Week 5 - F - General Trauma (4) - Fracture complications (Early/late, compartment syndrome, nerve/vascular, skin/soft tissue)

Question 1

When considering the complications of fractures, they can be categorised by the timing of the complication (Early vs Late) and the site of effect of the complication (Local vs Systemic).

Name some early local complications of fractures?

Answer 1

Compartment syndrome

Vascular injury

Nerve compression or injury

And necrosis of the skin

Question 2

Name some early systemic complications of a fracture?

Answer 2

Hypovalaemia

Fat embolism

Acute renal failure

Acute respiratory distress syndrome

Systemic inflammatory response syndrome

Multi organ dysfunction leading to death

Question 3

Why can acute renal failure occur as a result of a fracture?

Answer 3

If the fracture cause bleeding leading to hypovalaemia this will underperfuse the kidneys leading to acute renal failure

Question 4

Late local complications include stiffness, loss of function, non/mal union, DVT and volkmann’s ischaemic contracture

What is volkmann’s ischaemic contracture?

Answer 4

This is where there is ischaemia leading to contraction of the long flexors and extensors in the forearm

The ischaemia can result from compartment syndrome in a supracondylar frcacute

Question 5

What are the movememnts of the wrist and fingers in Volkmann’s sichaemic ocntractture?

Answer 5

Flexion of the wrist,

extension of the MCP and

flexion of the interphalngeal joints

Question 6

As volkamnns contracture is a supracondylar fracture causing compartment syndrome as the brachial artery is severed leading to bleeding and as this is not treated , it leads to the ischaemia

What are some presenting symptoms?

Answer 6

Pain

Pallor

Paraesthesia

Paralysis

Pulselessness

Question 7

What type of fracture can injure the bronchial artery and median nerve causing volkmann’s contracture due to compartment syndrome?

Answer 7

Supracondylar fracture of the humerus

Question 8

What is the main late systemic complication of fractures?

Answer 8

This would be pulmonary embolism

Question 9

Compartment syndrome is a serious complication and surgical emergency. Groups of muscles are bound in tight fascial compartments with limited capacity for swelling. What are the cardinal signs of compartment syndrome?

Answer 9

Increased pain on passive strectching of the involved muscle

Severe pain out of proportion

Question 10

What is the treatment of compartment syndrome?

Answer 10

Fasciotomy

Question 11

The limb will be tensely swollen and the muscle is usually tender to touch. What is a feature of end stage ischaemia which shows the diagnosis has been made late?

Answer 11

This would be loss of pulses

Question 12

Rising pressure can compress the venous system resulting in congestion within the muscle and secondary ischaemia Why is it that secondary ischaemia will occur in compartment syndrome?

Answer 12

This is due to oxygenated blood being unable to enter the compartment

Question 13

Nerve injury associated with a fracture is usually a neurapraxia or axonotmesis What is neuropraxia?

Answer 13

This is where the nerve has a temporary conduction defect from compression or stretch - usually resolves over time

This is temporary and will resolve over time with full recovery (can take up to 28 days)

Question 14

Axonotmesis occurs from either a sustained compression or stretch or from a higher degree of force. Although the nerve remains in continuity and the internal structure (endoneurial tubes) remain intact, the long nerve cell axons distal to the point of injury die in a process

What is the degenration of the nerve in axonotmesis known as?

Answer 14

This nerve degeneration is known as Wallerian’s degeneration

Question 15

What is wallerian’s degenration and what is the recovery?

Answer 15

This is where is the long nerve cell axons die distal to the point of injury

The axons regenerate in the endothelial tube at 1mm per day so recovery is variable

Question 16

A neurotmesis is a complete transection of a nerve and is rare in closed injuries but can occur in penetrating injuries. What does recovery require? recovery is variable

Answer 16

Requires surgery for nerve recovery

Question 17

The majority of nerve injuries associated with a fracture (or dislocation) usually resolve or improve with time. The presence of a nerve injury is not an indication for surgical exploration When is there evidence for the requirement of surgical intervention in a fracture causing nerve injury?

Answer 17

If there is evidence of nerve entrapment causing neuralgic pain

Question 18

What are the two main types of nerve injury from fracture and describe them?

Answer 18

Neuropraxia - nerve has temporary conduction dfect due to compression - will likely resolve over time with full recovery

Axontmesis - sustained compression of nerve where nerve is intact however the long axons of the nerve distal to the injury die known as Wallerians degenration

Question 19

Some injuries are characteristically associated with particular nerve injuries:

State the nerve Colles’ fracture

Anterior dislocation of the shoulder?

Humeral shaft fracture?

Answer 19

Colles fracture - dorsal angulation of fracture causing median nerve compression

Anterior dislocation of the shoulder - axillary nerve palsy

Humeral shaft fracture - radial nerve palsy (radial nerve travels in the radial groove in the humerus)

Question 20

What are the nerves for these fractures

Supracondylar fracture of the elbow

Posterior dislocation of the hip

Bumper injury to the lateral knee

Answer 20

Supracondylar fracture of the elbow - median nerve palsy (also brachial artery can lead to volkmann’s contracture if not noticed)

Posterior dislocation of the hip - sciatic nerve

Bumper injury to the lateral knee - common peroneal palsy

Question 21

What does the sciatic nerve pass through when it journeys to the posterior thigh?

