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1. COMPLICATIONS OF FRACTURES

2. Complications of fractures tend to be classified according to whether they are LOCAL or SYSTEMIC and when they occur IMMEDIATE(at the time of injury) EARLY (initial few days) LATE

3. IMMEDIATE COMPLICATIONS SYSTEMIC hypovolaemic Shock LOCAL injury to major vessels and nerves Muscles and tendons Joints viscera

4. EARLY COMPLICATIONS SYSTEMIC Hypovolaemic shock ARDS Fat embolism DVT & pulmonary embolism Aseptic traumatic fever Septicaemia Crush syndrome LOCAL Infection-non specific or specific like tetanus and gas gangrene. Compartment syndrome

5. HYPOVOLEMIC SHOCK It is the Commonest cause of death in fractures of major bones like pelvis or femur Patient losses around 1500 – 2000 ml of blood in pelvis # and 1000 – 1500 ml in femur # . Cause of hypovolemic shock may be external or internal haemorrhage External haemorrhage results from compound fractures with or without associated injury to major vessels Internal haemorrhage is usually massive bleeding into body cavities as chest and abdomen. Internal is more difficult to diagnose.

6. MANAGMENT Starts even before the cause is established Two large bore iv cannulas are kept Infuse 2000 ml of crystalloids (ringer lactate) followed by colloid ( haemaccel ) and blood if needed Localise the site of lesion- if in body cavities, perform chest aspiration or diagnostic peritonial lavage . Sometimes a simple x ray is enough , possibly chest x-ray and x-ray of abdomen Chest bleeding-ICDT( intercostal drainage tube) Abdominal bleeding- laparotomy Emergency angiography and embolisation of bleeding vessels for deeper vessels can be done

7. LATE COMPLICATIONS IMPERFECT UNION OF FRACTURE Delayed union Non union Mal union Cross union Others Avascular necrosis Shortening Joint stiffness Sudeck’s dystrophy Osteomyelitis Ischemic contracture Myositis ossificans Osteoarthritis Late nerve palsy (Tardy paralysis).

8. ADULT RESPIRATORY DISTRESS SYNDROME Respiratory distress following a trauma Cause- not definite. Hypothesized to be by release of Inflammatory cells and proteinaceous fluid that accumulate in the alveolar spaces leading to a decrease in diffusing capacity and hypoxemia. The microvasculature in disrupted. Onset- 24 hours after injury

9. Features: Tachypnea Laboured breathing X- ray- diffused pulmonary infiltrates Arterial Po2 below 50

10. VOLKMANN’S ISCHAEMIC CONTRACTURE VOLKMANN’S ISCHAEMIC CONTRACTURE it is developed in group of muscles, caused by ischaemia due to compression or spasm of arteries

11. AETIOLOGY It is seen in the forearm and hand and less commonly in the leg and foot ,due to application of tight plaster bandages in hospital practices. It can occur in grossly displaced supracondylar fractures, where the sharp anterior edge of upper fragment irritates or damages the brachial artery.

12. PATHOLOGY The condition is due to contusion, spasm or thrombosis of the brachial artery at the elbow, or the radial and ulnar arteries in the upper half of the forearm. It is also due to the oedema and increased pressure in the anterior osteofascial compartment of the forearm. There is an area of ischaemic necrosis of the pronator and flexor muscles of the forearm, followed by fibrosis and later contractures of these muscles. There may also be associated ischaemic paralysis of the median and ulnar nerves. In the later stages,there are secondary capsular contractures of wrist and the finger joints.

13. CLINICAL FEATURES It is described in two stages: 1.Acute Volkmann’s ischaemia 2. Chronic Volkmann’s ischaemia contracture

14. ACUTE VOLKMANN’S ISCHAEMIA Patient plastered for supracondylar fracture elbow may present the next day with acute unbearable pain and swelling in the fingers. Capillary filling in nail beds and radial pulse is absent. There may be paraesthesia and paresis due to ischaemia of median and ulnar nerve The clinical features are pain, pallor, paraesthesia , pulselessness and paralysis.

