Complications of Fracture Flashcards
Name 6 complications of prolonged bed rest
- Chest infection
- UTI
- Pressure sores
- Muscle wasting
- DVT
- PE
Name 4 complications of tissue damage
- Haemorrhage and shock
- Fat embolisation and respiratory distress syndrome
- Infection
- Muscle damage and rhabdomyolysis
Name 3 complications of anaesthesia
- Anaphylaxis
- Dental damage
- Aspiration
Name 3 immediate complications of fracture
- Haemorrhage
- Neuromuscular damage
- Visceral damage
Name 2 early complications of fracture
- Compartment syndrome
2. Infection of tissue or bone (worse if prosthesis involved)
Name 6 late complications of fracture
- Problems with union (delayed, non-, malunion)
- Avascular necrosis
- Sujek’s atrophy
- Myositis ossificans
- Joint stiffness
- Growth disturbance
What is Volkman’s ischaemic contracture?
A flexion contracture of the wrist, resulting in a claw-like deformity of the hands and fingers. It is more common in children. It is commonly caused by supracondylar fracture of the humerus.
What is compartment syndrome?
An increase in pressure within an osteofacial compartment, most commonly affecting the leg or arm. After 6h irreversible changes lead to muscle and nerve necrosis. Once infarcted, the muscle is replaced by fibrous tissue which will lead to contractures.
Causes: swelling that occurs after fracture or inside a plaster that is too tight.
How would you manage compartment syndrome?
Elevate limb Remove all bandages and split the cast Remove plaster if pain not relieved Ask a senior to assess patient Pressure probes Fasciotomy if symptoms progress
How does compartment syndrome typically present?
- Pain that is out of proportion to clinical findings
- Paresthesia
- Tightness
Common sites: lower limb (tibial #) or forearm.
Earliest sign: pain on passive stretching.
Do not confuse with an ischaemic limb (cold and pale) as the limb is commonly warm and erythematous.
How are nerve injuries classified?
Seddon classification:
I. Neuropraxia - no loss of axonal continuity.
II. Axonotmesis - loss of continuity of axon and myelin, preservation of ct framework
III. Neurotmesis - total disruption of entire nerve fibre
Name the nerve palsied associated with the following fractures:
- Shoulder dislocation
- Humeral shaft fracture
- Elbow dislocation
- Hip dislocation
- Neck of fibula # or knee dislocation
- Axilliary nerve palsy
- Radial
- Ulnar
- Sciatic
- Common peroneal
They are reversible though recovery may take months.
At what point does a delayed union fracture become described as a nonunion fracture?
There is no exact time point; however, if the bone has failed to unite after several months it is unlikely to do so without intervention (e.g. ORIF and/or bone grafting).
Name 4 factors that can contribute to causing delayed and nonunion fractures
- Lack of blood supply
- Excessive shearing forces between fragments
- Infection
- Interposition of tissue between fragments
What are the two types of nonunion fractures? Describe their characteristic x-ray appearances and likely causes.
Hypertrophic nonunion:
- Bone ends look rounded (elephant feet), dense and sclerotic
- A pseudoarthrosis may form between two ends
- Plenty of new bone formation but two ends fail to unite
- Likely due to movement or interposed tissue
Atrophic nonunion:
- Less common
- Bone looks osteopenic
- Probably due to inadequate blood supply
What is the most important factor required to encourage bone healing?
Stability
Name the 3 main problems associated with traditional bone grafting
- Painful procedure - taken from patient’s iliac crest
- Donor site morbidity > main site morbidity
- No structural integrity; merely a framework
Name 3 commercially available alternatives to traditional bone grafts taken from the patient’s iliac crest
- Demineralised bone matrix
- Bone morphogenic proteins (BMP-2 or OP-2)
- Bone graft substitutes
Longer-term results of clinical trials needed.
Define malunion
Fracture has healed in an imperfect position:
- Shortened, angulated or rotated
- Abnormal appearance and/or function
At which 3 sites does avascular necrosis most commonly occur?
- Neck of femur
- Scaphoid
- Talus
Describe the bone changes that occur with avascular necrosis. True or false: radiological changes appear before symptoms.
Bones become soft and deformed, causing pain, stiffness and OA. X-ray changes: sclerosis and deformity.
False: symptoms appear before.
What is complex regional pain syndrome type I also known as? How is it different from type II?
‘Sudek’s atrophy’ or ‘reflex sympathetic dystrophy’.
Type I has no evidence of nerve damage, whereas type II does.
What is Sudek’s atrophy?
A collection of symptoms thought to be due to an abnormal sympathetic response to injury.
- Persistant pain
- Swelling
- Redness
- Sweating
A patient has come to have a plaster cast removed several weeks after sustaining a Colles’ fracture. You notice that the patient has swollen hands and fingers, and their skin is warm, pink and glazed in appearance. Movement is decreased and the wrist and hand are painful to touch. What is the diagnosis and how would you treat this patient?
Dx: Sudek’s atrophy.
Usually self-limiting. If disabling, refer to anaesthetic pain specialist. Guanethidine nerve blocks and sympathectomy can help.
What is a Salter-Harris fracture and how is it categorised?
A fracture involving the epiphyseal plate or growth plate; common in children.
Type I: transverse # through growth plate.
Type II: # through growth plate and metaphysis, sparing epiphysis.
Type III: # through growth plate and epiphysis, sparing metaphysis.
Type IV: # through all three elements of bone.
Type V: compression # of growth plate - decrease in perceived space between epiphysis and diaphysis on x-ray
Recall the SALTER mnemonic for fracture classification. Which types are the most and least common?
Type I: Slipped Type II: Lower - 75% Type II: Above Type IV: Through Everything Type V: Rammed - rare
How are Salter-Harris fractures managed?
Manipulation under anaesthetic then immobilisation in plaster. Intra-articular injuries require anatomical reduction, usually by ORIF. Small amounts of displacement are acceptable as they tend to remodel.
