Types

• Early
– General
1. DVT, PE, fat embolism
2. Tetanus, gas gangrene
3. Hypovolemic shock, crush syndrome

Complications of fractures – Local

1. Visceral injury, Vascular injury, Nerve injury
2. Compartment syndrome, Hemarthrosis
3. Infections

• Late
Soft tissue complications

– General
1. Joint stiffness, Heterotopic ossification, Muscle contracture
-
2. Tendon rapture
3. Nerve entrapment, Complex regional pain syndrome

– Local
1. Delayed union, Non-union, Mal-union
2. Avascular necrosis
3. Osteoarthiritis
4. Shortening

Early general complications &

Hx: swelling, pain, tenderness

• DVT is very common complication after fracture and major

Next step: doppler US Increased CO2, tachycardia, tachypnea, decreased O2, low grade fever

• S

DVT & pulmonary embolism e

orthopedic operation.
• Tetanus
• Gas gangrene • Site: leg, thigh and pelvic vein. (proximal→ ↑ risk of PE)
More than leg

• Fat embolism syndrome • Risk factors:

• Hypovolemic Shock – Knee and hip replacement Arthropoasty

– Trauma (fracture of spine, pelvis, femur & tibia)

Endothelial injury

• Crush syndrome – Immobility

– Elderly
Stasis

– Malignancy and CV disease

– Hypercoagulable status
Hypercoagulability
 Symptoms & signs: If bilateral > Spinal muscular stenosis / vascular

1. Pain and tenderness in calf or thigh usually unilateral

A

2. Swelling Die due to asphyxia

3. Hotness ‫ وﺗﻄﻠﻊ ﻟﻔﻮق‬clot ‫ ﻟﻞ‬triggering ‫ﻣﻤﻜﻦ ﺗﻌﻤﻞ‬

4. Positive homan’s sign Calf pain at dorsiflexion of foot • Wound infection caused by [Link]
5. Pulmonary embolism as primary presentation (fever, tachypnea, • Tetanus toxin passes to anterior horn cells, where it fixed and
dyspnea and hemoptysis) can’t be neutralized so produces
Diagnosis: – Hyper excitability
1. Duplex ultrasonography – Reflex muscle spasm
For DVT in calf

2. V-Q scan
For PE
3. Spiral CT
Venography Symptoms:
4. Angiography – but invasive
• Tonic & clonic contractions of esp. jaw, face, around the
Prevention: Is the best to do As a prophylaxis before DVT
wound itself ,neck ,trunk, finally spasm of the diaphragm and
1. Elastic stockings
intercostal muscles leads to asphyxia and death.
2. Elevation the foot
3. Early mobilization
4. Low molecular weigh heparin 40mg\day Subcutaneous Clexan

Prophylaxis:
• DTP vaccine for general population (pediatrics)
• >10 years  booster dose of toxoid after all trivial skin
wound
• Not immunized  wound toilet and antibiotic (toxoid
immunization)

Treatment:
1. IV antitoxin
2. IV antibiotics (penicillin)
3. Muscle relaxant
4. Tracheal intubation
5. Control respiration
 Clinical features:
1. Sudden onset of pain localized to the infected area.
2. Swelling, edema
• Caused by clostridium perfringens and this organism 3. No pyrexia (cool)
can survive and multiply only in tissue with low
4. Profuse serous discharge with sweetish and mousy odor
oxygen tension.
5. Gas production
• Characterized by: It is essential to distinguish gas gangrene, which is characterized by myonecrosis, from anaerobic cellulitis, in which superficial gas formation is

– Rapid and extensive necrosis of muscle

abundant but toxaemia usually slight. Failure to recognize the difference may lead to unnecessary amputation for the non-lethal cellulitis.

Treatment:
– Gas formation 1. Early diagnosis
– Systemic toxicity 2. Surgical intervention and debridement are the mainstay of
• Associated with traumatic wounds that are deep, treatment.
necrotic and without communication to the surface. 3. IV antibiotics
4. Fluid replacement
Prevention

5. Hyperbaric Oxygen Deep, penetrating wounds in muscular tissue are dangerous; they should be explored, all dead tissue
should be completely excised and, if there is the slightest doubt about tissue viability, the wound
should be left open. Unhappily there is no effective antitoxin against C. welchii.