15. TREATMENT All constricting bandages and plasters should be removed immediately and flexion at the elbow lessened. If the fracture at the elbow has not been reduced, immediate manipulation must be done to reduce the fracture and relieve the pressure on the blood vessels If the pulse does not reappear after this, the artery is surgically explored and decompressed.

16. Incision of the skin and deep fascia releases the tension in the cubital fossa and forearm and restores the pulse in the vessel. If the vessel found damaged, it should be repaired with the help of a vascular surgeon

17. CHRONIC VOLKMANN’S ISCHAEMIC CONTRACTURE The deformity is typical the forearm is wasted, the wrist is flexed , the metacarpophalangeal joints remain extended and the interphalangeal joints are flexed. On passively extending the wrist, the finger flexion gets worse but on full flexion of the wrist ,the finger can be fully extended passively this is volkmann’s sign.

18. Clinically classified as : mild, moderate, severe where involvement of the flexor and extensor muscles is different.

19. TREATMENT In minimal deformities ,prolonged physiotherapy and splinting with elastic traction to the fingers will correct the deformity and improve function The soft tissue procedure used are the sliding of the origin of the common flexor muscles or lengthening the flexor tendons . The bony procedure used are shortening the forearm bones or excision of the carpal bones improving the appearance and function of the hand.

20. ISCHAEMIC CONTRACTURE IN LEG Volkmann’s ischaemic contracture also occur in the muscle of the leg and foot. In closed fracture of the proximal end of tibial shaft, the haematoma confined under the tender osteofascial compartment compresses the tibial arteries, causing progressive ischaemia and later contracture.

21. MYOSITIS OSSIFICANS Myositis ossificans is a condition where ,there is new bone formation in soft tissue around joints following trauma.

22. AETIOPATHOLOGY Myositis ossificans can occur after reduction of the dislocation of the elbow or supracondylar fracture. It can occur even after minimal injuries such as crack supracondylar fracture or crack fracture of the neck of the radius.

23. CLINICAL FEATURES In early stages, limitation of movement due to muscle spasm Later, a firm lump is palpable in front of the elbow. In final stages, a bony hard lump is felt surrounding the elbow with total loss of movement.

24. RADIOLOGICAL FEATURES In the early stages, a fussy ill defined radio-opacity is seen in front of the elbow. In the later mature stage, the radiograph shows a dense irregular radio-opaque mass.

25. TREATMENT In all cases of elbow injuries ,strict instructions must be given not to give massage or passive stretching to the joint after removal of the plaster. In the active stage ,the range or movement is recorded and the elbow is rested in a plaster slab. When the plaster is removed ,it will be found that the movement has improved and the shadow is smaller but denser. When the condition is well established and non progressive ,surgical excision of the myositic mass may be done to restore mobility

26. Fat embolism Fat embolism syndrome is a post traumatic complication causing sudden respiratory distress . It occurs within the first few days after major polytrauma or fracture of the pelvis or femur.

27. PATHOGENESIS Free fat globules of microscopic sizes from the bone marrow escape into the blood stream and cause embolic phenomena in the lungs, brain and skin.

28. CLINICAL FEATURES Sudden onset, presenting with acute pulmonary or cerebral symptoms. The early symptoms are shortness of breath, followed by restlessness and confusion. The clinical signs are pyrexia, tachycardia and tachypnoea with dyspnoea and cyanosis. Characteristic petechial rashes develop in the chest, axillae , foot, neck and conjuctiva . Disorientation and coma follow in more severe cases.

29. TREATMENT The only specific treatment of fat embolism is directed at improving the hypoxaemia due to respiratory distress. Oxygen is administered by nasal tubing or face mask ventilator Use of massive steroid therapy has been found to be helpful Mild or moderate cases recover in 7-10 days.

