[26] Fracture Complications Flashcards
What are the general complications of fractures?
Tissue damage
Complications of anaesthesia
Complications of prolonged bed rest
What may result from tissue damage in fractures?
Haemorrhage and shock
Infection
Muscle damage leading to rhabomyolysis
What complications of anaesthesia may occur?
Anaphylaxis
Damage to teeth
Aspiration
What complications might be caused by prolonged bed-rest?
Chest infection UTI Pressure sores Muscle wasting DVT and PE Decreased bone mineral density
What are the immediate specific complications of fractures?
Neurovascular damage
Visceral damage
What are the early complications of fractures?
Compartment syndrome
Infection
Fat embolism leading to ARDs
When is infection as a complication of fractures worse?
When associated with metalwork
What are the late complications of fractures?
Problems with union Avascular necrosis Growth disturbance Post-traumatic osteoarthritis Complex regional pain syndromes Myositis ossificans
Is severance of a nerve common in fractures?
No, it is rare
What is a more common mechanism of nerve injury in fractures?
Stretching over the bone edge
What does the Seddon classification of neurological complications of fractures despite?
Three types of injury - neuropraxia, axonotmesis, and neurotmesis
What is neuropraxia?
Temporary interruption of conduction without loss of axonal continuity
What is axonotmesis?
Disruption of nerve axon leading to distal Wallerian degeneration
What is preserved in axonotmesis?
The connective tissue framework of the nerve
What is the result of the connective tissue framework of the nerve being preserved in axonotmesis?
Regeneration can occur, an d recovery is possible
What is neurotmesis?
Disruption of the entire nerve fibre
What management is required in neurotmesis?
Surgery
What is the prognosis of neurotmesis?
Recovery is not usually complete
What nerve palsy can be caused by anterior shoulder dislocation?
Axillary nerve
What nerve palsy can be caused by humeral surgical neck fracture?
Axillary nerve
What will be found on examination in axillary nerve palsy?
Numb chevron
Weak abduction
What nerve palsy can be caused by fracture of humeral shaft?
Radial nerve
What will be found on examination in radial nerve palsy?
Waiter’s tip
What nerve palsy can be caused by elbow dislocation?
Ulnar nerve
What will be found on examination in ulnar nerve palsy?
Claw hand
What nerve palsy can be caused by hip dislocation?
Sciatic nerve
What will be found on examination in sciatic nerve palsy?
Foot drop
What nerve palsy can be caused by fractured neck of fibula?
Fibular nerve
What nerve palsy can be caused by knee dislocation?
Fibular nerve
What will be found on examination with fibular nerve palsy?
Foot drop
What aspect of the anatomy makes compartment syndrome possible?
Osteofacial membranes divide the limbs into separate compartments of muscles
How does compartment syndrome occur following a fracture?
Oedema following the fracture causes an increase in compartment presure, leading ot decrease venous drainage and therefore a further increase in compartment pressure
What happens if compartment pressure > capillary pressure?
Ischaemia and muscle infarction
What can muscle infarction in compartment syndrome lead to?
Rhabdomyolysis and ATN
Fibrosis leading to Volkmann’s ischaemic contracture
How does compartment syndrome present?
Pain > clinical findings
Pain on passive muscle stretching
Warm, erythematous, swollen limb
Increased cap refill time and weak/absent peripheral pulses
How is compartment syndrome managed?
Elevate limb
Remove all bandages and split/remove cast
Fasciotomy
What is delayed union?
When fracture union takes longer than expected
What is non-union?
When fracture fails to unite
What are the causes of problems with fracture union?
Ischaemia Infection Increased interfragmentary strain Interposition of tissue between fragments Intercurrent disease
What might cause ischaemia of fracture site?
Poor blood supply
Avascular necrosis
Give two examples of intercurrent disease that might cause problems with fracture union?
Malignancy
Malnutrition
What are the classifications of fracture non-union?
Hypertrophic
Atrophic
How does the bone look in hypertrophic non-union?
Bone end is rounded, dense, and sclerotic
How does the bone look in atrophic non-union?
Bone looks osteopenic
How are problems with union managed?
Optimise biology
Optimise mechanics
How can biology be optimised in bone union problems?
Manage infection
Improve blood supply
Bone graft if necessary
How can mechanics be optimised in bone union problems?
Open reduction and internal fixaiton
What is malunion?
When the bone has healed in an imperfect position
What is the problem with malunion?
Poor appearance and/or function
What is avascular necrosis?
Death of bone due to deficient blood supply
What are the common sites of avascular necrosis?
Femoral head
Scaphoid
Talus
What is the consequence of avascular necrosis?
Bone becomes soft and deformed, leading to pain, stiffness, and OA
What will be found on x-ray in avascular necrosis?
Sclerosis and deformity
What is myositis ossificans?
Heterotropic ossification of muscle at sites of haematoma formation
What does myositis ossificans result in?
Restricted, painful movement
Where does myositis ossificans commonly affect?
The elbows and quadriceps
How can myositis ossificans be managed?
Can be excised surgically
What is Pellegrini-Stieda disease?
A form of myositis ossificans
What is Pellegrini-Steida disease?
Calcification of the superior attachment of the MCL at the knee following traumatic injury
What is complex regional pain syndrome type 1?
A complex disorder of pain, sensory abnormalities, abnormal blood flow, sweating, and trophic changes in superficial and deep tissues
Is there any evidence of nerve injury in complex regional pain syndrome type 1?
No
What are the causes of complex regional pain syndrome type 1?
Fractures Carpal tunnel release Operations for Dupuytren's Zoster MI Idiopathic
When does complex regional pain syndrome type 1 present?
Weeks or months after the event
Where is affected in complex regional pain syndrome type 1?
Not the traumatised area that is affected, but a neighbouring area
What are the symptoms of complex regional pain syndrome type 1?
Lancing pain Hyperalgesia Allodynia Vasomotor symptoms Skin symptoms Neuromuscular symptoms
What are the vasomotor symptoms of complex regional pain syndrome type 1?
Hot and sweaty, or cold and cyanosed
What are the skin symptoms of complex regional pain syndrome type 1?
Swollen, or atrophic and shiny
What are the neuromuscular symptoms of complex regional pain syndrome type 1?
Weakness
Hyper-reflexia
Dystonia
Contractures
How is complex regional pain syndrome type 1 managed?
Usually self-limiting
Should refer to pain team, who might treat with amitryptilline or gabapentin. Sympathetic nerve blocks can also be tried
What is complex regional pain syndrome type 2?
Persistent pain following injury caused by nerve lesions
When might fractures lead to abnormal bone growth?
In children, when there is damage to the physis (growth plate)
What categories growth plate injuries?
The Salter-Harris classification
What is Salter-Harris 1?
Straight across the growth plate
What is Salter-Harris 2?
Through the growth plate horizontally and then up vertically
What is Salter-Harris 3?
Through the growth plate horizontally then down vertically
What is Salter Harris 4?
Through the growth plate vertically
What is a Salter Harris 5?
Crush injury
Give an example of a Salter Harris 1?
SUFE
What is the prognosis of Salter Harris 1?
Good - normal growth if good reduction
What can result from a Salter Harris 4?
Union across the physis may interfere with bone growth
What can result from Salter Harris 5?
Physis injury leading to growth arrest