Triggering of coagulation cascade PT extrinsic

• Usually occurs in young adult after closed fractures

PTT intrinsic

Formation of fat
of long bone. Closed/open Fat in bone
globules in
Fracture marrow escape
• Small blood vessels occluded by fat globules vessels

Risk factors:
• Closed fractures
Trigger clotting Stick in
• Multiple fractures cascade pulmonary bed
Fat embolus
• Pulmonary contusion
• Long bone/pelvis/rib fractures
Petechial rash on chest & axilla
Clinical features:
• Sudden onset dyspnoea
• Tachypnea and tachycardia
• Confusion, coma, convulsions Neurological symptoms • A generalized state of decreased tissue perfusion.
• Transient red-brown petechial rash affecting upper body, • If prolonged it may lead to irreversible damage of the life
especially axilla.
Petechiae on the trunk, axillae and in the conjunctival folds and retinae.

supporting organs.
• Hypoxia, no defenitive test, but hypoxia <60mmHg after
major trauma is suspicious ABGs h
Causes: Tibia > 200cc-500cc of blood
Femur > 1L-2L of blood
Pelvis > 2L-3L of blood

• Hypovolemic: reduction of blood volume (most important one

Supportive treatment to be dealt with firstly)
1. O2 administrated • Cardiogenic: direct injury to heart, the pump is not working
2. Blood, fluid replacement properly (massive MI). Due to Sternal fracture

Due to Spinal cord fracture

3. IV steroid + heparin ( may reduce pulmonary edema and IV • Neurogenic: injury to brain stem (vasomotor center) spinal
clotting ) cord loss of sympathetic tone  increase venous
4. Surgical stabilization of fracture capacitance  low venous return  low cardiac output
(bradycardia) + Hypotension

• A generalized state of decreased tissue perfusion. Decreased

Low cardiac
• If prolonged it may lead to irreversible damage of the life output
Low B.P tissue
supporting organs. perfusion
Causes:
• Hypovolemic: reduction of blood volume (most important one
to be dealt with firstly)
• Cardiogenic: direct injury to heart, the pump is not working ORGAN Progressive Hypoxia and
properly (massive MI). FAILURE cell damage acidosis
• Neurogenic: injury to brain stem (vasomotor center) spinal
cord loss of sympathetic tone  increase venous
capacitance  low venous return  low cardiac output
(bradycardia)
 Clinical features:
• Thirst
• Rapid shallow breathing
• Pale lips & skin • If no quick response, blood transfusion is
• Cold extremities and rapid thready pulse
mandatory ( we can use O blood group Rh (-)
• If compensation fails  impaired renal function test and
decreased urinary output until cross matching is available )
• Only give 1 L of NS before switching to blood
II > Wide pulse pressure
III > Decreased urine output S types of shock ‫أھﻢ إﺷﻲ ﺑﻤﯿﺰ ال‬
IV > Unconscious

Treatment:
1. Arrest bleeding (pressure→ tourniquet)*
2. Oxygen & IV morphine No vasopressor ???

3. Restoration of blood volume by rapid infusion of crystalloid

Give O -ve if not existed
solution or replace blood loss
4. Early reduction and splinting of fracture.
5. Keep monitoring of vital signs.

Rhabdomyolysis
When compression Myohaematin release
• Serious medical condition released from cells
• Characterized by major shock & renal failure following a
crushing injury to skeletal muscles or tourniquet left too long

Block tubules To kidney

• It’s a re-perfusion injury seen after the release of crushing
pressure, there will be release of muscular breakdown
products (myoglobin, k+, p) which have nephrotoxic effect
on the kidney
– Seen following a crushing injury to skeletal muscles (entrapment in a vehicle or rubble) or tourniquet left too long.
– The crushed limb is under-perfused and myonecrosis follows.
– When the limb is freed .. release of toxic metabolites (Reactive oxygen metabolites) > generating a re-perfusion injury.
Alternative mechanism: renal artery spasm  tubular necrosis
– Membrane damage and capillary fluid re-absorption failure result in swelling that may lead to a compartment syndrome, thus creating more tissue damage from escalating ischemia.
– Tissue necrosis also causes systemic problems such as renal failure from free myoglobin, which is precipitated in the renal glomeruli.
– Myonecrosis may cause a metabolic acidosis with hyperkalaemia and hypocalcaemia.
Clinically:
• Shock
• Pulsless limb  redness  swelling
• Loss of muscle sensation and power
• Decreased renal function, uremia, acidosis
Prognosis Early local complication
• If return within the patient survive
• But most of them die within 14 days
The most important measure is prevention.
Treatment: From an intensive care perspective, a high urine flow is encouraged with alkalization of the urine with sodium bicarbonate; this
prevents myoglobin precipitating in the renal tubules. If oliguria or renal failure occurs, then renal haemofiltration will be needed.

• Before compression release: avoid the disaster by n

amputation above the site of compression

• After compression is already released  cool the limb and
treat for shock and renal failure (dialysis) To reduce circulation in the limb
If a compartment syndrome develops, and is confirmed by pressure measurements, then a fasciotomy is indicated. Excision of dead muscle must be radical to avoid sepsis.
Similarly, if there is an open wound then this should be managed aggressively.
If there is no open wound and the compartment pressures are not high, then the risk of infection is probably lower if early surgery is avoided.

