Complications of the fracturesComplications of the fractures: : AA- general complications- general complications. .

BB- local complications- local complications. .

AA – – general complicationsgeneral complications. . 11 - -blood loss and shockblood loss and shock. .

22 - -cardiopulmonary failurecardiopulmonary failure. .

33 - -fat embolismfat embolism. .

44 - -DVTDVT. .

55 - -tetanustetanus. .

66 - -gas gangrenegas gangrene. .

77 - -crush syndromecrush syndrome. .

Fat embolismFat embolism: : Fat globules larger than 10 micro meter in diameter can enter the circulation Fat globules larger than 10 micro meter in diameter can enter the circulation after closed fractures of the long bones . It's source is from the bone after closed fractures of the long bones . It's source is from the bone marrow , it can be deposited in any site in the body mainly in the lung or marrow , it can be deposited in any site in the body mainly in the lung or even in the brain , the condition is more common in patients with multiple even in the brain , the condition is more common in patients with multiple

fracturesfractures. . ClinicallyClinically : :

The patient usually with lower limb fracture , early signs (within 72 hours of the The patient usually with lower limb fracture , early signs (within 72 hours of the injury ) has slight rise in temperature and pulse rate , then the patient injury ) has slight rise in temperature and pulse rate , then the patient develop breathlessness and mild mental confusion or restlessness ; develop breathlessness and mild mental confusion or restlessness ; petechiae can be looked for on the chest , back , axilla and conjunctival petechiae can be looked for on the chest , back , axilla and conjunctival

foldsfolds. . In sever cases there will be marked respiratory distress and coma due to In sever cases there will be marked respiratory distress and coma due to

hypoxia or brain embolihypoxia or brain emboli. . TreatmentTreatment : there is no infallible test for embolism ; monitoring of the patient is : there is no infallible test for embolism ; monitoring of the patient is mandatory , oxygen supply and even in sever cases ventilator can be used , mandatory , oxygen supply and even in sever cases ventilator can be used , but in sever cases recovery is unpredictable and the mortality rate is high but in sever cases recovery is unpredictable and the mortality rate is high

… early fixation of the fractures help in decrease its possibility… early fixation of the fractures help in decrease its possibility. .

Crush syndromeCrush syndrome: : the crushed limb is deprived from the blood flow , also in case of interruption of the crushed limb is deprived from the blood flow , also in case of interruption of blood supply for the limb for any cause ; tissues begin to die and toxic blood supply for the limb for any cause ; tissues begin to die and toxic metabolite accumulate and when reach to the circulation it causing a lot of metabolite accumulate and when reach to the circulation it causing a lot of

problemsproblems: : The resultant hyperkalemia , hypocalcaemia and metabolic acidosis can arrest The resultant hyperkalemia , hypocalcaemia and metabolic acidosis can arrest the heart ; the large molecules of myoglobin which released from dead the heart ; the large molecules of myoglobin which released from dead

muscles may lead to acute renal failuremuscles may lead to acute renal failure. . TreatmentTreatment: : The most important measure is preventionThe most important measure is prevention. .

High urine flow must be ensured by giving large volume of intravenous High urine flow must be ensured by giving large volume of intravenous crystalloid ; manitol alkaline diuretic can be givencrystalloid ; manitol alkaline diuretic can be given. .

Extensive wound excision (remove all the dead muscle if there is wound) is Extensive wound excision (remove all the dead muscle if there is wound) is mandatorymandatory. . Some time amputation is the resolution to save the lifeSome time amputation is the resolution to save the life. .

Gas gangreneGas gangrene: : This condition is caused by clostridial infection , mainly clos. Welchii ; which are This condition is caused by clostridial infection , mainly clos. Welchii ; which are anaerobic organism which can live and multiply in tissues with low oxygen anaerobic organism which can live and multiply in tissues with low oxygen tension ; so the dirt wound with dead muscle that has been closed without tension ; so the dirt wound with dead muscle that has been closed without adequate debridement is the most suitable media for the growth of this adequate debridement is the most suitable media for the growth of this

micro organismmicro organism. . The toxin which produced by this m.o. destroy the cell wall and rapidly lead to The toxin which produced by this m.o. destroy the cell wall and rapidly lead to

tissue necrosis and spread of the infectiontissue necrosis and spread of the infection. . ClinicallyClinically: : Clinical features appear within 24 hours of the injuryClinical features appear within 24 hours of the injury. .

