complications of fractures and management_hso
TRANSCRIPT
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COMPLICATIONS OFCOMPLICATIONS OF
FRACTURES AND ITSFRACTURES AND ITSMANAGEMENTMANAGEMENT
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INTRODUCTIONINTRODUCTION
Because bones areBecause bones are
surrounded by soft tissue,surrounded by soft tissue,
the physical forces thatthe physical forces that
produce a fracture alwaysproduce a fracture alwaysproduce some degree ofproduce some degree of
soft tissue injury as well.soft tissue injury as well.
The associated soft tissueThe associated soft tissue
injury may assume muchinjury may assume muchgreater clinical significancegreater clinical significance
than the fracture itself.than the fracture itself.
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INTRODUCTIONINTRODUCTION
Radiographs:Radiographs:
• Just provide suchJust provide such
graphic evidence of agraphic evidence of a
fracture.fracture.
• eldom provideeldom provideevidence of the e!tent ofevidence of the e!tent of
the associated softthe associated soft
tissue injury.tissue injury.
Therefore it must beTherefore it must bethought in term of thethought in term of the
fracture: "hat hasfracture: "hat has
happened to thehappened to the
surrounding soft tissue#surrounding soft tissue#
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Genaral
Blood Loss
Shock
Fat Embolism
Cardiorespiratory Failure
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LOCALLOCAL
Urgent Less Urgent LateUrgent Less Urgent Late
$ocal visceral$ocal visceral injuryinjury%ascular injury%ascular injury
&erve injury&erve injury'ompartment'ompartment
yndromeyndrome
(aemarthrosis(aemarthrosis
)nfection)nfection
*as gangrene*as gangrene
+racture blisters+racture blisters
laster soreslaster sores
ressure soresressure sores
&erve entrapment&erve entrapment
-yositis ssificans-yositis ssificans
$igament injury$igament injury
Tendon lesionsTendon lesions
Joint stiffnessJoint stiffness
/lgdystrophy/lgdystrophy
0elayed union0elayed union
-alunion-alunion
&on1union&on1union
/vascular necrosis/vascular necrosis
-uscle contracture-uscle contracture
Joint instabilityJoint instability
steoarthrosissteoarthrosis
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VISCERAL INJURYVISCERAL INJURY
enetration of the lungenetration of the lung
with life threateningwith life threatening
pneumothora! 11pneumothora! 11
following rib fractures.following rib fractures.
Rupture of the bladderRupture of the bladder
or urethra in pelvicor urethra in pelvic
fractures.fractures.
These injuries re2uireThese injuries re2uire
emergency treatment.emergency treatment.
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VASCULAR INJURYVASCULAR INJURY
The artery may be cut,The artery may be cut,
torn, compressed ortorn, compressed or
contused, either by thecontused, either by the
initial injury orinitial injury or
subse2uently by jaggedsubse2uently by jagged
bone fregments.bone fregments.
The effects vary fromThe effects vary from
transient diminution oftransient diminution of
blood flow to profoundblood flow to profoundischaemia, tissue deathischaemia, tissue death
and periphera3 gangrene.and periphera3 gangrene.
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Common vasc!ar "n#r"esCommon vasc!ar "n#r"es
InjuryInjury
+irst rib fracture+irst rib fracture
houlder dislocationhoulder dislocation
(umeral supracondylar fracture(umeral supracondylar fracture4lbow dislocation4lbow dislocation
elvic fractureelvic fracture
+emoral supracondylar fracture+emoral supracondylar fracture
5nee dislocation5nee dislocation
ro!imal tibialro!imal tibial
VesselVessel
ubclavianubclavian
/!illary/!illary
BrachialBrachialBrachialBrachial
resacral and internal iliacresacral and internal iliac
+emoral+emoral
oplitealopliteal
oplitealopliteal
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C!"n"ca! $eatre % Vasc!ar "n#r&C!"n"ca! $eatre % Vasc!ar "n#r&
araesthesia oraraesthesia or
numbness in the toesnumbness in the toes
or fingers.or fingers.
The injured limb isThe injured limb is
cold and pale, orcold and pale, or
slightly cyanosed.slightly cyanosed.
The pulse is wea3 orThe pulse is wea3 or
absentabsent
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Treatment % Vasc!ar "n#r&Treatment % Vasc!ar "n#r&
rompt reduction is necessary.rompt reduction is necessary. The circulation is then reassessed.The circulation is then reassessed. )f there is no improvement the vessels)f there is no improvement the vessels
must be e!plored by operation 6preferablymust be e!plored by operation 6preferablywith the benefit of preoperative orwith the benefit of preoperative orperoperative angiography7.peroperative angiography7.
