Complications of Fractures: Visceral, Vascular and Nerve Injuries Explained in Details

Complications of fractures includes early and late complications, early complications include visceral, vascular and nerve injuries and those will be explained in this article

Visceral injuries

• Visceral injuries commonly associated with fractures around the trunk, esp. the ribs, pelvis, clavicle…
• Examples: 
  • Rib injuries penetrate the lung and lead to pneumothorax
  • Pelvic fractures penetrate bladder or urethra
• Those injuries has to be expected and looked for

Vascular injury

• Arterial injury need emergency treatment
• The artery maybe cut, punctured, compressed, kinked, spasm, intimal dissection
• Causes include initial injury, swelling of the soft tissues compressing the vessel (esp. during compartments syndrome), bone fragments cutting or puncturing the vessel, reduction maneuvers and surgery
• The vessel sometimes look normal under direct vision but is blocked by thrombus or spastic
• The net effect of the arterial injury vary from slight decrease in blood supply to tissues distal to the fracture to profound ischemia and tissue death
• Clinical features
  • The injured limb is cold and pale
  • Distal pulses are weak compared to the other side or absent (examine them)
  • Capillary refill is delayed
  • Patient complains of numbness in the affected limb
• If the injury is in the ribs then think of subclavian artery injury
• If the injury is in the shoulder then think of axillary artery injury
• If the injury near the elbow then think of brachial artery injury
• If the injury in the pelvis then think of the internal iliac artery and its branches
• If the injury in the femur then think of femoral artery injury
• If the injury near the knee joint then think of popliteal artery injury
• Treatment
  • Resuscitate the patient according to the ATLS trauma protocol explained in one of the videos in this class titled “emergency management of the trauma patient”
  • If the limb is acutely ischemic and the injury is obvious (e.g. knee dislocation or femoral fracture) then vascular injury at same level and immediate surgical exploration and repair has to be done
  • If not acutely ischemic, and you suspect vascular injury then All the bandages and splints should be removed and duplex US is used, if doppler shows injured artery then should be referred to immediate surgery and repair
  • If doppler is negative and the fracture is not reduced and the position of the bones suggest  compression on certain arterial anatomical position then reduction is necessary and The circulation is reassessed again repeatedly over the next 30 minutes
  • If no improvement, the vessels must be explored by operation with the help of angiography
  • torn vessels can be sutured, torn vessel segment can be replaced by a vein graft, endarterectomy if the vessel is thrombosed
  • If operation has to be done for the artery to be repaired then operative holding method of the fracture is a must, could be internal or external fixation depending on the situation

Nerve injury

• Nerve injury means abnormal nerve function after injury
• Seddon classification classify nerve injuries into three types: neurapraxia, axonotmesis and neurotmesis

Neurapraxia

• The function of the nerve axon is disturbed by ischemia occur following to direct trauma to the nerve, traction or pressure on the nerve
• The ion pump stop working so no impulses are transmitted
• The degree of impairment of the nerve depends on how many axons are affected
• The structure of the nerve is unaffected
• Once the insult has been removed, the ion pump work again and function restored
• Example is when you sleep on your hand or arm and you wake up feeling tingling sensations that goes quickly after you wake up 

Axonotmesis

• More severe type of injury
• Section of the nerve axon is dead
• Nerve function can’t return initially even if the insult has been removed
• The myelin sheath stay intact and the axon able to grow again
• Nerve axon grows at rate of 1mm per day, so you can estimate the duration depending on the distance traumatized
• Tinel’s sign: is a sensation of tingling on percussion over the regenerating segment, good for assessment of the healing
• Scarring within the myelin sheath prevent regeneration and would lead to incomplete recovery

Neurotmesis

• Complete cut of the nerve due to penetrating injury
• the severed nerve has to be explored surgically and repaired after
• If not then it might fail to reach the correct target or maybe blocked by scar tissue or form a painful neuroma at the site of the injury

Clinical features of nerve injuries

• Nerve injury is common in fractures of the humerus and around the elbow and knee joints
• Neurological examination elicit motor dysfunction or sensory dysfunction

Treatment of nerve injuries

• Identify the injury and the cause
• Limit the progression by reducing the fracture
• If likelihood of neurotmesis is high then schedule the patient to surgery
• Axonotmesis injuries are observed for improvement on a period of 3-6 months, if no improvement then surgery is required

Infection after fractures

• infection could be osteomyelitis, cellulitis or muscle infection
• Osteomyelitis in orthopedic trauma is very significant problem because it is hard to treat and affect fracture healing
• Open fractures may easily lead to osteomyelitis, that is why antibiotic cover is so important in these fractures
• Closed fractures rarely get infected unless there is severe soft tissue injury or the fracture treated with operative reduction and holding methods
• Antibiotic treatment, wound care, multiple surgical procedures are needed
• Patient factors like diabetes, immunosuppression, obesity and smoking are risk factors to infection
• Infection may lead to delay healing, non union, loss of function and amputation
• Clinical features
  • Patient present with localized pain, chronic, worsening, not related to activity and worse at night; associated with fatigue and rigors
  • On examination there is tenderness, induration, discharging sinus
• Investigations
  • Blood tests: CBC, ESR, CPR and blood cultures
  • Wound swabs sent for culture and biochemistry tests
  • X ray films: shows bone resorption and periosteal reaction in osteomyelitis
  • CT and MRI might be needed
• Treatment
  • Knowing the infective microorganism through culture then starting antibiotic therapy according to the microorganism detected
  • Debridement procedures are needed in osteomyelitis

Hemarthrosis

• Fractures inside the joint capsule may cause bleeding into the joint
• Clinically the joint is swollen and painful and patient refuse to move it
• The blood should be aspirated 

Course Menu

This article is apart from Orthopedic Trauma Basic Principles Course, This course covers these topics: