Complications of FracturesComplications of Fractures

COMPLICATION OF COMPLICATION OF FRACTUREFRACTURE

General Local

Early Late

General complications Shock

Hypovolemic or hemorrhagic shock. Septic shock. Neurogenic shock.

Fat embolism. Pulmonary embolism. Crush syndrome. Multiple organs failure syndrome (MOFS). Thrombo-embolism. Tetanus. Gas gangrene.

Local complications Early

1. Visceral injury (the lung, the bladder, the urethra, and the rectum).

2. Vascular injury.

3. Nerve injury.

4. Compartment syndrome.

5. Haemoarthrosis.

6. Infection.

7. Gas gangrene.

8. Fracture blisters.

9. Plaster and pressure sores.

Late

1. Delayed union.

2. Non-union.

3. Malunion.

4. Avascular necrosis.

5. Growth disturbance.

6. Bed sore.

7. Myositis ossificans.

8. Muscle contracture.

9. Tendon lesions.

10. Nerve compression and entrapment.

11. Joint instability.

12. Joint stiffness.

13. Complex regional pain syndrome. ( algodystrophy).

14. Osteoarthritis.

General complicationsGeneral complications

ShockThree types of shock may complicate

fracturesHypovolemic or hemorrhagic shockThis type of shock is due to blood loss due

to vascular injury. The vessels may be injured by the fracture pieces or in open fractures the vessels are injured by the same cause like in missile or bullet

injury.In hypovolemic shock there will be reduction in the circulating volume causing reduction in venous return and cardiac output.

The patient usually; severely pallor, shivering, rigor, hypotensive and sometimes comatose.

Treatment by 1) control of hemorrhage (may require surgery).

restoration of circulating volume (fluid and blood products).

Crush syndromeCrush syndrome

Occur inOccur inLarge bulk of muscle crushedLarge bulk of muscle crushedTourniquet left for TOO longTourniquet left for TOO long

What happened?What happened?11stst theory =Compression released theory =Compression releasedacid acid

myohaematin myohaematin enter the enter the circulationcirculationkidneykidneyblocks the tubulesblocks the tubules Renal failure and death.Renal failure and death.

What we can see?What we can see?

LimbLimb PulselessPulseless RedRed SwollenSwollen

Renal Renal Secretion diminishedSecretion diminished Low output uraemiaLow output uraemia AcidosisAcidosis

NeurologicallyNeurologically DrowsyDrowsynot treated not treated DEATH DEATH

How to treat it?How to treat it?

11stst rule = Limb crushed severely(>6hrs) rule = Limb crushed severely(>6hrs)

How the amputation done?How the amputation done?Above the compression or crushed injuryAbove the compression or crushed injuryBefore compression is releasedBefore compression is released

Venous thrombosis & Pulmonary Venous thrombosis & Pulmonary EmbolismEmbolism

Commonest Commonest Complications of Trauma Complications of Trauma & Surgery& Surgery

Most frequentlyMost frequentlyCalfCalfLess frequent in proximal of thigh & pelvisLess frequent in proximal of thigh & pelvis

Pulmonary EmbolismPulmonary EmbolismFrom Proximal of thigh & pelvisFrom Proximal of thigh & pelvis Incidence=5% & Fatal = 0.5%Incidence=5% & Fatal = 0.5%

What cause DVT?What cause DVT?

The primary cause in surgicalThe primary cause in surgicalHYPERCOAGULABILITYHYPERCOAGULABILITY of the Blood of the Blood

due to activation of due to activation of Factor XFactor X by by Thromboplastin Thromboplastin from from damaged tissuesdamaged tissues

Thrombosis occursThrombosis occurssecondary factors aresecondary factors areStasisStasisPressurePressureProlonged immobilityProlonged immobilityEndothelial damageEndothelial damageIncrease in no & stickiness of plateletIncrease in no & stickiness of platelet

What are the high risk group?What are the high risk group?

Old peopleOld peopleCardiovascular DiseaseCardiovascular DiseaseBedridden patientBedridden patientPatients undergoing hip arthroplastyPatients undergoing hip arthroplasty

What we can see in DVT?What we can see in DVT?

