complication of fractures and...
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Complication of Fractures and Dislocations
นพ.อธิพงศ์ กองฤทธ์ิกลุ่มงานออร์โธปิดกิส์ โรงพยาบาลนครพงิค์
วนัพฤหัสบดทีี ่22 ม.ีค. 2561
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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
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Local complication
Acute complication
• Local Visceral Injury
• Neurovascular Injury
• Compartment Syndrome
• Infection
Late complication
• Delayed union
• Non-union
• Malunion
• Joint stiffness
• Osteoarthritis
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Acute complication
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• 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
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Neurovascular Injury
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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
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Vascular injury
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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
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Nerve injury
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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
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Acute Compartment Syndrome
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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
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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)
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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
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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
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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
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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
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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
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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
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Fasciotomy
• In the calf, all four compartments should be released
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Complications
• Volkmann ischemic contractures
• Permanent nerve damage
• Limb ischemia and amputation
• Rhabdomyolysis and renal failure
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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
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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
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Open Fracture
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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
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Gustilo and Anderson Classification of Open Fractures
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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
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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
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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
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Late complication
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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
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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
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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
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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
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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)
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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
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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
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Biology : GoodStability : Lacking
Biology : PoorStability : Lacking
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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
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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
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Malunion
• Clinical features• deformity & shortening of the limb
• limitation of movements
• Treatment• Osteotomy & Internal fixation
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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
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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
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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
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• 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)
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Thank you for your attention