Complications of Fractures

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Complications of Fractures
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Fracture Healing

• Weeks to months are required for most fractures
  to heal
• Adequate reduction
• Adequate blood supply
• Type of fracture
• Flat bones heal rapidly

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Complications

• Two Categories
• Early
• Shock, fat embolism, DVT, PE, and infection
• Delayed
• Delayed union, reaction to internal fixation
  devices,

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Shock

• Hypovolemic shock from hemorrhage
• Visible and non-visible blood
• Bone is vascular, large quantities of blood can
  be lost due to trauma
• Treatment
• Stabilizing fracture to prevent further
  hemorrhage
• Restoring blood volume and circulation
• Relieving pain
• Protection from further injury

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Fat Embolism

• Fat emboli develops after fx of long bones,
  pelvic bones, multiple fx or crush injuries.
• Occurs most frequently in ages 20-30 years and
  elderly adults (hip)
• Fat globules diffuse into the vascular
  compartment
• Emboli occlude small vessels that supply the
  lungs, brain, kidney and brain

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Clinical Manifestations of Fat Emboli

• Hypoxia
• Tachypnea
• Tachycardia
• Pyrexia
• Dyspnea, crackles, wheezes
• Precordia chest pain
• Cough
• Large amount of white sputum

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Prevention and Management

• Immediate immobilization of fractures
• Adequate support for fractured bone during
  turning and positioning
• Maintenance of fluid and electrolyte balance
• Monitor high risk patients
• Support resp. system

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Prevention and Management

• Controlled volume ventilation
• To prevent and treat PE
• Corticosteroids
• Inflammatory lung reaction
• Cerebral edema
• Vasopressors
• To support cardiovascular function
• Prevent hypotension
• Shock
• PE
• Accurate IO

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Prevention and Management

• Analgesics
• Morphine for pain
• Benzodiazepine midazolam, (Versed)
• To relieve anxiety
• Calm reassurance
• To allay apprehension

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Compartment Syndrome (CS)

• Is an area of the body encased by bone or fascia
• Is a painful condition that results when pressure
  within the muscles builds to dangerous levels.
  This prevents nourishment from reaching nerve and
  muscle cells.
• Develops when pressure in a compartment is
  greater than the normal

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Three Types of Compartment Syndrome

• Acute Compartment Syndrome
• A sudden and severe decrease in blood flow to the
  tissues distal to the injured area ? ischemic
  necrosis
• Chronic Compartment Syndrome
• Characterized by pain and swelling caused by
  exercise.
• Crush Compartment Syndrome
• From a crushing injury

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Compartment Syndrome Symptoms

• Deep, throbbing, unrelenting pain
• Caused by
• Reduction in size of the muscle compartment ,
• Because the enclosing fascia is to tight
• Cast or dressing to restrictive
• Edema or hemorrhage
• The classic sign of acute compartment syndrome is
  pain, especially when the muscle is stretched.

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Compartment Syndrome Symptoms

• The pain may be intensely out of proportion to
  the injury, especially if no bone is broken.
• If the area becomes numb or paralysis sets in,
  cell death has begun and efforts to lower the
  pressure in the compartment may not be successful
  in restoring function.

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Assessment and Diagnosis

• Frequent assessment of neurovascular function
  after a fracture
• Focus on the 5Ps
• Pain, paralysis, parethesias, pallor
  pulselessness

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Assessment and Diagnosis

• Sensory deficits
• Deep throbbing pain, escalating pain ?s passive
  stretching.
• Parethesia, (burning or tingling sensation and
  numbness) nerve involvement
• Motion Deficits
• Moving fingers or toes distal to the problem
• Peripheral Circulation
• Assessing color, temperature, cap refill time,
  swelling and pulses

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Neurovascular Checks

• HAVE I DOCUMENTED
• Temperature
• Coldness of an extremity distal to the injury,
  combined with pallor or duskiness indicates
  pressure on the artery and requires immediate
  medical intervention
• Movement
• Test motor function by having patient move
  extremity distal to the injury

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Neurovascular Checks

• Color
• Pallor suggests poor arterial perfusion and
  cyanosis suggests venous congestion
• Perfusion
• (Capillary Refill Time) CRT gt than 2 seconds
  suggests decreased arterial capillary perfusion
• Loss of pulse of an extremity distal to the
  injury requires immediate medical intervention

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Neurovascular Checks

• Pulses
• Palpate pulses distal to extremity, they should
  be full and strong.
• Pain assessment
• Should be done on admission and every 4 hours
  thereafter, unless more frequent assessment is
  indicated

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Wick Catheter

• Inserted into a muscle
• Measures compartmental pressure
• Normal pressure 8 mm Hg or less

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Medical Management of CS

• Notify physician immediately if neurovascular is
  compromised
• Elevation of extremity
• Release of restrictive devices (dressings or
  cast)
• Fasciotomy (surgical decompression of the fascia)
• Wound left open 3-5 days
• Covered with moist sterile saline dressings
• Affected extremity splinted and elevated
• ROM q 4-6 hours
• Skin grafts in 3-5 days

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Complications

• After a fasciotomy
• Avascular necrosis of the bone (AVN)
• Infection
• DVT
• PE
• Delayed union, malunion and nonunion

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THE END !