Pain the calf or thighPain the calf or thighSoft tissue tendernessSoft tissue tendernessSudden slight increase in temperatureSudden slight increase in temperatureSudden increase in pulse rateSudden increase in pulse rate

Homann’s Sign positiveHomann’s Sign positive

How to diagnose DVT?How to diagnose DVT?

Ascending venography (bilaterally)Ascending venography (bilaterally) US scanning (detecting prox DVT)US scanning (detecting prox DVT)Radioactive iodine labelled fibrinogen(clot)Radioactive iodine labelled fibrinogen(clot)Doppler technique (measure blood flow)Doppler technique (measure blood flow)

How about pulmonary embolism?How about pulmonary embolism?

Difficult to diagnose =only minority have Difficult to diagnose =only minority have symptoms (chest pain, dyspnoe, symptoms (chest pain, dyspnoe, heamoptysis)heamoptysis)

So high risk patients should be examine So high risk patients should be examine for pulmonary consolidationfor pulmonary consolidationX-rayX-rayPulmonary angiographyPulmonary angiography

How to prevent it?How to prevent it?

Prophylactic treatmentProphylactic treatmentFoot elevationFoot elevationGraduated compression stockingsGraduated compression stockingsExercise Exercise Anticoagulant treatmentAnticoagulant treatment

Subcut low dose heparin 5000 units preops & 3/7 Subcut low dose heparin 5000 units preops & 3/7 postops (but CI in older patientpostops (but CI in older patientbleeding)bleeding)

Change to low molecular weight heparin (less Change to low molecular weight heparin (less likely to cause bleeding)likely to cause bleeding)

What is the treatment?What is the treatment?

Localized DVTLocalized DVTElastic stockingsElastic stockingsLow dose subcut heparin (5000 unit)Low dose subcut heparin (5000 unit)

More extensive DVTMore extensive DVTBed restBed restElastic stockingsElastic stockingsFull anticoagulationFull anticoagulation

Heparin IV (10000 units 6 hourly)Heparin IV (10000 units 6 hourly)Continue for 5-7/7 with last 2/7 warfarin introduceContinue for 5-7/7 with last 2/7 warfarin introduce

How to treat Pulmonary Embolism?How to treat Pulmonary Embolism?

Cardiorespiratory resuscitationCardiorespiratory resuscitationOxygenOxygenLarge dose heparin (15 000 units)Large dose heparin (15 000 units)Streptokinase (dissolve clot)Streptokinase (dissolve clot)Antibiotics (prevent lung infection)Antibiotics (prevent lung infection)

TETANUSTETANUS

What is Tetanus?What is Tetanus?Tetanus organism live only in dead Tetanus organism live only in dead

tissuetissueexotoxin exotoxin blood & lymph to CNS blood & lymph to CNS anterior horn cellanterior horn cell

Will developWill developTonic clonic contractionTonic clonic contraction

Jaw and face (trismus and risus sardonicus)Jaw and face (trismus and risus sardonicus) Neck and trunkNeck and trunk Diaphragm and Intercostal muscle Diaphragm and Intercostal muscle

spasmspasmASPHYXIAASPHYXIA

What is the prophylaxis?What is the prophylaxis?

Active immunization (tetanus toxoid)Active immunization (tetanus toxoid)Booster doses (immunized patients)Booster doses (immunized patients)Non Immunized patientsNon Immunized patients

Wound toilet & antibioticsWound toilet & antibiotics If wound contaminated If wound contaminated antitoxinantitoxin

Treatment for TetanusTreatment for Tetanus

IV antitoxinIV antitoxinHeavy SedationHeavy SedationMuscle Relaxant drugMuscle Relaxant drugTracheal IntubationTracheal IntubationControlled respirationControlled respiration

GAS GANGRENEGAS GANGRENE

By clostridial infection (esp C.welchii)By clostridial infection (esp C.welchii)Anaerobic with low oxygen tensionAnaerobic with low oxygen tensionProduce toxinsProduce toxinsdestroy cell walldestroy cell walltissue tissue

necrosis necrosis SpreadingSpreading

The clinical featuresThe clinical features

Within 24 hoursWithin 24 hours Intense painIntense painSwelling Swelling Brownish dischargeBrownish dischargePulse rate increasedPulse rate increasedCharasteristis smellCharasteristis smellLittle or no pyrexiaLittle or no pyrexiaGas formation not markedGas formation not markedToxaemicToxaemiccomacomaDEATHDEATH

How to prevent it?How to prevent it?

