FRACTURESAnandkumar BalakrishnaWong Poh SeanMohd Hanafi Ramlee

CONTENT DEFINITION PRINCIPLE MANAGEMENT COMPLICATIONS

DEFINITION

A fracture is a break in the structural continuity of bone.

CAUSES Sudden trauma

direct(fracture of the ulna caused by blow on the arm)

indirect(spiral fractures of the tibia and fibula due to torsion of the leg, vertebral compression fractures, avulsion fractures)

Stress or fatigue-repetitive stress(athletes, dancers, army recruits)

Pathological(osteoporosis, Paget’s disease, bone tumour)

TYPES OF FRACTURESCLOSED/ SIMPLE

• no opening in the skin.

OPEN/ COMPOUND

• bone fragments have broken through the skin.

COMPLETE

• bone is completely broken into 2 or more fragments.

• -eg:• transverse

fracture • oblique fracture• spiral fracture• impacted

fracture• comminuted

fracture• segmental

fracture

INCOMPLETE

• bone is incompletely divided and the periosteum remains in continuity.

• -eg:• greenstick

fracture • torus fracture• stress fracture• compression

fracture.

COMPLETE FRACTURES

OBLIQUE FRACTURE

SEGMENTAL FRACTURE

SPIRAL FRACTURE

TRANSVERSE FRACTURE

COMMINUTED FRACTURE

IMPACTED FRACTURE

INCOMPLETE FRACTURE

GREENSTICK

TORUS

FRACTURES DISPLACEMENT After a complete fracture the fragments

usually displaced: partly by the force of injury partly by gravity partly by the pull of muscles attached to them.

4 types: Translation/Shift Alignment/Angulation Rotation/Twist Altered length

SHIFT ANGULATION /TILT

TWIST/ROTATION

SIDEWAYS

OVERLAPIMPACTION

HOW FRACTURES HEAL? Healing by callus Healing without callus

Healing by callus Callus is the response to movement at the

fracture site to stabilize the fragments as rapidly as possible.

Steps:

Tissue destruction and haematoma formation.

Inflammation and cellular proliferation.

Callus formation: dead bone is mopped up & woven bone(immature) appears in fracture callus.

Consolidation: woven bone(immature) is replaced by lamellar bone(mature).

Remodelling:Newly formed bone is remodelled to resemble the normal structure.

Healing without callus For fracture that is absolutely immobile:

impacted fracture in cancellous bone. fracture rigidly immobilized by internal fixation

New bone formation occurs directly between fragments.

Gaps between the fracture surfaces are invaded by new capillaries & bone forming cells growing in from edges.

For very narrow crevices(<200um), osteogenesis produces lamellar bone(mature).

For wider gaps, osteogenesis begins with woven bone (immature) first which is then remodelled to lamellar bone (mature bone).

RATE OF REPAIR DEPENDS UPON:

Type of bone

cancellous

bone heals faster than

cortical bone.

Type of fracture

spiral fracture heals faster than

transverse

fracture.

State of blood flow

poor circulation will

slow the

healing proces

s.

Patient’s general

constitution

healthy bone heals faster.

Patient’s age

healing is

faster in

children than adults.

CAUSES OF DELAYED UNION OR NON-UNION OF THE

FRACTURES

Distraction & separation of the fragments

Interposition of soft tissues between the fragments.

Excessive movement at the fracture

site

Poor local blood supply

Severe damage to soft tissues which makes

them nearly/non-

viable.

Infection

Abnormal bone.

FRACTURES- PRINCIPLE OF TREATMENT

Management of Closed Fracture

First aid management Airway, Breathing and Circulation Splint the fracture Look for other associated injuries Check distal circulation – is distal circulation

satisfactory? Check neurology – are the nerve intact? AMPLE history- Allergies, Medications, Past

medical history, Last meal, Events Radiographs – 2 views, 2sides, 2 joints, 2

times.

General Resuscitation

Manipulation (improve position of fragments)

Splintage (hold fragments together until unite)

Exercise & weight-bearing

Hold

Exercise

Reduce

Principle Of Treatment

Safety

MoveSpeed

Hold

The Fracture Quartet

Outline

Clo

sed

Fra

ctu

re

Reduce

Closed Reduction

Mechanical Traction

Open Reduction

Hold

Sustained Traction

Cast Splintage

Functional Bracing

Internal Fixation

External Fixation

Exercise

Reduce Aim for adequate apposition and normal

alignment of the bone fragments The greater contact surface area between

fragments, the more likely is healing to occur

However, there are some situations in which reduction is unnecessary:

When there is little or no displacement When displacement does not matter (e.g. in

some fractures of the clavicle) When reduction is unlikely to succeed (e.g.

