periosteum
Osteogenic cells (osteoblasts)
→ collagen formation, calcium
hydroxyapetite deposition
CALLUS
Chondrogenic cells (chondroblasts)
→ cartilage formation

first signs of clinical union (4 weeks)

then comes radiological union (6 weeks)

3. REMODELLING PHASE

Months to years
Reshaping of the formed bone
Factors Affecting Fracture Healing

Favorable
Unfavorable

Favorable:

• fracture through cancellous bone

• soft tissue Injury minimal and hematoma well contained
• no shearing or rotatory stresses at fracture site
• fracture at ends of bone (excellent blood supply)
Unfavorable:
SMOKING !!!!

• Impairment or loss of blood supply to fragments

• Intraarticular fractures
• some systemic disorders
• osteoporosis
• malnutrition
• chronic hypoxia
• certain drugs
• corticosteroids
• excessive thyroid hormones
 FRACTURE COMPLICATION

► INFECTION
► Soft tissue to OSTEOMYELITIS.
► Prevent infection after open fractures the most important factor is ANTIBIOTIC
PROPHYLAXIS.
► For wound care G-A type 1: 3 litres G-A Type 2: 6 Litres G-A Type 3: 9 Litres.
► Antibiotic prophylaxis: 1. generation cefalosporin
► Dirty wounds especially for gr(-) Aminoglicozide or tobramycin
► For Anaerop organisms high dose penicillin or flagyl.
COMPARTMENT SYNDROME

► It is the increase of interstitial pressure in the closed osteofascial

compartment, which disrupts microvascular circulation.
► It can be seen in all extremities after fracture, especially in the tibia, hand
and foot, especially after closed fracture.
► IT IS CONSIDERED if the compartment pressure is above 30 mmHg.
5 P SIGNS
► PAIN IS THE MOST IMPORTANT CLINICAL FINDING
► PALLOR (PALNESS, WHITENING IN COLOR)
► PULSELESSNESS: DISAPPEARANCE OF PULSES
► PARESTHESIA: LOSS OF SUPERFICIAL SENSE, TWO-POINT DISCRIMINATION
PARALYSIS: ENGINE LOSS. After this stage it is irreversible.
► The most pathognomonic examination finding: Severe pain occurs with passive
movements of the muscles passing through the relevant compartment.
 TREATMENT

► SURGICAL RELEASE OF THE RELEVANT

COMPARTMENT URGENTLY (FASCIOTOMY)
DELAYED UNION AND NONUNION

► IF THERE IS NO CALLUS FORMATION AT THE FRACTURE SIDE AFTER 6-9 MONTHS

DELAYED UNION.

► 3 MONTHS AFTER DELAYED UNION IS NONUNİON.

Delayed union AND nonunion

► Local causes
► Open, segmentel fractures,
infection,inaduquate boneblood
supply, insuffcient internal
osteosynthesis

► Systemic factors
► Patient health condition, smoking,
nutrition, pain killers.
MALUNİON
 MALUNION

► Union of bone fragments at nonanatomic position.

► Results in osteoarthritis and joint stiffness.

 ETIOLOGY

► IMPROPER REDUCTION

► INSUFFICIENT IMMOBILIZATION
 TREATMENT

► REGAIN ALIGNMENT, LENGTH AND ROTATION BY CLOSE OR OPEN TECHNIQUE.

VASCULAR INJURY
► SupraCondylar humerus fracture➜➜ Brachial Arter.

► Supracondylar femur ve tibia plato fracture ➜➜ POPLİTEAL ARTER

► Femur diaphsis fracture ➜➜ FEMORAL ARTER

► Clavikula fracture ➜➜ SUBCLAVİAN ARTER

► Pelvis fracture ➜➜ PRESACRAL VENOUS PLEXUS

► ORTHOPAEDIC EMERGENCY
► First fix the fracture especially
► with EF then call vascular surgeon
► to repair the arter.
AVASCULAR NECROSIS
► Results of vascular impairment because of fracture.
► Late(chronic) sign.
► Subchondral sclerosis and collapse of the head.
► Pain and ROM restriction. Early stages: MRI for Diagnosis.
► Treatment: SURGERY (COMMONLY). Core-decompression(drilling of the
necrotic portion of the head), core decompression and grefting(autogrefts or
allogrefts), core-decompression and vascularized fibula, rotational
osteotomies to prevent the collapse of the femoral head, total hip
arthroplasty.
NOROLOGICAL INJURY
FRACTURES AND NERVE INJURY

► Most common nerve injuries that accompanied the fractures

► Shoulder fracture dislocation➜➜➜ AXILLER NERVE

► HUMERUS SHAFT FX ➜➜➜ RADIAL NERVE

► RADIAL HEAD FX ➜➜➜ POSTERIOR İNTEROSSEOUS NERVE

► FIBULAR HEAD FX ➜➜➜ PERONEAL NERVE

AXILLER NERVE

► Originates from C5-6 Roots.