Deep penetrating wound should be Deep penetrating wound should be EXPLOREDEXPLORED

ALL dead tissue ALL dead tissue completely EXCISEDcompletely EXCISEDDoubt about tissue viabilityDoubt about tissue viabilityleft it OPENleft it OPENNo antitoxinNo antitoxin

Treatment for gas gangreneTreatment for gas gangrene

The key = EARLY DIAGNOSISThe key = EARLY DIAGNOSISGeneral measures (fluid, IV antibiotics)General measures (fluid, IV antibiotics)Hyperbaric oxygen (limiting spread)Hyperbaric oxygen (limiting spread)Decompression of woundDecompression of woundRemoval of all dead tissueRemoval of all dead tissueAmputation (advanced case)Amputation (advanced case)

FAT EMBOLISMFAT EMBOLISM

Only minority patients with circulating fat Only minority patients with circulating fat globules will develop POST TRAUMATIC globules will develop POST TRAUMATIC RESPIRATORY DYSFUNCTIONRESPIRATORY DYSFUNCTION

Source of fat emboli=bone marrowSource of fat emboli=bone marrowUsually in MULTIPLE CLOSED Usually in MULTIPLE CLOSED

FRACTUREFRACTUREBut other condition also reported (burns, But other condition also reported (burns,

renal infarction, cardiopulmonary renal infarction, cardiopulmonary operation)operation)

How can we detect it?How can we detect it?

Usually young adults with LL fractureUsually young adults with LL fractureEarly warning signs (72 hrs. of injury)Early warning signs (72 hrs. of injury)

Rise in temperature and pulse rateRise in temperature and pulse rateMore pronounced caseMore pronounced case

BreathlessnessBreathlessnessMild mental confusionMild mental confusionPetechia (chest & conjuntival fold)Petechia (chest & conjuntival fold)

Most severe caseMost severe caseMarked respiratory distress Marked respiratory distress coma coma ARDSARDS

How to treat it? How to treat it? Mild caseMild case

Monitoring of blood PO2Monitoring of blood PO2Signs of hypoxia Signs of hypoxia

OxygenOxygen If severeIf severe

Intensive care with sedation and assisted ventilationIntensive care with sedation and assisted ventilationSwan ganz Catheterization (monitor cardiac Fx)Swan ganz Catheterization (monitor cardiac Fx)Fluid balanceFluid balanceSupportive Supportive

Heparin-thromboembolismHeparin-thromboembolism Steroids-pulmonary oedemaSteroids-pulmonary oedema Aprotinin-prevent aggregation of chylomicronsAprotinin-prevent aggregation of chylomicrons

COMPLICATION OF COMPLICATION OF FRACTUREFRACTURE

General Local

Early Late

* Early complication : those that arise during the first few weeks following injury.

Early ComplicationEarly Complication

Local Visceral InjuryLocal Visceral InjuryVascular InjuryVascular InjuryNerve InjuryNerve InjuryCompartment SyndromeCompartment SyndromeHaemarthrosisHaemarthrosis InfectionInfectionGas gangreneGas gangrene

Local visceral InjuryLocal visceral Injury

Fracture around the trunk are often Cx by Fracture around the trunk are often Cx by injury to the adjacent viscera :injury to the adjacent viscera :

Pelvic fracture Pelvic fracture

Rib fracture penetration to the lungs Rib fracture penetration to the lungs

Pneumothorax

Bladder and urethral rupture

Vascular injuryVascular injury

Most commonly – knee, femoral shaft, Most commonly – knee, femoral shaft, elbow, and humerus.elbow, and humerus.

Artery may be cut, torn, compressed or Artery may be cut, torn, compressed or contused. contused.

Intima may be detached, thrombus block, Intima may be detached, thrombus block, artery spasmartery spasm

Effect ?? ↓↓ bld flow coz Ischemia leads to Effect ?? ↓↓ bld flow coz Ischemia leads to tissue death & peripheral gangrenetissue death & peripheral gangrene

Common vascular injuries may associate with the following fractures.

