Musculosceletal Trauma

Complications
(Fracture)
Presentator :

Yudistira Prama Tirta

Moderator:

Dr. Wahyu Widodo, SpOT

Introduction
Complication : an adverse event that occurs

following a procedure (risk of the procedure),

treatment (side effect or toxicity), or illness
A fracture may be complicated initially by an

associated injury, or it may become

complicated subsequently, either early or late
The complication : local (fracture site) or

remote (other organs)

May be caused by original injury or iatrogenic

General Complications
Shock

Hypovolemia : most common cause in trauma patient

Changes in BP, skin color and pulse rates guides to resuscitation

Resuscitation :crystalloid solutions through large-bore iv lines,

monitored by urine output (0.5 mL/kg/hr in adults)

estimated 1 liter of blood lost 3 to 4 L of crystalloid solution will be

required

Life threatening hemorrhage : X-ray head, cervical, thorax,

pelvis + USG

General Complications
Acute Respiratory Distress Syndrome
(ARDS)

ARDS direct lung injury from blunt /

penetrating trauma to the chest / alveolar
injury, or prolonged shock / septicaemia

Clinical features:

About 36 hours after injury : mild dyspnoea,

with diminished pO2
2nd or 3rd day : restless, mildly cyanosed, abN
blood gas (pO2 < 60mmHg)
Bilateral infiltrate on CXR(some cases do
present unilaterally or with pleural effusion
PCWP < 18 or PaO2/FiO2 < 200

Treatment strategy

Supportive : low volume and high

frequency ventilation(ARDSNet protocol)
ICU

General Complications (Infection)

Tetanus

C.tetani (gram + rod,

anaerobe, flourished on dead
tissue)

Pathology :

anaerobic clostridium
(C.Welchii) which
produces a toxin that
destroys cell wall leading
to tissue necrosis

Symptoms:

Symptoms :

Tetanus toxin passes to anterior

horn cells where it fixes and cant
be neutralized so produces
hyperexitability and reflex muscle
spasm

Gas Gangrene

tonic and clonic contractions of

esp. jaw, face, neck and trunk,
finally spasm of diaphragm and
Intercostalis muscles so death

Therapy :

IV human antitoxin, IV antibiotics,

thorough wound toileting, muscle
relaxant, intubation, and controlled
respiration, active immunization

severe pain, swelling,

brownish discharge, gas
production (characteristic
smell), tachycardia and
hyperpyrexia

Treatment:

IV antibiotics with fluid

replacement, wound opening
and debridment

Appleys. System of Orthopaedics & Fractures. 8th

ed. 2001

General Complications
Crush Syndrome
Trapped limb
Deprived blood flow, tissue
begin to die, toxic metabolic
accumulates
When freed reperfusion
injury (reactive O2
metabolites)
Failure in capillary & muscle
cells ion pumps swelling
compartment syndrome
further ischaemia
Toxic metabolic in circulation
hiperK, hypoCa, metabolic
acidosis cardiac arrest
Muscle breakdown large
load of myoglobin excreted
by kidney renal failure

Management :
Prevention; during
prolonged extrication,
ensured high urine flow
(large volume iv
crystalloid)
Compartment syndrome
fasciotomy
Provisional amputation

Classification of the Complications

Initial complications

Local complications

Skin injuries

Remote
complications

Major artery
Major vein
Local Hemorrhage

Neurological
Injuries
Muscular injuries
Visceral injuries

Multiple injuries
Hemorrhagic shock

Local
complications

From without
From within

Vascular injuries

Early complications

Sequelae of
immediate
complications
Joint
complications
Bony
complications

Remote
complications

Fat embolism
Pulmonary
embolism
Pneumonia
Tetanus

Late
complications
Local
complications

Joint complications :
persistent joint
stiffness, degenerative
arthritis
Bony complications :
malunion/ nonunion/
delayed union, chronic
osteomyelitis,
Sudecks
posttraumatic painful
osteoporosis (RSD)
Muscular
complications :
myositis ossificans
Neurological
complications : tardy
nerve palsy

Remote
complications
Salter RB. Textbook of Disorders
and Injury of

Initial Complications (Local)

Skin Injuries

From without : abrasion (dirt)

cleansed (X) tattoo effect
Laceration, puncture wounds,
penetrating missile wound, avulsion of
skin, skin loss debridement +
primary / delayed closure / grafts / flap
Gross swelling blister / bleb
formation
From within : skin penetration by
fracture fragment

During fracture treatment

Bed sore (decubitus ulcer) sacrum /

heels
Cast sore
Salter RB. Textbook of Disorders and Injury of

Vascular Injuries (Artery)

Major arteries are particulary vulnerable to injury in

association with specific fractures and dislocation
Injury
First rib fracture
Shoulder dislocation
Humeral supracondylar
fracture
Elbow dislocation
Pelvic fracture
Femoral shaft or
supracondylar fracture
Knee dislocation
Proximal tibial
Forefoot

Vessel
Subclavian
Axillary
Brachial
Brachial
Presacral & internal iliac
Femoral
Popliteal
Popliteal
Dorsalis pedis

Appleys. System of Orthopaedics & Fractures. 8th

Neurological Complications

Brain, Spinal Cord, Peripheral Nerves

Relatively common in association with specific

fracture & dislocations

Location

Injury

1 Brain

Skull fractures

2 Spinal cord

Cervical & thoracic spine fr_disloc

3 Cauda equina

Lumbar spine fr_disloc

4 Sciatic nerve

Posterior hip disloc & fr_disloc

5 Medial & lat

popliteal

Knee dislocation

6 Lateral popliteal

Vulnerable to bandage / cast

pressure

7 Ulnar nerve

Avulsion fr-separation medial

epicondyle

8 Median nerve

Humeral supracondylar fracture

9 Radial nerve

Humeral shaft fracture

10 Circumflex
nerve
Shoulder
dislocation& Fractures. 8th
Appleys.
System
of Orthopaedics
ed. 2001
Salter RB. Textbook of Disorders and Injury of

Visceral Complications

Penetration by a sharp fracture fragment from nearby

bone, may damage :

Heart hemopericardium with cardiac tamponade (rib

fracture)
Perforate pleura hemothorax
Perforate lung hemopneumothorax
Perforate liver, spleen, kidneys by displaced fracture of
lower ribs
Paralytic ileus & gastric dilatation thoracolumbar fracture
Rupture of bladder/ urethra, or colon / rectum pelvic fracture

Require emergency treatment