30. DELAYED UNION & NON- UNION Delayed union of a fracture is one wherein healing has not progressed at the average rate for the site and type of fracture Non union is established when the fracture shows no visible progressive signs of healing for 3months and a minimum of 9 months has elasped since injury

31. AETIOLOGY Causes of delayed and non-union are : 1.Soft tissue interposition between the fragment. 2.Segmental fractures with impaired blood supply to middle fragment. 3. Open fractures. 4.Comminuted fractures. 5.Infected fracture. 6.Pathological fractures 7.Inadequate immobilization 8.Insecure fixation and premature weight bearing

32. PATHOLOGY There are two types of non union: 1.The hypertrophic type, sclerosed and vascular. There is a fibrous union and this has a biological capacity to unite 2. The atrophic type where the fragments are inert and avascular . The ends of fragments are tapering ,osteoporotic and very mobile with sometimes a false joint with even a synovial lining.

33. CLASSIFICATION NON-UNION Is classified as : 1. hypervascular non-union .Elephant foot type .Horse hoof type . Oligotrophic type 2. Avascular non –union .comminuted .gap .atrophic .torsion wedge

34. CLINICAL FEATURES It occurs in long bones such as humerus , forearm or tibia. It occurs in intracapsular fracture of the neck of femur and in the fracture scaphoid . The characteristic sign is abnormal mobility or yielding at the fracture site without pain.

35. RADIOLOGICAL FEATURES Radiologically , there is sclerosis of fracture surfaces and closure of the medullary canal in the hypertrophic type. There is osteoporosis and tapering of fracture ends in the atrophic type.

36. NON UNION

37. TREATMENT Established non –union in long bones has to be treated by operation . The fracture site is freshened by excision of the scar tisue and the bone ends fixed by internal fixation and supplemented by cancellous bone grafts to promote osteogenesis .

38. MALUNION This means that the fracture has anatomically malunited with angulation ,rotation or overriding of the fragments . This is failure to reduce the fragments into proper alignment or failure to hold them in position till union.

39. CLINICAL FEATURES The patient presents with a deformity at the fracture site. It commonly occurs at the shaft of long bones or at end of the bones ( supracondylar fracture humerus , colles fracture) If the deformity is minimal and the function of the limb is satisfactory , malunion can be accepted. In young children , malunion tends to correct at remodelling at the fracture site.

40. Treatment Corrective osteotomy and internal fixation.

41. MALUNION

42. CROSS-UNION This can occur in fractures of the shafts of the radius and ulna and in fractures of tibia and fibula . The proximal fragment of one bone unites with the distal fragment of the other bone. when it occurs in the forearm, supination and pronation movements are lost .

43. SUDECK’S OSTEODYSTROPHY Sudeck’s osteodystrophy is a post traumatic painful stiffness of the hand and fingers. It commonly occurs as a complication of colles ’ fracture or even as minor trauma to the hand. It also occurs in the foot after injuries. It is considered to be a traumatic,reflex sympathetic dystrophy,producng vasomotor distrabances . Clinically: The hand is swollen, painful, smooth and glossy. Skin creases are obliterated. Nails and hair are atrophic. Associated with capillary and venous dilatation. joints of the hands are stiff and painful.

44. Clinical features-- ctd The joints of the hand are stiff and painful. In the early stage, the affected part is warm but later it becomes colder than normal.

45. RADIOLOGICAL FEATURES In early stages, there are generalised speckled areas of osteoporosis. Later, the cortex also gets demineralised with a glassy appearance of all bones of the forearm and hand.

46. TREATMENT Treatment is by vigorous physiotherapy using active exercises, assisted movements ,splinting and keeping the part elevated. In very severe cases ,relief may be obtained by a cervical sympathetic block or sympathectomy operation.

47. DISLOCATION OF JOINTS

48. DEFINITION DISLOCATION is the total displacement of articular end of a bone from the joint cavity. Incomplete displacement is called SUBLUXATION. REDUCTION means restoration of normal alignment of bones.

49. CLASSIFICATION DISLOCATIONS are classified as: Congenital. Traumatic. Pathological. Paralytic.

50. TRAUMATIC This usually follows a serious violence Clinical types of dislocation are as follows: Acute dislocation Old unreduced dislocation Reccurent dislocation

51. ACUTE DISLOCATION: The traumatic dislocation commonly occur in the shoulder, elbow and hip. These are further classified according to the direction of the displacement of the distal bone in relation to the proximal ( eg . Anterior,posterior , etc).

