complications of fractures Flashcards
Early Complications
Life threatening complications:
• Crush Syndrome=Due to major injury to soft tissue due to trauma or anoxia. Myoglobin is
released from damaged muscles. This causes myoglobinuria and renal
failure. The patient goes into shock and also presents with acidosis and
hyperkalaemia. Treatment is controversial. The damaged limb may be
amputated. If the anoxia is due to a tourniquet, it can be released slowly
and then the patient is treated symptomatically
• Fat Embolus Syndrome=Bone marrow from fracture site is taken into blood stream and ends up in pulmonary circulation. A poorly understood pathology. Signs include
shortness of breath, restlessness and confusion. ABG will show
hypoxaemia. Treatment includes oxygen, corticosteroids and early
fracture stabilisation
• Visceral Damage=Must always have a high index of suspicion in pelvic fractures.
Pneumothorax, rupture of bladder.
• Hypovolemic Shock=Due to massive haemmorrage. May not be diagnosed immediately in
closed fractures.
• Site of Fracture=A high cervical spine fracture or dislocation is life threatening.
EARLY COMPLICATIONS
Local
• Vascular Damage=Must check distal pulses and perfusion and if not present, assume arterial
damage until proven otherwise. After 6 hours the limb may not be saved.
Urgent treatment is required.
• Compartment Syndrome=This occurs when the pressure in a muscle compartment increases to equal or more than the intra-compartmental arterial pressure. Blood flow
then ceases within the compartment.
Ischaemic muscle dies within 6-8 hours, ischaemic nerve dies within 2-4
hours. Muscle cannot regenerate, so fibrosis occurs, causing contractures and
loss of function. The nerves may regenerate, but partial motor or sensory
loss may persist.
Maintain a high index of suspicion with knee hyperextension injuries,
crushed hands and closed proximal fractures of the tibia and fibula.
• Skin Damage=Skin may be stretched tightly over the fracture. If the fracture not reduced
within 2-3 hours, skin may slough, causing an open injury.
Excessive swelling can also cause blistering that may delay the treatment
of the fracture.
Skin that has lost sensation due to nerve or cord damage is at risk for injury
or the development of pressure sores.
• Nerve Damage =Nerve damage from a closed injury is usually a neuropraxia or an
axonotmesis. It is usually not explored.
Nerve damage from an open fracture is usually complete laceration of
the nerve and should be repaired or tagged for later repair.
- Muscle and Tendon Damage=Soft tissue is always injured to a varying degree
- Infection=This is common in open fractures
Complications of treatment
- Chest Complications: Atelectasis may follow anaesthesia.
- Fluid Overload
•Allergic Skin Reactions: May be due to dressings or adhesive plaster used for skin traction. Signs
and symptoms include itching and rash.
• Problems with Plaster Cast: May be too tight or poorly padded. If the patient complains of this it must
be investigated.
Intermediate Complications
Life threatening
• DVT and Pulmonary Embolism: Common in lower limb and pelvic fractures, but can occur in any patient who is on bed rest. Increased levels of circulating thromboplastins and
stasis from immobility are what predisposes these patients.
• Gas Gangrene: Tissue infection that results in the following symptoms:
Subcutaneous emphysema
Blisters filled with brown-red fluid
Drainage from the tissues, foul-smelling brown-red or bloody fluid Tachycardia, Moderate to
high fever
Moderate to severe pain around a skin injury
Pale skin color, later becoming dusky and changing to dark red or purple
Progressive swelling around a skin injury
Sweating, Jaundice
Rx
Antibiotics, debridement, skin grafts and amputation
• Necrotising Fasciitis: Necrotising Fasciitis
Invasive infection of the fascia by flesh-eating bacteria which destroys the
muscles, skin, and underlying tissue.
Symptoms:
Small, red, painful lump or bump on the skin
Changes to a very painful bruise-like area and grows rapidly,
sometimes in less than an hour
The center may become black and die
The skin may break open and ooze fluid
Feeling ill, fever, sweating, chills, nausea, dizziness, weakness, shock
Rx
Antibiotics, debridement, skin grafts, hyperbaric oxygen therapy, amputation
• Tetanus: Clostridiium Tetanii produces exotoxin that interferes with the inhibition of
motor neurons. Causes spasms and convulsions.
• Fat Embolism: May also occur at this stage.
• Sepsis: May be from original wound, surgery or poor infection control in the ward.
May develop into septicaemia with ARDS and renal failure.
Local
- Tendon
- Nerve
- Bone
- Joint
- Visceral
Local:
• Skin
Cast sores=Common. Must be investigated if patients complain of pressure in the cast.
Bed sores/ Pressure Sores=Particularly in elderly, neurologically compromised and debilitated
patients. Common sites are heels, sacrum and greater trochanter, as well
as the occiput in patients on cervical traction. Four stages of pressure
sores.
Fracture blisters=Especially due to dependency. Patients must be advised on how to
elevate the limb.
• Muscle
Disuse atrophy and muscle adhesions=Occur very quickly and can be easily prevented with appropriate
physiotherapy.
Tendon=Tendonitis=Certain fractures may predispose the patient to tendonitis due to their
close proximity.
Shortening=Due to immobilization.
Nerve=Nerve palsy from crutches, casts or positions
If very thin patients lie with their legs in full external rotation they may
develop peroneal nerve palsy. The incorrect use of crutches may lead to
the development of radial nerve palsy.