with compression fracture of the vertebrae)

Operative

Closed reduction

Mechanical Traction

Non-operative

Open reduction

Reduction

Closed Reduction Suitable for

Minimally displaced fractures Most fractures in children Fractures that are likely to be stable after

reduction

Most effective when the periosteum and muscles on one side of fracture remain intact

Under anaesthesia and muscle relaxation, a threefold manoeuvre applied: Distal part of the limb is pulled in line of the

bone Disengaged, repositioned Alignment is adjusted

Mechanical Traction Some fractures (example fracture of femoral

shaft) are difficult to reduce by manipulation because of powerful muscle pull

However, they can be reduced by sustained muscle mechanical traction; also serves to hold the fracture until it starts to unite

Open Reduction Operative reduction under direct vision Indications:

When closed reduction fails When there is a large articular fragment that

needs accurate positioning For avulsion fractures in which the fragments

are held apart by muscle pull When an operation is needed for associated

injuries When a fracture needs an internal fixation

Non Operativ

e

• Sustained traction

• Cast Splintage• Functional

Bracing

Operative

• Internal Fixation

• External Fixation

Hold

HOLD

To prevent displaceme

nt

To alleviate pain by some

restriction of

movement

To promote soft-tissue

healing

To allow free

movement of the

unaffected parts

Safety

MoveSpeed

Hold

Sustained Traction• Traction is applied to limb distal to the

fracture• To exert continuous pull along the long axis

of the bone

• Can move joint• Can exercise musle

Advantage

• Useful for spiral fractures of long bone shafts:• Shaft of femur• Tibia• Lower humerus

Indication

Disadvantage and complications Patient kept on bed for long time Pressure ulcer General weakness Pulmonary infection Contracture Pin tract infection Thromboembolic event

Methods Traction by gravity Balanced traction Fixed traction

Traction By Gravity

Example: Fracture of humerus-Weight of arm to supply traction-Forearm is supported in a wrist sling

Traction is applied to the limb either by way of adhesive strapping, kept in place by bandages skin traction• Sustain a pull no more than 4-5 kg

Contraindications:

• Abrasion, dermatitis, wound• Vascular insufficiencies• When greater traction force

in needed

Balanced Traction

Thomas’s Splint

Traction applied via stiff wire or pin inserted through the bone distal to the fracture skeletal traction• Can apply several

times as much force

Complications:• Pin tract infection• Damage to epiphyseal

growth plate• Vertical fracture of the

bone• Injury to the vessels or

nerves

Fixed Traction Principle = balanced traction Useful for when patient has to be

transported Thomas’s splint

Cast Splintage Methods:

Plaster of Paris Fibreglass

Especially for distal limb # and for most children #

Disadvantage: joint encased in plaster cannot move and liable to stiffen

Can be minimized: Delayed splintage (traction initially) Replace cast by functional brace after few

weeks

Safety

MoveSpeed

Hold

Tight cast put on too tightly/limb swells

Pressure sores even a well-fitting cast may

press upon the skin over a bony

prominence (the patella, the heel)

Skin abrasion or laceration during

removal of the plaster

Complications

Brace supportive device that

allows continued

function of the part

Principle functional long

bone is supported

externally by POP or by a mouldable

plastic material but the function

of joints are preserved

Indication fractures of

shaft of femur or tibia

Functional Bracing

Functional bracing is not rigid applied when fracture is beginning to unite, after about 3-6 weeks of traction or restrictive splintage

Advantages:

• Fractures held reasonably well

• Joints can be moved• Patient can leave hospital• Method is safe

Safety

MoveSpeed

Hold

INTERNAL FIXATION

Principle

Bony fragment may be fixed with:• screws, • transfixing pins or

nails, • a metal plate held by

screws, • a long intramedullary

nails,• circumferential band, • or a combination with

these method

Indication

1. Fracture that cannot be reduced except by

operation

2. Fracture that are inherently unstable

and prone to displacement after

reduction

3.Fracture that unite poorly and slowly• Principally fracture of

the femoral neck

4.Pathological fracture• Bone disease may

prevent healing

5.Multiple fracture• Where early fixation

reduced the risk of general complication

6.Fracture in patient who present severe nursing difficulty

Type of internal fixation

screw• Interfragmentary screw (lag

screw) are used for fixing small fragment onto the main bone

wires• Kirschner wire (often inserted

percutaneously without exposing the fracture

• Used in situation where fracture healing is predictably quick

Plates and screw• Useful for treating metaphyseal

fracture of long bones and diaphyseal fracture of radius and ulna

Intramedullary nail• Suitable for long bones• Nail is inserted onto medullary

canal to splint the fracture• Rotational of fracture are

resisted by introducing locking screw which tranfix the bone cortices and the nail proximal and distal to the fracture.

