Orthopaedics unit 5 Common fractures - deck 5 Flashcards
What consequences/complications of a fracture are inevitable ?
Blood loss and soft tissue bruising
What are the 2 main categories of complications which can arise due to a fracture ?
Early and late complications
What are the 2 main sub-categories of both early and late complications which may develop because of a fracture?
- Primary - a consequence of the injury itself
- Secondary - a consequence of the treatment
What are late complications following a fracture generally due to?
The fracture itself - but a few are unfortunately precipitated by the treatment, or lack of it.
List the early primary complications as a result of a fracture
- Blood loss
- Infection (open)
- Fat embolism
- Renal failure
- Soft tissue injury
- Compartment syndrome
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List the early secondary complications which may arise as a result of treatment of a fracture
- Plaster disease
- Renal stones
- Immobility
- Infection
- Compartment syndrome
Think - Perth Royal Infirmary Is Crap
List the late primary complications which may arise as a result of a fracture
- Non-union
- Delayed union
- Mal-union
- Growth arrest
- Arthritis
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List the late secondary complications which may arise as a result of treatment of a fracture
- Mal-union
- Infection
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In terms of fractures what may cause infection to occur ?
After open fracture or internal fixation
What is the commonest cause of bone infection in the western world?
Surgery
Infection prevents union of a fracture - T or F?
False - Although infection may delay or prevent union this is not always inevitable. Provided a fracture is held stable then it will unite despite infection.
If there is infection and… what? then non-union is most likely
Movement
What should be done if a fixed fracture is infected but stable ?
It may be temporarily treated by drainage of any pus collection and by antibiotics until union has occurred.
If an open fracture that is not stable, or an unstable but fixed fracture, becomes infected then what should be done ?
Stabilisation by external fixation followed by surgical wound cleansing and later bone grafting will be required.
Define pneumonitis
Inflammation of the lungs
Is the cause of fat embolism after a fracture known ?
It is unclear what exactly the cause is:
- It was originally said to be due to the precipitation of marrow fat in the lungs. The breakdown of fats to fatty acids is said to precipitate an inflammation of the lungs (pneumonitis).
- However, the condition seems part of a more generalised abnormal response to injury
Are fat embolisms following a fracture common ?
No
Who is typically most commonly affected by fat embolisms following a fracture ?
Typically after the fracture of a long bone in men under twenty years old
Describe the typical presenting signs and symptoms of a fat embolism
Symptoms usually present 2-5 days following injury:
- Tachyponea and mild confusion initially
- may have a rash on the chest and neck
- In severe cases the respiratory distress increases to the point where ventilation is required, but even with this support, the condition carries a significant mortality.
Describe the treatment of fat embolism
Early diagnosis followed by treatment with high percentage oxygen and chest physiotherapy reduces the consequences, but late diagnosis is less than helpful. Steroids given early or even prophylactically are said to reduce the severity but this remains controversial.
Who is at risk for the development of renal failure following a fracture/injury?
People with massive soft tissue injury who are trapped for prolonged periods, particularly where they are shocked or the trapped limbs are relatively starved of blood (ischaemic), are prone to develop kidney failure.
For people who develop renal failure following a fracture/trauma what is found in the kidneys ?
Myoglobin, which is the oxygen carrying material in muscle, is found in abundance in the kidneys of people who die from this set of circumstances.
What is compartment syndrome sometimes also called ?
Volkmanns ischaemia
What causes compartment syndrome to occur and where can it occur ?
It is caused by excessive localised tissue swelling following a fracture, it can occur in the upper or lower limbs
What is the classic location for compartment syndrome to develop?
In the forearm, may also occur in the calf
What is every muscle surrounded by ?
A tough fibrous tissue called fascia
What are groups of muscles surrounded by ?
A very thick layer of fibrous tissue called the fascial sheath
What is the function of the fascial sheath ?
Supports the muscles and gives them shape as well as anchoring them to bone and surrounding soft tissues.
What do the fascial sheaths surrounding different groups of muscles form?
They create isolated compartments
What is contained within a muscle compartment ?
Muscles, blood vessels and nerves.
Describe how a fracture can cause compartment syndrome
- If a bone is broken then bleeding will occur into the adjacent compartments and there will also be swelling from the inflammatory reaction.
- Both these factors lead to an increase in pressure within the compartment.
- Rises in pressure may reduce blood flow locally to the muscles. The reduced local muscle blood supply results in ischaemia ==> compartment syndrome
What increases the risk of development of compartment syndrome following a fracture ?
The more severe the injury the greater the likelihood of compartment syndrome development
Can compartment syndrome occur without a fracture ?
Yes - rarely it can also be precipitated in association with exercise - for example shin splints
Define what shin splints is
This is the term used to describe the often agonising pain some athletes get in their shins when they run, often early in a training schedule.
What are the key signs and symptoms of compartment syndrome ?
- Pain which is out of proportion to that expected by the injury.
- Loss of function of the muscles and often altered sensation over the compartment.