1. First rib or clavicle fracture (subclavian artery).2. Shoulder dislocation (Axillary artery).3. Humeral supracondylar fracture (brachial

artery).4. Elbow dislocation (Brachial artery).

5. Pelvic fracture (presacral and internal iliac).6. Femoral supracondylar fracture (Femoral artery).7. Knee dislocation (Popliteal artery).8. Proximal tibia (popliteal or its branches).

Clinical featuresClinical features

Pt with ischemia may have 5 P’s:Pt with ischemia may have 5 P’s:- paraesthesia/numbness- paraesthesia/numbness- pain- pain- pallor- pallor- pulselessness- pulselessness- paralysis- paralysis

Investigate if suspect vascular injury : Investigate if suspect vascular injury : Angiogram Angiogram

TreatmentTreatment

Emergency treatmentEmergency treatmentAll bandages/splints removedAll bandages/splints removedThe fracture X-Ray again The fracture X-Ray again Circulation reassessed for next half hourCirculation reassessed for next half hour If no improvement, do vessels explorationIf no improvement, do vessels explorationSuture torn vessels, vein grafting, if Suture torn vessels, vein grafting, if

thrombosed do endarterectomythrombosed do endarterectomyAim: to restore bld flowAim: to restore bld flow

Nerve InjuryNerve Injury

Variable degree of motor and sensory loss Variable degree of motor and sensory loss along the distribution of the nervealong the distribution of the nerve

May be neurapraxia, axonotmesis or May be neurapraxia, axonotmesis or neurotmesisneurotmesis

Radial nerve is most frequently damaged Radial nerve is most frequently damaged nerves.nerves.

NerveNerve TraumaTrauma EffectEffect

AxillaryAxillary Dislocation of Dislocation of shouldershoulder

Deltoid paralysisDeltoid paralysis

RadialRadial # of humerus# of humerus Wrist dropWrist drop

MedianMedian Supracondylar # of Supracondylar # of humerushumerus

Pointing indexPointing index

UlnarUlnar # medial epicondyl # medial epicondyl humerushumerus

Claw handClaw hand

SciaticSciatic Post dislocation of hipPost dislocation of hip Foot dropFoot drop

Common Common peronealperoneal

Knee dislocation # Knee dislocation # neck of fibulaneck of fibula

Foot dropFoot drop

In closed injuries – nerve is seldom severed and In closed injuries – nerve is seldom severed and spontaneous recovery should be awaited.spontaneous recovery should be awaited.

In open fractures – complete In open fractures – complete lesion(neurotmesis) : the nerve is explored lesion(neurotmesis) : the nerve is explored during wound debridement and repaired.during wound debridement and repaired.

Compartment SyndromeCompartment Syndrome DefinitionDefinition       

Compartment syndrome involves the compression of Compartment syndrome involves the compression of nerves and blood vessels within an enclosed space, nerves and blood vessels within an enclosed space, leading to impaired blood flow and nerve damage. leading to impaired blood flow and nerve damage.

Fascia separate groups of muscles in the arms and legs Fascia separate groups of muscles in the arms and legs from each other. Inside each layer of fascia is a confined from each other. Inside each layer of fascia is a confined space, called a compartment, that includes the muscle space, called a compartment, that includes the muscle tissue, nerves, bones and blood vessels.tissue, nerves, bones and blood vessels.

A rise in pressure within these compartments may A rise in pressure within these compartments may jeopardize the blood supply to the muscles & nerves jeopardize the blood supply to the muscles & nerves within the compartment.within the compartment.

Causes:Causes:-any injury/infection leading to edema of muscle-any injury/infection leading to edema of muscle-fracture haematoma within the compartment-fracture haematoma within the compartment-ischemia to the compartment leading to muscle-ischemia to the compartment leading to muscle oedemaoedema

-Due to tight bandages or casts-Due to tight bandages or casts

Hallmark Symptoms:Hallmark Symptoms:      - severe pain that does not respond to - severe pain that does not respond to

elevation elevation or pain medication. or pain medication. - In more advanced cases, there may be - In more advanced cases, there may be decreased sensation, weakness, and decreased sensation, weakness, and

paleness paleness of the skin. of the skin.

