complications of fractures by Dr Saleh.pptx

This presentation include detailed discussion of most complications of most common fractures.

1. COMPLICATIONS OF FRACTURES BY : DR SHOAIB BUGHIO P.G TRAINEE DOST UNIT II LUMHS JAMSHORO

2. CLASSIFICATION OF COMPLICATIONS : 1. GENERAL COMPLICATIONS . 2. EARLY COMPLICATIONS : I ) URGENT . II) LESS URGENT . 3. LATE .

3. GENERAL COMPLICATIONS 1. BLOOD LOSS . 2. SHOCK . 3. FAT EMBOLISM . 4. CARDIORESPIRATORY FAILURE .

4. EARLY COMPLICATIONS EARLY COMPLICATIONS MAY APPEAR AS PART OF PRIMARY INJURY OR ONLY AFTER FEW DAYS OR WEEKS .

5. VISCERAL INJURY THE MOST IMPORTANT BEING PENETRATION OF LUNGS IN RIBS FRACTURE . CAUSING LIFE THREATING PNEUMOTHORAX . RUPTURE OF BLADDER OR URETHERA IN PELVIC FRACTURES . THESE INJURIES REQUIRE EMERGENCY TREATMENT .

6. VASCULAR INJURY THE FRACTURES MOST OFTEN ASSOCIATED WITH DAMAGE TO MAJOR ARTERY ARE AROUND KNEE , ELBOW , HUMERS & FEMORAL SHAFTS . THE ARTERY MAY BE CUT , TORN , COMPRESSED OR CONTUSED : EITHER BY INITIAL INJURY OR SUBSEQUENTLY BY SWELLING , BONY FRAGMENTS OR REDUCTION MANOUUVRES . PATIENT MAY COMPLAIN OF PARASTHESIA OR NUMBNESS . THE INJURED LIMB IS COLD , PALE OR CYNOSED . PULSE IS WEAK OR ABSENT .

7. IF VASCULAR INJURY IS SUSPECTED AN ANGIOGRAM OR DUPLEX SHOULD BE PERFORMED IMMEDIATELY .

8. TREATMENT XRAY SHOULD BE ASSESED CAREFULLY , IF POSITION SUGGESTS THAT ARTERY IS BEING KINKED OR COMPRESSED REDUCTION IS NECESSARY . CIRCULATION IS REASSESD REPEATEDLY OVER NEXT HALF AN HOUR . IF NO IMPROVEMENT VESSEL MUST BE EXPLORED BY OPERATION , PREFERBLY WITH PRE OR PER-OPERATIVE ANGIOGRAPHY . CUT VESSEL IS REPLACED BY VEIN GRAFT . IF VESSEL REPAIR IS UNDERTAKEN , INTERNAL FIXATION IS PREFERED .

9. NERVE INJURY NERVE INJURY IS COMMON WITH HUMERAL SHAFT , INJURIES AROUND ELBOW & INJURIES AROUND KNEE .

10. CLOSED NERVE INJURIES ARE SELDOM SEVERED & SPONTANEOUS RECOVERY SHOULD BE WAITED AS IT OCCURS IN 90 % CASES IN 4 MONTHS . OPEN INJURIES ARE MORE LIKELY TO COMPLETE , NERVE SHOULD BE EXPLORED AND REPAIRED .

11. INFECTION OPEN FRACTURE MAY GET INFECTED , CLOSED FRACTURES ARE HARDLY DO : UNLESS OPEN FOR OPERATION . POST TRAUMTIC WOUND INFECTION IS NOW MOST COMMON CAUSE OF CHRONIC OSTEOMYLITEUS .

12. GAS GANGRENE TERIFYING CONDITION IS PRODUCED BT CLOSTRIDIM SPECIES : CLOSTRIDIUM WELCHII . THESE ANAEROBIC BACTERIA CAN SURVIVE LOW OR NO OXYGEN TISSUES : DIRT WOUND OR WOUND WHICH IS NOT PROPERLY DEBIRMENT HAS BEEN DONE . TOXINS PRODUCE CAN DESTROY TISSUES PRODUCING WHICH IS NEVER FORGETTEN . BEST TREATMENT IS THE PREVENTION . REPEATIVE DEBIRTMENTS ARE PERFORMED TO VIATILSE THE TISSUES ; UNTILL NO ANY DEAD TISUE REMAINS .