/ torn vessel can be sutured, or a/ torn vessel can be sutured, or a
segment may be replaced by a vein graft.segment may be replaced by a vein graft. )f it is thrombosed, endarterectomy may)f it is thrombosed, endarterectomy may
restore the blood flow.restore the blood flow.
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NERVE INJURYNERVE INJURY
'omplaints of'omplaints of
numbness ornumbness or
paraesthesia in theparaesthesia in the
nerve distribution.nerve distribution.
)n close injury the nerve)n close injury the nerve
is seldom severed, andis seldom severed, and
spontaneous recoveryspontaneous recovery
should be awaited 8 itshould be awaited 8 itoccurs in 9; of casesoccurs in 9; of cases
within < months.within < months.
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Common nerve "n#r"esCommon nerve "n#r"es
InjuryInjury NerveNerve
houlder dislocationhoulder dislocation /!illary/!illary
(umeral shaft fracture(umeral shaft fracture RadialRadial
(umeral supracondylar fracture(umeral supracondylar fracture Radial or medianRadial or median
4lbow medial condyle4lbow medial condyle =lnar=lnar
-onteggia fracture1dislocation-onteggia fracture1dislocation osterior interosseousosterior interosseous
(ip dislocation(ip dislocation ciaticciatic
5nee dislocation5nee dislocation eronealeroneal
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NERVE INJURYNERVE INJURY
If recovery has notIf recovery has not
occurred by theoccurred by theexpected time, and ifexpected time, and if
nerve conductionnerve conduction
studies fail to showstudies fail to show
evidence of recovery,evidence of recovery,
the nerve should bethe nerve should be
explored.explored.
Early exploration shouldEarly exploration should
also be considered ifalso be considered if
signs of a nerve injurysigns of a nerve injury
appear afterappear after
manipulation of themanipulation of thefracture. ( iegel andfracture. ( iegel and
!elberman, "##"$!elberman, "##"$
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NERVE INJURYNERVE INJURY
)n open fracture any)n open fracture any
nerve lesion is morenerve lesion is more
li3ely to beli3ely to be
complete> the nervecomplete> the nerveis e!plored duringis e!plored during
wound debridementwound debridement
and repair, eitherand repair, either
then or as athen or as asecondary proceduresecondary procedure
? wee3 later? wee3 later
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COMPARTMENT SYNDROMECOMPARTMENT SYNDROME
Bleeding, oedema orBleeding, oedema or
inflamation may increaseinflamation may increase
the pressure within one ofthe pressure within one of
the osteofascialthe osteofascial
compartment.compartment.
There is reduced capillaryThere is reduced capillary
flow which result in muscleflow which result in muscle
ischaemia, furtherischaemia, further
oedema, still greateroedema, still greaterpressure and yet morepressure and yet more
profound ischaemia.profound ischaemia.
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/ %icious circle that ends, after @A hours or less, in necrosis of/ %icious circle that ends, after @A hours or less, in necrosis ofnerve and muscle within compartment.nerve and muscle within compartment.
&erve is capable of regeneration but muscle, once infarcted,&erve is capable of regeneration but muscle, once infarcted,
can never recover and is replaced by inelastic fibrous tissuecan never recover and is replaced by inelastic fibrous tissue
6 %$5-/&& )'(/4-)' '&TR/'T=R4 76 %$5-/&& )'(/4-)' '&TR/'T=R4 7
Reduced
Blood flow
Oedema
Ischaemia
Increase
Compartment
pressure
ainful
ale
ulseless
araesthetic
aralysed
Fasciotomy
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C!"n"ca! Featres % Com'artment S&n(romeC!"n"ca! Featres % Com'artment S&n(rome
)schaemic muscle is highly)schaemic muscle is highly
sensitive to stretch, it shouldsensitive to stretch, it should
be tested by stretching thembe tested by stretching them
8 when the toes or fingers8 when the toes or fingers
are passively hypere!tendedare passively hypere!tended
there is increase pain in thethere is increase pain in thecalf or forearm.calf or forearm.
The presence of a pulse doesThe presence of a pulse does
not e!clude the diagnosis.not e!clude the diagnosis.
)n doubtful cases the)n doubtful cases the
diagnosis can be confirmeddiagnosis can be confirmedby measuring theby measuring the
intracompartmentalintracompartmental
pressure.pressure.
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Treatment % Com'artment S&n(romeTreatment % Com'artment S&n(rome
The threatened compartmentThe threatened compartmentmust be promptlymust be promptly
decompressed. 'ast, bandagedecompressed. 'ast, bandage
and dressing must beand dressing must be
completely removed.completely removed.
