complication of fractures and...
TRANSCRIPT
Complication of Fractures and Dislocations
นพ.อธิพงศ์ กองฤทธ์ิกลุ่มงานออร์โธปิดกิส์ โรงพยาบาลนครพงิค์
วนัพฤหัสบดทีี ่22 ม.ีค. 2561
Complication of Fractures and Dislocations
General complication
• Shock• Hypovolemic or hemorrhagic shock
• Neurogenic shock
• Septic shock
• Fat embolism
• Thrombo-embolism
• Pulmonary embolism
• Multiple organs failure syndrome (MOFS)
• Tetanus
• Gas gangrene (Clostridium sp. infections)
Local complication
• Acute
• Late
Local complication
Acute complication
• Local Visceral Injury
• Neurovascular Injury
• Compartment Syndrome
• Infection
Late complication
• Delayed union
• Non-union
• Malunion
• Joint stiffness
• Osteoarthritis
Acute complication
• Fracture around the trunk are often complicated by injury to the adjacent viscera
• Pelvic fracture Bladder and Urethal rupture
• Rib fracture Penetration to the lungs Pneumothorax
• Chance fractue of spines Gastrointestinal injury (50%)
• The treatment depends on the part injured and fracture pattern
Local visceral Injury
Neurovascular Injury
Neurovascular Injuries
• Fractures and dislocations can be associated with vascular and nerve damage
• Always check neurovascular status before and after reduction
Injury Vessel
1st rib fracture Subclavian artery/vein
Shoulder dislocation Axillary artery
Humeral supracondylar fracture Brachial artery
Elbow Dislocation Brachial artery
Pelvic fracture Presacral and internal iliac
Femoral supracondylar fracture Femoral artery
Knee dislocation Popliteal artery/vein
Proximal tibial Popliteal artery/vein
Injury Nerve
Shoulder dislocation Axillary
Humeral shaft fracture Radial
Humeral supracondylar fracture Radial or median
Elbow medial condyle Ulnar
Monteggia fracture-dislocation Posterior-interosseous
Hip dislocation Sciatic
Knee dislocation Peroneal
Common vascular injuries Common nerve injuries
Vascular injury
Clinical and Management
• Injured limb cold, cyanosed, pulse weak/absent
• Paraesthesia/numbness
Remove all bandages and splintsReduce the fracture/ dislocation and reassess circulation
If vascular injury suspected angiogram should be performed immediately
If no improvement then vessels must be explored by operation
Nerve injury
Clinical and Management
• Paresthesia and Motor weakness to supplied area
• Closed injuries: • Nerve seldom 90% recovery in 4 months
• If not do nerve conduction studies +/- repair
• Open injuries: • Nerve injury likely complete
• Should be explored at time of debridement/repair
• Indications for early exploration:
• Nerve injury associated with open fracture
• Nerve injury in fracture that needs internal fixation
• Presence of concomitant vascular injury
• Nerve damage diagnosed after manipulation of fracture
Acute Compartment Syndrome
COMPARTMENT SYNDROME
• A devastating condition that occurs when the pressure in a closed fascial space rises enough to occlude capillary blood flow, rendering the enclosed muscles and nerves ischemic
COMPARTMENT SYNDROME
• Prolonged ischemia cell damage which leads to edema
• Edema further increase compartment pressure Vicious cycle
• Extensive muscle and nerve death >4 hours
• Nerve may regenerate but infarcted muscle is replaced by fibrous tissue (Volkmann’s ischaemic contracture)
Most commonly in calf and forearm :- May occur in thigh, buttock, foot, hand, or upper arm
Early diagnosis is essential :- Early treatment restores blood flow and prevents irreversible ischemia and resultant muscle and nerve necrosis
COMPARTMENT SYNDROME
Clinical Evaluation
• Progressive pain : out of proportion to the injury and not responsive to normal doses of pain medication
• Exacerbated by passive motion : stretch of the involved muscle
• Hard or tense to touch
• Other signs are late findings or are unreliable • pallor, paresthesia, paralysis, and pulselessness