Injuries with a high risk of developing Injuries with a high risk of developing Compartments synd:Compartments synd:

# of the elbow# of the elbow# of the forearm bone# of the forearm bone# of the proximal third of the tibia# of the proximal third of the tibia

The vicious cycle of The vicious cycle of Volkmann’s ischaemiaVolkmann’s ischaemia

Arterial ischaemia blood flowArterial ischaemia blood flow

Damage Damage

Direct injury

oedema

Compartmentpressure

5P’sPainPallorParaesthesiaPulselessParalysis

…………......…………….

Fasciotomy

A vicious cycle cont. until the total vascularity of A vicious cycle cont. until the total vascularity of the muscles and nerves is jeopardized.the muscles and nerves is jeopardized.

This result in ischaemic muscle necrosis and This result in ischaemic muscle necrosis and nerve damage. (within 12 hours)nerve damage. (within 12 hours)

The necrotic muscle undergo healing with The necrotic muscle undergo healing with fibrosis, leading to Volkmann’s contracture.fibrosis, leading to Volkmann’s contracture.

Nerve damage may result in motor and sensory Nerve damage may result in motor and sensory loss. In extreme case loss. In extreme case gangrene gangrene

clinically:clinically:

- should be tested by stretching the - should be tested by stretching the

muscles muscles when the toes or fingers are when the toes or fingers are

passively hyperextended there is ↑ pain passively hyperextended there is ↑ pain

in the calf or forearm.in the calf or forearm. Early preventing : limb elevationEarly preventing : limb elevation Dx : confirmed by direct intracompartmental Dx : confirmed by direct intracompartmental

pressure measuring > 40mmHg is an indication pressure measuring > 40mmHg is an indication of compartment decompression and fasciotomy.of compartment decompression and fasciotomy.

TreatmentTreatment

First removed all the bandages & dressing.First removed all the bandages & dressing.

Fasciotomy is performed.Fasciotomy is performed. The wound should be left open and inspected The wound should be left open and inspected

2 days later.2 days later. If there is muscle necrosis If there is muscle necrosis debridement debridement If muscle is healthyIf muscle is healthy suture (w/o tension)/ suture (w/o tension)/

skin grafted / simply heal by 2˚ intention.skin grafted / simply heal by 2˚ intention.

HaemarthrosisHaemarthrosis

Fractures involve joints, leads to acc. of Fractures involve joints, leads to acc. of blood within the joints.blood within the joints.

C/Feature :The joint is swollen and tense C/Feature :The joint is swollen and tense and patient will resists any movement.and patient will resists any movement.

Tx : the blood should be aspirated before Tx : the blood should be aspirated before dealing with the fracture.dealing with the fracture.

InfectionInfection

Causes:Causes: Open fracture (common)Open fracture (common) Use of operative method in the Tx of Use of operative method in the Tx of ##

Wound becomes inflamed and starts draining Wound becomes inflamed and starts draining seropurulent fluid.seropurulent fluid.

Infection may be superficial, moderate Infection may be superficial, moderate (osteomyelitis), severe (gas gangrene).(osteomyelitis), severe (gas gangrene).

Post-traumatic wound infx is most common Post-traumatic wound infx is most common cause of chronic osteomyelitis cause of chronic osteomyelitis union will be union will be slow and ↑ chance of refracturing.slow and ↑ chance of refracturing.

Treatment:Treatment:AntibioticAntibioticExcising all devitalised tissueExcising all devitalised tissue If Sx of acute infx and pus formation : If Sx of acute infx and pus formation :

tissue around the fracture should be tissue around the fracture should be opened & drainedopened & drained

Gas gangreneGas gangrene Produced by anaerobic orgs : Produced by anaerobic orgs : Clostridium sp Clostridium sp infections.infections. These orgs can survive in ↓ OThese orgs can survive in ↓ O22 tension tension Toxins produced will destroy the cell wall and leads to Toxins produced will destroy the cell wall and leads to

tissue necrosistissue necrosis C/feature: within 24hr. Pt complains:C/feature: within 24hr. Pt complains:

- intense pain- intense pain- swelling around the wound- swelling around the wound- brownish discharge- brownish discharge- gas formation - gas formation - pyrexia- pyrexia- characteristic smelling- characteristic smelling- PR ↑- PR ↑- toxaemic - toxaemic coma coma death death