/ differential pressure/ differential pressure
between diastolic andbetween diastolic and
compartment should becompartment should bemonitored, if it falls below ?monitored, if it falls below ?
mm(g, immediate openmm(g, immediate open
fasciotomy is performedfasciotomy is performed
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)AEMART)ROSIS)AEMART)ROSIS
+ractures involving a joint may cause+ractures involving a joint may cause
acute haemarthrosis.acute haemarthrosis.
The joint is swollen and tense andThe joint is swollen and tense and
the patient resist any attempt atthe patient resist any attempt at
moving it.moving it.
The blood should be aspirated beforeThe blood should be aspirated before
dealing with the fracture.dealing with the fracture.
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INFECTIONINFECTION
pen fracture may becomepen fracture may become
infected.infected. 'losed fractures hardly ever'losed fractures hardly ever
do unless they are opened bydo unless they are opened by
operation.operation.
ost1traumatic woundost1traumatic wound
infection is now the mostinfection is now the mostcommon cause of chroniccommon cause of chronic
osteitis.osteitis.
This does not prevent theThis does not prevent the
fracture from uniting, butfracture from uniting, butunion will be slow and chanceunion will be slow and chance
of refracturing is increase.of refracturing is increase.
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C!"n"ca! $eatres * In$ect"onC!"n"ca! $eatres * In$ect"on The history is of anThe history is of an
open fracture or anopen fracture or anoperation on a closedoperation on a closed
fracture.fracture.
The wound becomesThe wound becomesinflamed and startsinflamed and starts
draining seropurulentdraining seropurulent
fluid, a sample of whichfluid, a sample of which
may yield a growth ofmay yield a growth of
staphylococci or mi!edstaphylococci or mi!edbacteria.bacteria.
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Treatment * In$ect"onTreatment * In$ect"on /ll open fractures should/ll open fractures should
be regarded asbe regarded aspotentially infected 8potentially infected 8
antibiotics andantibiotics and
meticulously e!cising allmeticulously e!cising all
devitaliCed tissue.devitaliCed tissue.
igns of acute infectionigns of acute infectionand pus formation, theand pus formation, the
tissue around thetissue around the
fracture should befracture should be
opened and drained.opened and drained.
4!ternal fi!ation is useful4!ternal fi!ation is useful
in such casesin such cases
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GAS GANGRENEGAS GANGRENE
roduced by 'lostridial infection ,especially 'lostridiumroduced by 'lostridial infection ,especially 'lostridium
welchii 8 anaerobic organism that can survive and multiplywelchii 8 anaerobic organism that can survive and multiply
only in tissues with low o!ygen tension.only in tissues with low o!ygen tension.
The prime site is a dirty wound with dead muscle that hasThe prime site is a dirty wound with dead muscle that hasbeen closed without ade2uate debridementbeen closed without ade2uate debridement..
To!ins produced by the organisms destroy the cell wall andTo!ins produced by the organisms destroy the cell wall and
rapidly lead to tissue necrosis, thus promoting the spreadrapidly lead to tissue necrosis, thus promoting the spreadof the disease.of the disease.
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C!"n"ca! $eatre % Gas gangreneC!"n"ca! $eatre % Gas gangrene
/ppear within A< hours of injury./ppear within A< hours of injury.
)ntense pain, swelling around the wound and a)ntense pain, swelling around the wound and a
brownish discharge may be seen. *as formationbrownish discharge may be seen. *as formation
is usually not very mar3ed.is usually not very mar3ed.
ulse rate is increase and a characteristic smellulse rate is increase and a characteristic smell
becomes evident. Rapidly the patient becomesbecomes evident. Rapidly the patient becomes
to!aemic and may lapse into coma and death.to!aemic and may lapse into coma and death.
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C!"n"ca! $eatre % Gas gangreneC!"n"ca! $eatre % Gas gangrene
)t is essential to distinguish gas gangrene, which)t is essential to distinguish gas gangrene, which
is characteriCed by myonecrosis, from anaerobicis characteriCed by myonecrosis, from anaerobic
cellulitis, in which superficial gas formation iscellulitis, in which superficial gas formation is
abundant but to!aemia usually slight.abundant but to!aemia usually slight.
+ailure to recogniCe the difference may lead to+ailure to recogniCe the difference may lead to
unnecessary amputation for the nonlethalunnecessary amputation for the nonlethal
cellulitis.cellulitis.
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Prevent"on % Gas gangrenePrevent"on % Gas gangrene
0eep, penetrating wound in muscular tissue are0eep, penetrating wound in muscular tissue are
dangerous> they should be e!plored, all deaddangerous> they should be e!plored, all dead
tissue should be completely e!cised.tissue should be completely e!cised.