advantages

Precise reduction

• ORIF-open reduction and internal fixation

Immediate stability

• Hold the fracture securely

Early movement

• ‘fracture disease ‘ like oedema,s tifness,etc may abolish

Complications

Infection

Non-union

Implant failure

Refracture

Infe

ctio

nIatrogenic infection chronic osteomylitisRisk of infection depends on:1)The patient devitalised tissue, dirty wound, unfit patient2)The surgeon thorough training, a high degree of surgical dexterity and adequate assistant are all essential3)The facilities aseptic routineThe infection should be rapidly controlled by intravenous antibioticIf infection cannot be controlled, the implant should be replaced with some form of external fixation

Non

un

ion

Cause:1) excessive stripping of soft tissue2) unnecessary damage to blood supply in the course of operative fixation 3)rigid fixation with a gap between the fragment

Implant failureMetal is subjected to fatigue

• Metal is subjected to fatigue

• So, undue stress should therefore be avoided until the fragment has united.

• Pain at the site of fracture site is a danger signal.

Refracture

• It is important not to remove the metal implant too soon

• A year is minimum and 18 to 24 month is safer

• For several weeks after the implant removal the bone is weak so full weight-bearing should be avoided

EXTERNAL FIXATION

Principle

The bone is transfixed above and below the fracture with screw or pins or tension wire and these are then clamped to a frame or connected to each other by rigid bars outside the skin

IndicationFracture associated with soft tissue injury• Where the wound can be left

open for inspection, dressing and definitive coverage

Severely comminuted and unstable fracture• Which can be held out to

length until healing commence

Fracture of the pelvis• Which often cannot be

controlled quickly by any other method

Fracture associated with nerve and vessel

damage

Infected fracture• Where internal fixation

might not be suitable

United fracture• Where dead or sclerotic

fragment can be excised and the remaining ends brought together in the external fixator

(a)The patient was fixed with a plate and screw but did not unite (b) external fixation was applied

Advantages

technically quick and easy to

perform

no soft tissue stripping;

       

ease of removing hardware;

risk of infection at the site of the

fracture is minimal

Complication

Damage to soft tissue

structure

Over distracti

on

Pin track infection

• Transfixing pins and wires may injure the nerve and vessel or may tether ligament and inhibit joint movement

• So, the surgeon must be thoroughly familiar with the ‘safe corridor’ for inserting the pins

Damage to soft tissue structure

• If there is no contact between the fragment, union may be delayed or prevented

Over distraction

• There is a risk of infection where the pins are inserted from the skin into the bone.

• So, meticulous pin-site care is essential

• Antibiotic should be administered immediately if infection occur

Pin track infection

Exercise Prevention of edema

active exercise and elevation Active exercise also stimulates the circulation.

Prevents soft-tissue adhesion and promotes fracture healing.

Preserve the joint movement Restore muscle power Functional activity

Management of Open FracturesA break in skin and underlying soft tissues leading directly to communicating with the fracture

Open Fracture

First Aid & Management of the Whole Patient

Prompt wound debridement

Antibiotic prophylaxis

Stabilization of the fracture

Definitive wound cover

First Aid & Management of the Whole Patient

Airway

Breathing

Circulation

80

1. Emergency Management of Open Fracture

A,B,C Splint the limb Sterile cover - prevent contamination Look for other associate injury Check distal circulation – is distal circulation satisfactory? Check neurology – are the nerve intact? AMPLE history- Allergies, Medications, Past medical history,

Last meal, Events Radiographs – 2 view, 2sides, 2 joints, 2 times. Relieve pain Tetanus prophylaxis Antibiotics Washout / Irrigation Wound debridement fracture stabilisation

Open Fractures Classification

Preoperative Assessment

HISTORY

Age

General health & comorbidities

Alcohol & drugs

Ambulatory status

Cause of injury

• High or low energy• Potential for infection• Previous injuries

PHYSICAL EXAMINATION

ATLS

Other injuries

Vascular status of limb

• Limb color, pulse, capillary refillNeurological status of limb

• Power, sensation

Preoperative Assessment

EXAMINATION OF OPEN WOUNDLocation & extent of the wound

Length of wound

Number of skin wounds

Degree of skin contamination

RADIOLOGICAL EXAMINATION

X-ray: AP, lateral

CT & MRI: open pelvic, intra-

articular, carpal, tarsal

fractures

Treatment- Outline

Irrigation

Debridement: Skin, Fat, Muscle, Bone

Wound closure

Analgesic + Antibiotic + Antitetanus (AAA): IV, IM

Fracture stabilization

1) Analgesic + Antibiotic + Antitetanus Prophylaxis

Antitetanus

Toxoid for immunised Human antiserum for non-immunised

Broad spectrum 3rd generation cephalosporin, aminoglycosideGentamicin or metronidazole for gram negative organism.