Early local complication

1. Visceral injury • Fractures around the trunk are often complicated by visceral
injury, ex:
2. Vascular injury – Rib fractures are associated with life threatening
3. Nerve injury Common more than vascular pneumothorax or with spleen, liver injuries.
– Pelvic injuries are associated with bladder or urethral
4. Compartment syndrome Most commonly in leg & forearm
rupture and cause severe hematoma in the retroperitoneum.
5. Hemarthrosis Fracture around joint > causes hematoma formation > blood if sustained
and not aspirated it will cause irritation > eventually leading to fibrosis • Surgery of over the
treatment of fracture. (These injuries require emergency treatment, before the fracture is dealt with)

6. Infections Complications of pelvic fracture

Urogenital damage
APC fractures are the usual cause of urogenital tract damage; symphyseal widening is associated with urethral
injury, and displaced rami fractures may cause bladder injury. All that needs to be provided urgently in a
seriously ill patient is adequate urinary drainage, which is accomplished by suprapubic cystostomy. Definitive
repair can be delayed while the patient's general condition improves and expert urological advice is sought.
Late complications include urethral stricture, incontinence and impotence.
Bowel injury
If there is a bowel injury at presentation, a de-functioning colostomy is performed so as not to contaminate the
pelvis. A re-anastomosis is performed at 6-12 months once healing has occurred
Vaginal injury
Displaced pubic ramus fractures can tear the lateral wall of the vagina, in which case there is an open injury.
Tears should be washed out and repaired.

G [Link]
 Popliteal artery injury is the most common injury in the knee

:
• Most associated with injuries around knee, elbow, humerus
and femoral shaft.
• Commonly associated with high-energy open fractures.
• They are rare, but well-recognized.
• Cause:
– Initial trauma
– Bone fragment That’s why we splint the fx
• Mechanism of injuries:
– The artery may be cut or torn.
– Compressed by the fragment of bone.
– Normal appearance with intimal detachment that lead to
thrombus formation. (can confirm w/ CT angio)
– Segment of artery may be in spasm.
When you don’t feel distal pulses > always check for
Reversed by a vasodilator capillary refill time + appearance and temperature
[Link] of the patient limb (hot/cold)

Fractures commonly associated with vascular injury

Clinical features: Injury Vessel

• Classical presentation of ischemia 5 Ps: 1st rib fracture

+ clavicular fracture
subclavian
Pain, Pallor, Pulseless, Paralysis & Shoulder dislocation Axillary
Paraesthesia Humeral supracondylar Brachial
Most common fracture sites that’s most likely to cause vascular injury:
1. Supracondylar fracture
2. Humerus shaft fracture
3. Medial tibial plateau fracture
fracture
4. Popliteal artery injury

Elbow dislocation Brachial

Investigations: Distal radius fractures smith & colles Radial

Show that the fracture is at one of the ‘high-risk’ sites mentioned before
Pelvic fracture Presacral and internal iliac
• X-ray: suggest high-risk fracture. Hip dislocation Femoral anterior

Femoral supracondylar Femoral

• Angiogram to confirm diagnosis. An angiogram is performed on the operating table if needed,
but the damage is usually at the level of the fracture or joint
dislocation anyway. fracture
Knee dislocation Popliteal

[Link]
Proximal tibial fracture Popliteal or its branches
 Management:
• Emergency because the effect of ischemia especially
Temporarily
on the muscle is irreversible after 6 hours. • It’s more common than arterial injuries.
1. Temporary vascular shunt to perfuse distal limb. • The most commonly injured nerve is the radial nerve
2. Skeletal stabilization – temporary external fixation in its groove or in the lower third of the upper arm
Definitive
often used. Before vascular repair especially in oblique fracture of the humerus.
3. Definitive vascular repair. • Common with humerus, elbow and knee fractures
4. Staged definitive skeletal internal fixation if • Most nerve injuries are due to tension neuropraxia.
required. s Regeneration rate > 1mm per day

[Link] [Link]

Nerve compression, as distinct from a direct injury, sometimes occurs with fractures of dislocations around the wrist.
Complaints of numbness or paraesthesia in the distribution of the median or ulnar nerves should be taken seriously and the
patient monitored closely; if there is no improvement within 48 hours of fracture reduction or splitting of bandages around *
the splint, the nerve should be explored and decompressed. Go straight to neurosurgery if:
- Vascular injury b.
Closed Injuries - Stab wound Clavicular fracture Injury Supra-clavicular nerve nerve
- High energy wound Shoulder dislocation + Proximal
humerus fracture Axillary
• The nerve is rarely severely affected just neuropraxia or Humeral shaft fracture Radial
axonotmesis and spontaneous recovery is usually the rule.
Humeral supracondylar Radial
• Sometimes it’s trapped between the fragment and it’s found to
-