)f there is the slightest doubt about tissue)f there is the slightest doubt about tissue
viability, the wound should be left open.viability, the wound should be left open.
=nhappily there is no effective antito!in against=nhappily there is no effective antito!in against
'.welchii.'.welchii.
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Treatment % Gas gangreneTreatment % Gas gangrene
The 3ey to life1saving treatment is earlyThe 3ey to life1saving treatment is early
diagnosis.diagnosis.
+luid replacement and intravenous antibiotic are+luid replacement and intravenous antibiotic are
started immediately.started immediately.
(yperbaric o!ygen has been used as a means of(yperbaric o!ygen has been used as a means of
limiting the spread of gangrene.limiting the spread of gangrene.
The mainstay of treatment is promptThe mainstay of treatment is prompt
decompression of the wound and removal of alldecompression of the wound and removal of all
dead tissue.dead tissue.
)n advanced cases, amputation may be essential.)n advanced cases, amputation may be essential.
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FRACTURE +LISTERSFRACTURE +LISTERS
These are due to elevation of the superficialThese are due to elevation of the superficial
layers of s3in by oedema, and can sometime belayers of s3in by oedema, and can sometime be
prevented by firm bandaging.prevented by firm bandaging.
They should be covered with a sterile dryThey should be covered with a sterile dry
dressing.dressing.
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PLASTER SORESPLASTER SORES AND AND PRESSURE SORESPRESSURE SORES
laster sores occur where s3in presses directlylaster sores occur where s3in presses directly
onto bone. They should be prevented by paddingonto bone. They should be prevented by padding
the bony points and by moulding the wet plasterthe bony points and by moulding the wet plaster
so that pressure is distributed to the soft tissueso that pressure is distributed to the soft tissue
around the bony points.around the bony points.
"hile a plaster sore is developing the patient"hile a plaster sore is developing the patient
feels localiCed burning pain. / window mustfeels localiCed burning pain. / window must
immediately be cut in the plaster, or warning painimmediately be cut in the plaster, or warning pain2uic3ly abates and s3in necrosis proceeds2uic3ly abates and s3in necrosis proceeds
unnoticed.unnoticed.
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DELAYED UNIONDELAYED UNION
)f the time is unduly)f the time is unduly
prolonged, the termprolonged, the term
Ddelayed union is used. Ddelayed union is used.
+actors causing delayed+actors causing delayed
union can be summariCedunion can be summariCed
as :as :
• BiologicalBiological
• BiomechanicalBiomechanical
• atient relatedatient related
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+IOLOGICAL FACTORS+IOLOGICAL FACTORS
)&/04E=/T4 B$0 =$F)&/04E=/T4 B$0 =$F
/ badly displaced fracture of a long bone will/ badly displaced fracture of a long bone will
cause tearing of both the periosteum andcause tearing of both the periosteum and
interruption of the intramedullary blood supply.interruption of the intramedullary blood supply.
.. 4%4R4 +T T)=4 0/-/*44%4R4 +T T)=4 0/-/*4
1 Reducing the effect of muscle splintage.1 Reducing the effect of muscle splintage.
1 0amaging blood supply.1 0amaging blood supply.
1 0iminishing the osteogenic stimulus.1 0iminishing the osteogenic stimulus... 4R)T4/$ TR))&*4R)T4/$ TR))&*
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+IOMEC)ANICAL FACTORS+IOMEC)ANICAL FACTORS
.. )-4R+4'T $)&T/*4)-4R+4'T $)&T/*44!cessive traction, e!cessive movement or4!cessive traction, e!cessive movement orisolated fracture of forearm or leg will delayisolated fracture of forearm or leg will delayossification in the callus.ossification in the callus.
.. %4R1R)*)0 +)G/T)&%4R1R)*)0 +)G/T)&
'ontrary to popular belief, rigid fi!ation delays'ontrary to popular belief, rigid fi!ation delaysrather than promotes fracture union. =nion byrather than promotes fracture union. =nion byprimary bone healing is slow.primary bone healing is slow.
.. )&+4'T)&)&+4'T)&There is bone lysis, necrosis and pus formationThere is bone lysis, necrosis and pus formationbut also implants which are used to hold thebut also implants which are used to hold thefracture tend to loosen.fracture tend to loosen.
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C!"n"ca! $eatres % De!a&e( Un"onC!"n"ca! $eatres % De!a&e( Un"on
+racture tenderness persists and if the bone is+racture tenderness persists and if the bone is
subjected to stress, pain may be acute.subjected to stress, pain may be acute.