Inability to recognize may lead to unnecessary amputation Inability to recognize may lead to unnecessary amputation for the non-lethal cellulitis.for the non-lethal cellulitis.

swelling around the wound,swelling around the wound,brownish dischargebrownish discharge

gas formationgas formation

Prevention:Prevention: deep penetrating wound in muscular tissue are deep penetrating wound in muscular tissue are

dangerous;should be explored, all dead tissue dangerous;should be explored, all dead tissue should be completely excised, and if there doubt should be completely excised, and if there doubt about the tissue viability should left open the woundabout the tissue viability should left open the wound

Treatment:Treatment: Early Dx is life savingEarly Dx is life saving General measures:General measures:

Fluid replacement & IV Antibiotic (immediate)Fluid replacement & IV Antibiotic (immediate) Hyperbaric OHyperbaric O2 2 (limiting the spread of gangrene)(limiting the spread of gangrene) Mainstay : prompt decompression & remove Mainstay : prompt decompression & remove

dead tissuedead tissue

LATE COMPLICATIONSLATE COMPLICATIONS

• Delayed unionDelayed union• Non-unionNon-union• MalunionMalunion• Joint stiffnessJoint stiffness• Myoisitis ossificansMyoisitis ossificans• Avascular necrosisAvascular necrosis• AlgodystrophyAlgodystrophy• OsteoarthritisOsteoarthritis

• Joint instabilityJoint instability• Muscle contracture Muscle contracture

(Volkmann’s contracture)(Volkmann’s contracture)• Tendon lesionsTendon lesions• Nerve compressionNerve compression• Growth disturbanceGrowth disturbance• Bed soresBed sores

DELAYED UNIONDELAYED UNION

Fracture takes more than the usual time to Fracture takes more than the usual time to unite.unite.

CausesCauses Inadequate blood supplyInadequate blood supply Severe soft tissue damageSevere soft tissue damage Periosteal strippingPeriosteal stripping Excessive tractionExcessive traction Insufficient splintageInsufficient splintage InfectionInfection

PERKINS’ TIME TABLEPERKINS’ TIME TABLE

Upper LimbUpper Limb Lower LimbLower Limb

Callus visibleCallus visible 2-3 wks2-3 wks 2-3 wks2-3 wks

UnionUnion 4-6 wks4-6 wks 8-12 wks8-12 wks

ConsolidationConsolidation 6-8 wks6-8 wks 12-16 wks12-16 wks

Clinical featuresClinical features Fracture tendernessFracture tenderness

(Esp when subjected to stress)(Esp when subjected to stress)

X-RayX-Ray Visible fracture lineVisible fracture line Very little callus formation or Very little callus formation or

periosteal reactionperiosteal reaction

Severe soft tissue Severe soft tissue damagedamage

InfectionInfection Excessive Excessive tractiontraction

Intact fibulaIntact fibula

TreatmentTreatment ConservativeConservative

- To eliminate any possible cause- To eliminate any possible cause

- Immobilization- Immobilization

- Exercise- Exercise OperativeOperative

- Indication : - Indication :

Union is delayed > 6 mthsUnion is delayed > 6 mths

No signs of callus formationNo signs of callus formation

- Internal fixation & bone grafting- Internal fixation & bone grafting

NON-UNIONNON-UNION

Condition when the fracture will never unite w/o Condition when the fracture will never unite w/o interventionintervention

Healing has stopped.Healing has stopped.Fracture gap is filled by fibrous tissue Fracture gap is filled by fibrous tissue (pseudoarthrosis)(pseudoarthrosis)

CausesCauses Improper Tx of delayed unionImproper Tx of delayed union Too large a gapToo large a gap Interposition of periosteum, muscle or cartilage between Interposition of periosteum, muscle or cartilage between

the fragmentsthe fragments

Clinical featuresClinical features Painless movement at the fracture sitePainless movement at the fracture site

X-RayX-Ray Fracture is clearly visibleFracture is clearly visible Fracture ends are rounded, smooth and scleroticFracture ends are rounded, smooth and sclerotic Atrophic non-unionAtrophic non-union : : - Bone looks inactive- Bone looks inactive

(Bone ends are often tapered / (Bone ends are often tapered / rounded)rounded)

