complications of fractures -1

Complications of fracture

د0عادل الهنداوي LICTURE-4

General complications

1- Shock: is inadequate tissue perfusion which if
persist, it will cause damage to vital organs. In # , the shock can be:
Neurogenic shock: due to pain, the blood will pool in the skeletal muscles. Treatment by splint the # & give analgesia like morphine or pethidine.
Hypovolaemic shock: is due to blood loss from bone ends, nearby soft tissue &injured blood vessels e.g. in a simple femoral shaft #, there may be 1- 1.5 liter of blood lost into the soft tissue of the thigh outside the circulation. Treatment arrest the bleeding & restore the lost blood.

2-Crush syndrome: may occur if a large bulk of muscles is crushed
or if a tourniquet has been left unreleased for > 6 hours. After release,
the acid myohaematin (cytochrome C), resulting from muscle breakdown, will be released into the circulation &may block renal tubules or cause renal artery spasm, both may lead to acute renal failure. So to avoid that, the limb should be amputated above the level of the forgotten tourniquet and before releasing it. Antibiotic cover . Renal dialysis may be needed.

Local complications:

Late
Less urgent
urgent

Delayed union
Fracture blister
Visceral injury

Malunion
Plaster sore
Vascular injury

Non-union
Pressure sore
Nerve injury

Avascular necrosis
Nerve entrapment
Compartment syndrome

Muscle contracture
Myositis ossificans
Hemarthrosis

Joint instability
Ligament injury
Infection

Osteoarthritis
Tendon lesion
Gas gangrene

Joint stiffness

Algodystrophy




Early complications(urgent and less urgent):-

1-Visceral injury:
like pelvic # may be associated with bladder or urethral injury, or ribs # causing lung injury.
2-Vascular(arterial) injury:
The usual sites are fractured knee, elbow, humerus & femur. The artery may be cut, torn, compressed, thrombosed due to intemal injury or only in spasm.
CF: the limb become: pale (or blue), cold, numb (paraesthesia in fingers or toes) with absent or weak pulse &in severe cases, peripheral gangrene.
Treatment by; remove all the dressing & the pop cast, reduce the displaced # & wait for 1/2 an hour, if there is no improvement, then explore the vessel and deal with it accordingly:
suture a tear, remove a thrombus or replace a segment with vein graft.
Certainly, the # should be stabilized before start repairing the vessel.

3-nerve injury:-
In closed injury, the nerve is usually compressed & the lesion is neuropraxia which recovers within few days or weeks. If not, do explore &deal with the lesion.
In open injury: the nerve is usually cut (neurotmesis) which require early repair or after 3 weeks.

4-Compartment syndrome: is an increase in hydrostatic pressure in a closed osteofascial space or compartment result in decrease in perfusion of intracompartment muscles and nerve, the usual sites are forearm and leg.
Causes:-1-increase volume of compartment,e.g: fracture, bleeding
2-decrease size of compartment,e.g:tight cast or bandage.
Pathogenesis: bleeding or edema will increase the pressure in one of the closed osteofascial compartment cause decrease capillary blood flow lead to muscle ischemia which cause more edema and increase intracompartmental pressure & so on(vicious circle).
Results:
Muscle &nerve necrosis occur after 4-8 hours of complete ischemia. The muscle will be replaced by fibrous tissues causing contracture (Volkmann s ischemic contracture(late complication) of the flexor forearm muscles with fingers flexion. The nerves may regenerate later.
CF: early: you should suspect the condition if the limb is: unduly painful, swollen, tense & passive fingers movement causes pain. So measure intracompartment pressure (ICP) which is normally 0-10 mmHg.
In late cases, there will be the 5Ps:
pain, paraesthesia, pallor, paralysis &pulselessness.
Treatment: in mild cases: remove all the dressing & splints and wait for one hour, if not improved or ICP >30-40mmHg., then do fasciotomy.
The wound of fasciotomy is left open for late closure.
Treatment; of Volk. contracture: release of the contracted muscles at their origin or tendon transfer.