G1RayG1Ray
1 The fracture line remains visible and there is1 The fracture line remains visible and there is
very little callus formation or periosteal reaction.very little callus formation or periosteal reaction.
1 The bone ends are not sclerosed or athropic.1 The bone ends are not sclerosed or athropic.
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Conservat"ve Treatment % De!a&e( Un"onConservat"ve Treatment % De!a&e( Un"on
The two important principles are:The two important principles are:
@.@. To eliminate any possible cause of delayedTo eliminate any possible cause of delayed
union.union.
A.A.
To promote healing by providing the mostTo promote healing by providing the most
appropriate biological environment.appropriate biological environment.
+racture loading is an stimulus to union by:+racture loading is an stimulus to union by:
a. By encouraging muscular e!ercisea. By encouraging muscular e!ercise
b. By weightbearing in the cast or braceb. By weightbearing in the cast or brace
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O'erat"ve Treatment % De!a&e( Un"onO'erat"ve Treatment % De!a&e( Un"on
)f union is delayed for more than H months and)f union is delayed for more than H months and
there is no sign of callus formation, fi!ation andthere is no sign of callus formation, fi!ation and
bone grafting are indicated.bone grafting are indicated.
The operation should be planned in such a way asThe operation should be planned in such a way as
to cause the least possible damage to the softto cause the least possible damage to the softtissue.tissue.
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NON*UNIONNON*UNION
The fracture gap become a typeThe fracture gap become a type
of pseudoarthrosis.of pseudoarthrosis.
)n hyperthropic non1union the)n hyperthropic non1union the
bone ends are enlarged,bone ends are enlarged,
suggesting that osteogenesissuggesting that osteogenesis
is still active but not 2uiteis still active but not 2uitecapable of bridging the gap.capable of bridging the gap.
)n athropic non1union)n athropic non1union
osteogenesis semms to haveosteogenesis semms to have
ceased. The bone ends areceased. The bone ends are
often tapered or rounded withoften tapered or rounded withno suggestion of new boneno suggestion of new bone
formation.formation.
C $ "C $ "
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Cases o$ non*n"onCases o$ non*n"on
The )njuryThe )njury
oft tissue lossoft tissue loss
Bone lossBone loss
)ntact fellow bone)ntact fellow bone
oft tissue interpositionoft tissue interposition
The boneThe bone
oor blood supplyoor blood supply
oor haematomaoor haematoma
)nfection)nfection
athologic lesionathologic lesion
The surgeonThe surgeon
0istraction0istraction
oor splintageoor splintage
oor fi!ationoor fi!ation
)mpatience)mpatience
The patientThe patient
)mmense)mmense
)mmoderate)mmoderate
)mmovable)mmovable
)mmpossible)mmpossible
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CONSERVATIVE TREATMENTCONSERVATIVE TREATMENT
"ith hyperthropic non1union,"ith hyperthropic non1union,
1 +unctional bracing may be sufficient to induce1 +unctional bracing may be sufficient to induce
union.union.
1 ulse electromagnetic fields.1 ulse electromagnetic fields.
1 $ow fre2uency pulsed ultrasound can1 $ow fre2uency pulsed ultrasound can
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OPERATIVE TREATMENTOPERATIVE TREATMENT
(ypertrophic non1union,(ypertrophic non1union,
rigid fi!ation alone mayrigid fi!ation alone may
lead to union.lead to union.
/trophic non1union,/trophic non1union,fi!ation alone is notfi!ation alone is not
enough. +ibrous tissue inenough. +ibrous tissue in
the fracture gap, as well asthe fracture gap, as well as
the hard, sclerotic bonethe hard, sclerotic bone
ends, are e!cised and boneends, are e!cised and bone
grafts are pac3ed arroundgrafts are pac3ed arround
the fracture.the fracture.
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MALUNIIONMALUNIION
"hen the fragments join in"hen the fragments join in
an unsatisfactory positionan unsatisfactory position
6unacceptable angulation,6unacceptable angulation,
rotation or shortening7 therotation or shortening7 the
fracture is said to befracture is said to be
malunited.malunited.
'auses are failure to'auses are failure to
reduce a fracturereduce a fracture
ade2uately, failure to holdade2uately, failure to hold
reduction while healingreduction while healing
proceeds or gradual collapsproceeds or gradual collaps
of comminuted orof comminuted or
osteoporotic bone.osteoporotic bone.
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C!"n"ca! $eatres * Ma!n"onC!"n"ca! $eatres * Ma!n"on
The deformity is usuallyThe deformity is usually
obvious, but sometimesobvious, but sometimes
apperent only on G1ray.apperent only on G1ray.
