Sclerosis increase the risk of

posttraumatic arterial thrombosis

Recognition of Arterial
Complication
Initial pallor
of the skin
distally

Loss of
arterial
pulse

Mottled

Complete arterial
occlusion in a limb is
associated with:

Coolness of
the skin

Dark
discoloration
that heralds
gangrene

 Doppler probe is
very helpful in
detecting a
peripheral pulse
that is to weak to be
palpable
Arteriography is
useful in localizing the
precise site of
arterial occlusion

Compartment Syndromes
Compartment syndrome When the
increased pressure of progressive edema
within a rigid osteofascial compartment
of either the forearm or the leg (between the
knee and the ankle) threatens the
circulation to the enclosed
(intracompartmental) muscles and nerves.
Formerly known as Volkmanns ischemia

most
frequently
involve:

The flexor
compartment
of the forearm
The anterior
tibial
compartment
of the leg

 Peripheral nerves within the

compartment can withstand only 2 to 4
hours of ischemia have some potential
for regeneration
Muscle can survive up to 6 hours of
ischemia BUT cannot regenerate.
Necrotic muscle is replaced by dense
fibrous scar tissue that gradually shortens
to produce a compartmental contracture
or Volkmanns ischemic contracture

A compartment syndrome may be secondary to

one of two different phenomena
1. Proximal (extracompartmental) occlusion of
the main artery supplying the compartment
2. Intracompartmental injury to either bone, soft
tissue, or both with resultant hemorrhage
In both types, the intracompartmental pressure
rise rapidly to dangerous levels, unless this
pressure is relieved by a complete surgical
fasciotomy

 The injuries that are most frequently complicated

by a compartment syndrome are:
1. Displaced supracondylar fractures of the
humerus with damage to the brachial artery
in children
2. Excessive longitudinal traction in treatment
of fractures of the femoral shaft in children
with resultant arterial spasm
3. Fractures (as well as surgical osteotomies)
of the proximal third of the tibia
4. Drug-induced coma with resultant pressure
on major arteries from lying on hard surface
in an awkward position for a prolonged
period

The clinical picture:

1. Severe pain after pain free internal
(from muscle ischemia) (PAIN)
2. Transient decrease in peripheral
circulation with relative pallor (PALLOR)
3. Coolness of the skin as well as puffy
swelling of the hand or foot (PUFFINESS)
4. Ischemic disturbance of the involved
peripheral nerve function as evidenced
by paresthesia, hypoesthesia, paralysis
(PARESTHESIA)

Treatment of vascular
complication
1. Any constricting cast or bandage must be
completely removed
2. Any distortion of the fractured limb or extreme
position of nearby joint should be lessened
3. If the fracture is being treated by continuous
traction, the amount of traction should be
decreased
4. If these measures fail to restore adequate
peripheral circulation, an emergency arteriogram is
indicated if there is no improvement within half
an hour, the artery should be explored surgically

Sequelae of arterial
complications

Gangrene
Compartment syndrome
Intermittent claudication
Gas gangrene

Venous Complications
Division of a major vein: Injuries
to major veins should be repaired
surgically to prevent the late
sequelae of persistent venous
congestion distally

Venous thrombosis and

Pulmonary embolism
The combination of deep vein thrombosis
(DVT) and pulmonary embolism (PE) is a
common cause of morbidity and
mortality in adult orthopedic patients
Adults are more susceptible to
thrombosis than children
The main factor that precipitates
thrombosis is venous statis, other factors
include increased coagulabity and vessel
wall damage

 After a fracture, the venous lesion is usually

a phlebothrombosis, as opposed to an
inflammatory thrombosis
The thrombus is only loosely adherent to the
wall of the vein, it may come loose and pass
to the lungs to produce PULMONARY
EMBOLISM
There is an increased risk of DVT and PE in
smokers and in women who are taking oral
contraceptives