be divided and more likely to be completely injured. (esp. children) Median ([Link])
• It’s should be explored during wound debridement or in 2nd Medial condyle Ulnar
operation.
Suture if it can be
Elbow dislocation Can cause
Ulnar
carpal tunnel
Colles syndrome
done without &
Lower end of radius Median
Open Injuries tension, otherwise
smith

graft. Hip dislocation Posterior Anterior > Femoral

Sciatic
Knee dislocation Peroneal = fibular
• A complete lesion (neurotmesis) is more likely, the nerve
is explored: Fracture of fibular neck Peroneal
• During wound debridement and repaired Radial nerve injury > drop hand
Peroneal nerve injury > drop foot
Axillary .. fracture of proximal humerus (head)
Radial ... fracture of the shaft of the humerus

• 3 weeks later by nerve suturing and grafting.

Median .. fracture of the distal humerus “supra-condylar”
Monteggia fracture: displacement in radius > radial nerve injury (posterior interosseous branch) (posterior displacement type)
Galeazzi fracture: displacement in ulna > ulnar nerve injury Ulnar .. fracture of the distal humerus “supra-condylar”
(anterior displacement type)
 Most common symptom > Pain
out of proportion not responding to
analgesia • Fracture of the arm and leg can give rise to severe ischemia
Other symptoms > Paresthesia,
even if there is no damage to major vessel. Capillary
be good
problem, so pulse may
Normal compartment pressure is < 30 paralysis, swelling, pulseless, leading
If > 30, it will cause closure of capillary then venules & arterioles then artery eventually to fibrosis & amputation
• Bleeding or edema will increase the pressure within one of the
High-risk injuries are fractures of the elbow, the forearm bones, the proximal one-third

• Trauma is the most common cause.

of the tibia and multiple fractures of the hand or foot.
Other precipitating factors are operation (usually for internal fixation) or infection. Be
aware that a compartment syndrome may also arise in a crush injury, a circumferential
osteofascial compartments, this leads to a decrease in capillary
Most common site > leg burn or even in a tight plaster cast. Or it can arise from a re-perfusion injury.
blood flow which in turn leads to muscle ischemia, further
• Most commonly in forearm and calves.
edema, still greater pressure, and yet more profound
• Muscles are arranged in different compartments and ischemia….vicious circle
surrounded by one fascia, this arrangement called osteofascial
• Distal pulses & neurological functions are normal until very
compartment.
late.
• Compartment syndrome occurs when muscle swells within
• After 12 hours or less, this vicious circle ends in necrosis of
osteofacial compartment and occludes its blood supply >>
nerves and muscles within the compartment.
infarction and late ischemic contracture.
– Nerve are capable of regeneration, but the muscle once infarcted can
• Reasons that lead to increase the pressure inside:
1st most common cause > Fractures
2nd most common cause > Vascular
3rd cause > extravasation never recover and are replaced by fibrous tissue.
1. Bleeding • This condition is called volkmann’s ischemic contracture
2. Edema • Muscle will be dead after 4-6 hrs of total ischemia so there is
4- reperfusion

3. Infection [Link]
no time to lose! s
If there's compartment in arm > brachial artery compression > fibrosis of flexor muscles > Volkmann's
(flexion of wrist, extention of MCP, flexion of DPIP joint, thumb flexion and pronation)

Vicious circle # PAIN OUT OF PROPORTION #

1. Very painful, swollen, tense limb. Diagnosis: clinically

2. Stretch the muscle if the pain increases then this goes with compartment
syndrome. Ischaemic muscle is highly sensitive to stretch, so when the toes or fingers are passively hyperextended, there is increased pain in the calf or forearm.
The classic features of ischaemia are the five Ps: Pain, Paraesthesia, Pallor, Paralysis and Pulselessness. However, in a compartment syndrome the

3. Ischemia (5ps) ischaemia occurs at the capillary level, so pulses may still be felt and the skin may not be pale! The earliest of the classic' features are pain out of
proportion (or a 'bursting' sensation), altered sensibility and paresis (or, more usually, weakness in active muscle contraction). Skin sensation should be

Arterial Reduction carefully and repeatedly checked.

ischemia
of blood flow
4. High-risk injuries:
damage
• Fracture of the elbow, forearm
• Fracture of the proximal third of the tibia
5. Predisposing factor:
• Operation (internal fixation)
• Infection
Increase 6. In doubtful cases, confirm diagnosis by measuring compartment pressure
edema by using a catheter which is introduced into the compartment close to the level
pressure
of fracture A differential pressure (the difference between diastolic and
Direct injury compartment pressure) of less than 30mmHg is an indication for immediate
decompression. (or if compartment pressure is > 30 mmHg, because
differential pressure may not be reliable if pt is hypotensive)
Management:
1. Remove the cause (tight dressing, fluids ..) + raise leg + analgesia
2. Close observation
3. If no response > open fasciotomy

Treatment
Causes irritation > adhesions > adhesion of capsule > limitation of movement

• Don’t wait for the obvious sings of ischemia to appear. If you • Bleeding into a joint spaces
suspect an impending compartment syndrome, start • Occurs if a joint is involved in the fracture. Articular fracture

treatment straightaway If three or more of the 'classical' signs are present, the diagnosis is almost certain.
If the signs are equivocal, the limb should be examined at 15 minute intervals and if there is no improvement within
2 hours of splitting the dressings, fasciotomy should be performed.