Rotational deformity of theRotational deformity of the
femur, tibia, humerus orfemur, tibia, humerus or
forearm may be missedforearm may be missed
unless the limb isunless the limb is
compared with its oppositecompared with its opposite
fellow.fellow.
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C!"n"ca! $eatres * Ma!n"onC!"n"ca! $eatres * Ma!n"on
Rotational deformity of aRotational deformity of a
metacarpal fracture ismetacarpal fracture is
detected by as3ing thedetected by as3ing the
patient to flatten thepatient to flatten the
fingers onto the palm andfingers onto the palm and
seeing whether the normalseeing whether the normalregular fan1shapedregular fan1shaped
appearance is reproduced.appearance is reproduced.
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Treatment % Ma!n"onTreatment % Ma!n"on
A $e, g"(e!"nes are o$$ere( A $e, g"(e!"nes are o$$ere(
@.@. )n adults, angulation of more than @ 8 @I)n adults, angulation of more than @ 8 @I%% in a longin a long
bone, or a noticeable rotational deformity, may needbone, or a noticeable rotational deformity, may need
correction by remanipulation, or by osteotomy andcorrection by remanipulation, or by osteotomy and
internal fi!ation.internal fi!ation.
A.A. )n children, angular deformities near the bone ends will)n children, angular deformities near the bone ends will
usually remodel with time> rotational deformity will not.usually remodel with time> rotational deformity will not.
?.?. )n the lower limb, shortening of more then A.cm is)n the lower limb, shortening of more then A.cm is
seldom acceptable to the patient and a limb lengtheningseldom acceptable to the patient and a limb lengthening
procedure may be indicated.procedure may be indicated.
they are not
to be ignored.to be ignored.
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Treatment % Ma!n"onTreatment % Ma!n"on
A $e, g"(e!"nes are o$$ere( A $e, g"(e!"nes are o$$ere(
I. 4arly discussion with the patient, and a guided view of theI. 4arly discussion with the patient, and a guided view of the
G1rays, will help in deciding on the need for treatment andG1rays, will help in deciding on the need for treatment and
may prevent later misunderstanding.may prevent later misunderstanding.
H. -alalignment of more than @IH. -alalignment of more than @I%% in any plane may causein any plane may cause
asymmetrical loading of the joint above or below and theasymmetrical loading of the joint above or below and the
late development of secondary osteoarthritis> this applieslate development of secondary osteoarthritis> this applies
particularly to the large weightbearing joints.particularly to the large weightbearing joints.
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AVASCULAR NECROSIS AVASCULAR NECROSIS
'ertain regions are notorious for'ertain regions are notorious for
their propensity to developtheir propensity to develop
ischaemia and bone necrosisischaemia and bone necrosis
after injury:after injury:
@. The head of the femur@. The head of the femur
6after fracture of femoral nec36after fracture of femoral nec3or dislocation of the hip7.or dislocation of the hip7.
A. The pro!imal part of theA. The pro!imal part of the
scaphoid 6after fracturescaphoid 6after fracture
through its waist7.through its waist7.
?. The lunate 6following?. The lunate 6following
dislocation7.dislocation7.
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AVASCULAR NECROSIS AVASCULAR NECROSIS
)schaemia occurs during the first few)schaemia occurs during the first few
hours following fracture orhours following fracture or
dislocation.dislocation.
(owever, the clinical and radiological(owever, the clinical and radiological
effects are not seen until wee3s oreffects are not seen until wee3s or
even months later.even months later.
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C!"n"ca! $eatre % Avasc!ar Necros"sC!"n"ca! $eatre % Avasc!ar Necros"s
ThereThere are no symptomsare no symptomsassociated with avascularassociated with avascular
necrosis, but if the fracture failsnecrosis, but if the fracture fails
to unite or if the bone collaps theto unite or if the bone collaps the
patient may complain of pain.patient may complain of pain.
The G1ray shows:The G1ray shows:
11 )ncrease in bone density.)ncrease in bone density.1 &ew bone ingrowth in the1 &ew bone ingrowth in the
necrotic segment.necrotic segment.1 0isuse osteoporosis in the1 0isuse osteoporosis in the
surrounding partssurrounding parts
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Treatment % Avasc!ar Necros"sTreatment % Avasc!ar Necros"s
)n old people with necrosis)n old people with necrosisof the femoral head anof the femoral head an
arthroplasty is the obviousarthroplasty is the obvious
choice, in younger people,choice, in younger people,
realignment osteotomy 6orrealignment osteotomy 6or
even arthrodesis7 may beeven arthrodesis7 may be
wiser.wiser.