52. Clinically, the acute traumatic dislocation is diagnosed by history and findings. There is acute pain and swelling around the joint. There is gross deformity at the joint, the bony landmarks are distorted. The clinical signs common to all dislocation fall into two groups: 1.Signs denoting the absence of the articular end of a bone from its normal anatomical position 2.Signs denoting the presence of the displaced end of the bone in an abnormal position SHOULD LOOK FOR ASSOCIATED NERVE AND VASCULAR INJURIES

53. MANAGEMENT Radiographs confirm the diagnosis and detect associated fractures. Acute dislocation of a joint is an orthopaedic emergency and it requires immediate reduction under anaesthesia . After reduction, the part should be immobilised till the soft tissues such as the capsule and the ligaments heal. After about 3-4 weeks, the joint is mobilised by exercise therapy.

54. OLD UNREDUCED DISLOCATION : Patients with unreduced dislocation present themselves for the treatment from weeks to months after the primary dislocation This is unfortunately common in our country and are difficult problem and need prolonged treatment

55. TREATMENT Closed reduction under anaesthesia is attempted in cases presenting within 4weeks. This should not be done in dislocations more than 6 – 8 weeks as there is a danger of fracture during the manipulation. Surgical reduction is indicated in such cases.

56. RECURRENT DISLOCATION : When a traumatic dislocation of a joint is followed by subsequent frequent dislocation by minimal trauma, it is called recurrent dislocation. This is particularly more common in the shoulder joint and patellofemoral joint .

57. PATHOLOGICAL DISLOCATIONS Pathological dislocation is caused by some disease process and is common in the hip joint. This occurs when there is destruction of the head of femur or excessive distension of the joint capsule. This is of two types : DESTRUCTIVE DISLOCATION DISTENSIVE DISLOCATION

58. DESTRUCTIVE DISLOCATION It is common in following conditions: Tuberculosis of the hip when there is a travelling acetabulum . Septic arthritis of the hip of infancy where there is total d estruction of the head of the femur.

59. DISTENSIVE DISLOCATION The head of the femur gets dislocated when the joint capsule is rapidly distended by an effusion of synovial fluid or pus

60. PARALYTIC DISLOCATION Paralytic dislocation occurs when there is marked imbalance of muscle power It can occur in the hip whenever there is an overaction of hip flexors and adductors and is always a posterior dislocation In poliomyelitis , when the hip extensors and abductors are paralysed , the normal adductors and flexors overact and cause dislocation In cerebral palasy , the spasm of the adductors and flexors causes the dislocation

61. FRACTURES IN CHILDREN

62. Fractures in children are important as the presence of epiphysis in long bones make them vulnerable to damage to the growth plate, resulting in growth disorders and deformities. There are several differences between the bones of children and adults Children’s bones are pliable and withstand greater bending force than the rigid adult bone.

63. As the periosteum is thick, it remains intact on one side of the cortex in moderate violence resulting in green stick fractures Children’s fracture unite much faster than those in adults Inaccurate reduction with angulation can still heal in good shape due to remodelling . Shortening due to overlapping in long bone fractures as in femur gets corrected upto ½ inch due to stimulation of growth in epiphysis

64. Injuries in children occur as domestic injuries- at home and at play, mostly due to fall. The types of injuries are as follows: BIRTH FRACTURES BATTERED BABY FRACTURES EPIPHYSEAL FRACTURE SEPERATION

65. BIRTH FRACTURES These are seen in newborn babies and are more common in deliveries in breech presentation, particularly when there is difficulty in labour . Immobilisation by simple strapping for few weeks is sufficient for these fractures. The common birth fractures are, fracture shaft femur, fracture shaft humerus , fracture clavicle

66. Fracture shaft of femur This occurs when the obstetrician tries to bring the leg down in the breech delivery by hooking his finger around the groin of the baby. Fracture shaft of humerus This also occurs during extraction of the upper limb in breech deliveries.

67. Fracture clavicle This occurs during difficult extraction of the after coming head in breech presentation. This is often associated with birth injuries to the brachial plexsus . A crack fracture clavicle may be missed at birth and the baby may be brought 2 or 3 weeks later with lump in the clavicle due to callus formation .