1. Decompression by immediate open fasciotomy (open all Presentation:

compartments through medial and lateral incisions) and left • Swollen tense joint
open for 2 days Muscle necrosis criteria: (4C's)
1. Color
Why to remove it?
Risk of infection
• The patient resists any attempt to moving it
2. Consistency
1. Debridement if there is muscle necrosis 3.4. Contractility
Capability to bleed

2. If tissue is healthy the wound can be sutured or skin-grafted or the

wound is left to heal by secondary intention Treatment:
2. Limb should be examined every 15 min for 2 hours if there • Blood aspiration before dealing with the fracture; to
is no improvement or if the pressure falls below 30 prevent the development of synovial adhesions.

• Usually seen in open fractures; rarely with closed fractures

unless opened by operation (ex; internal fixation).
s Antibiotics should be administered within 3 hours

• Open fracture in 6h the risk of infection increases up to 10x.

• All open fracture should be treated by prophylactic antibiotics Late local complications
– Wound excision and debridement
– Skeletal stabilization
– Wound closure
• Post-traumatic bone infection is the most common cause of
chronic osteomyelitis
• Infection may be early within days after surgery or late
occurring months after surgery.
 Outlines • Normally fractures unite within 2 to 5
months
• Delayed union (till 6 mon.)
May lead to

• Non-union (after 6 mon.) Average times for fracture healing

• Mal-union (abnormal healing) Upper limb Lower limb
• Avascular necrosis Callus visible
Soft callus
2-3 weeks
• Osteoarthiritis Union 4-6 weeks 8-12 weeks
• ShorteningBone loss / comminuted fracture
Consolidation 6-8 weeks 12-16 weeks

• The fracture not healed after a reasonable time period has

passed (the expected time to heal).
• Delayed union means:
– No signs of union
– The fragments are mobile 3 to 4 months after injury
• Signs of union:
– Callus formation
– Less mobility
– Less pain
– Medullary canal formation
 Of delayed union :

1. Poor blood supply • Tenderness

2. Severe soft tissue damage • Acute pain when the bone is subjected to stress
3. Infection
4. Treatment complication: • The fracture is not consolidated
• Excessive periosteal stripping during internal • X-ray:
fixation Over-enthusiastic periosteal stripping during internal fixation is an avoidable cause of non-union.
– Visible fracture line
• Imperfect splintage Excessive traction (creating a fracture gap) or excessive movement at the fracture site will delay ossification in

– Little/no callus formation or periosteal reaction

the callus. In forearm or leg fractures, an intact fellow bone may also serve to splint a fracture apart.

– Excessive traction
– Excessive movement at fracture site – Bone ends are not sclerosed or atrophic
• Over rigid fixation (with distraction of bony fragments)
Contrary to popular belief, rigid fixation delays rather than promotes fracture union. It is only because the fixation device holds the fragments
securely that the fracture seems to 'unite. Union by primary bone healing is slow, but provided stability is maintained throughout, the fracture
does eventually unite.
 Best test to follow healing is CT scan

Conservative:
1. Eliminate any underlying cause of delayed union
2. Promote healing by providing the most appropriate
biological environment.
3. Immobilization (by cast or by internal fixation) should be sufficient to prevent movement at the fracture site.

4. Union stimulus by
• Encouraging muscular exercise
• Weight bearing cast or brace

Operative: if union is delayed for more than 6 months and there is no sign of callus formation

Non-union
• Internal fixation Over rigid fixation, in excessive mov sites

• Bone grafting

• Permanent failure of bone healing after 6 months. • Visible fracture

• Movement can be elicited at the fracture site and pain • The bone on either side of fracture may be
diminishes. – Exuberant Enlarged

– Rounded off
In such cases, cell proliferation is predominantly

• The fracture gap turns into pseudarthrosis. fibroblastic; the fracture gap is filled by fibrous tissue
and the bone fragments remain mobile, eventually
creating a false joint or pseudarthrosis.