Answer 21

The greater sciatic foramen and then inferior to the piriformis

Question 22

Vascular injury can happen with penetrating and blunt trauma. Vessels can be stretched, compressed, torn or transected. Partial tears affecting the arterial intima can thrombose resulting in arterial occlusion.

Which artery is risk in knee dislocation?

Answer 22

Popliteal artery is at risk

Question 23

Any signs of reduced distal circulation (reduced or absent pulses, pallor, delayed capillary refill, cold to touch) mandates urgent vascular surgery review and emergency surgical management Which fractures are associated with life threatening hearmorrhage from arterial or venous bleeding?

Answer 23

Pelvic fractures

Question 24

What artery does a supracondylar fracture of the elbow risk?

Answer 24

Risks brachial artery injury

Question 25

What should be used to temporarily restore circulation in a vascular injury?

Answer 25

Vascular shunt or repair using a bypass graft

Question 26

What should be used to prevent the fracture from any shearing force in a vascular injury?

Answer 26

Skeletal stabilisation with internal or external fixation

Question 27

A shearing force on the skin can result in avulsion of the skin from its underlying blood vessels known as de‐gloving What can this result in?

Answer 27

This can result in skin ischaemia and necrosis if not treated

Question 28

In de-gloving what wil the skin not do under pressure?

Answer 28

If applying pressure to the skin, it will not blanche in de gloving of the skin and the skin may be insensate

Question 29

Not all fractures need to have radiographic evidence of fracture union. For many fractures, clinical signs can tell if the fracture is healing or there is non–union

Ongoing pain . Ongoing oedema ,Movement at the fracture site, Resolution of pain and function , Absence of point tenderness, No local oedema, Resolution of movement at fracture site

State which of these are healing and which are non union

Answer 29

Healing - absence of point tenderness, no local oedema, resolution of movement at fracture site, resolution of pain and function

Non -union - ongoing oedema, movement at the fracture site, ongoing pain

Question 30

What is a fracture which has not healed in the expected time known as?

Answer 30

This is delayed union

Question 31

What may be causes of delayed union however is able to be treated?

Answer 31

Infection may result in delayed union however may be treated with antibiotics

Question 32

Different bone fractures take longer to heal than others Tibial fractures are one of the slowest healing taking around how many weaks?

Answer 32

Takes around 16 weeks to heal

Question 33

Do metaphyseal or cortical fractures tend to heal quicker?

Answer 33

Metaphyseal fractures tend to heal quicker than corticol fractures

Question 34

Fractures tend to heal poorly if there is infection that is not treated, poor blood supply, smoking can also affect the healing time

There are two types of non union fractures, what are they?

Answer 34

Hypertrophic non-union and atrophic non union

Question 35

non-/delayed union can occur due to instability and excessive motion at the fracture site

Is this hypertrophic or atrophic?

Answer 35

This is hypertrophic non union

Question 36

atrophic non‐union can occur due to rigid fixation with a fracture gap, lack of blood supply to the fracture site, chronic disease or soft tissue interposition. Infection can cause delayed union but can be treated to have normal healing, what type of non-unon can it cause?

Answer 36

Can cause either hypertrophic or atrophic

Question 37

Some fractures are particularly prone to problems with healing due to poor blood supply including scaphoid waist fractures, fractures of the distal clavicle, subtrochanteric fractures of the femur and a Jones fracture

What is jones fracture?

Answer 37

Jones fractures occur in a small area of the fifth metatarsal that receives less blood and is therefore more prone to difficulties in healing

Question 38

If there is any non-union when a bone fracture is trying to heal, evidence of what should be looked for as the cause?

Answer 38

Evidence of infection eg CRP and bacterial sampling

Question 39

If infection is present what may be required?

Answer 39

Surgical debridement with potential limb shortners

Question 40

Due to the shortening of the limb as treatment in non union with infection, what technique may be used to lengthen the limb? It is a special external fixation apparatus

Answer 40

Ilizarov technique

Question 41

Deep vein thrombosis can occur particularly after pelvic or major lower limb fractures with a period of immobility. What should be given as prophylaxis do all at risk patinets?

Answer 41

LMWH - anti-coagulant

Question 42

What fractures are common for getting avascular necrosis? What are risk factors for avascular necrosis

Answer 42

Femoral head , scaphoid and talus

Steroids and alcohol

Question 43

If avascular necrosis does occur What may be required as treatment? (if femoral head, scaphoid or talus - think back to the arthriits management)

Answer 43

If femoral head - total hip replacement

Scaphoid and talus - wrist and ankle may require arthrodesis - fusion of the joint

Question 44

CRPS - complex regional pain syndrome is a poorly understood heightened chronic pain response after injury What can symptoms include?

Answer 44

constant burning or throbbing, sensitivity to stimuli not normally painful (allodynia) including cold or light touch, skin colour changes and reduced ranage of motion

Question 45

The principal late systemic complication particularly after pelvic of lower limb fracture is?

Answer 45

Pulmonary embolism