68. BATTERED BABY SYNDROME Battered baby syndrome is a condition where children are brought with one or more fractures with a suspicious history of fall. The history does not correlate with the type of fracture There may be multiple generalised contusions along with a single fracture. There may be fracture of long bones along with the ribs and skull fractures. Radiography reveals multiple fractures with a subperiosteal new bone at different stages of healing.

69. All this suggest repeated violence by the parent or attendent . These children should be admitted in hospital for management and also to prevent further violence. The management includes the social workers assistance by tactful enquries to determine the family background and to provide counselling . Family background may reveal poverty, parental seperation , alcoholism, and drug addiction, unwanted babies and unwed mothers A psychologist will also be needed for parental counselling .

70. EPIPHYSEAL INJURIES Fracture separation of the epiphysis is common in children and occurs in the age group of 5-10 years. It is common in elbow region . The normal elbow also must be radiographed to identify the normal epiphysis Types of epiphyseal injuries described by Salter & Harris

71. SALTER -HARRIS CLASSIFICATION Type I - simple separation of the epiphysis ( eg . Epiphysis of medial epicondyle at the elbow) Type II- fracture separation with meataphyseal segment ( eg.lower radial epiphysis) the fragment often includes a small triangular metaphyseal segment, and hence it is not a pure seperation of epiphysis (THURSTON –HOLLAND SIGN)

72. Type III - fracture line only through epiphysis Type IV - fracture through metaphysis,physis and epiphysis Type V - compression injuries of the epiphysis ( eg . At the lower end of tibia)

73. Classification

74. SALTER HARRIS CLASSIFICATION

75. Type 1 E piphyseal separation without metaphyseal fragment, or extension into the epiphysis . ZONE OF HYPERTROPHY

76. Type I A type 1 fracture is transverse fracture through the hypertrophic zone of the physis . In this injury, the width of the physis is increased. The growing zone of the physis usually is not injured, and growth disturbance is uncommon. Usually dx’d by clinical presentation alone. On clinical examination, the child has point tenderness at the epiphyseal plate, which is suggestive of a type I fracture.

77. X-rays of undisplaced type I physeal fractures, therefore, are normal except for associated soft tissue swelling, making careful patient examination particularly important in this injury

78. Type 2 physeal fracture line extends into the metaphysis. THURSTON HOLLAND FRAGMANT OR SIGN

79. Type II A type II fracture is a fracture through the physis and metaphysis , but the epiphysis is not involved in the injury. These fractures may cause minimal shortening; however, the injuries rarely result in functional limitations. mechanism: shear or avlusion with angular force; healing is rapid, and growth is rarely disturbed; Type II is the most common

80. Type 3 F racture extends from the articular surface to the physis and continues peripherally through the physis

81. Type III A type III fracture is a fracture through the physis and the epiphysis. This fracture passes across the hypertrophic layer of the physis and extends to split the epiphysis, inevitably damaging the reproductive layer of the physis . Prone to chronic disability because, by crossing the physis, it extends into the articular surface of the bone. Rarely result in significant deformity; therefore, they have a relatively favorable prognosis. A type of ankle fracture termed a Tillaux fracture is a type of Salter-Harris type III fracture that is prone to disability. Treatment is often surgical.

82. Type 4 The fracture line extends across the physis from the epiphysis and articular surface into the peripheral metaphysis. The fracture line extends across the physis

83. Type IV A Type IV fracture involves all 3 elements of the bone: The fracture passes through the epiphysis, physis , and metaphysis . Similar to a type III fracture, a type IV fracture also is an intraarticular fracture; thus, it can result in chronic disability. By interfering with the growing layer of cartilage cells, these fractures can cause premature focal fusion of the involved bone. Therefore, these injuries can cause deformity of the joint. – Even w/ perfect reduction, growth is affected & prognosis is guarded;

84. Type V compression or crush injury of the epiphyseal plate

85. Type V A type V injury is a compression or crush injury of the epiphyseal plate with no associated epiphyseal or metaphyseal fracture. This fracture is associated with growth disturbances at the physis . Initially, diagnosis may be difficult, and it often is made retrospectively after premature closure of the physis is observed. In the older teenagers, the diagnosis is particularly difficult. The clinical history is paramount in the diagnosis of this fracture. A typical history is that of an axial load injury. These injuries have a poor functional prognosis. Angulation and limb length inequality may be long term complications

86. Epiphyseal seperation near the elbow often requires open reduction and internal fixation Compression or crush injury of the epiphysis results in premature fusion and arrest of growth at the epiphysis causing shortening or deformity.