- Relatively avascular- Relatively avascular Hypertrophic non-unionHypertrophic non-union : : - Excessive bone formation - Excessive bone formation

` - on the side of the gap` - on the side of the gap - Unable to bridge the gap- Unable to bridge the gap

Hypertrophic non-unionHypertrophic non-union Atrophic non-unionAtrophic non-union

TreatmentTreatment Ununited scaphoid fracture Ununited scaphoid fracture →→ asymptomatic asymptomatic Hypertrophic non-union (Esp long bone)Hypertrophic non-union (Esp long bone)

→ → Rigid fixation (internal / external)Rigid fixation (internal / external)

sometimes need bone graftingsometimes need bone grafting Atrophic non-unionAtrophic non-union

→ → Fixation & bone graftingFixation & bone grafting

MALUNIONMALUNION

Condition when the fragments join in an Condition when the fragments join in an unsatisfactory position (unaccepted unsatisfactory position (unaccepted angulation, rotation or shortening)angulation, rotation or shortening)

Causes Causes Failure to reduce a fracture adequatelyFailure to reduce a fracture adequately Failure to hold reduction while healing proceedsFailure to hold reduction while healing proceeds Gradual collapse of comminuted or osteoporotic Gradual collapse of comminuted or osteoporotic

bone.bone.

Clinical featuresClinical features Deformity & shortening of the limbDeformity & shortening of the limb Limitation of movementsLimitation of movements

TreatmentTreatment Angulation in a long bone (Angulation in a long bone (> 15 degrees)> 15 degrees)

→ → Osteotomy & internal fixationOsteotomy & internal fixation Marked rotational deformityMarked rotational deformity

→ → Osteotomy & internal fixationOsteotomy & internal fixation Shortening (> 3cm) in 1 of the lower limbsShortening (> 3cm) in 1 of the lower limbs

→ → A raised boot ORA raised boot OR Bone operationBone operation

JOINT STIFFNESSJOINT STIFFNESS

Common complication of fracture Tx following Common complication of fracture Tx following immobilizationimmobilization

Common siteCommon site : knee, elbow, shoulder, : knee, elbow, shoulder, small joints of the handsmall joints of the hand

CausesCauses Oedema & fibrosis of the capsule, ligaments, muscle Oedema & fibrosis of the capsule, ligaments, muscle

around the jointaround the joint Adhesion of the soft tissue to each other or to the Adhesion of the soft tissue to each other or to the

underlying bone (intra & peri-articular adhesions)underlying bone (intra & peri-articular adhesions) Synovial adhesions d/t haemarthrosis Synovial adhesions d/t haemarthrosis

TreatmentTreatment Prevention :Prevention :

- Exercise- Exercise- If joint has to be splinted - If joint has to be splinted → Make sure in correct position→ Make sure in correct position

Joint stiffness has occurred:Joint stiffness has occurred:- Prolonged physiotherapy- Prolonged physiotherapy- Intra-articular adhesions - Intra-articular adhesions → → Gentle manipulation under anaesthesia Gentle manipulation under anaesthesia followed by continuous passive motionfollowed by continuous passive motion- Adherent or contracted tissues- Adherent or contracted tissues → → Released by operation Released by operation

MYOSITIS OSSIFICANSMYOSITIS OSSIFICANS

Heterotopic ossification in the muscles after an injuryHeterotopic ossification in the muscles after an injury

Usually occurs inUsually occurs in Dislocation of the elbowDislocation of the elbow A blow to the brachialis / deltoid / quadricepsA blow to the brachialis / deltoid / quadriceps

CausesCauses (thought to be due to) muscle damage(thought to be due to) muscle damage w/o a local injury (unconscious / paraplegic patient)w/o a local injury (unconscious / paraplegic patient)

Clinical featuresClinical features Pain, soft tissue tendernessPain, soft tissue tenderness Local swellingLocal swelling Joint stiffness Joint stiffness Limitation of movementsLimitation of movements Extreme cases: - Bone bridges the jointExtreme cases: - Bone bridges the joint

- Complete loss of movement- Complete loss of movement (extra-articular ankylosis) (extra-articular ankylosis)

X-RayX-Ray NormalNormal Fluffy calcification in the soft tissueFluffy calcification in the soft tissue