• Few cases of delayed union may progress to Non-union if • 2 types:

not treated. – Hypertrophic: bones ends are enlarged suggesting that
osteogenesis is still active but not capable of bridging the
gap (mechanical due to ↑ mobility→ needs stabilization)
There is callus formation but without healing > problem is in stabilization but there’s good blood supply

– Atrophic: the bones tapered or rounded, osteogenesis

:ceased (damaged cells→ must excise necrotic edges and

graft, then fix the fracture)
Biological problem > There is no callus formation & no healing, problem is in stabilization and there’s poor blood supply
Conservative: 1st thing is to eliminate the cause

• Occasionally symptomless, needing no treatment Or, at most, a removable splint

• Functional bracing may be sufficient to induce union

• Electrical stimulation promotes osteogenesis Jjj
Operative:
• Very rigid internal fixation for hypertrophic non-union
• Fixation with bone graft for atrophic non union.
To increase blood supply
Bone graft
1. Auto-graft (ileus crest graft) > The best
2. Allo-graft (From animals, dead bone) > Vascularized graft

• Fragments join in an unsatisfactory position (unacceptable

angulation, rotation or shortening)
Malunion in humerus may be acceptable, but in femur, it’s not acceptable; because it affects function & may cause shortening

MAL-U

• Causes:
• Failure to a fracture adequately.
• Failure to while healing proceeds.
• Gradual of osteoporotic bone.
 Clinically / x-ray

• The deformity is usually obvious, but sometimes the true

extent of malunion is apparent only on x-ray.
• Painful limitation of joint movements. Malunion will compress ulnar nerve or
median nerve (causing carpal tunnel)

– Valgus deformity may present at elbow with delayed ulnar palsy. Thumb (anterior)
Posterior

– Rotational deformity can be missed in the femur, tibia, humerus or

forearm unless is compared with it’s opposite fellow.
• X-rays are essential to check the position of the fracture
while uniting during the first 3 weeks so it can be easily
corrected.

‫ ﻣﺴﺘﻮاھﺎ‬ulna ‫ال‬ Can do full

radius ‫أﻋﻠﻰ ﻣﻦ ال‬ extension but
not full flexion

The problem is
located posteriorly
> malunion of
colles fracture >
no hand flexion

Adults:
• Reduction & Re-manipulation – if noted early
– Apposition is important for healing

:
– Alignment and rotation - important for function
• Osteotomy & internal fixation – if noted later
Internet:
Osteotomy is a surgical operation whereby a bone is cut to
shorten or lengthen it or to change its alignment

– Angulation more than 10-15 degrees in long bone

– Apparent rotational deformity
Children:
• Angular deformity near the bone ends often remodel with time, but
rotational deformity will not.
Lower limb shortening: 2-5 cm > shorten the normal leg
5-8 cm > lengthen the abnormal leg

• Shoe raise for shortening less than 2 cm. 8-20 cm > shorten the normal leg & lengthen the abnormal leg
> 20 cm > amputation

• Limb length equalization procedures for shortening more than 2 cm.

 Causes:
- Trauma Common sites
- Sickle cell disease
- lymphoma
- leukemia

• Poor blood supply to an area of bone leads to bone death. Site Cause
• Also called osteonecrosis.
• Fracture neck of the femur
I

Head of the femur

• It’s an early complication: (discovered late) • Posterior dislocation of the hip
– Ischemia occurs during the 1st few hours. 2

Proximal pole of scaphoid Fracture through the waist of the

– Clinical and radiological effects are seen until weeks or
scaphoid
proximal ‫ ﻟَـ‬distal ‫ ﺑﯿﺠﻲ ﻣﻦ‬blood supply ‫ﻷﻧﮫ ال‬
months later.
3

Lunate Following dislocation

Body of the talus Fracture through neck of the talus

“Clinically”
Ficat classification
of osteonecrosis AVN > Can progress to osteoarthritis with change of joint shape

• Deformation of the bone, this leads a few years later to

• Secondary osteoarthritis & painful limitation of joint
movement.

Definitive dx when acute - MRI

• X-ray – shows increase in bone density (consequence of new
bone ingrowth in the necrotic segment and disuse osteoporosis
in the surrounding parts).
• Bone scan
– Shows cold area on the bone.
– Changes can be seen before X-ray changes.
 ‫ ھﻮن ﻣﺶ‬arthritis ‫ﻻﺣﻆ ال‬
flattened ‫ﻣﺪّور إﻧﻤﺎ‬

So it’s type IV > need

total head replacement

Talus Fracture

Hip dislocation

Fx at neck of femur

Scaphoid Fracture
 Grade <3 : Revasculrization
Grade >= 4 : Salvage procedure / Arthroplasty

Bone scan
• Prevention by early reduction of susceptible fractures &
dislocations.
• Necrosis of the femoral head:
– Arthroplasty for old people.
– Realignment osteotomy or arthrodesis for younger
people. R