13. TREATMENT KEY TO LIFE SAVING IS EARLY DIAGNOSIS . GENERAL MEASURES INCLUDES FLUID THEARPY . HYPERBARIC OXYGEN HAS BEEN USED TO STOP THE SPREAD . DECOMPRESSION OF THE WOUND , REMOVEL OF DEAD TISSUES . AMPUTATION IS ESSENTIAL IN ADVANCED CASES .

14. PLASTER & PRESSURE SORES PLASTER SORE OCCUR WHEN SKIN PRESSES DIRECTLY ONTO BONE . THIS SHOULD BE AVOIDED BY APPLYING EXTRA PADDING ON BONY POINTS TO AVOID PRESSURE . WHILE PLASTER SORE STARTS DEVELOPING THE WINDOW SHOULD BE CREATED .

15. LATE COMPLICATIONS DELAYED UNION : IF THE TIME OF UNION IS UNDULY PRLONGED , THE TERM DELAYED UNION IS USED . CAUSES : BIOLOGICAL , BIOMECHANICAL OR PATIENT RELATED .

16. BIOLOGICAL 1 . INADEQUATE BLOOD SUPPLY 2. SEVERE SOFT TISSUE DAMAGE 3 . PERIOSTEAL STRIPPING .

17. BIO MECHANICAL 1. IMPERFECT SPLINTAGE . 2. OVER-RIGID FIXATION . 3. INFECTION PATIENT RELATED : 1. IMMENSE 2. IMMODERATE 3. IMMOVABLE 4. IMPOSSIBLE

18. TREATMENT CONSERVATIVE : TWO IMPORTANT PRINCIPLES ARE : 1 . ELIMINATE POSSIBLE CAUSE OF DELAYED UNION 2. PROVIDE APPROPRIATE ENVIROMENT TO PROMOTE HEALING . IMMOBILIZATION SHOULD BE SUFFICIENT TO PREVENT SHEAR , IMPORTANT STIMULUS TO UNION IS : 1. ENCOURAGE MUSCLE EXERSICES . 2. ALLOW PARTIAL WEIGHT BEARING IN CAST .

19. OPERATIVE MANAGEMENT EACH CASE IS TREATED ACCORDING TO ITS OWN MERIT . AS A GENERAL RULE , IF DELAYED UNION IS MORE THAN 06 MONTHS & NO ANY SIGN OF CALLUS FORMATION IS SEEN THEN OPEN REDUCTION & INTERNAL FIXATION WITH BONE GRAFTING IS INDICATED .

20. NON – UNION NON UNION IS DEFINED AS FRACTURE WHICH PERSISTS FOR 09 MONTHS . OR FRACTURE WHICH HAS SHOWN NO SIGN OF HEALING OR ANY CALLUS FORMATION FOR PAST 03 MONTHS . OR FRACTURE WHICH WILL NOT HEAL WITHOUT ANY INTERVENTION IS LABBELED AS NON – UNION .

21. CAUSES : CASS CONTACT : SUFFICIENT CONTACT BETWEEN BONE FRAGMENTS . ALIGMNMENT : ADEQUATELY ALIGNED . STABILITY : FRACTURE HELD SUFFICIENT STABILITY . STIMULATION : FRACTURE SUFFICIENTLY STIMULTED .

22. TREATMENT CONSERVATIVE : 1 . NON UNION IS OCCASIONALY TREATED AS CONSERVATIVE , HYPERTROPHIC NON UNION FUNCTIONAL BRACING MAY BE SUFFICIENT TO INDUCE UNION . 2. PULSED ULTRASANOGRAPHY . 3. LOW FREQUENCY ELECTROMAGNTIC WAVES .

23. OPERATIVE MANAGEMENT HYPERTROPHIC NON UNION CAN BE TREATED BY RIGID FIXATION EITHER BY INTERNAL FIXATION OR EXTERNAL FIXATION .