The patient has sever pain and swelling around the wound and brownish The patient has sever pain and swelling around the wound and brownish discharge may be seen , little or no pyrexia , high pulse rate , gas in the discharge may be seen , little or no pyrexia , high pulse rate , gas in the tissue can be detected by x – ray but it is not very marked ; characteristic tissue can be detected by x – ray but it is not very marked ; characteristic

smell become evidentsmell become evident. . Rapidly the patient become toxemic and may pass into coma and deathRapidly the patient become toxemic and may pass into coma and death. .

PreventionPrevention: :

Any deep wound in the muscleAny deep wound in the muscle should be explored , all dead tissue should be explored , all dead tissue should be totally removed , if there is doubt about tissue validity , should be totally removed , if there is doubt about tissue validity , then the wound should be left openedthen the wound should be left opened. .

TreatmentTreatment ::

Early diagnosis is the key for success of the treatment which includeEarly diagnosis is the key for success of the treatment which include : :

I.V fluid replacement , intravenous antibiotic ( benzyl penicillin in high I.V fluid replacement , intravenous antibiotic ( benzyl penicillin in high doze , metronidazole )doze , metronidazole ). .

Hyperbaric oxygen has been used to decrease spread of infectionHyperbaric oxygen has been used to decrease spread of infection; ;

Decompression of the wound and remove the dead tissueDecompression of the wound and remove the dead tissue. .

In advance cases amputation may be essentialIn advance cases amputation may be essential. .

BB- - local complication of the fractureslocal complication of the fractures: :

aa- early complications- early complications . .

bb- late complications- late complications. .

aa- early complications- early complications: : 11 - -vascular injuries and compartment syndromevascular injuries and compartment syndrome. .

22 - -nerves injuriesnerves injuries. .

33 - -tendons injuriestendons injuries. .

44 - -visceral injuriesvisceral injuries. .

55 - -haemoarthrosishaemoarthrosis. .

66 - -infectioninfection. .

Compartment syndromeCompartment syndrome: : Fractures of upper and lower limbs can give rise to sever ischemia Fractures of upper and lower limbs can give rise to sever ischemia even if there is no damage to a major vesselseven if there is no damage to a major vessels. .

Bleeding , edema or inflammation may increase the pressure within Bleeding , edema or inflammation may increase the pressure within one of the osteofacial compartment ; there is reduced capillary flow one of the osteofacial compartment ; there is reduced capillary flow which result in muscle ischemia , further edema , still greater which result in muscle ischemia , further edema , still greater pressure and yet more profound ischemiapressure and yet more profound ischemia. .

Vicious circle that end after 12 hours or less , in necrosis of nerve and Vicious circle that end after 12 hours or less , in necrosis of nerve and muscle within the compartmentmuscle within the compartment. .

Nerve is capable of regeneration but muscles once infarcted , can Nerve is capable of regeneration but muscles once infarcted , can never recover and it replaced by inelastic fibrous tissue never recover and it replaced by inelastic fibrous tissue (Volkmann's(Volkmann's ischemic contracture )ischemic contracture ). .

A similar events may be caused by swelling of a limb inside a tight A similar events may be caused by swelling of a limb inside a tight plaster castplaster cast. .

Late complications of the fracturesLate complications of the fractures: : 11 - -delayed union and non uniondelayed union and non union. .

22 - -malunionmalunion. .

33 - -avascular necrosisavascular necrosis. .

44 - -growth disturbance of the bonegrowth disturbance of the bone. .

55 - -myositis ossificansmyositis ossificans. .

66 - -tendons rupturestendons ruptures. .

77 - -nerves compressionnerves compression. .

88 - -bed sorebed sore. .

99 - -joint stiffnessjoint stiffness. .

1010 - -joints instabilityjoints instability. .

1111 - -sudeck dystrophysudeck dystrophy. .

1212 - -osteoarthritisosteoarthritis. .

11 - -delayed union and non uniondelayed union and non union: : non unionnon union :it is failure of the fracture to unite after double of the :it is failure of the fracture to unite after double of the

expected time of healing which is determined by perkin`sexpected time of healing which is determined by perkin`s tabletable. .

Causes of non unionCauses of non union: : A- causes related to the type of injuryA- causes related to the type of injury: :

11 - -extensive soft tissue damage and loss i.e in compound fracturesextensive soft tissue damage and loss i.e in compound fractures. . 22 - -bone loss in compound fracturesbone loss in compound fractures. .