/vascular necrosis in the/vascular necrosis in the
scaphoid or talus may needscaphoid or talus may need
no more than symptomaticno more than symptomatic
treatment, but vascular bonetreatment, but vascular bonegrafting, or arthrodesis ofgrafting, or arthrodesis of
the wrist or an3le, isthe wrist or an3le, is
sometime needed.sometime needed.
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GRO-T) DISTUR+ANCEGRO-T) DISTUR+ANCE
)n children, damage to the physis may lead to)n children, damage to the physis may lead to
abnormal or arrested growth.abnormal or arrested growth.
+ractures that split the epiphysis inevitably+ractures that split the epiphysis inevitably
traverse the growing portion of the physis, and sotraverse the growing portion of the physis, and so
further growth may be asymmetrical and thefurther growth may be asymmetrical and the
bone end characteristically angulated.bone end characteristically angulated.
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TENDON LESIONSTENDON LESIONS
Rupture of the e!tensorRupture of the e!tensor
pollicis tendon may occur Hpollicis tendon may occur H
8 @A wee3s after a fracture8 @A wee3s after a fracture
of the lower radius.of the lower radius.
0irect suture is seldom0irect suture is seldom
possible and the resultingpossible and the resulting
disability is treated bydisability is treated by
transferring the e!tensortransferring the e!tensor
indicis proprius tendon toindicis proprius tendon to
the distal stump of thethe distal stump of the
ruptured thumb tendon.ruptured thumb tendon.
TENDON LESIONS
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TENDON LESIONSTENDON LESIONS
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NERVE COMPRESSIONNERVE COMPRESSION
eroneal nerve mayeroneal nerve may
damage if an elderlydamage if an elderly
patient lies with the legpatient lies with the leg
in full e!ternal rotation.in full e!ternal rotation.
Radial palsy may followRadial palsy may follow
the faulty use ofthe faulty use of
crutches.crutches.
NERVE COMPRESSION
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NERVE COMPRESSIONNERVE COMPRESSION Bone or joint deformity may resultBone or joint deformity may result
in local nerve entrapment within local nerve entrapment with
typical feature such as numbnesstypical feature such as numbnessor paraesthesia, loss of power andor paraesthesia, loss of power and
muscle wasting in the distributionmuscle wasting in the distribution
of the affected nerve.of the affected nerve.
'ommon site are :'ommon site are :
@. the ulnar nerve, due to a@. the ulnar nerve, due to avalgus elbow following an un1valgus elbow following an un1
united lateral condyle fracture.united lateral condyle fracture.
A. the median nerve, followingA. the median nerve, following
injuries around the wrist.injuries around the wrist.
?. the posterior tibial nerve,?. the posterior tibial nerve,
following fractures around thefollowing fractures around thean3le.an3le.
TREATMENT NERVE COMPRESSION
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TREATMENT % NERVE COMPRESSIONTREATMENT % NERVE COMPRESSION
Treatment is by earlyTreatment is by earlydecompression of thedecompression of the
nerve.nerve.
)n the case of the ulnar)n the case of the ulnarnerve this may re2uirenerve this may re2uire
anterior transposition.anterior transposition.
MUSCLE CONTRACTUREMUSCLE CONTRACTURE
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MUSCLE CONTRACTUREMUSCLE CONTRACTURE
+ollowing arterial injury or+ollowing arterial injury or
a compartment syndrome,a compartment syndrome,
the patient may developthe patient may develop
ischaemic contractures ofischaemic contractures of
the affected musclesthe affected muscles
66Volkmann’s ischaemicVolkmann’s ischaemiccontracturecontracture7.7.
The sites most commonlyThe sites most commonly
affected are the forearmaffected are the forearm
and hand, the leg and theand hand, the leg and thefoot.foot.
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JOINT INSTA+ILITYJOINT INSTA+ILITY
+ollowing injury a joint+ollowing injury a joint
may give way. 'ausesmay give way. 'auses
include :include :
@. $igamentous la!ity@. $igamentous la!ity
A. -uscle wea3nessA. -uscle wea3ness
?. Bone loss?. Bone loss
)njury may also lead to)njury may also lead to
recurrent dislocation. Therecurrent dislocation. The
commonest sites are thecommonest sites are theshoulder and the patella.shoulder and the patella.
JOINT STIFFNESSJOINT STIFFNESS
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JOINT STIFFNESSJOINT STIFFNESS
/ haemarthrosis forms and/ haemarthrosis forms and
leads to synovial adhesions.leads to synovial adhesions. edema and fibrosis of theedema and fibrosis of the
capsule, the ligaments andcapsule, the ligaments and
the muscles around thethe muscles around the
joint. joint.