• Necrosis of the scaphoid or talus

– Symptomatic treatment

Avascular necrosis of the head of the femur

• A fracture involving a joint  damage the articular cartilage

 post traumatic osteoarthritis within a period of months.
Even if the cartilage heals, irregularity or incongruity of the joint surfaces may cause localized stress and so predispose to secondary osteoarthritis years later.
line ‫زي ﻟﻤﺎ ﺗﻠّﺰق ﻗﻄﻊ ﻗﺰاز < ﺑﻀﻞ ﻓﻲ‬

• Even if the cartilage heals, irregularity of the joint surface 

Post-traumatic localized stress secondary osteoarthritis years later.
• X-ray:
In Articular surface > Needs anatomical fixation

– Narrowing space
1

Osteophytes
2

– Sclerosis
4

– Ossification
– Cyst formation
3

– Deformity (valgus/varus)
– Subluxation
Initial healing in a fx
 Goals:
• Reduce pain and stiffness
• Allow for greater movement
• Slow the progression of the disease

• Anti-Inflammatory Medications
Osteophytes • Cortisone injections
• Occupational and physiotherapy
• Weight loss
• Activity modification
• Diet: obesity is a risk factor for developing osteoarthritis
If failed:
- Realignment Osteotomy (Young)
- Arthroplasty (Old)

Causes
• Common complications of fractures
of the long bones
2. Crushing: actual bone loss
3. Growth defects: growth plate or epiphyseal injuries
Salter harris type 2 Salter harris type 4

Treatment
• Upper limbs (shortening goes unnoticed)
• Lower limb:
– shoe raise for shortening less than 2 cm
– Limb length equalization procedures for shortening more
than 2 cm

Late soft tissue complication

 Outline
Causes:
• Joint stiffness • After fracture
Hemarthrosis forms & leads to synovial adhesions

• Direct injury to the joint

• Heterotopic ossification
• Edema and fibrosis
•
9

Muscle contracture • Adhesion

• Tendon rapture Symptoms:
• Pain on moving a joint
• Nerve entrapment
• Loss of range of motion
• Complex regional pain syndrome Made worse by: All these conditions are made worse by prolonged immobilization; moreover, if the joint has been held in a position where the ligaments are at their
shortest, no amount of exercise will afterwards succeed in stretching these tissues and restoring the lost movement completely.

• Prolonged immobilization
• Position of joint, because if they were held in which ligaments
are at their shortest, no exercise will succeed in stretching these
tissue and restoring the lost movement completely

Treatment
• Elevation. To minimize swelling & soft tissue congestion
Functional bracing rather than full cast immobilization

• Functional bracing (orthopedic brace) used to immobilize a

joint or body segment, restrict movement in a given direction.
• Exercise.
• Splinted. If a joint has to be splinted, make sure that it is held in the ‘position of safe immobilization’

• In stiff joints, prolonged and patient physiotherapy can work

wonder.
• Surgery.
 Extra-skeletal ossification happens if trauma was on elbow or hip
Give endomethacin + radiotherapy (as a prophylaxis)
maturation ‫ ﺷﮭﻮر ﻟﺤﺘﻰ ﯾﺨﻠﺺ ﻧﻤﻮ وﯾﺼﯿﺮ‬٦ ‫إذا ﺻﺎرت < ﺑﺨﻠﯿﮫ ل‬
Quadriceps
muscle

After a trauma or surgery Greater

trochanter

• It’s the process by which bone tissue forms outside of the skeleton.
• After an injury in muscles around the elbow, or spontaneously in
unconscious patient. Trauma > muscle hematoma > calcification > myositis ossificans

The patient (usually a fit young man) complains of pain and local swelling.
Clinical features: X-ray is normal at first but a bone scan may show increased activity.

Over the next 2-3 weeks the pain gradually subsides, but joint movement is

• Pain limited and x-ray may show fluffy calcification in the soft tissues.

By 8 weeks bony mass is easily palpable and is clearly defined in the x-ray.

• Local swellings
• X-ray will appear normal at first but bone scan shows increased
Do bone scan
> If hot ossification: immature (wait till it mature)
Treatment: > If cold: mature (excise it)

activity • Gentle and gradual active

Next 2-3 weeks movements (If heterotopic bone is blocking movements)

• Pain gradually subside • Excise the bony mass if

• Limited joint movements. mature, as evidenced by cold
Needs 6 months

• X-ray fluffy calcification in soft tissue bone scan.

By 8 weeks • Indomethacin (ppx) or For Hip surgery / elbow surgery patients who are expected to have calcification

radiotherapy
• Palpable bony mass that clearly defined in x-ray

Compartment syndrome/ischemia > muscle fibrosis > contracture

Volkmann’s ischaemic contracture.

• Common sites: Forearm, hand, leg & foot.