► Brakial plexsus- superior truncus-posterior cord- radiaL nerve

► Active abduction of the shoulder, deltoid atrophy and hypoesthesia of the

shoulder.
 Radial nerve ınjury

► C5-T1 spinal roots

► Brachial plexus- posterior cord.

► Sensation of the dorsal side of the
hand, posterolateral side of the
forearm.
► İnnerves mainly Triceps,
brakioradialis, ancaneus, ECRL ve
ECRB.
► DROP ARM, LOSS OF SENSATION.
Posteior interosseous nerve injury

► Only motor branch, no sensory

branch
► EDC, EDM, ECU,EİP,EPL, EPB, APL
muscles
Peroneal nerve injury

► Dorsiflexion of the foot and ankle.

► DEEP BRANCH:TA, EHL,EDL,EHB,
EDB, PERONEOUS TERTİUS muscles
innervation, sensation of the
dorsum of the 1. web.
► SUPERFICIAL : PL ve PB. MUSCLE
innervation.
► Sensation of the foot other than 1.
web, and lateral side of the cruris.
heterotrophic ossification (HO)
► HO Heterotopic Ossification is the formation of bone in atypical, extraskeletal
tissues that may occur following localized trauma.

► Clinical signs: Patients typically present with painless loss of motion of the
affected joint.

► Treatment is focused on prevention with oral indomethacin and perioperative

radiation. Surgical excision is indicated in the presence of mature lesions
associated with severe loss of motion and function.
FAT EMBOLISM
► Fat Embolism Syndrome is an acute respiratory disorder caused by an
inflammatory response to embolized fat globules that may enter the
bloodstream as a result of acute long bone fractures or intramedullary
instrumentation. Patients present with hypoxia, changes in mental status, and
petechial rash.
• Incidence 3-4% with isolated long bone trauma
• 10-15% with polytrauma
► Muttiple systems are affected, the most commons are lungs, brain,
cardiovascular system and skin.
• symptoms usually present within 24
hours of inciting event
• Symptoms :patient complains of
feeling "short of breath», patient
appears confused,tachycardia,
tachypnea, petechiae (axillary
region, conjunctivae)
Radiology and lab signs are
nonspecific.
Supportive approaches including
early fixation of the fracture,
ensuring fluid-electrolyte balance
and eliminating hypoxia are
recommended in the treatment.
DEEP VEIN THROMBOSIS AND PULMONARY
EMBOLI
► Risk factors
► Smoking
► Varicose veins
► Spinal cord injury
► Immobilization
► senility
► Obesity
► history of thromboembolism
► Genaral anesthezia
► Hip and vertebra fractures
DVT signs

► swelling
► pain
► Homans test positive.
► Diagnosis
► .Venography is gold standard
Pulmoner Embolism

► pain
► dyspnea
► tachycardia
► tachypnea
DIAGNOSIS

► PULMONER
ANJIOGRAPY
GOLD
METHOD .
 PE TREATMENT

► Heparin (7-10) days than warfarin.

(3 months)
► Use PTT labratory test for dosage
of HEPARIN.
► INR for Kumadin.
SUDECK ATROPHY (Posttraumatic Reflex
Sympathetic Dystrophy)
RSD

is an idiopathic condition caused by an aberrant inflammatory response that leads

to sustained sympathetic activity. Patients present with extremity pain out of proportion to
physical exam findings

► Lankford and Evans classification: 3 phases

► Acute stage: 0-3 moths. pain,swelling, redness, hyperhidrosis, hyperesthesia.
► Imaging: Normal x-rays, positive three-phase bone scan
► Subacute stage:(dystrophic stage) 3-12 months. Worsening pain, cyanosis, dry skin,
stiffness, skin atrophy
► Imaging:subchondral osteoporosis
► Chronic stage: (atrophic) after 12 months. Diminished pain, glossy skin, fibrosis, joint
contractures, loss of hair and nails
► Imaging: Extreme osteopenia on x-ray
 TREATMENT

► Nonoperative
► Physical theraphy
► Drugs (betablocker, alpha blocker
steroids, anti-epileptics,
antidepressants, Gaba agonists,
bisphosphonates, calcitonin)

► Operative
► Sympathetic blockade or
sympathectomy