- The pulse distal to the compartment is normal
What is a useful diagnostic test for compartment syndrome?
To stretch the muscles in the compartment, such as extending the fingers or toes. This usually precipitates extreme pain ==> compartment syndrome
What is the treatment of compartment syndrome ?
All dressings should be removed and plasters split to the skin and eased - this will not affect the splintage properties of the plaster.
If this fails then surgical intervention (opening the fascial sheath to decompress the compartment) is inevitable - fasciotomy.
How can compartment syndrome be prevented?
The condition can be prevented by early elevation of the injured limb to prevent swelling occurring, by careful attention to the padding of casts, and by ensuring that dressings are not too tight.
After injury the injured part of the body needs to be immobilised for a short period - what is it important to remember about imobilisation ?
The whole person does not need immobilising at any time and people must begin to mobilise and rehabilitate as soon after injury as possible
Who’s responsibility is it to ensure they mobilise following an injury?
The patients
Who will help the patient to mobilise following an injury?
Therapists and medical staff
What 3 things characterises ‘fracture disease’ (sometimes called plaster disease)
This refers to muscle wasting, stiffness and skin sores
What is fracture disease a complication of ?
Fracture treatment and imbolisation
What does early mobilisation following an injury discourage the development of ?
- osteoporosis - the “thinning” of bone caused by disease,
- renal stone formation - caused by calcium from the thinning bone,
- stiffness - caused by disease of joints,
- muscle wasting - caused by muscle disuse
- skin sores - caused by pressure of the plaster cast.
How common is non-union and delayed union of fractures ?
About 2% of all fractures go on to non-union and a few more than this will be delayed
If left to heal naturally how long do upper limb and lower limb fractures take to heal in general?
- Upper limb fractures - 6 wks
- Lower limb fractures - 12wks
What 2 factors can influence how long a fracture may take to heal?
The degree of violence involved and how the fracture was treated
Who heals faster children or adults ?
Children
Once growth has ceased i.e. they are not increasing in height etc, is time for union of a fracture age dependent ?
No it is not
What is the most common bone to develop non-union ? and why specifically is it thought that this bone most commonly develops it ?
The tibia - due to its rather exposed site under the skin with little surrounding muscle and soft tissue
List the common factors known to contribute to causing non-union of a fracture
- Excess movement.
- Too little movement - a result of rigid internal fixation.
- Soft tissue interposition - soft tissue between the bone ends. (by bone ends meaning fragments)
- Poor blood supply.
- Infection.
- Excessive traction, or splintage of bones too far apart.
- Intact adjacent bone - e.g. tibia and fibula.
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Non-union may be said to occur when the injured person and/or the surgeon feels that healing has taken too long. When is the rough figures for upper and lower limb fractures to say non-union has occurred?
- Lower limb fractures - 10wks
- Upper limb fractures - 20wks
Define what delayed union is
A period between expected union and accepted non-union when the decision to do something is contemplated
What are the causes of delayed union of a fracture?
They are the same as for non-union:
- Excess movement.
- Too little movement - a result of rigid internal fixation.
- Soft tissue interposition - soft tissue between the bone ends. (by bone ends meaning fragments)
- Poor blood supply.
- Infection.
- Excessive traction, or splintage of bones too far apart.
- Intact adjacent bone - e.g. tibia and fibula.
What is the treatment for non-union of a fracture?
Remove any underlying cause for the non-union and then stimulate union through stabalising the fracture sufficiently and adding a bone graft
What bone is used for the bone graft in treating non-union?
The bone used for a graft is usually autologous (taken from the bone, usually the pelvis, of the same individual) and is placed next to the fracture.
Define what mal-union of a fracture is
When the fracture has been allowed to heal in a position that prevents normal function
What does mal-union usually imply?
Failure of the treatment method, or neglect by a surgeon, or by non-attendance at out-patient clinics
What is essential to review how well the treatment of a fracture is going ?
- Regular out-patient review is the mainstay of fracture management
- Regular radiological
- Clinical examinations
What is the epiphyseal growth plate ?
The growth plate, also known as the epiphyseal plate or physis, is the area of growing tissue (hyaline cartilage) in the metaphysis at each end of a long bone in children and adolescents.
If a fracture breaches the germinal layer of the epiphyseal growth plate what may happen ?
Bone growth may be arrested at the point of breach, resulting in deformity
Children have a great capacity to remodel mal-united fractures, what deformities cant they remodel?
Rotatory deformities
When will arthritis develop secondary to a fracture ?
If a joint is excessively stressed due to the fracture
What are the 3 potential ways in which a fracture can result in excessive stress on a joint, which in turn results in arthritis development ?
- If a fracture goes across a joint and disturbs the surfaces so that the joint is no longer congruent (i.e. the two surfaces are no longer parallel)
- A very angulated fracture will also stress a joint by putting uneven forces on it.
- Occasionally, direct damage to the articular cartilage will result in arthritis
Does good fracture management completely eliminate the risk of arthritis development following a fracture ?
It minimises it but never totally excludes it