60-70% of open wound are associated with positive cultures, mostly normal flora

AnalgesicPethidine/morphine

Antibiotic• Gustilo Grade I- first generation of cephalosporin

for 72 hours• Gustilo Grade II- first generation cephalosporin

for 72 hours + Gram negative coverage (gentamicin) for at least 72 hours

• Gustilo Grade III- first generation cephalosporin +G –ve coverage for at least 72 hours

• For soil contamination- penicillin is added for clostridial coverage

2) IrrigationFluids such as

normal isotonic saline or antibiotic

solutions + hydrogen peroxide

A method of wound cleansing by removing

debris mechanically with pressurised fluid.

Advantages:

• Flushes away the foreign matter and contaminated blood clot

• Helps in assessment of viability of tissues

• Reduces bacterial population

3) Debridement

All dead and contaminated tissues must be removed

Performed in a systematic manner• Skin & fascia• Muscles• Tendon• Bone

89

Surgical Debridement Type II and type III require surgical

debridement. Important aspect of wound

management. Reduce bacteria, remove foreign

bodies, remove devitalized tissue. Removal of dead tissue reduces

bacterial burden and accelerate healing.

4) Wound Closure• For wounds less than 8 hours

old after debridementPrimary closure

• Wound left open after debridement for 2-3 days

• If clean, close the wound

Delayed primary closure (<5days)

• Type IIIAnother debridement

• For infected woundSecondary closure

• Partial thickness • Full thicknessSkin grafting

Wound Closure Uncontaminated I & II can be sutured –

provided without tension All other wounds left open, packed with

moist sterile gauze, to be inspected 24-48 hours – primary delayed closure

If wound cannot be closed without tension – skin grafting

5) Fracture Stabilization

• A window is made in the plaster over the wound for dressing

Immobilisation in a plaster

• Eg. open fracture of tibiaSkeletal traction

• Can be easily applied• Readily reduced and adjusted• Wound can be assessed for dressing• Excellent stability

External fixator

• Rarely usedInternal fixator

Stabilization of the fracture To reduce infection and assist recovery of soft

tissue Depends on:

degree of contamination length of time from injury to operation amount of soft tissue damage

If <8 hours: up to IIIA treated as closed fractures: Splintage Intramedullary nailing Plating External fixation

Others: External fixation

Aftercare

The limb is elevated &

it's circulation carefully

monitored

Antibiotic cover

If the wound has been left open, it is inspected after 2-3 days & covered

appropriately

Physiotherapy and

rehabilitation

COMPLICATION OF FRACTURE

Early Late

General ShockDiffuse CoagulopathyTetanusRespiratory DysfunctionDVT & Pulmonary Emb.Fat Emboli Syndrome

Crush SyndromeChest InfectionUrinary Tract InfectionGas Gangrene

Bone Infection Non-union / Mal-union / Delayed unionAvascular NecrosisLength discrepancyDisuse Osteoporosis

Joint HaemarthrosisLigament injury

Instability / Mal-alignmentOsteoarthritisStiffnessOveruse injuries

Soft Tissue

Plaster SoreTendon RuptureNeurovascular InjuryCompartment SyndromeVisceral injury

Nerve compressionVolkmann’s contractureBedsoresMyositis OssificansTendinitis & Tendon rupture

GENERAL

BONE

JOINT

SOFT TISSUE

General Complications

1. Shock2. Diffuse coagulopathy3. Respiratory

dysfunction4. Crush syndrome5. Venous thrombosis &

Pulmonary embolism6. Fat embolism7. Gas Gangrene8. Tetanus

General 1: ShockAltered physiologic status with generalized

inadequate tissue perfusion relative to metabolic requirements. irreversible

damage to vital organs

• direct injury to heart effect the pump functionsCardiogenic

• injury to brain stem (vasomotor center) spinal cord loss of sympathetic tone increase venous capacitance low venous return àlow cardiac output (but bradycardia)

Neurogenic

• reduction of blood volumeHypovolemi

c

500-1000ml

100-300ml

1000-2000ml

1000-2000ml

1500-3000ml

1500-3000ml

VOLUME DISTRIBUTION

General 1: ShockWhy we need to treat

shock?