33 - -soft tissue inter positionsoft tissue inter position. . 44 - -intact fellow boneintact fellow bone. .

55 - -infectioninfection. . B- causes related to the bone itselfB- causes related to the bone itself. .

11 - -poor blood supplypoor blood supply. . 22 - -poor hematoma formationpoor hematoma formation. .

33 - -flimsy periosteumflimsy periosteum. . 44 - -diseased bone ( pathological fractures )diseased bone ( pathological fractures )

C-C- causes related to the surgeoncauses related to the surgeon : these includes technical faults like : these includes technical faults like::

11 - -over tractionover traction. .

22 - -poor splintagepoor splintage. .

33 - -poor fixationpoor fixation. .

44 - -impatienceimpatience. .

D-D- cause related to the patientcause related to the patient: :

11 - -immenseimmense. .

22 - -immoderateimmoderate. .

33 - -immovableimmovable. .

44 - -impossibleimpossible . .

Types of non unionTypes of non union: :

11 - -atrophic non unionatrophic non union. .

22 - -hypertrophic non unionhypertrophic non union. .

Treatment of non unionTreatment of non union: : AA- conservative treatment- conservative treatment: :

11 - -functional bracefunctional brace. .

22 - -pulse electromagnetic fieldspulse electromagnetic fields. .

33 - -low frequency pulsed ultra soundlow frequency pulsed ultra sound. .

BB- operative treatment- operative treatment: :

11 - -refreshment of the fracture site . refreshment of the fracture site . 22- perfect reduction- perfect reduction. .

33 - -rigid fixation with compression . rigid fixation with compression . 44- bone grafting- bone grafting . .

22 - -malunionmalunion: :

When the fracture is in unsatisfactory position e.g unacceptable When the fracture is in unsatisfactory position e.g unacceptable angulation , rotation or shortening and unite in this position , so the angulation , rotation or shortening and unite in this position , so the deformity will persist and it is called maluniondeformity will persist and it is called malunion. .

It is caused by , either failure of reduction or failure of holding of the It is caused by , either failure of reduction or failure of holding of the fracturefracture. .

33 - -avascular necrosisavascular necrosis: :

In certain regions , when fracture occur it may complicated with In certain regions , when fracture occur it may complicated with interruption of blood supply to certain parts of the bone lead to interruption of blood supply to certain parts of the bone lead to avascular necrosis . e.g of these parts of bonesavascular necrosis . e.g of these parts of bones: :

11 - -femoral head necrosis after fracture neck of femurfemoral head necrosis after fracture neck of femur. . 22 - -proximal part of the scaphoid after fracture waist of the scaphoidproximal part of the scaphoid after fracture waist of the scaphoid. .

33 - -body of the talus after fracture neck of talusbody of the talus after fracture neck of talus. .

44 - -growth disturbancegrowth disturbance: :

This complication occur when there is damage to the growth plate of the bone by the This complication occur when there is damage to the growth plate of the bone by the fracturefracture. .

55 - -bed sorebed sore: :

It is pressure sore or ulceration occur in bed ridden patient at the areas which It is pressure sore or ulceration occur in bed ridden patient at the areas which sustained pressure mainly lower back , buttocksustained pressure mainly lower back , buttock. .

It is occur very rapidly and healed very slowlyIt is occur very rapidly and healed very slowly. .

The prevention is better than treatmentThe prevention is better than treatment. .

66 - -myositi`s ossificansmyositi`s ossificans: :

Deposition of calcium in the muscles lead to stiffness of the near jointDeposition of calcium in the muscles lead to stiffness of the near joint. .

Indomethacin is helpful in treatmentIndomethacin is helpful in treatment. .

77--Tendons lesionsTendons lesions: :

aa- - tendonitistendonitis e.g tibialis posterior tendonitis in fracture medial malioli e.g tibialis posterior tendonitis in fracture medial malioli. .

bb- - rupture of tendonrupture of tendon e.g rupture of extensor pollicis longus tendon in e.g rupture of extensor pollicis longus tendon in

Cole's fractureCole's fracture. .

88 - -sudeck dystrophysudeck dystrophy: :

It is post traumatic localized reflex sympathetic over activity also known It is post traumatic localized reflex sympathetic over activity also known as algodystrophyas algodystrophy. .

The patient has continuous pain , swelling , redness , the skin look The patient has continuous pain , swelling , redness , the skin look shiny , pinkish , decrease in hair distribution warmth , localized shiny , pinkish , decrease in hair distribution warmth , localized tenderness and the near by joints are stifftenderness and the near by joints are stiff. .

