Complications of Fractures

Question 1

Types of fracture complications?

Answer 1

Early OR late

Local OR general/systemic

Question 2

Examples of early local complication?

Answer 2

• Compartment syndrome
• Vascular injury with distal ischaemia
• Nerve injury
• Skin necrosis

Question 3

Types of nerve injury?

Answer 3

1st degree (neurapraxia) - temporary conduction block/demyelination; resolves within 28 days and, if it does not, suspect another type of block

2nd degee (axonotmesis) - nerve cell axon dies distally from the point of injury (Wallerian degeneration); the structure of the nerve is intact and it regenerates at 1mm per day but there is never full recovery (some weakness/loss of sensation)

3rd degree (neurotmesis) - nerve is transected but this is rare with fracture/dislocation and tends to be with high-energy injuries OR penetrating injuries; there is no recovery without surgery

Question 4

Indications for exploration of nerve injury?

Answer 4

• Open fracture
• Penetrating injury
• Neuralgic pain with ongoing compression (burning pain and tingling in the sensory distribution of the nerve)

Question 5

Ix for nerve injury?

Answer 5

If no function is returning:

• Nerve conduction studies can provide info on recovery potential and prognosis

Question 6

Treatment options of nerve injury?

Answer 6

Nerve grafting (using an expendable nerve, e.g: sural nerve)

Tendon transfers (if there are motor deficits)

Question 7

Early systemic complications of fractures?

Answer 7

• Hypovolaemia
• Fat embolism
• ARDS (acute respiratory distress syndrome)
• SIRS (systemic inflammatory response syndrome)
• MODS (multi-organ dysfunction syndrome)

Question 8

Late local complications of fractures?

Answer 8

• Stiffness, loss of function and “fracture disease”
• Post-traumatic OA
• Non-union (atrophic or hypertrophic)
• Malunion
• Volkmann’s ischaemic contracture
• Chronic regional pain syndrome
• Osteomyelitis
• AVN, e.g: femoral head, humeral head, talus, scaphoid
• DVT

Question 9

What is fracture disease?

Answer 9

Atrophy of bone, soft tissues, nail, skin, and cartilage as a complication of fracture

Question 10

Describe hypertrophic and atrophic non-union

Answer 10

Hypertrophic non-union - there is abundant callus formation but failure of union; there is too much movement at the fracture site; may be due to inadequate fixation of the fracture (treated with rigid immobilisation)

Atrophic non-union - no callus is formed and the fracture gap is too big with no movement occurring; often due to impaired bone healing:

• Vascular causes, like impaired blood supply to the bone fragments
• Metabolic causes, like diabetes or smoking)
• Steroids, NSAIDs and bisphosphonates

Question 11

What is malunion?

Answer 11

Fracture heals in a non-anatomic position leading to pain, stiffness, loss of function and deformity

Question 12

Signs of fracture healing?

Answer 12

Improved pain, no tenderness, no movement at fracture site and no swelling/oedema

Question 13

Complication of atrophic or hypertrophic non-union?

Answer 13

Infection

Question 14

What is Volkmann’s ischaemic contracture?

Answer 14

Permanent flexion contracture of the hand at the wrist, resulting in a claw-like deformity of the hand and fingers; it is esp. assoc. with supracondylar fractures of the humerus

Question 15

What is complex regional pain syndrome?

Answer 15

AKA Regional Sympathetic Dystrophy, algodystrophy, Sudeck’s atrophy

Exaggerated pain response after injury that may/may not be related to peripheral nerve injury:

• Causalgia (burning, neuralgic pain)
• Allodynia
• Swelling
• Skin changes

Treatment is difficult

Question 16

Late systemic complications of fractures?

Answer 16

PE