• Distal pulses may remain present long after muscle and nerve ischemia and damage are irreversible
Etiology
• Bleeding into a compartment from arterial injury
• Infiltration of fluids
• Overly tight bandages
• Swelling of the muscle due to injury
• Reperfusion after ischemia
• Burns
• Prolonged pressure
• Marked and prolonged elevation of the extremity
• Overexertion
COMPARTMENT SYNDROME
• Open fracture does not preclude, particularly with severe blunt trauma or crush injuries
• Severe pain, decreased sensation, pain to passive stretch of fingers or toes, and a tense extremity
• Strong suspicion or Unconscious patient : • Monitoring of compartment pressures
0 mm Hg
10 mm Hg
30 mm Hg
60 mm Hg
120 mm Hg
Pulse Pressure
Ischemia
Elevated Pressure
Normal
Difference between diastolic pressure and compartment pressure (delta pressure)< 30mmHg is indication for immediate decompression
• Compartment pressures
>30 mmHg raise concern
• Within 30 mmHg of diastolic blood pressure (ΔP) indicate compartment syndrome
Immediate fasciotomies
Treatment
• Suspected :• Limb should be placed at a level equal to the heart
• All casts or dressings should be split to the skin
• Diagnosis : • Emergency to the operating theater for decompressive fasciotomy• All tight compartments must be released
Fasciotomy
• In the calf, all four compartments should be released
Complications
• Volkmann ischemic contractures
• Permanent nerve damage
• Limb ischemia and amputation
• Rhabdomyolysis and renal failure
Infection
• Causes:• Open fracture (common)
• Fracture hematoma can get infected by organisms from bloodstream
• Post-surgical infection most common cause of chronic osteomyelitis
• Wound becomes inflamed and starts draining seropurulent fluid
• Treatment• Superficial and limited infection local cleaning and antibiotics
• Deep infections drainage of pus, debridement of local necrotic tissues, irrigation of the wound
Infection
• Internal fixation is in place : • Fixation device isn’t loose it should not be removed
• Majority of internally fixed fracture unite in spite of infection with antibiotic treatment and drainage
• Fixation is loose revising or removing the internal fixation and using external fixation • maintain stability and to allow dressing changes and wound care
• Uncontrolled infection can lead to septic arthritis and osteomyelitis
Open Fracture
Open fracture
Open fracture or Compound fracture : an osseous disruption in which a break in the skin and underlying soft tissue communicates directly with the fracture and its hematoma
Gustilo and Anderson Classification of Open Fractures
Steps of Managing an Open Fracture
1. การรักษาผู้ ป่วย open fracture ทกุรายถือเป็น emergency surgery
2. Initial evaluation, diagnose other life-threatening injuries
3. ให้ antibiotics ท่ีเหมาะสมให้เร็วท่ีสดุและให้ตอ่หลงัผา่ตดัในชว่งเวลาท่ีจ ากดั รวมถงึ tetanus toxoid และ antitoxin
Antibiotic Coverage for Open FracturesType I : First-generation cephalosporinType II, III: Add an aminoglycosideFarm injuries: Add penicillin and an aminoglycoside
4. Immediate debride the wound using copious irrigation, ส าหรับ open fracture
type II และ III ให้ท า repeat debridement ภายใน 24 ถงึ 72 ชัว่โมง5. Stabilize the fracture
6. Leave the wound open for 5 to 7 days, secondary wound coverage procedure
7. Perform early autogenous cancellous bone graft กรณีท่ีมีชิน้กระดกูหายไป8. Rehabilitate the involved extremity
Steps of Managing an Open Fracture
COMPLICATIONS
• Infection• Cellulitis or osteomyelitis
• Compartment syndrome• Severe loss of function
• It may be avoided by • High index of suspicion
• Serial neurovascular examinations
• Compartment pressure monitoring
• Prompt recognition of impending compartment syndrome• Fascial release at the time of surgery