• Blood redistribution• Renal shutdown• Intestinal ischemia• Tissue hypoxia• Metabolic acidosis• Reduced hepatic blood

flow• Acute Respiratory

Distress Sydrome• Altered consciousness

How to manage shock?

• Identify: Thirst, rapid shallow breathing, the lips and skin are pale and the extremities feel cold, impaired renal function test and decreased urinary output.

• ABC• IV lines: fluids and blood• Oxygenation/Ventilation• Urinary Catheter• Central Venous Pressure• Ionotropic drugs

General 2: DIFFUSE COAGULOPATHY

Consumptive Coagulopathy

• activation by tissue thromboplastin

• endothelial injury activating platelets

• massive blood transfusion

Management

• Stop the bleeding• Fresh Frozen

Plasma (FFP)• Cryoprecipitate• Platelet

transfusion• Heparin

General 3: RESPIRATORY DYSFUNCTION

Pathophysiology

• Alveolar edema• endothelial

injury• capillary

permeability• Poor lung

compliance• inactivated

surfactant• Arterial

hypoxemia

Management

• Oxygenation• Ventilation• positive end

expiratory pressure (PEEP)

General 4: Crush Syndrome[traumatic rhabdomyolitis]

Serious medical condition characterized by major shock & renal failure following a crushing

injury to skeletal muscles or tourniquet left too long

When compressi

on released

Myohaematin release from cells

Nephrotoxic effects

Block tubules

Oliguria, uremia,

metabolic acidosis

Bywaters’ Syndrome

General 4: Crush SyndromeClinically

• Shock• Pulseless limb redness

swelling• Loss of muscle sensation

and power• Decrease renal secretion• Uremia, acidosis• Prognosis

• If renal secretion return within 1 week the patient survive

• But most of them die within 14 days

Management

• PREVENTION• Strict tourniquet timing

• Amputation• limb crushed severely• tourniquet left on > 6 hrs • above site of compression

& before compression released

• Monitor intake & output• Dialysis• Correct electrolytes &

acidosis• Antibiotics

General 5: Deep vein thrombosis and pulmonary embolism.

Virchow’s triad factor Clot formation in large vein thrombus breaks off Emboli

Site: leg, thigh and pelvic vein. Risk factors:

Knee and hip replacement Elderly Immobility Malignancy

Cardiovascular disease Trauma Hypercoagul

able status

General 5: Management Deep vein thrombosis and pulmonary embolism.

PREVENTION Correct hypovolemia Calf muscle exercise Proper positioning Well fitting bandages &

cast Limb elevation Graduated compression

stockings Calf muscle stimulation

Anticoagulation Ambulate patient Established

thrombosis/embolism Limb elevation Heparinization Thrombolysis Oxygenation or

ventilation

General 6: Fat EmbolismFat globules from marrow pushed into circulation by the force of trauma that

causing embolic phenomena

Fractures that most often cause FES• Long

bones• Ribs• Tibia• Pelvis

Closed/open

Fracture

Fat in bone

marrow escape

Formation of fat

globules in vessels

Fat embolus

Stick in target organ

Triad of symptoms

General 6: Fat Embolism

Triad of Symptoms

• Brain: mental confusion

• Lung: breathlessness, ARDS

• Skin: Petechia

Management

• Prevent hypoxemia• oxygenation or

ventilation• Rule out head

injury• CT Scan of brain

• Monitor fluid & electrolyte balance• CVP, urinary

catheter

General 6: Fat EmbolismSKIN: Fat droplets

obstruct alveolar capillaries

thromboplastin release consumption of coagulation fx &

platelets DIVC/Skin necrosis Petechia

LUNG: Fat droplets obstruct alveolar

capillaries thromboplastin release alter

membrane permeability / lung

surfactant oedema respiratiory failure

[V/Q Mismatch]

BRAIN: Fat droplets obstruct capillaries

confusion coma/fits death

General 7: Gas GangreneRapid and extensive necrosis of the muscle accompanied by gas formation and systemic

toxicity due to clostridium perfringens infection

Clinical Features

• sudden onset of pain localized to the infected area.

• swelling , edema• +/- pyrexia• profuse serous discharge

with sweetish and mousy odor .

• Gas production

Management

• early diagnosis .• surgical intervention and

debridement are the mainstay of treatment.

• IV antibiotics• fluid replacement.• hyperbaric Oxygen

General 7: Gas Gangrene

Prevention: ALL DEAD TISSUE [4C] SHOULD BE COMPLETELY

EXCISED,

General 8: TetanusA condition after clostridium tetani infection

that passes to anterior horn cells where it fixed and cant be neutralized later produces hyper-excitability and reflex muscle spasm

Clinical Features

• Tonic and clonic contractions of esp. jaw, face, around the wound itself ,neck ,trunk, finally spasm of the diaphragm and intercostal muscles leads to asphyxia and death.

