Complications of fractures

Question 1

Name 5 urgent local complications of fractures

Answer 1

• Vascular injury
• Local visceral injury
• Compartment syndrome
• Haemarthrosis
• Nerve injury
• Infection
• Gas gangrene

Question 2

Name 5 less urgent local complications of fractures

Answer 2

• Pressure sores and blisters
• Nerve entrapment
• Heterotopic ossification: bone formation in soft tissue
• Ligament injury
• Tendon lesions
• Joint stiffness
• Regional pain syndrome

Question 3

Name 5 late local complications of fractures

Answer 3

• Malunion
• Non-union
• Avascular necrosis
• Muscle contracture
• Joint instability
• Regional pain syndrome
• Osteoarthritis

Question 4

Name 2 emergency viscercal injuries following fracture

Answer 4

• Pneumothorax: rib fractures
• Ruptured bladder or urethra: pelvic fractures

These require emergency treatment prior to fracture treatment

Question 5

Name the 3 commonest vascular injuries seen with fractures?

Answer 5

• Anterior tibial artery: high tibial fracture
• Brachial artery: supracondylar fracture
• Femoral artery: femoral shaft fracture

Question 6

List the hard signs of arterial injury

Answer 6

• External bleeding
• Rapidly expansile haematoma
• Audible bruit
• Palpable thrill
• Signs of acute limb ischaemia
  
  • not corrected upon reduction or relignment of fracture

Question 7

Outline the clinical features of acute limb ischaemia

Answer 7

• Pain
• Pallor
• Paraesthesia
• Paralysis
• Pulselessness
• Perishingly cold

Question 8

What is the warm ischaemia duration prior to irreversible ischaemic damage?

Answer 8

Up to 6 hours

Question 9

Name the vessel injury associated with first rib fracture

Answer 9

Subclavian artery

Question 10

Name the vessel injury associated with shoulder dislocation

Answer 10

Axilliary artery

Question 11

Name the vessel injury associated with humeral supracondylar fracture

Answer 11

Brachial artery

Question 12

Name the vessel injury associated with elbow dislocation

Answer 12

Brachial artery

Question 13

Name the vessel injury associated with pelvic fracture

Answer 13

Presacral and internal iliac vessels

Question 14

Name the vessel injury associated with femoral supracondylar fracture

Answer 14

Femoral artery

Question 15

Name the vessel injury associated with knee dislocation

Answer 15

Popliteal artery

Question 16

Name the vessel injury associated with proximal tibial fracture

Answer 16

Popliteal artery or anterior tibial artery

Question 17

Name the nerve injury associated with shoulder dislocation

Answer 17

Axillary nerve

Question 18

Name the nerve injury associated with humeral shaft fracture

Answer 18

Radial nerve

Question 19

Name the nerve injury associated with humeral supracondylar fracture

Answer 19

Radial or median nerve

Question 20

Name the nerve injury associated with elbow medial condyle fracture

Answer 20

Ulnar nerve

Question 21

Name the nerve injury associated with elbow dislocation

Answer 21

Ulnar nerve

Question 22

Name the nerve injury associated with Montegia fracture

Answer 22

Posterior interosseous nerve

Question 23

Name the nerve injury associated with hip dislocation

Answer 23

Sciatic nerve

Question 24

Name the nerve injury associated with knee dislocation

Answer 24

Peroneal nerve

Question 25

What is the progonosis for nerve injuries in closed fractures?

Answer 25

* Spontaneous recovery: 90% within 4 months * Nerve is rarely severed * If nerve has not recovered in the expected time, and conduction studies fail to show evidence of recovery -\> exploration

Question 26

What is the prognosis of nerve injuries in open fractures?

Answer 26

* More likely to be complete lesion * Should be explored during wound debridement * Repaired at time of wound closure

Question 27

Define gas gangrene

Answer 27

A life-threatening clostridial infection featuring: * Muscle necrosis * Sepsis * Gas production

Question 28

Outline the pathophysiology of gas gangrene

Answer 28

Clostridium perfringens enters open fracturs usually after contact with soil. Since it is an anaerobic organism, it requires a sufficiently devitalised tissue environment to cause infection. Toxins are released which lead to coagulation, thrombosis, and haemolysis of RBCs. They also cause cardiac depression and vasodilatation.

Question 29

How does gas gangrene present?

Answer 29

Symptoms appearwithin 24 hours of injury * Intense pain * Swelling * Foul-smelling discharge * Mild fever, tachycardia * Vesicles and bullae develop * Rapidly develop sepsis

Question 30

Name one important differential diagnosis for gas gangrene that must be ruled out, and why?

Answer 30

Anaerobic cellulitis: absence of myonecrosis Failure to recognise the difference may lead to unecessary amputation for non-lethal cellulitis

Question 31

How is gas gangrene prevented?

Answer 31

* Explore all deep, penetrating wounds in muscular tissue * Completely excise all dead tissue * Leave wound open

Question 32

How is gas gangrene treated?

Answer 32

* Fluid replacement * IV antibiotics * Hyperbaric oxygen: limits spread of gangrene * **Prompt decompression of wound and removal of all dead tissue** * Amputation in advanced cases

Question 33

Name 4 causes of delayed union of fractures

Answer 33

* **Severe soft-tissue damage** * Poor blood supply * Periosteal stripping: avoid cause during internal fixation * Infection * Implant failure: loosen or break apart * Patient factors

Question 34

What is complex regional pain syndrome?

Answer 34

Chronic debilitating continuous burning pain that affects the limbs. Usually associated with sensory, motor, autonomic, skin, and bone abnormalities. Type I: absence of identifiable nerve injury Type II: presence of damage to a major nerve

Question 35

List 3 symptoms of complex regional pain syndrome

Answer 35

* Pain: typically burning and out of proportion * Not confined to a nerve or dermatome * Muscle weakness and disuse atrophy * Sensitivity to touch * Allodynia: pain from non-painful stimulus * Hyperalgesia: increased pain sensitisation * Swelling * Spontaneous temperature changes in limb * Spontaneous sweating * Pilomotor: goosebumps

Question 36

What is the management of complex regional pain syndrome?

Answer 36

* Analgesics or neuropathic medication * Education * Physical rehabilitation * Psychological needs