Bone
Loss of reduction=May be due to failure of fixation or movement at the fracture site.
Joint=Stiffness=Any joint will become stiff from prolonged immobilization. This will be more
severe and permanent in abnormal joints. For this reason joint stiffness is a
big problem in elderly patients. Intra-articular fractures, joint infections,
muscle adhesions and post-traumatic ossification(myositis ossificans) will
cause severe joint stiffness.
Prevent joint stiffness by not immobilizing where possible, minimizing
oedema by compression and elevation, avoiding vigourous passive
movement and stretching, particularly of an infected joint.
Instability=Due to the injury itself or muscle weakness.
Visceral=Prolonged ileus=Associated with thoraco-lumbar and lumbar injuries, paraplegia and
pelvic fractures. May need to consult general surgeon if diagnosis
unclear. Acute abdomen must be excluded.
Hypostatic Pneumonia=Common in elderly and very young. Aspiration will predispose or
atelectasis post surgery.
Late Complications
Life threatening complications
• Site of Fracture
• Cord Threatening complications=Inadequate treatment of unstable cervical spine may result in death from minor trauma
=Inadequate treatment of unstable spine might eventually result in cord
damage.
Local
Bone related complications: Bone, Joint, Nerve, Tendon, Quality of Life
Malunion
The bone has united, but in a deformed position with a functional and /or
cosmetic deficiency.
Primary cause: initial reduction was not adequate
Secondary cause: reduction displaced and not detected early enough,
often due to non-compliant patient
Types: short, shift, tilt, twist. Lengthening is rare. Cross union of major
relevance in the forearm.
Effects: loss of function, cosmetic, OA may follow
Treatment: nothing if only cosmetic, appliance, osteotomy, arthrodesis etc
Delayed Union
The fracture has not united within the average period required. Union is
continuing, but it is slow.
Causes: poor blood supply (little muscle coverage, prone to AVN, double
fractures), infection, open fractures, inadequate splintage, ORIF with
excessive soft tissue dissection, paired bones with one fractured and the
other intact, over-traction
X-Ray: fracture site is visible, bone ends are not sclerosed, medullary
cavity is open, some callus may be seen
Treatment: immobilize correctly, use limb/ weight bear, osteotomy of
fellow intact bone
Non-union
The process of repair has ceased and bony union will only be possible with
surgical intervention.
Causes: excess soft tissue loss, excess bone loss, intact fellow bone, soft
tissue interposition, poor blood supply, poor haemotoma, infection,
pathological fracture, over distraction, poor splintage, poor fixation,
impatience, patient compliance
Types: hypertrophic – bone ends are sclerosed and bulbous, atrophic –
bone ends are tapering with no calcification around bone ends
Pathology: fibrous tissue usually fills the gap, pseudoarthrosis sometimes
occurs
Treatment: Usually needs grafting
Avascular Necrosis
Loss of blood supply to fracture fragment due to vascular anatomy. May
cause delayed or non-union.
Treatment: prolonged immobilization and non weight bearing to prevent
collapse. Excision if the fragment is small. Arthrodesis or joint replacement
if required.
Growth Disturbances
After epiphyseal injury in childhood may get partial fusion of the growth
plate causing distortion of physis. May also get complete fusion of the
growth plate with cessation of bone growth and shortening of the limb.
Childhood fractures of the femoral shaft may also result in increased
length of 1,5 to 2,5 cm. This may eventually equalize with the other limb.
Chronic Sepsis
Common in severe compound fractures following ORIF.
Prevent: meticulous care of open fractures, avoid unnecessary
operations.
Treatment: Usually needs removal of sequestrum and debridement,
drainage and antibiotics. Call in a wound care specialist.
Disuse osteoporosis
Common after immobilization, especially in the elderly. May lead to
pathological fracture. Patient must be warned about activity control until
evidence of good mineralisation.
Joint complications
Joint stiffness caused by periarticular soft tissue adhesions, caused by
surgery, sepsis, poor immobilization. Can also be caused by posttraumatic ossification (myositis ossificans). Made worse by vigourous
passive mobilization that increases muscle damage. Excision of the bony
mass often fails.
• Sudecks atrophy (RSD) is associated with severe joint pain and
stiffness. Malunion of intra-articular fracture will cause marked loss of
range, as will an undiagnosed dislocation.
Symotoms:
✓ Continuous burning pain,
✓ local swelling,
✓ warmth and redness
✓ progresses to pallor and atrophy
• Intra-articular adhesions occur especially after joint fractures or
sepsis.
• Osteoarthritis, particularly post intra-articular fracture.
• Joint instability may occur due to intra-articular bone loss, ligament
disruption or muscle wasting.
Nerve complications
Late neuritis may occur following prolonged traction over deformity, for
example ulnar neuritis associated with cubitus valgus deformity following
lateral condylar fracture. Treatment involves repositioning the nerve.
Nerves may become trapped in scar tissue of callus which can also lead
to functional impairment.
Tendon complications
Late rupture may occur from constant friction over irregular bone. A
common case is the attrition rupture of the extensor pollicis longus tendon
following Colle’s fracture.
Quality of Life
Patients may undergo prolonged hospitalization, inability to work or
participate in recreational activities. This may lead to depression and loss
of self esteem. Patients may end up with permanent disability or morbidity
such as osteoarthritis