Management

• Prophylaxis• Treatment• Antitoxin & antibiotic• Muscle relaxant• Tracheal intubation• Respiration control

Early Complications

1. Visceral Injury2. Vascular Injury3. Compartment

Syndromes4. Nerve injury5. Haemarthrosis6. Infection

Early 1: Visceral injury

Fractures around the trunk are often complicated by visceral injury. E.g. Rib fractures

pneumothorax / spleen trauma / liver injuries.

E.g. Pelvic injuries bladder or urethral rupture / severe hematoma in the retro-peritoneum .

Rx: Surgery of visceral injuries

Early 2: Vascular injury Commonly associated with high-

energy open fractures. They are rare but well-recognized.

Mechanism of injuries: The artery may be cut or torn. Compressed by the fragment of bone. normal appearance, with intimal

detachment that lead to thrombus formation.

segment of artery may be in spasm. It may cause

Transient diminution of blood flow Profound ischaemia Tissue death and gangrene

Early 2: Vascular injury5P

’s o

f is

ch

em

ia

Pain

Pallor

Pulseless

Paralysis

Paraesthesia

X-ray: suggest high-risk fracture.Angiogram should be performed to confirm diagnosis.

Early 2: Vascular injury muscle ischaemic is

irrevesible after 6 hours. Remove all bandages

and splint & assess circulation

Skeletal stabilization – temporary external fixation.

Definitive vascular repair. Vessel sutured endarterectomy

Vessel Injury

subclavian

1st rib fracture

Axillary Shoulder dislocation

Brachial Humeral supracondylar fracture

Brachial Elbow dislocation

Presacral and internal iliac

Pelvic fracture

Femoral Femoral supracondylar fracture

Popliteal Knee dislocation

Popliteal or its branches

Proximal tibial fracture

Early 3: Compartment Syndrome

Leg

• 4 compartments: anterior, lateral, superficial and deep posterior

• NOT interconnected

Forearm

• 3 compartments: dorsal, superficial and deep volar

• interconnected, hence fasciotomy of 1 compartment may decompress the other 2

A condition in which increase in pressure within a closed fascial compartment leads to

decreased tissue perfusion. Untreated, progresses to tissue ischaemia

and eventual necrosis

Early 3: Compartment Syndrome

Most common sites (in ↓ freq): leg (after tibial fracture) → forearm → thigh → upper arm. Other sites: hand, foot, abdomen, gluteal and cervical regions.

High risk injuries: # of elbow, forearm bones, and proximal 3rd of

tibia (30-70% after tibial #) multiple fracture of the foot or hand crush injuries circumferential burns

Early 3: Compartment Syndrome [aetiology]

↑ Compartmental volume (↑ fluid content)

• Trauma – fractures /osteotomies, crush injury

• Vascular – haemorrhage, post-ischaemic swelling

• Soft tissue injury – burns, prolonged limb compression

• Iatrogenic – intraosseous fluid resuscitation in children, intraarterial drug injection

• Extreme muscular exertion

↓ Compartment volume (constriction of the

compartment)

• Constrictive dressings/plaster casts

• Thermal injuries with eschar formation

• Pneumatic antishock garments (MAST)

• Surgical closure of fascial defects

↑ fluid content Constriction of compartment

↑ INTRACOMPARTMENTAL PRESSURE

Obstruct venous return

Vascular congestion

Further ↑ intracompartmental pressure

↓ capillary perfusion

Muscle and nerve ischaemia

Capillary basement membranes become leaky → oedema

Compromise arterial circulation

→ PROGRESSIVE NECROSIS OF MUSCLES AND NERVES !!

Vicious cycle

Early 3: Compartment Syndrome

Sequence started with:

severe pain/bursting sensation (early)

paraesthesia/hypoaesthesia

motor weakness

loss of peripheral pulses and capillary refill (late signs, poor prognosis)

A vicious circle that ends after 12 hours or less

Necrosis of the nerve and muscle within the compartment

Nerve-capable to regenerate

Muscle-infarcted

Never recover

Replaced by inelastic fibrous tissue( Volkmann’s ischaemic contracture)

Investigations of compartment sydromes

Intra-compartment Pressure Measurement (ICP) Use of slit catheter; quick and easy Indications:

Unconscious patient Those who are difficult to assess Concomitant neurovascular injury Equivocal symptoms

Especially long bone # in lower limb Perform as soon as dx considered > 40mmHg – urgent Rx! (normal 0 – 10 mmHg)

Investigations of compartment syndromes

Other Ix – limited value; +ve only when CS is advanced Plasma creatinine and CPK Urinanalysis – myoglobinuria Nerve conduction studies

Ix to establish underlying cause or exclude differentials X-ray of affected extremity Doppler US/arteriograms – determine presence of

pulses; exclude vascular injuries and DVT PT/APTT – exclude bleeding disorder

Management Prompt DECOMPRESSION of affected

compartment Remove all bandages, casts and dressings Examination of whole limb Limb should be maintained at heart level

Elevation may ↓ arterio-venous pressure gradient on which perfusion depends

Ensure patient is normotensive. Hypotension ↓ tissue perfusion, aggravate the

tissue injury.

