Complications of Fractures

Question 1

early local complications

Answer 1

compartment syndrome, vascular injury with ischaemia, nerve compression/injury, skin necrosis

Question 2

compartment syndrome

Answer 2

serious complication and surgical emergency

rising pressure congests venous systems resulting in congestion in muscle and 2y ischaemia

clinical signs: inc pain on passive stretching and severe pain outwith the anticipated severity

pain, paraesthesia, pallor, paralysis and pulselessness.

Question 3

what is loss of pulses in compartment syndrome a sign of

Answer 3

end stage ischaemia - diagnosis has been made too late

Question 4

what happens to ischaemic muscle if left untreated in compartment syndrome

Answer 4

Volkmann’s contracture

permanent flexion contracture of hand at wrist - passive extension is painful

Question 5

1st degree nerve injury

Answer 5

neurapraxia

temporary conduction block/demyelination from compression or stretch

resolve over time (28 days) with full recovery

Question 6

2nd degree nerve injury

Answer 6

axonotmesis

occurs from either sustained compression/stretch or higher degree of force

long nerve cells axons distal to point of injury die - Wallerian degeneration. structure of nerve (endoneurial tubes) remains intact

axons regenerate along endoneurial tubes at a rate of 1mm per day

recovery is variable

Question 7

3rd degree nerve injury

Answer 7

neurotmesis

complete transection of a nerve - usually penetrating injuries

no recovery without surgery

Question 8

when is the presence of a nerve injury an indication for surgical exploration

Answer 8

evidence of nerve entrapment in fracture causing neuralgic pain

if recovery is poor, nerve grafting from a cutaneous nerve and tendon graft to recruit muscles with intact nerve supply can be used

Question 9

what are supracondylar fracture f the elbow associated with

Answer 9

median nerve injury - anterior interosseous branch

Question 10

what is a bumper injury to the knee associated with

Answer 10

bumper injury is a fracture of the lateral tibial plateau caused by valgus force on the knee

common fibular nerve palsy

Question 11

skin necrosis

Answer 11

surgical emergency, as it makes the fracture open

a shearing force on the skin can result in avulsion of the skin from its underlying blood vessles (degloving) which results in ischaemia and necrosis.

skin wont blanch on pressure and may be insensate

Question 12

how do fracture blisters occur

Answer 12

inflammatory exudates cause lifting of the epidermis of the skin

Question 13

early systemic complications

Answer 13

hypovolaemia

fat embolism (major long bone fractures), shock,

Acute Respiratory Distress Syndrome,

acute renal failure,

Systemic Inflammatory Response Syndrome,

Multi‐Organ Dysfunction Syndrome

Death

Question 14

late local complications

Answer 14

stiffness, loss of function

CRPS

infection

non and mal union

Volkmann’s ischaemic contracture

post traumatic OA

DVT

Question 15

mal union

Answer 15

fracture has healed in a non anatomic position sufficient to cause symptoms: pain, stiffness, loss of function and deformity

Question 16

clinical signs of non-union

Answer 16

ongoing pain and oedema, movement at fracture site

bridging callus

Question 17

delayed union

Answer 17

different fractures heal at different rates, energy of injury, patient age and health status must also be taken into account

the tibia can take up to 16 weeks

metaphyseal tend to heal faster than cortical

a delayed union is one that hasnt healed within the expected time

Question 18

what can a delayed union progress to

Answer 18

infection non union

Question 19

atrophic non union

Answer 19

lack of good blood supply, no movement, too big a fracture gap or tissue trapped in fracture gap

Question 20

how does smoking cause atrophic non-union

Answer 20

impairs healing as causes vasospasm

vascular disease, chronic ill health and malnutrition also impair healing

Question 21

hypertrophic non-union

Answer 21

can occur due to instability and excessive motion at fracture site with abundant hard callus formation but too much movement to allow callus to bridge gap

Question 22

complex regional pain syndrome

Answer 22

poorly understood heightened chronic pain response after injury

characteristics variable: allodynia, chronic swelling, stiffness, painful movement, constant burning/throbbing, skin colour changes

can be caused by peripheral nerve injury (type 2) - type 1 is not

Question 23

managment of CRPS

Answer 23

analgesics, antidepressants (amitryptline), anticonvulsants (gabapentin) and steroids may help

Question 24

infected fracture fixation

Answer 24

acute infections - antibiotic therapy with/out surgical washout may be adequate

>weeks - fracture healing may still be accomplished with antibiotics but metalwork will need removal

problematic infection - remove all implants and debride infected bone

Question 25

what is the main late systemic complication

Answer 25

PE - usually several days after injury

Question 26

soft tissue injury grades

Answer 26

1 - sprain

2- partial tear

3 - tear

Question 27

treatment of soft tissue injury

Answer 27

RICE and early movement to prevent stiffness

Question 28

presentation of fat embolism

Answer 28

Question 29

which type of embolus is associated with pyrexia

Answer 29

fat

Question 30

fracture of which bone often caues fat embolism

Answer 30

femoral shaft - fat from medulla