/dhesion of the soft tissues/dhesion of the soft tissuesto each other or to theto each other or to the
underlying bone.underlying bone.
/ll these condition are made/ll these condition are made
worse by prolongedworse by prolongedimmobiliCation.immobiliCation.
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Treatment % Jo"nt St"$$nessTreatment % Jo"nt St"$$ness
The best treatment is prevention:The best treatment is prevention:
1 by e!ercises that 3eep the joints mobile from1 by e!ercises that 3eep the joints mobile from
the outset.the outset.
1 if the joint has to be splinted, ma3e sure that it1 if the joint has to be splinted, ma3e sure that it
is held in the Dposition of safety.is held in the Dposition of safety.
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Treatment % Jo"nt St"$$nessTreatment % Jo"nt St"$$ness
Joints that are already stiff ta3e time to mobiliCe,Joints that are already stiff ta3e time to mobiliCe,
but prolonged and patient physiotherapy canbut prolonged and patient physiotherapy can
wor3 wonders.wor3 wonders.
)f the situation is due to intra1articular adhesions,)f the situation is due to intra1articular adhesions,
gentle manipulation under */ may free the jointgentle manipulation under */ may free the joint
sufficiently to permit a more pliant response tosufficiently to permit a more pliant response to
further e!ercise.further e!ercise.
ccasionally, adherent or contracted tissues needccasionally, adherent or contracted tissues need
to be released by operation.to be released by operation.
ALGODYST)ROP)Y .COMPLE/ALGODYST)ROP)Y .COMPLE/
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ALGODYST)ROP)Y .COMPLE/ ALGODYST)ROP)Y .COMPLE/
REGIONAL PAIN SYNDROME0REGIONAL PAIN SYNDROME0
udec3, in @9, describe a conditionudec3, in @9, describe a condition
characteriCed by painful osteoporosis of the handcharacteriCed by painful osteoporosis of the hand
after fracture, it was calledafter fracture, it was called Sudeck’s atrophy.Sudeck’s atrophy.
&ow recogniCed as the late stage of a post&ow recogniCed as the late stage of a post
traumatictraumatic reflex sympathetic dystrophyreflex sympathetic dystrophy 6also6also
3nown as3nown as algodystrophy algodystrophy 77
ALGODYST)ROP)Y .COMPLE/ALGODYST)ROP)Y .COMPLE/
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ALGODYST)ROP)Y .COMPLE/ ALGODYST)ROP)Y .COMPLE/
REGIONAL PAIN SYNDROME0REGIONAL PAIN SYNDROME0
The patient complains ofThe patient complains ofcontinuous pain.continuous pain.
$ocal swelling, redness and$ocal swelling, redness and
warmth as well aswarmth as well as
tenderness and moderatetenderness and moderate
stiffness of the nearbystiffness of the nearby
joints. joints.
G1ray characteristicallyG1ray characteristicallyshow patchy rarefaction ofshow patchy rarefaction of
the bone.the bone.
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TreatmentTreatment
)n the early stage> anti1inflamatory drugs are)n the early stage> anti1inflamatory drugs are
helpful.helpful.
)f this does not produce improvement,)f this does not produce improvement,
amitriptyline may help to control the pain.amitriptyline may help to control the pain.
ympathetic bloc3 or sympatholytic drugs such asympathetic bloc3 or sympatholytic drugs such as
intravenous guanethidine have been advocatedintravenous guanethidine have been advocated
for this condition.for this condition.
rolonged and dedicated physiotherapy willrolonged and dedicated physiotherapy will
usually be needed.usually be needed.
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OSTEOART)RITISOSTEOART)RITIS
/ fracture involving a joint/ fracture involving a jointmay severely damage themay severely damage the
articular cartilage and givearticular cartilage and give
rise torise to post traumatic post traumatic
osteoarthritisosteoarthritis within awithin a
period of monthsperiod of months
4ven if the cartilage heals,4ven if the cartilage heals,
irregularity of the jointirregularity of the joint
surface may causesurface may cause
localiCed stress and solocaliCed stress and sopredispose topredispose to secondarysecondary
osteoarthritisosteoarthritis years lateryears later
OSTEOART)RITISOSTEOART)RITIS
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OSTEOART)RITIS
-alunion of a metaphyseal-alunion of a metaphysealfracture may radically alterfracture may radically alter
the mechanics of a nearbythe mechanics of a nearby
joint and this, too, can joint and this, too, can
give rise to secondarygive rise to secondary
osteoarthritis.osteoarthritis.
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