Management Measure intra-compartment pressure

If > 40mmHg Immediate open fasciotomy

If < 40mmHg Close observation and re-examine over next hour If condition improve, repeated clinical evaluation

until danger has passed

Don’t wait for the obvious sings of ischemia to appear. If you suspect An impending compartment syndrome, start treatment straightaway

Fasciotomy

Opening all 4 compartments Divide skin and deep fascia for the

whole length of compartment Wound left open Inspect 5 days later If muscle necrosis, do debridement If healthy tissue, for delayed closure or

skin grafting

Complications Volkmann’s ischaemic contracture Motor/sensory deficits Kidney failure from rhabdomyolysis (if very

severe) Infection – fasciotomy converts closed # to open # Loss of limb Delay in bone union

Prognosisexcellent to poor, depending on how quickly CS is treated and whether complications develop

Early 4: Nerve Injury It’s more common than

arterial injuries. The most commonly

injured nerve is the radial nerve [in its groove or in the lower third of the upper arm especially in oblique fracture of the humerus]

Common with humerus, elbow and knee fractures

Most nerve injuries are due to tension neuropraxia.

nerve Injury

Axillary 1. Shoulder dislocation

Radial 2. Humeral shaft fracture

Median 3. Lower end of radius

Radial or median(ant.interosseous)

4. Humeral supracondylar (esp. children)

Ulnar 5. Medial condyle

Ulnar 6. Elbow dislocation

Sciatic 7. Hip dislocation

Peroneal 8. Knee dislocation

Peroneal 9. Fracture of fibular neck

Early 4: Nerve Injury

Damaged by laceration, traction, pressure or prolonged ischaemia

Neurapraxia

• axon remains intact but conduction ceases due to segmental demyelination. Spontaneous recovery in a few days or weeks

Axonotmesis

• axonal separation with degeneration of distal portions. Sheath remains intact, thus recovery likely but delayed

Neurotmesis

• nerve completely divided. Spontaneous recovery unlikely.

Early 4: Nerve InjuryClinical features Numbness and

weakness Skin smooth and

shiny but feels dry Muscle wasting

and weakness Sensation blunted Tinel’s sign +ve

Investigations Electromyography Nerve conduction study May help to establish

level and severity of lesion

Early 4: Nerve Injury

Open injuries

• Exploration• Cleanly divided – repair

immediately• Torn/crushed – left alone

or ends lightly tacked together, re-explore 2 – 3 weeks later for scar tissue removal and suturing

Closed injuries

• Usually nerve sheath intact

• Rate of axonal regeneration = 1mm/day

• If no sign of recovery – re-exploration with excision of scar tissue and suturing of clean-cut ends, nerve grafting if gap too large

• Splinting 3-6 weeks then physiotherapy

Early 5: Haemarthrosis Bleeding into a joint spaces. Occurs if a joint is involved in

the fracture. Presentation:

swollen tense joint; the patient resists any attempt to moving it

treatment: blood aspiration before dealing

with the fracture; to prevent the development of synovial adhesions.

Early 6: INFECTION Closed fractures – hardly ever Open fractures – may become infected Post traumatic wound – may lead to

chronic osteomyelitis

Clinical features

• wound is inflammed• draining seropurulent

fluid

Treatment

• antibiotic• excise the devitalised

tissue• tissues opened &

drained the pus

Late Complications

1. Delayed Union2. Non-union3. Mal-union4. Avascular Necrosis5. Osteoarthritis6. Joint Stiffness

Late 1: DELAYED UNION Union of the upper limbs - 4-6

weeksUnion of the lower limbs - 8-12

weeks(rough guide)Any prolong time taken is

considered delayed

Late 1: DELAYED UNION

Factors are either biological or biomechanical Biological :

Poor blood supply Tear of periosteum, interruption of intramedullary circulation Necrosis of surface# and healing process will take longer