DIAGNOSIS
The calf:
- local pain
- there is tenderness in the midline posteriorly and
distal swelling due to congestion
- Passive dorsiflexion of the ankle aggravates the
pain (Homans sign)
The thigh:
- The entire lower limb becomes swollen
Less than 50% DVTs can be diagnosed clinically
Venogram, Plethysmography, and Doppler
Ultrasound other method to investigation

The Complication of
Pulmonary Embolism
A small size undetected,
or only mild chest pain
Moderate size sudden
onset of chest pain,
dyspnea, and sometimes
hemoptysis
A massive pulmonary
embolus severe chest
pain, immediately
blanches, and literally
drops dead

Prevention of Venous
Thrombosis
Avoiding constant local pressure on veins
Encouraging the patient to
- actively contract all muscles in the injured
limb
- move about as much as possible given the
limits imposed by the treatment of the
fracture
Patients at high risk of developing a DVT
should be given a prophylactic anticoagulant

Treatment of Venous
Thrombosis
Appropriate anticoagulant drugs
Recent thrombosis in the femoral
vein is best treated by surgical
thromboectomy to decrease the risk
of PE and to prevent the late sequel
of persistent venous obstruction in
the lower limb

Neurological Complications
Neurological
complication
are relatively
common in
association
with specific
fractures and
dislocation

Visceral Complications
They may also be injured by penetration
by a sharp fracture fragment from a
nearby bone
The example are:
1. Hemopericardium cardiac tamponade
2. Hemothorax and hemopneumothorax
3. Perofarte the liver, spleen, or kidneys
4. Rupture the bladder or urethra
5. etc

Other Complications
Joint Infection
of a joint (septic
arthritis)
Bone
Infection of
bone
(osteomyelitis)
Avascular
necrosis of
bone
osteomyelitis

Remote Complications

Fat embolism syndrome

Pulmonary Embolism
Pneumonia
Tetanus
Delirium tremens

Fat Embolism Syndrome

Fat globules can be found in the circulation
of most adults after a major fracture of the
long bone
Fat embolism syndrome is the combination
of systemic fat embolization and a
significant respiratory distress syndrome
with severe arterial hypoxia
This syndrome may complicate fractures in
those who have some types of preexisting
systemic collagen disease

Clinical Features
Pulmonary emboli: dyspnea,
hemoptysis, tachypnea, and cyanosis
Cerebral emboli: headache, confusion,
and irritability followed by delirium,
stupor, and coma
Cardiac emboli: tachycardia, drop in
blood presure
Skin: petechial hemorrhages
Other: febrile

 Radiographic features: snow storm

appearance
Laboratory features: there is no
pathognomonic laboratory test, the diagnosis is
primarily clinical, but this condition can be
happened:
The serum fatty acids are elevated
Free fat in the sputum and urine
The HB usually drop sharply very early in
the process
Thrombocytopenia

Late Complications
Local Complications
Late joint complications
Bone complications
Muscular complications
Late rupture of tendons
Neurological complications

Late Joint Complications

1.
2.
3.
4.

Joint Stiffness
Periarticular adhesions
Intra-articular adhesions
Adhesions between muscles and
muscles and bone
5. Posttraumatic degenerative joint
disease or arthritis

Bone Complications
1.
2.
3.
4.

Abnormal healing of fractures

Persistent Infection of bone
Posttraumatic osteoporosis
Sudecks Posttraumatic Painful
Osteoporosis (Reflex Sympathetic
Dystrophy)
5. Refracture
6. Metal failure

Abnormal healing of
fractures
The healing of fracture may be
abnormal in one of three ways:
1. Union may occur in the usual time
but in an abnormal position
(MALUNION)
2. Union may be delayed beyond a
reasonable time (DELAYED UNION)
3. Union may fail to occur (NONUNION)

Malunion

Delayed Union

Nonunion

Muscular complication:
Traumatic myositis
ossificans