24. IN ATROPHIC NON –UNION , FIXATION ALONE IS NOT ENOUGH , SCLEROSED AND NECROTIC ENDS ARE EXCISED AND ARE PACKED BY BONE GRAFTS . IF THE NECROTIC PIECE IS LARGE ENOUGH IT IS TO BE FILLED BY GRAFTS OR BY USING ILIZROV TECHNIQUES .

25. MAL – UNION WHEN THE FRAGMENTS ARE JOINED IN UNSATISFACTORY POISTION ( UNACCEPATBLE ANGULATION , ROTATION OR SHORTENING ) THE FRACTURE IS DEFINED AS MALUNITED . CAUSES ARE : 1. FAILURE TO REDUCE . 2. FAILURE TO HOLD REDUCTION . 3. GRADUAL COLLAPSE OF COMMUNITED 4. OSTEOPOROTIC BONE .

26. TREATMENT TREATMENT GUIDELINES OF MAL-UNION ARE : 1 . IN ADULTS FRACTURES SHOULD BE REDUCED TO ANATOMICAL POSITION AS MUCH AS POSSIBLE , ANGULATION OF 10-15 DEGREES OR NOTICEBALY ROTATIONAL DEFORMITY NEEDS CORRECTION . CORRECTION MAY NEED REMANIPULATION OR CORRECTION OSTEOTOMIES . 2 . IN CHILDREN ANGUKAR DEFORMITY NEAR THE BONE ENDS WILL REMODEL BUT ROTATIONAL DEFORMITY WILL NOT .

27. 3. IN LOWER LIMB SHORTENING OF 2 CM IS ACCEPTABLE . 4. THE PATIENTS EXPECTATIONS MAY BE QUITE DIFFERENT FROM SURGEONS : THEY SHOULD NOT BE IGNORED . 5. EARLY DISCUSIONS WITH PATIENTS TO GUIDE THEM WHICH DEFORMITY IS ACCEPATBLE . 6 . THE MAL-ALIGNMENT OF MORE THAN 15 DEGREES IN ANY PLANE MAY CAUSE ASYMTRICAL LOADING ON JOINT ABOVE AND BELOW ; ULTIMATELY LEADS TO SECONDARY OSTEOARTHRITIS .

28. AVASCULAR NECROSIS CERTAIN AREAS ARE PRONE TO DEVELOP BONE NECROSIS AFTER INJURY WHICH ARE : 1 . HEAD OF FEMUR ( AFTER NECK OF FEMUR FRACTURE OR HIP DISLOCATION ) . 2 . PROXIMAL PART OF SCAPHOID . 3 . LUNATE DISLOCATION 4 . THE BODY OF TALUS DUE TO TALAR NECK FRACTURE .

29. TREATMENT IN ELDERLY PATIENTS WITH NECK FEMUR FRACTURE : ARTHOPLASTY IS OBVIOUS CHOICE . AVN OF TALUS OR SCAPHOID MAY NEED NOT MORE THAN SYMPTOMATIC TREATMENT . SOMETIMES ARTODESIS IS NEEDED OF WRIST OR ANKLE .

30. JOINT STIFFNESS JOINT STIFFNES AFTER FRACTURE COMMONLY OCCURS AT ELBOW , SHOULDER , KNEE & WORST OF ALL IN SMALL JOINTS OF HAND. SOMETIMES JOINT ITSELF IS INJURED CAUSING HAEMARTHOSIS WHICH LEADS TO SYNOVIAL ADHESIONS . OFTEN STIFFNESS DUE TO EDEMA , CAUSING FIBROSIS OF CAPSULE , LIGAMENTS AND MUSCLES AROUND IT . ALL THESE CONDITIONS ARE WORSEN BY PROLONGED CAST .

31. TREATMENT BEST TREATMENT IS PREVENTION . BY EXERSICES KEEP THE JOINT MOBILE . IS CAST IS APPLIED IT SHOULD BE IN POSITION OF SAFE IMOBILISATION . JOINTS WHICH ARE STIFFED PROLONG PHSYIOTHERAPY CAN WORK WONDERS . IF FAILS TO DO SO THEN ARTHOSCOPIC GUIDED MAY RELEASE MAY FREE THE JOINT . OCCASIONALY ADHESIONS ARE TO BE REMOVED BY PERFORMING SURGERY .

