Complications, Pitfalls, Rehabitilation of Fracture Management

Complications of Fractures

Types of Complications

• Mal-union
• Non-union
• Fat embolism
• DVT
• Avascular necrosis
• Stiffness
• Neurological
• Vascular
• Complication of surgery
  • Infection

Mal-union

• Healing in poor position
  • Deformity
  • Shortening
  • Loss of function: e.g.?
  • Risk of early osteoarthritis: e.g.?
• Related to
  • Poor reduction or poor fixation

Non-union

• Failure to heal
  • 3% overall
  • 50% of some specific fractures
  • Related to
    • Treatment: (infection, AVN)
    • Local problems: AVN- blood supply
    • Systemic problems (Disease, Smoking)

Fat Embolism

• A syndrome
  • Marrow elements (fat) released into the vascular system and travel to the lungs
  • Triglycerides (fat) metabolized to FFA by pneumatocytes and these FFA are toxic to tissue
  • Especially brain, blood vessels, kidneys
  • ARDS
  • Risk of death

Diagnosis

• ARDS
• Mental status changes
• Petechial hemorrhage

Treatment

• Respiratory Support
• Early recognition

DVT

• DVT / Pulmonary embolism
  • Causes of DVT after fracture
    • Immobilization causes blood stasis
    • Hypercoagulability
    • Intimal injury of vessels
  • Thrombosis of LL veins
  • Embolism to heart and then lungs
  • Mechanical blockage
  • Ventilation/perfusion mismatch

DVT Prevention

• Mobilization

  • Patient
  • Limb

• Mechanical

  • Skeletal stabilization
  • SCD*, foot pumps
  • Compression

• Chemical anticoagulation

• SCD: Sequential Compression Device

Osteoarthritis of joints

In non-anatomically reduced  intra-articular fractures (step present)

With mal-alignment of extra-articular fractures causing abnormal stress forces on nearby joints

Avascular Necrosis

• More related to specific fractures:
• Peculiar blood supply arrangement
  • Neck of femur
  • Scaphoid
  • Talus

Neurological Complications

• Nerve Injuries
  • Peripheral nerves in relation to bone
    • e.g. Radial nerve in fracture of humeral shaft
  • Spinal nerves
    • In injuries of spine (vertebral column)

Vascular Complications

• Kinking of vessels more common than tears
• Compartment syndrome
  • e.g. Brachial artery in supracondylar fracture of humerus
  • e.g. Popliteal artery in knee dislocation

Infection after Fractures

• After open fractures
  • More if more severe injury
  • More if delayed treatment (Time)
  • More in contaminated open wounds

• After open reduction and internal fixation
  • More if prolonged surgery
  • More if tissues not respected
  • With foreign material of internal fixation

Pitfalls in Fracture Management

• History of mechanism of injury not obtained
  • Combination injury missed
  • Soft tissue not considered
• Failure to consider occult fractures
• X-rays not proper; exposure, views…etc.
• Inadequate film accepted

Summary - Complications of Fractures

• Mal-union
• Non-union
• Fat embolism
• DVT
• Avascular necrosis
• Stiffness
• Neurological
• Vascular
• Complications of surgery
  • Infection