Complications of Fractures: Joint stiffness, Joint Instability and Osteoarthritis

Complications of fractures include early and late complications, early complications was explained in the previous article, now in this article late complications like joint stiffness, joint instability and osteoarthritis will be explained

Joint stiffness

in this fracture complication, The joint become difficult to move and it mostly occur after fractures
Common locations: knee joint, elbow, shoulder, small joint of the hands
Causes include joint capsule fibrosis, adhesions and edema that occur due to prolonged immobilization of the joint
Treated by exercising the joints early after the fracture occurred, if already stiffed then physiotherapy is needed

Joint instability

Sensation of the joint may give away
Causes include ligamentous laxity, muscle weakness and bone loss
Joint instability may lead to recurrent dislocations, esp. in the shoulder and patella

Osteoarthritis

OA is degeneration of the joint cartilages
Occurs when the fracture is inside the joint capsule damaging the articular cartilage
It is either post traumatic OA occurs in periods of months after injury due to direct damage to the articular cartilage or secondary arthritis that occur years later due to irregularity of the joint surface because of not so perfect reduction

Avascular necrosis

Some bones and parts of bones have high risk of developing ischemia and necrosis after injury due to poor blood supply
Common bone:

The femoral head
The proximal part of the scaphoid bone
The lunate bone
The body of the talus bone

Ischemia occurs initially following the injury but clinical features and radiological features of the necrosis seen after weeks or months
Patient present with pain at the injured bone
X ray shows osteopenia, patchy sclerosis, rim calcification
Mikael Häggström, CC0, via Wikimedia Commons

Bed sores

Ulcers form due to prolonged pressure on the skin mostly in elderly and paralyzed patients or from wearing a cast for long time
The commonly form over the sacrum, heals
Treatment is difficult, excision and grafting is an option and negative pressure dressing is advised
Jmarchn, CC BY-SA 3.0 <https://creativecommons.org/licenses/by-sa/3.0>, via Wikimedia Commons

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
Davplast, CC BY-SA 4.0 <https://creativecommons.org/licenses/by-sa/4.0>, via Wikimedia Commons

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