32. COMPLEX REGIONAL PAIN SYNDROME IN 1900 SUDECK DESCRIBED CONDITION CHARECTERISED BY PAINFUL OSTEOPOROSIS OF THE HAND . THE SAME CONDITION SOMETIMES OCCURS AFTER FRACTURES OF EXTERIMITIES & FOR MANY YEARS IT WAS CALLED SUDECK ATROPHY . NOW IT IS ADVANCED ATROPHIC DISORDER DUE TO LATE POST TRAUMATIC REFLEX SYMPATHATIC DYSTROPHY ALSO CALLED AS ALGODYSTROPHY .

33. THE PATIENTS COMPLAINS OF CONTINOUS PAIN , OFTEN DESCRIBED AS BURNING IN CHARACTER . AT FIRST THERE IS LOCAL SWELLING , REDNESS AND WARMTH , TENDERNESS & STIFFNES NEAR JOINT . SKIN BECOMES PALE & ATROPHIC . XRAY SHOWS THE PATCHY REFRACTION OF BONE .

34. ELEVATION & CONTINUE EXERCISES ARE IMPORTANT IN EVERY POST FRACTURE BUT ESSENTIAL IN CRPS . ANTI-INFLAMATORY DRUGS & ANALGESICS ARE ADVISED . INVOLVEMENT OF PAIN SPECIALIST ALONG WITH DEDICATED PHYSIOTHERAPY . SOMETIMES USE OF AMITRIPTYLINE , CARBAMAZEPINE OR GABAPENTINE .

35. OSTEOARTHRITIS A FRACTURE INVOLVING JOINT MAY SEVERLY DAMAGE ARTICULAR CARTILAGE & GIVE RISE TO POST TRAUMATIC OSTEOARTHRITIS WITHIN MONTHS . EVEN IF CARTILAGE HEALS YET IRREGULARITY IN SURFACEMAY LEADS TO SECONDARY OSTEO ARTHRITIS . PROBLEM ARISES FROM THE AREAS WHICH WERE PREVIOUSLY COMMUNITED OR DEPRESSED .

36. MALUNION IN THE SHAFT OF LONG BONES MAY PRE DISPOSE TO SECONDARY OSTEOARTHRITIS HOWEVER THERE IS LITTLE EVIDENCE THAT WHEN ANGULATION WAS LESS THAN 15 DEGREES THAT LEADS TO SECONDARY OSTEOARTHRITIS .

37. 1. MOST COMMON GENERAL COMPLICATION OF FRACTURE ? A. BLOOD LOSS . B. SHOCK . C. FAT EMBOLISM . D. CARDIORESPIRATORY FAILURE . E. ALL

38. B . SHOCK

39. 2. COMMON VESSEL INJURED IN SUPRACONDYLE HUMERUS FRACTURE IS ? A. RADIAL B . ULNAR C. MEDIAN D. BRACHIAL E. ALL

40. D. BRACHIAL

41. 3. MOST COMMON CAUSE OF CHRONIC OSTEOMYLITIS IS ? SMOKING B. DIABETIS C. POST OPERATIVE WOUND D. SUPRACONDYLE HUMERUS FRACTURE E. NON UNITED FRACTURES .

42. C. POST OPERATIVE WOUND

43. 4. WHICH OF THESE IS NOT A TYPE OF NON UNION ? ELEPHANT HOOF B. HORSE HOOF C. CHICKENS NECK D. INFECTIVE E. ATROPHIC

44. C. CHICKENS NECK

45. 5. COMMON SITES OF AVASCULAR NECROSIS EXCLUDED? HEAD OF FEMUR . B .PROXIMAL PART OF SCAPHOID . C. LUNATE DISLOCATION . D. THE BODY OF TALUS . E. HEAD OF RADIUS .

46. E. HEAD OF RADIUS .