X- rayX- ray show localized osteoporosis show localized osteoporosis. .

TreatmentTreatment: :

Removal of splintage of the fracture (pop) and start active Removal of splintage of the fracture (pop) and start active physiotherapy , analgesic anti inflammatory drugs , sympatholytic physiotherapy , analgesic anti inflammatory drugs , sympatholytic

drugs e.g guanithidin i. v or even sympathetic blockdrugs e.g guanithidin i. v or even sympathetic block . .

99 - -muscles contracturemuscles contracture: :

Usually follow arterial injuries with the fractures or compartment syndrome . e.g Usually follow arterial injuries with the fractures or compartment syndrome . e.g for it is Volkmann's ischemic contracture in the forearm for it is Volkmann's ischemic contracture in the forearm. .

1010 - -nerve compressionnerve compression . By the mal united bone or by the callus . By the mal united bone or by the callus. .

1111 - -joint instabilityjoint instability. .

1212 - -joint stiffnessjoint stiffness . It is occur due to immobilization of the limb during . It is occur due to immobilization of the limb during

the period of healing of the fracture . It can reduced by avoid prolonging the period of healing of the fracture . It can reduced by avoid prolonging the period of holding of the fracture , using functional orthosis , or by using the period of holding of the fracture , using functional orthosis , or by using internal or external fixators which they permit movement of the joints at the internal or external fixators which they permit movement of the joints at the

time of healing of the fracturestime of healing of the fractures. .

1313 - -osteoarthritisosteoarthritis: :

This occur when the fracture involve the articular surface of the jointThis occur when the fracture involve the articular surface of the joint. . It can be minimized by perfect reduction of the articular surface and internal It can be minimized by perfect reduction of the articular surface and internal

fixationfixation. .

Stress fracturesStress fractures: :

Stress or fatigue fracture is one occurring in normal bones of healthy Stress or fatigue fracture is one occurring in normal bones of healthy patient but it is not caused by a specific traumatic incident , but by patient but it is not caused by a specific traumatic incident , but by

repetitive minor trauma or stressrepetitive minor trauma or stress. .

It affect many bones but the common examples are Marsch fractureIt affect many bones but the common examples are Marsch fracture

))fracture metatarsal bones , mainly the second onefracture metatarsal bones , mainly the second one ( ( in the military people in the military people ; and fractures in the lower third of the fibula (runner's people); and fractures in the lower third of the fibula (runner's people). .

Pathological fracturePathological fracture: :

It is fracture that occur in abnormal bone or diseased bone , and it It is fracture that occur in abnormal bone or diseased bone , and it suspected when the force which cause the fracture is less than the suspected when the force which cause the fracture is less than the

ordinary force needed to break the normal boneordinary force needed to break the normal bone. .

Any condition lead to weaken the bone can lead to pathological fracture Any condition lead to weaken the bone can lead to pathological fracture e.g osteomyelitis , bone tumors , metabolic bone diseases …..etce.g osteomyelitis , bone tumors , metabolic bone diseases …..etc..

Dislocation and subluxation of the jointsDislocation and subluxation of the joints: :

DislocationDislocation : it mean the joint surfaces are completely displaced and : it mean the joint surfaces are completely displaced and

no longer in contact (complete separation of the twono longer in contact (complete separation of the two articular surfacesarticular surfaces. ( . (

SubluxationSubluxation : it represent a lesser degree of displacement . Such that : it represent a lesser degree of displacement . Such that

articular surfaces are still partly apposedarticular surfaces are still partly apposed. .

Injuries of the physisInjuries of the physis: :

ClassificationClassification : : Salter Harris classificationSalter Harris classification: :

Type oneType one : transverse fracture through the growth plate : transverse fracture through the growth plate. . Type twoType two : it is similar to type one but it contain triangular piece from : it is similar to type one but it contain triangular piece from

the metaphysisthe metaphysis. . Type threeType three : the fracture split the epiphysis vertically : the fracture split the epiphysis vertically. . Type fourType four : splitting the epiphysis vertically and extend to the : splitting the epiphysis vertically and extend to the

metaphysismetaphysis. . Type fiveType five : compression of the growth plate (crushing) and it result in : compression of the growth plate (crushing) and it result in

growth disturbance of the bone ( baddest type )growth disturbance of the bone ( baddest type ). .