Severe soft tissue damage Most important factor Longer time for bone healing due less inflammatory cell

supply Infection: bone lysis, tissue necrosis and pus Periosteal stripping

Less blood circulation to bone

Mechanical Over-rigid fixation-fixation devise

Imperfect splintage Excessive traction creates a gap#(delay

ossification in the callus)

Late 1: DELAYED UNION

Clinical features: Tenderness persist Acute pain if bone is subjected to stress*( * ask pt to walk, move affected limb)

X RAYS -visible line# and very little callus formation/periosteal reaction

- bone ends are not sclerosed/ atrophic (it will eventually unite)

Late1: DELAYED UNION

Tx: conservative and operative Eliminate possible causes of delay Promote healing

Immobilization should be sufficient to prevent movement at # site(cast / internal fixation)

Not to neglect # loading so, encourage muscle exercise and weight bearing in the cast/brace

Operation > 6 mths & no signs of callus formation Internal fixation and bone graffting(operation-least possible damage to the soft tissue)

Late 1: DELAYED UNION

Late 2 : NON-UNION

In a minority of cases, delayed union--non-union Factors contributing to non-union:-

inadequate treatment of delayed union too large gap interposition of soft tissues between the fragments

The growth has stopped and pain diminished- replaced by fibrous tissue - pseudoarthrosis

Treatment :- conservative / operative atrophic non-union – fixation and grafting hypertrophic non-union – rigid fixation

Late 2: NON UNION

bone ends are rounded off or exuberant Hypertrophic non union

Bone ends are enlarged, osteogenesis is still active but not capable of bridging the gap

‘elephant feet’ on X ray

Atrophic non union Cessation of osteogenesis No suggestion of new bone formation

Non-unionX- rayA – Atrophic non- unionB – Hypertrophic non- union

A B

Late 2: Non union

Tx: Mostly symptomless Conservative

Removable splint For hypertrophic non-union, functional bracing-

induce union Pulsed electromagnetic fields and low frequency

pulsed u/s can also be used to stimulate union.

Operative Hypertrophic--Rigid fixation (internal or external) Atrophic--Excision of fibrous tissue ,sclerotic tissue

at bone end, bone grafts packed around the fracture

Late 3: MALUNION

Factors:- failure to reduce the fracture failure to hold the reduction while healing

proceed gradual collapse of comminuted / osteoporotic

bone

fragments that are joined in an unsatisfactory position

MALUNION

Late 3: Mal-union

X-ray are essential to check the position of the fracture while uniting. important- the first 3 weeks so it can be easily corrected

Clinical features: Deformity usually obvious , but sometimes

the true extent of malunion is apparent only on x-ray

Rotational deformity can be missed in the femur, tibia, humerus or forearm unless is compared with it’s opposite fellow

Treatment Decision about the need for re-

manipulation and correction-difficult

In adults Fracture-reduced as near to the anatomical position as possibleapposition for healing

alignment and rotation is important for function

Angulation(>10-15) in long bone or apparent rotational deformity may need correction by re-manipulation or by osteotomy and internal fixation

In children angular deformity near the bone ends often remodel with timeRotational deformity will not

In lower limb shortening

Shortening less than 2 cm: compensated by shoe raise

Shortening more than 2 cm: limb lengthening should be consider.

Long term effect of mal-alignment (>15) results in asymmetrical loading of joint and results in late development of 2 osteoarthritis.

Late 4: AVASCULAR NECROSIS

Certain region-known for their propensity to develop ischaemia and bone necrosis Head of femur Proximal part of scaphoid Lunate Body of talus

(Actually this is an early complication however the clinical and radiological effects are not seen until weeks or even months)

No clinical feature of avascular necrosis but if there is a failure to unite or bone collapse-pain

A B

The cardinal X-ray feature – increased bone density in the weight-bearing part of the joint(new bone ingrowth in necrotic segment)

Treatment:-

Avascular necrosis can be prevented by early reduction of susceptible fractures and dislocations.

Arthroplasty - Old people with necrosis of the femoral head.

Realignment osteotomy or arthrodesis - for younger people with necrosis of the femoral head

Symptomatic treatment for scaphoid or talus

Late 5: OSTEOARTHRITIS

A fracture-joint may damage the articular cartilage and give rise to post traumatic osteoarthritis within a period of months.

Even if the cartilage heals, irregularity of the joint surface may cause localized stress and so predispose to secondary osteoarthritis years later

Late 6: JOINT STIFFNESS Commonly occur at the joints close to

malunion or bone loss eg: knee, elbow, shoulder

Causes of joint stiffness haemarthrosis → lead to synovial adhesion oedema and fibrosis adhesion of the soft tissues

Worsen by prolong immobilization Treatment

prevented with exercise physiotherapy

THANK YOU!!!!

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