TreatmentTreatment Early stage : Joint should be restedEarly stage : Joint should be rested Then : Gentle active movementsThen : Gentle active movements When the condition has stabilized : When the condition has stabilized :

Excision of the bony massExcision of the bony mass Anti-inflammatory drugs may Anti-inflammatory drugs may ↓ joint stiffness↓ joint stiffness

AVASCULAR NECROSISAVASCULAR NECROSIS

Circumscribed bone Circumscribed bone necrosisnecrosis

CausesCauses Interruption of the arterial Interruption of the arterial

blood flowblood flow Slowing of the venous Slowing of the venous

outflow leading to outflow leading to inadequate perfusioninadequate perfusion

Common siteCommon site : : Femoral headFemoral head Femoral condylsFemoral condyls Humeral headHumeral head Capitulum of humerusCapitulum of humerus ScaphoidScaphoid (proximal part) (proximal part) TalusTalus (body) (body) LunateLunate

Conditions a/w AVNConditions a/w AVN Perthes’ diseasePerthes’ disease Certain fracturesCertain fractures Epiphyseal infectionEpiphyseal infection Sickle cell diseaseSickle cell disease Caisson diseaseCaisson disease Gaucher’s diseaseGaucher’s disease Alcohol abuseAlcohol abuse High-dosage corticosteroidHigh-dosage corticosteroid

Clinical featuresClinical features Joint pain, stiffness, swellingJoint pain, stiffness, swelling Restricted movementRestricted movement

X-RayX-Ray ↑ ↑ bone densitybone density Subarticular fracturingSubarticular fracturing Bone deformityBone deformity

TreatmentTreatment Avoid weight bearing on the necrotic boneAvoid weight bearing on the necrotic bone Revascularisation (using vascularised bone grafts)Revascularisation (using vascularised bone grafts) Excision of the avascular segmentExcision of the avascular segment Replacement by prosthesesReplacement by prostheses

ALGODYSTROPHYALGODYSTROPHY((COMPLEX REGIONAL PAIN SYNDROMECOMPLEX REGIONAL PAIN SYNDROME)) Previosly known as Sudeck’s atrophyPreviosly known as Sudeck’s atrophy Post-traumatic reflex sympathetic dystrophyPost-traumatic reflex sympathetic dystrophy Usually seen in the foot / handUsually seen in the foot / hand

(after relatively trivial injury)(after relatively trivial injury) Clinical featuresClinical features

Continuous, burning painContinuous, burning pain Early stage : Local swelling, redness, warmthEarly stage : Local swelling, redness, warmth LaterLater : Atrophy of the skin, muscles : Atrophy of the skin, muscles Movement are grossly restrictedMovement are grossly restricted

X-RayX-Ray Patchy rarefaction of the bones (Patchy rarefaction of the bones (patchy osteoporosispatchy osteoporosis))

OsteoporosisOsteoporosis AlgodystrophyAlgodystrophy

TreatmentTreatment Physiotherapy (elevation & active exercises)Physiotherapy (elevation & active exercises) DrugsDrugs

- Anti-inflammatory drugs- Anti-inflammatory drugs

- Sympathetic block or sympatholytic drugs - Sympathetic block or sympatholytic drugs

(Guanethidine)(Guanethidine)

OSTEOARTHRITISOSTEOARTHRITIS

Post-traumatic OAPost-traumatic OA Joint fracture wt severely damaged articular cartilageJoint fracture wt severely damaged articular cartilage Within period of monthsWithin period of months

22OO OA OA Cartilage healsCartilage heals Irregular joint surface may caused localized stress Irregular joint surface may caused localized stress

→ → 22OO OA OA Years after joint injuryYears after joint injury

Clinical featuresClinical features PainPain StiffnessStiffness SwellingSwelling DeformityDeformity Restricted movementRestricted movement

TreatmentTreatment Pain relief : AnalgesicsPain relief : Analgesics

Anti-inflam Anti-inflam agentagent

Joint mobility : PhysiotherapyJoint mobility : Physiotherapy Load reduction : wt reductionLoad reduction : wt reduction Realignment osteotomy (young Realignment osteotomy (young

pt)pt) Arthroplasty (pt Arthroplasty (pt > 60yr)> 60yr)

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