• The muscle and its tendons shorten, resulting in
reduced flexibility.
• Following arterial injury or compartment
Brachial artery compression

syndrome, the patient may develop ischemic T

contracture or (volkman’s ischemic contracture)

• Nerve injury by ischemia sometimes recover while
muscles never do.
 Clinically:
Richard von volkmann • Deformity
• Stiffness Nerves injured by ischaemia sometimes recover, at least partially; thus the
patient presents with deformity and stiffness, but numbness is inconstant.

• Numbness (inconstant) Locations:

the forearm and hand, the leg and the foot.
In a severe case affecting the forearm, there will be muscle wasting and
In severe case (like forearem) clawing of the fingers.

• Muscle wasting
• Clawing of the fingers

Treatment:
• Detachment of flexor muscle at their origin, may improve the
deformity. And function
but function is no better if sensation and active movement are not restored

• If the sensation and active movement are not restored, nerve

graft and tendon transfers

Achilles tendon rupture

Calcaneus fracture or chronic inflammatory

• After fracture
• Treatment
– Direct suture
– Tendon transfer of
extensor indicis
proprius to distal
stump of the ruptured
thumb tendon.
– No treatment usually
in late rupture of the
long head of biceps
after fractured head of Tendon rupture

femur. Rupture of the extensor pollicis longus tendon may occur after a fracture of the lower radius.
& rupture of achilles tendon may occur after calcaneus fracture.
Direct suture is seldom possible and the resulting disability is treated by transferring the extensor
indicis proprius tendon to the distal stump of the ruptured thumb tendon. Late rupture of the long
head of biceps after a fractured neck of humerus usually requires no treatment.
 Carpal tunnel borders:
Scaphoid tuberosity + pisiform + triquetrum
Floor > the rest of the carpal bones
Roof > flexor retinaculum/carpal tunnel/
transverse carpal ligament
Carpal tunnel contents: (10)
4 tendons of flexor digitorum profundus
4 tendons of flexor digitorum superficialis
1 tendon of flexor pollicis longus
Colles & smith > carpal tunnel 1 median nerve

• Nerve becomes trapped or pinched due to some physiological • Nerve becomes trapped or pinched due to some physiological
abnormalities. abnormalities.
• Common sites are ulnar nerve & median nerve. • Common sites are ulnar nerve & median nerve.
Clinical features: Clinical features:
• Numbness (parasthesia) • Numbness (parasthesia)
• Loss of power • Loss of power
• Muscle wasting in distribution of the affected nerve. • Muscle wasting in distribution of the affected nerve.
– Claw hand in ulnar nerve entrapment – Claw hand in ulnar nerve entrapment
– CTS (entrapment median nerve) – CTS (entrapment median nerve)
• Treatment is early decompression of the nerve • Treatment is early decompression of the nerve

Ulnar nerve and peroneal nerve entrapment

Claw hand
Ulnar n. Impingement
Nerve compression
Nerve compression may damage the lateral popliteal nerve if an elderly or emaciated patient lies with the leg in full external rotation.
Radial palsy may follow the faulty use of crutches. Both conditions are due to lack of supervision.

Faulty use of crutches may lead to radial palsy.

• The cause of this syndrome is currently unknown
Trauma-crush injury in foot
Tight dressing
9
Radial nerve injury Prolonged cating (prolonged stabilization)

• Crutches are medical • Chronic progressive disease

devices used when a patient Other names:
is injured usually anywhere • Sudeck in 1900.
below the waist They • Sudeck’s atrophy.
usually consist of supports
• Reflex sympathetic dystrophy Or algodystrophy
to provide the patient with
extra stability to enable 2 types based on the presence of nerve lesion following the
normal movement. injury.
• Type I, also known as reflex sympathetic dystrophy (RSD),
Sudeck's atrophy, reflex neurovascular dystrophy (RND) or
algoneurodystrophy, does not have demonstrable nerve
lesions. Defect in sympathetic chain

• Type II (causalgia) has evidence of obvious nerve damage.

Severe CRPS of right arm Type 1

Patient complains
Cause is immobilization

• Initially,
Colles fracture after we remove the cast
– Continuous pain (burning in nature)
• Local swelling.
• Redness
• Warmth.
• Tenderness.
– Moderate stiffness of the joint (near the site of injury).
• After weeks:
– Pale, atrophic skin.
– Increased restricted movement.
– May develop fixed deformity.
X-ray
• Patchy rarefaction of the bone. Areas of lost density

- You can diagnose it with bone scan (stage 3)

- Nerve conduction studies (type 2)
 Osteoprosis in CRPS Treatment
One bone that undergoes disuse > Local osteoporosis

• Elevation.
• Active exercise.
Vitamin C, NSAIDs

• Physiotherapy.
Early stage treatment:
I
Areas of low density • Anti-inflammatory drugs and amitriptyline (helpful)
• Sympathatic block or sympatholytic drugs.
Disuse of bone depending on plate

(unpredictable)
s Sympathectomy > Chemical / Surgical

Thank you