5-Haemarthrosis: in cases of intra articular fractures or ligament injury, the joint become swollen, tense and painful.
Treatment: the blood should be aspirated under strict aseptic condition & joint splinted untill the pain subsided, then start early active exercise

6-Infection: usually occur in open #, but could affect closed # following open reduction &internal fixation.
Clinically: the wound become inflamed, discharging seropurulent fluid. Culture will reveal the organism.treament by meticulous debridement & AB. Stabilize the # with external fixation.

7-Fracture blister Is due to elevation of superficial layers of the skin by edema especially in ankle #.
Prevention: firm bandaging.
Treatment: cover with sterile dressing.

8-Plaster sore: is due to pressure of Pop cast on bony prominence causing skin ischemia with burning sensation which is an alarm to open a window in the cast to relief the pressure otherwise, skin necrosis will occur.
Prevention: good padding over bony points &gentle casting.
Treatment: cut a window for dressing.






3-Venous thrombosis & pulmonary embolism: the incidence
of deep vein thrombosis(DVT) following major trauma or surgery
is about 30% and that of pulmonary embolism is about 5%,and 0.5% fatal.
Causes of DVT:
1-activation of factor 10 by thromboplastine released from tissue damage. 2-blood stasis.
3-endothelial damage of blood vessels.
4-increase number &stickiness of platelets.
Risk factors: 1-old patients. 2-cardiovascular disease.
3-Bed ridden patients.
C/F:- pain,tender,fever,tachycardia,homan s sign +ve
Invastigations:- 1- venography.
2- Doppler study.
Prevention:
1-early mobilization &exercise of the patient.
2-elevation of affected limb.
3-elastic bandage to prevent blood pooling.
4-anticoagulants like heparin.
Treatment of extensive DVT especially in thigh and pelvis:
1-bed rest. 2-heparin IV 10 000 IU 6 hourly for 5-7 days or
according to partial thromboplastin time ( 1.5- 2 of the normal),
then shift to warfarin with the dose according to prothrombine
time for 3 months.
Pulmonary embolism: if massive, will cause sudden death.
If small, it may cause chest pain, dyspnea and haemoptysis.

4- Tetanus: the tetanus organism require dead tissue to grow, so good debridement is important in prevention. The exotoxin is carried to the central nervous system via blood and lymphatics. Once it reach the anterior horn cells, it will be fixed their and cannot be neutralized by antitoxin.
Clinical features: early tonic and later clonic muscle contraction, especially of the jaw, face, those near the wound &later, those of the
neck and back. If the diaphragm and intercostal muscles are affected,
the patient may die because of asphyxia.
Prophylaxis: good wound toilet, active immunization using toxoid and booster dose after injury (those who were not immunized, are given human antitoxin serum).
treatment of established tetanus: IV antitoxin, sedation, muscle relaxant
(diazepam), antibiotics(penicillin) &if required, assisted ventilation.

5- gas gangrene: is caused by Clostridia perfringens(welchii), anaerobic gram +ve rods growing only in tissue with low oxygen tension, so the usual site is dirty wound with dead muscle that has been closed with inadequate debridement. Clinically, within 24 hours, the wound become swollen, painful, brown discharge with specific smell, gas in the tissue, rapid pulse, little fever and later, the patient may become toxic and comatose. teatment: excision of all dead tissue, IV antibiotic, hyperbaric oxygen may limit infection. In severe cases, amputation may required.

6- fat embolism: is thought to be due to liberation into the
circulation of fat globules larger than 10mm, the aggregation
of them may obstruct capillaries especially in the lungs.
CF: usually, a young adult, within 72 hours from injury, gets
slight fever, rapid pulse, dyspnea, confusion, skin petechiae
and in severe cases, respiratory distress and coma.
Diagnosis: is suspected if blood Po2 is < 60 mmHg.
Treatment by assisted ventilation, fluid balance, heparin to prevent thromboembolism and steroid to decrease pulmonary odema.