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