Late complication
Delayed union
• Failure of a fracture to consolidate within the expected time
• Healing processes are still continuing, but the outcome is uncertain
• Causes➢ Inadequate blood supply
➢ Severe soft tissue damage
➢ Periosteal stripping
➢ Excessive traction
➢ Insufficient splintage
➢ Infection
PERKINS’ TIME TABLE
Upper Limb Lower Limb
Callus visible 2-3 wks 2-3 wks
Union 4-6 wks 8-12 wks
Consolidation 6-8 wks 12-16 wks
Clinical features- Persistent pain at fracture site- Instability at fracture site- Non weight bearing- Disuse muscle atrophy
X-Ray- Visible fracture line - Very little callus formation or periosteal reaction
Treatment
• Conservative- To eliminate any possible cause
- Immobilization
- Exercise
• Operative- Indication :
Union is delayed > 6 months
No signs of callus formation
- Internal fixation & bone grafting
Nonunion
• Fracture has not healed and is not likely to do so without intervention
• Healing has stopped, no signs of healing after >3-6 months (depending upon the site of fracture)
• Fracture gap is filled by fibrous tissue (pseudoarthrosis)
NonunionCauses :
• Instability at fracture site• inadequate method of stabilization
• Inadequate blood supply at fracture• Poor surgical technique following open reduction,
following trauma at time of fracture
• Infection
• Excessive gap at fracture site
• Excessive post-op use of limb
Clinical features- Painless movement at fracture site - No pain at fracture site- Instability at fracture site- May be weight bearing with pseudoarthrosis
X-Ray- Fracture is clearly visible- Fracture ends are rounded, smooth and sclerotic- Atrophic non-union :
- Bone looks inactive (Bone ends are often tapered / rounded)- Relatively avascular
- Hypertrophic non-union :- Excessive bone formation on the side of the gap- Unable to bridge the gap
Biology : GoodStability : Lacking
Biology : PoorStability : Lacking
Treatment
• Hypertrophic nonunion• Rigid immobilization
• Open reduction and compression of fracture with cancellous bone graft
• Avascular nonunion• Surgery required
• Open medullary canal, debride sclerotic bone
• Apply rigid fixation
• Cancellous bone graft
Malunion
• Condition when the union of fracture in unsatisfactory position
(unaccepted angulation, rotation or shortening)
• Causes• Failure to reduce a fracture adequately
• Failure to hold reduction while healing proceeds
• Gradual collapse of comminuted or osteoporotic bone
Malunion
• Clinical features• deformity & shortening of the limb
• limitation of movements
• Treatment• Osteotomy & Internal fixation
Joint Stiffness
• Common complication of fracture treatment following immobilization
• Common site : knee, elbow, shoulder, small joints of the hand
• Causes• edema & fibrosis of capsule, ligaments, muscle around joint
• adhesion of soft tissue to each other or to the underlying bone (intra & peri-articular adhesions)
• Synovial adhesions due to hemarthrosis
Treatment
- Prevention :- Exercise
- If joint has to be splinted → Make sure in correct position
- Joint stiffness has occurred :- Prolonged physiotherapy
- Intra-articular adhesions
→ Gentle manipulation under anesthesia
followed by continuous passive motion
- Adherent or contracted tissues
→ Released by operation
Osteoarthritis
• Post-traumatic OA➢Joint fracture with severely damaged articular cartilage➢Within period of months
• Secondary OA➢Cartilage heals➢Irregular joint surface may caused localized stress
→ secondary OA➢Years after joint injury
• Clinical features• Pain
• Stiffness
• Swelling
• Deformity
• Restricted movement
• Treatment• Pain relief : Analgesics
Anti-inflammatory agent
• Joint mobility : Physiotherapy
• Load reduction : Weight reduction
• Realignment osteotomy (young pt)
• Arthroplasty (pt > 60yr)
Thank you for your attention