Complications of fractures and dislocations

Question 1

Give four potential complications of serious fractures/dislocations and trauma

Answer 1

Complex regional pain syndrome (type 1)
Crush syndrome
Acute compartment syndrome
Fat embolism

Question 2

What is complex regional pain syndrome?

Answer 2

Chronic neuropathic pain that follows soft-tissue or bone injury (type 1) or nerve injury (type 2) and lasts longer and is disproportionately severe for the original tissue damage.

Question 3

What four symptoms/signs are characteristic of complex regional pain syndrome?

Answer 3

Pain
Oedema
Reduced range of movement
Temperature/colour changes

Question 4

What is crush syndrome?

Answer 4

Severe systemic manifestation of trauma and ischaemia involving soft tissues, principally skeletal muscle, due to prolonged severe crushing.
Cell membranes become more permeable, therefore potassium, enzymes and myoglobin leak out of cells.
Results in ischaemic renal dysfunction secondary to hypotension.
Diminished renal perfusion results in acute tubular necrosis and uraemia.

Question 5

Give the two main features that are characteristic of crush syndrome

Answer 5

Hypovolaemic shock

Hyperkalaemia

Question 6

Why does hypovolaemic shock occur in crush syndrome?

Answer 6

Due to sequestration of water (third spacing) in injured muscle cells

Question 7

Describe the presentation of crush syndrome

Answer 7

Crush injury to a large mass of skeletal muscle
Sensory and motor disturbances in compressed limbs
- limbs become tense and swollen
- may be pulseless
Tea coloured urine due to myoglobinuria and/or haemoglobinuria
May be oliguria with hypovolaemic shock
Nausea, vomiting, confusion, agitation

Question 8

Describe the management of a patient with crush syndrome

Answer 8

Give oxygen
Venous access should be established asap
Maintenance of fluid balance is crucial
Give analgesia

Question 9

Give six potential complications of crush syndrome

Answer 9

Metabolic acidosis
Hyperkalaemia (can lead to arrhythmias)
Acute kidney injury
Disseminated intravascular coagulation
Infection
Compartment syndrome

Question 10

What is acute compartment syndrome?

Answer 10

Increased pressure within a muscle compartment which compromises circulation and function of the tissues within that area.

Question 11

What are the most common body parts to be affected by acute compartment syndrome?

Answer 11

Leg or forearm

Question 12

Give six clinical features of acute compartment syndrome

Answer 12

Pulse
Paraesthesia
Pain
Pallor (uncommon) or Pink (common)
Pressure (wood-like)
Paralysis

Question 13

What investigations would be used to help diagnose acute compartment syndrome?

Answer 13

Bloods - creatinine kinase would be raised

Measurement of intracompartmental pressure

Question 14

How is acute compartment syndrome treated?

Answer 14

Treat conservatively if stable and not severe
- remove anything that is potentially constrictive and observe closely
However most cases will require urgent surgical treatment by fasciotomy

Question 15

What are the potential complications of acute compartment syndrome?

Answer 15

Tissue ischaemia and subsequent necrosis

Ischaemic contracture; dead muscle becomes fibrotic and shortens

Question 16

What is fat embolism syndrome?

Answer 16

Fat microglobules embolise to small blood vessels in the lungs or other parts of the body.

Question 17

What are the three major charactoristics of fat embolism syndrome?

Answer 17

Acute respiratory distress
Cerebral dysfunction
Petechial rash

Question 18

Fractures of which bones pose greatest risk of FES?

Answer 18

Long bones
Pelvis
Ribs

Question 19

Describe the investigations carried out if FES is suspected?

Answer 19

• Cytology of urine, blood and sputum – may see fat globules but low sensitivity
• CXR – “snow storm appearance”, may also see RV dilataion
• Blood gases – hypoxia, hypocapnoea
• FBC – low platelets
• Other bloods – low haematocrit, low calcium, high lipase
• Brain MRI – diagnose cerebral fat embolism
• Transoesophageal echocardiography (TEE)

Question 20

Describe the management of a patient with FES

Answer 20

• High flow oxygen
• Fluid management
o Albumin can be useful in fluid resuscitation
• Mechanical ventilation may be required
• Surgical stabilisation of long bone fractures