Fracture Complications PDF

Risk factors of fracture complications:  Age.  Nutritional status.  Smoking.  Alcohol use.  Immobility.  Diabetes (type 1 or type 2).  Use of non-steroidal anti-inflammatory drugs (NSAIDs) within 12 months.  A recent motor vehicle acc...

Risk factors of fracture complications:  Age.  Nutritional status.  Smoking.  Alcohol use.  Immobility.  Diabetes (type 1 or type 2).  Use of non-steroidal anti-inflammatory drugs (NSAIDs) within 12 months.  A recent motor vehicle accident (one month or less prior to fracture).  Estrogen-containing hormone therapy (although this may be a proxy for osteoporosis). Types of Fracture complications: 1.Early complications of fracture: Acute complications are generally those occurring as a result of the initial trauma and include neurovascular and soft tissue damage, blood loss and localized contamination and infection. 2.Late complications of fractures Delayed complications may occur after treatment or as a result of initial treatment and may include malunion, embolic complications, osteomyelitis and loss of function. 3.Iatrogenic complications of fracture treatment: Early complications of fracture Life-threatening complications 1. These include vascular damage such as disruption to the femoral artery or its major branches by femoral fracture, damage to the pelvic arteries by pelvic fracture. 2. Patients with multiple rib fractures may develop pneumothorax, flail chest and respiratory compromise. 3. Hip fractures, particularly in elderly patients, lead to loss of mobility which may result in pneumonia, thromboembolic disease. Systemic life threatening complications: 1. Shock. 2. Fat embolism. 3. Thromboembolism (pulmonary or venous). 4. Exacerbation of underlying diseases such as diabetes or coronary artery disease (CAD). 5. Pneumonia. I. Shock: hemorrhagic most common occur to fractures of the pelvis, long bones & polytrauma. Signs & symptoms for shock:  Firm, distended abdomen or extremity soft tissue.  Extreme edema, tenderness, & Ecchymosis hear the site of the injury.  Increase in heart & respiratory rates with decrease in BF.  Pallor & cold, clammy skin.  Anxiety, agitation or confusion. Fat embolism: most common with fracture of long bones, the onset of symptoms occurs with 24 - 27 hour. Signs & symptoms for fat embolism: Anxiety, feeling of impending doom, confusion. PO2 < 60 mm Hg. Increased respiratory rate. Shortness of breath. Blood tinged sputum. Chest pain. Tachycardia. Petechiae of trunk, abdomen, sclera or conjunctiva. Fever of unknown cause. I. Thromboembolism Local life threatening complications:  Vascular injury.  Visceral injury causing damage to structures such as the brain, lung or bladder.  Damage to surrounding tissue, nerves or skin.  Haemarthrosis.  Compartment syndrome (or Volkmann's ischemia).  Wound Infection - more common for open fractures.  Fracture blisters. Local life threatening complications: I. Compartment syndrome: Definition of Compartment syndrome is a complication caused by increased pressure within a confined myofascial space resulting in circulatory compromise, ischemia and if not treated, tissue necrosis will occur. Pathophysiology of Compartment syndrome: Subsequent tissue damage may result in permanent neurologic injury and necrosis of muscle. Increased internal pressure within a compartment may be caused by swelling, bleeding or increased capillary permeability. While external compartment pressure is caused by peripheral compression such as tight casts or dressings.  Management of compartment syndrome: 1. Ongoing pain management is also crucial and medication may be needed to treat anxiety, which may compound the vasoconstriction. 2. Surgical treatment consists of relieving pressure, achieved through fasciotomy for internal compression or in the case of excessive external pressure e.g. bivalving the cast.  The skin becomes cold to touch and capillary refill is usually less than 3 seconds.  Paresthesia related to nerve compression implies decreased neurovascular function and pain is likely to decrease with progressive injury.  Serious injury is imminent when pulses are not palpable due or the patient shows signs of limb paralysis.  Nurses carry out prescribed wound care, monitor and report red and white blood counts as well as administer antibiotics to prevent infection.  Nurses also provide teaching to explain to patients and caregivers why vigilant monitoring is necessary. - Emotional support may also offset some of the anxiety and discomfort. I. Fracture blisters  These are a relatively uncommon complication of fractures in areas where skin adheres tightly to bone with little intervening soft tissue cushioning. Examples include the ankle, wrist, elbow and foot. Risk factors, other than site, include any condition which predisposes to poor skin healing, including diabetes, hypertension, smoking, alcohol excess and peripheral vascular disease.  Late complications of fractures  Local complications  Delayed union (fracture takes longer than normal to heal).  Malunion (fracture does not heal in normal alignment).  Non-union (fracture does not heal).  Joint stiffness.  Contractures.  Myositis ossificans.  Avascular necrosis.  Osteomyelitis.  Growth disturbance or deformity. Systemic of late complications - Gangrene, tetanus, septicemia. - Fear of mobilizing.  Local complications of late complication  Non-union:  It occurs when there are no signs of healing after >3-6 months (depending upon the site of fracture).  Delayed union:  It is failure of a fracture to consolidate within the expected time which varies with site and nature of the fracture and with patient factors such as age. Healing processes are still continuing, but the outcome is uncertain.   Malunion:  It occurs when the bone fragments join in an , usually due to insufficient reduction.  Factors predisposing to delayed union  Severe soft tissue damage.  Inadequate blood supply.  Infection, insufficient splintage.  Excessive traction, older age.  Severe anaemia, diabetes.  Low vitamin D level.  Hypothyroidism.  Medications including NSAIDs and steroids.  Complicated/compound fracture.  Osteoporosis.  Presentation of non-union  Pain at fracture site, persisting for months or years.  Non-use of extremity.  Tenderness and swelling.  Joint stiffness (prolonged >3 months).  Movement around the fracture site (pseudarthrosis).  Palpable gap at fracture site.  Absence of callus  Closed medullary cavities suggest non-union.  Radiologically, bone can look inactive, suggesting the area is avascular (known as atrophic non-union) or there can be excessive bone formation on either side of the gap (known as hypertrophic non-union).  Management of non-union Non-surgical approaches:  Early weight bearing and casting may be helpful for delayed union and non-union.  Bone stimulation. This delivers pulsed ultrasonic or electromagnetic waves to stimulate new bone formation. It needs to be used for up to an hour every day, and may take several weeks to be effective.  Surgical approaches:  Debridement to establish a healthy infection-free vascularity at the fracture site.  Bone grafting to stimulate new callus formation. Bone may be taken from the patient or may be cadaveric.  Internal fixation to reduce and stabilize the fracture. (Bone grafting provides no stability).  Iatrogenic complications of fracture treatment:  Cast application complication  Pressure ulcers, Thrombophlebitis  Thermal burns during plaster hardening  Traction application complication - Muscle wasting and weakness.  Other complications of traction include:  Pressure ulcers, thromboembolism.  Pneumonia/urinary tract infections.  Permanent foot drop contractures.  Peroneal nerve palsy.  Pin tract infection.  External fixation Problems caused by external fixation include:  Pin tract infection.  Pin loosening or breakage.  Interference with movement of the joint.  Neurovascular damage due to pin placement.  Misalignment due to poor placement of the fixator.  Psychological complications: Altered body image and a sense of visible disability, deformity or mutilation can occur.