87. PATHOLOGICAL FRACTURES

88. DEFINITION : It is a fracture occurring in a bone weakened by a pathological lesion following a trivial trauma. Clinical features : When a patient presents with a fracture with a history of minimal or trivial violence, one should suspect pathological fracture. On careful questioning, the patient may admit of having had some local pain or discomfort even before the occurrence of fracture. The pain at the site of fracture is usually less than that in a traumatic fracture.

89. The causative pathology may be very obvious as in case of advanced primary malignancy but sometime the pathological fracture may be the first sign of the occult primary. The common cause of the pathological fracture in elderly is a secondary deposits from a primary malignancy elsewhere or multiple myeloma of bone. Secondaries in the bone indicate advanced stage of the disease. Pathological fracture in the vertebrae often present as an exacerbation of backache and the primary could be diagnosed only if one keeps the suspicion index high.

90. RADIOLOGICAL FEATURES: The fracture line is often transverse and clean cut. The fracture line runs across a localised osteolytic area in the shaft of the bone. Sometimes the whole bone may show evidence of generalised rarefraction or osteosclerosis

91. Causative pathology The lesion which weakens the bone and make it susceptible to fracture could be classified as follows 1. Generalised Disorders 2. local lesions

92. Generalised disorders Children : 1.Osteogenesis imperfecta 2.Rickets Adults 3.Osteomalacia 4.Osteosclerosis 5.Hyperparathyroidism Old age 6.Generalised osteoporosis of bone( senile or postmenopausal) 7 .Pagets disease of bone 8.Carcinomatosis 9.Multiple myelomatosis

93. Local lesions Benign : Solitary bone cyst in children and adolosence . Parathyroid lesion ( localised ), fibrous dysplasia. Enchondroma of bone in hands and feet. Osteomyelitis . Malignant : 1.Secondary deposits in bone from primary lesion in thyroid, breast, bronchus,kidney and prostate. 2.Primary malignant tumour in bone, eg , Ewings tumour

94. Management Confirm the diagnosis of pathological fracture. This is done by establishing the nature of the causative pathology by Thorough clinical examination Blood biochemistry including serum calcium, inorganic phosphates, serum proteins, electrophoretic pattern Imaging techniques: plain x ray , CT scan, isotope bone scan, magnetic resonance imaging. Biopsy at the site of the fracture or any other accessible lesion.

95. Treatment This should include T reatment of fracture (by reduction and retention of the of fragments by immobilisation ) Treatment of the disease. An operative curetting followed by internal fixation will help in establishing diagnosis, removal of the pathology, and also treatment of the fracture Most pathological fracture unite well after treatment Pathological fracture through a benign lesion like simple bone cyst or enchondroma is treated by surgical curettage and bone grafting with excellent results.

96. Most often through a malignant secondary deposit occurs in a geriatric patient, who is already debilitated by primary disease. Management of such a pateint needs a team work of orthopaedic surgeon, the geriatric physician, oncologist and radiotherapist so that the elderly person may spend the remaining months of his life free from the miseries of pain. The senior citizen is entitled to enjoy a pleasant quality of life as long as he lives and meet his end with dignity.

97. STRESS FRACTURES Stress fractures are fractures usually occurring in weight bearing bones, caused by repeated minimal stresses. It is seen following unaccustomed strenuous exercises in military recruits under training. It commonly occurs in the metatarsals of the foot(MARCH FRACTURE), upper tibia & fibula, and neck of femur.

98. The patient present with diffuse pain of few weeks duration with no history of specific injury to the site Clinically, there is localised tenderness at the bone. Radiography shows a hairline crack in the bone and there may even be some callus around the site. Rest for few weeks and symptomatic tratment is usually sufficient.