Outline of Fracture Management & Complication

Presented By:

Dr. Md. Taufiq Ul Islam

Resident

Fracture

• It is a break in the continuity of bone or cartilage.

• A fracture is a soft tissue injury with underlying broken bone

Causes of Fracture

Fractures may be caused by:

1. A single traumatic event

2. Repetative stress

3. Abnormal weakening of a bone i.e. pathological fracture.

Types of Fracture• Etiologically: Traumatic, Stress or Pathological.• Depending upon fracture pattern:

a. Simple: Spiral, Oblique or transverse.b. Wedge: Spiral wedge or bending wedgec. Multifragmentory.

• Deformity and displacement:a. Rotationb. Angulationc. Displaced or translation (occurs in two planes)

• Associated soft tissue injury:a. Open or closedb. Neurovascular statusc. Ligamentous injuries

Biomechanics of Fracture Healing

• The changes associated with fracture healing may be considered as three phases that occur sequentially but may overlap. These are:

1. Phase of inflammation

2. The development of osteogenic repair tissue

3. Phase of remodelling.

Healing of Fracture

1. Fracture & Hematoma

2. Formation of granulation tissue

3. Replacement of granulation tissue by callus

4. Replacement of callus by lamellar bone

5. Remodeling of bone to normal contour

• Reactive phase or phase of inflammation

• Reparative phase

• Remodeling phase

Factors Affecting Fracture Healing

• Local Factors:1. Movement between

fracture fragments2. Extensive damage3. Surrounding soft tissue

injury4. Interruption of blood

supply5. Infection6. Interposition of soft

tissue in fracture gap7. Fracture near or

including joint8. Repeated trauma

• General Factors:1. Age of the patient2. General health condition3. Drugs e.g.

Corticosteroids4. Associated other bone

pathology e.g. Osteoporosis

5. Comorbid conditions.

Principles of Fracture Treatment

• Need to consider

1. Reduction

2. Rigid Immobilization

3. Rehabilitation

• Necessity for reduction depends on type of fracture.

• Undisplaced vs. displaced fractures.

• Closed vs. open reduction.

• Immobilization is always needed until the fracture unites.

• Can be done by external or internal methods

• External methods include Plaster casts, Tractions and External Fixation.

• Internal methods include Plates, Intramedullay Nails, K-wires.

• Indication for internal fixation:

1. Fracture requiring open reduciton

2. Unstable fracture3. Intra-articular

fractures4. Pathological fracture5. Multiple injury

patients

• Indication for external fixation

1. Open fractures2. Non-union of

fracture3. Filling of segmental

limb defects – trauma, tumor and osteomyelitis.

4. Limb lengthening

Advantages

• Internal fixation:

1. Anatomical reduction, absolute stability

2. Allows primary bone healing

3. Earlier mobilization.

4. Early discharge.

• External fixation:

1. Rapid application

2. Can be applied in acutely injured.

3. Stablizes comminuted fractures that are unstable for ORIF

4. Provides outside # zone fixation for open fractures.

Disadvantages

• Internal fixator:

1. Infection

2. Anaesthetic risk

3. Failure of fixation

4. Malposition of metal work.

• External fixation:

1. Discomfort for the patient

2. Pin tract infection

3. Failure of fixation.

Management

• Management of fracture depends upon the condition of the patient and type of fracture.

Traumatic Fractures• Diagnose and treat life threatening injuries• Emergency orthopaedic involvement

a. Life threateningi. Traumatic amputationii. Major vascular injuryiii. Pelvic fracture disruptioniv. Haemorrhage from open fracturev. Multiple long bone fracturevi. Severe crush injury

b. Limb threateningi. Vascular injuryii. Major joint dislocationiii. Crush injury iv. Open fracturesv. Compartment syndrome vi. Nerve injury

Management of Traumatic Fractures

– Emergency orthopaedic management (Day 1)

– Monitoring of fracture (Days to weeks)

– Rehabilitation + treatment of complications (weeks to months)

Compound Fractures

• All open fractures must be assumed to be contaminated• Object of treatment is to prevent them becoming infected• First aid treatment is the same as for a closed fracture• Peripheral neurovascular status should be assessed• In addition the wound should be covered with a sterile

dressing• Wound should be photographed so that repeated

uncovering is avoided repeated exposure• Antibiotic prophylaxis should be given• Tetanus immunisation status should be evaluated

Management of Compound Fractures.

• Open fractures require early operation

• Ideally this should be performed within 6 hours of injury

• Aims of surgery are to:o Clean the woundo Remove devitalised tissueo Stabilise the fracture• Small clean wounds can be sutures• Large dirty wounds should be

debrided and left open• Debrided wounds can be closed by

delayed primary suture ar 5 days

Pathological fractureGeneralised bone disease• Osteoporosis• Metabolic bone disease - osteomalacia, hyperparathyroidism• Paget's disease• MyelomatosisLocalised benign bone disorder• Chronic infection• Solitary bone cyst• Fibrous cortical defect• ChondromaPrimary malignant bone tumours• Osteosarcoma• Chondrosarcoma• Ewing's tumour

Early Complications

• Local

1. Neurovascular injury

2. Visceral injury

3. Haematoma

4. Infection

5. Soft tissue swelling

6. Skin loss

7. Compartment syndrome

8. Neurovascular injury

• General

1. DIC

2. Hypovolaemic shock

3. Crush injury

4. Atelectesis

5. SIRS

6. Fat embolism.

Late Complications

• Local1. Delayed union2. Malunion3. Non union4. Joint stiffness5. OA of joint6. Pressure sore7. Contracture8. AVN9. Sudek’s atrophy/RSD/

Complex regional pain syndrome

10. Myositis ossificans

• General1. DVT2. PE3. Disuse atrophy4. Psychological impact5. Economic loss

Thank You