Complication of Fractures and Dislocations นพ.อธ พงศ กองฤทธ กล มงานออร โธป ด กส โรงพยาบาลนครพ งค ว นพฤห สบด ท 22 ม.ค. 2561

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Alfred McCormick
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1 Complication of Fractures and Dislocations นพ.อธ พงศ กองฤทธ กล มงานออร โธป ด กส โรงพยาบาลนครพ งค ว นพฤห สบด ท 22 ม.ค. 2561

2 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) Acute Late Local complication

3 Local complication Acute complication Local Visceral Injury Neurovascular Injury Compartment Syndrome Infection Late complication Delayed union Non-union Malunion Joint stiffness Osteoarthritis

4 Acute complication

$injury to the adjacent viscera Pelvic fracture Bladder and Urethal rupture Rib$ $fracture Penetration to the lungs Pneumothorax Chance fractue of spines$

5 Local visceral Injury 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

6 Neurovascular Injury

7 Neurovascular Injuries Fractures and dislocations can be associated with vascular and nerve damage Always check neurovascular status before and after reduction Common vascular injuries Common nerve injuries Injury Vessel Injury Nerve 1 st rib fracture Subclavian artery/vein Shoulder dislocation Axillary Shoulder dislocation Axillary artery Humeral shaft fracture Radial Humeral supracondylar fracture Brachial artery Humeral supracondylar fracture Radial or median Elbow medial condyle Ulnar Elbow Dislocation Brachial artery Monteggia fracture-dislocation Posterior-interosseous Pelvic fracture Presacral and internal iliac Hip dislocation Sciatic Femoral supracondylar fracture Femoral artery Knee dislocation Peroneal Knee dislocation Popliteal artery/vein Proximal tibial Popliteal artery/vein

8 Vascular injury

$Paraesthesia/numbness Remove all bandages and splints Reduce the fracture/$ dislocation and reassess circulation If no improvement then vessels must be

dislocation and reassess circulation If no improvement then vessels must be

9 Clinical and Management Injured limb cold, cyanosed, pulse weak/absent Paraesthesia/numbness Remove all bandages and splints Reduce the fracture/ dislocation and reassess circulation If no improvement then vessels must be explored by operation If vascular injury suspected angiogram should be performed immediately

10 Nerve injury

$injury likely complete Should be explored at time of debridement/repair Indications for early exploration: Nerve injury associated with open fracture Nerve injury in fracture that needs internal$

11 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

12 Acute Compartment Syndrome

space rises enough to occlude capillary blood

13 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

14 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)

COMPARTMENT SYNDROME Most commonly in calf

15 COMPARTMENT SYNDROME 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

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

16 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

muscle due to injury Reperfusion after ischemia Burns

17 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

$COMPARTMENT SYNDROME Open fracture does not preclude, particularly with severe blunt trauma or crush injuries Severe pain, decreased sensation,$

18 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

Compartment pressures >30 mmhg raise concern Within 30 mmhg

syndrome Immediate fasciotomies 120 mm Hg Difference between

30mmHg is indication for immediate decompression 60 mm Hg

19 Compartment pressures >30 mmhg raise concern Within 30 mmhg of diastolic blood pressure (ΔP) indicate compartment syndrome Immediate fasciotomies 120 mm Hg Difference between diastolic pressure and compartment pressure (delta pressure)< 30mmHg is indication for immediate decompression 60 mm Hg Pulse Pressure Ischemia 30 mm Hg 10 mm Hg 0 mm Hg Elevated Pressure Normal

20 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

21 Fasciotomy In the calf, all four compartments should be released

22 Complications Volkmann ischemic contractures Permanent nerve damage Limb ischemia and amputation Rhabdomyolysis and renal failure

23 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

24 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

25 Open Fracture

$Open fracture Open fracture or Compound$ $communicates directly with the fracture and$

26 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

27 Gustilo and Anderson Classification of Open Fractures

$Steps of Managing an Open Fracture 1. การร กษาผ ป วย open fracture ท กรายถ อเป น emergency surgery 2. Initial evaluation, diagnose other life-threatening injuries 3.$

28 Steps of Managing an Open Fracture 1. การร กษาผ ป วย open fracture ท กรายถ อเป น emergency surgery 2. Initial evaluation, diagnose other life-threatening injuries 3. ให antibiotics ท เหมาะสมให เร วท ส ดและให ต อหล งผ าต ดในช วงเวลาท จ าก ด รวมถ ง tetanus toxoid และ antitoxin Antibiotic Coverage for Open Fractures Type I : First-generation cephalosporin Type II, III: Add an aminoglycoside Farm injuries: Add penicillin and an aminoglycoside

$fracture type II และ III ให ท า repeat debridement ภายใน 24 ถ ง$ Leave the wound open for 5 to 7 days, secondary wound coverage

29 Steps of Managing an Open Fracture 4. Immediate debride the wound using copious irrigation, สาหร บ open fracture type II และ III ให ท า repeat debridement ภายใน 24 ถ ง 72 ช วโมง 5. Stabilize the fracture 6. Leave the wound open for 5 to 7 days, secondary wound coverage procedure 7. Perform early autogenous cancellous bone graft กรณ ท ม ช นกระด กหายไป 8. Rehabilitate the involved extremity

Serial neurovascular examinations Compartment pressure monitoring Prompt

30 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

31 Late complication

$Delayed union Failure of a fracture to consolidate within the expected time Healing processes are still continuing, but the outcome is$

32 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

33 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 wks

$Clinical features - Persistent pain at fracture site$ $- Disuse muscle atrophy X-Ray - Visible fracture$

34 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

35 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

$fracture) Fracture gap is filled by fibrous tissue$

36 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)

$Nonunion Causes : Instability at fracture site inadequate method of$ $fracture Infection Excessive gap at fracture site Excessive post-op$

37 Nonunion Causes : 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

$Clinical features - Painless movement at fracture site - No pain at fracture site - Instability at fracture site - May be weight bearing with pseudoarthrosis X-Ray - Fracture is clearly visible -$

38 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

40 Biology : Good Stability : Lacking Biology : Poor Stability : Lacking

$Treatment Hypertrophic nonunion Rigid immobilization Open reduction and compression of fracture with cancellous bone graft$

41 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

$Malunion Condition when the union of fracture in unsatisfactory$ $Failure to reduce a fracture adequately Failure to hold reduction$

42 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

43 Malunion Clinical features deformity & shortening of the limb limitation of movements Treatment Osteotomy & Internal fixation

$Joint Stiffness Common complication of fracture treatment following immobilization Common site : knee, elbow, shoulder, small joints of the hand Causes edema & fibrosis of$

44 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 & periarticular adhesions) Synovial adhesions due to hemarthrosis

physiotherapy - Intra-articular adhesions Gentle manipulation under

45 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

$Osteoarthritis Post-traumatic OA Joint fracture with$ months Secondary OA Cartilage heals Irregular joint

46 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

agent Joint mobility : Physiotherapy Load reduction : Weight

47 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)

48 Thank you for your attention

Orthopedics Dr. Ali Lecture 6 General Principles of Fractures VI

Orthopedics Dr. Ali Lecture 6 General Principles of Fractures VI Early Complications (those that arise during the first few weeks following injury) 1. Local Visceral Injury 2. Vascular Injury 3. Nerve