Complications of Fractures Flashcards
early local complications
compartment syndrome, vascular injury with ischaemia, nerve compression/injury, skin necrosis
compartment syndrome
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.
what is loss of pulses in compartment syndrome a sign of
end stage ischaemia - diagnosis has been made too late
what happens to ischaemic muscle if left untreated in compartment syndrome
Volkmann’s contracture
permanent flexion contracture of hand at wrist - passive extension is painful
1st degree nerve injury
neurapraxia
temporary conduction block/demyelination from compression or stretch
resolve over time (28 days) with full recovery
2nd degree nerve injury
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
3rd degree nerve injury
neurotmesis
complete transection of a nerve - usually penetrating injuries
no recovery without surgery
when is the presence of a nerve injury an indication for surgical exploration
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
what are supracondylar fracture f the elbow associated with
median nerve injury - anterior interosseous branch
what is a bumper injury to the knee associated with
bumper injury is a fracture of the lateral tibial plateau caused by valgus force on the knee
common fibular nerve palsy
skin necrosis
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
how do fracture blisters occur
inflammatory exudates cause lifting of the epidermis of the skin
early systemic complications
hypovolaemia
fat embolism (major long bone fractures), shock,
Acute Respiratory Distress Syndrome,
acute renal failure,
Systemic Inflammatory Response Syndrome,
Multi‐Organ Dysfunction Syndrome
Death
late local complications
stiffness, loss of function
CRPS
infection
non and mal union
Volkmann’s ischaemic contracture
post traumatic OA
DVT
mal union
fracture has healed in a non anatomic position sufficient to cause symptoms: pain, stiffness, loss of function and deformity
clinical signs of non-union
ongoing pain and oedema, movement at fracture site
bridging callus
delayed union
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
what can a delayed union progress to
infection non union
atrophic non union
lack of good blood supply, no movement, too big a fracture gap or tissue trapped in fracture gap
how does smoking cause atrophic non-union
impairs healing as causes vasospasm
vascular disease, chronic ill health and malnutrition also impair healing
hypertrophic non-union
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
complex regional pain syndrome
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
managment of CRPS
analgesics, antidepressants (amitryptline), anticonvulsants (gabapentin) and steroids may help
infected fracture fixation
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
what is the main late systemic complication
PE - usually several days after injury
soft tissue injury grades
1 - sprain
2- partial tear
3 - tear
treatment of soft tissue injury
RICE and early movement to prevent stiffness
presentation of fat embolism
which type of embolus is associated with pyrexia
fat
fracture of which bone often caues fat embolism
femoral shaft - fat from medulla
