Complications of Fractures

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Complications of Fractures
Some Selected Complications of Fractures

Complications of Fractures

Summary of complications of fractures

Onset	Examples
Urgent early complications	Visceral injury, vascular injury, nerve injury, compartment syndrome, hemarthrosis, infection, gas gangrene
Less urgent early complications	Fracture blister, pressure sore, heterotrophic ossification, ligament injury, tendon injury, nerve compression, joint stiffness, complex regional pain syndrome (algodystrophy)
Late complications	Delayed union, non-union, malunion, avascular necrosis, growth disturbance, bed sores, muscle contracture, joint instability, osteoarthritis

Some Selected Complications of Fractures

Visceral injury
- Rib fracture: pneumothorax
- Pelvic fracture: ruptured bladder or urethra
Vascular injury
- Order an angiogram or duplex if suspected
- Signs and symptoms: paresthesia, numb toes or fingers, cold and pale limb, slight cyanosis, weak peripheral pulse
High-risk fractures for vascular injury
- Knee dislocation: Popliteal
- Elbow dislocation: Brachial
- Femoral shaft fracture: femoral
- Humeral shaft fracture: Brachial
- Supracondylar humeral fracture: Brachial
- First rib fracture: subclavian
- Shoulder dislocation: axillary
- Pelvic fracture: presacral, internal iliac
- Proximal tibial: popliteal or its branches
Nerve injury
- Closed nerve injury: seldom severed, await spontaneous recovery (90% of cases in 4 months)
- Open nerve injury: Completely severed. Explore nerve at debridement and repair at debridement or wound closure
- Acute nerve compression: common in fractures or dislocations of the wrist
High-risk fractures for nerve injury
- Shoulder dislocation: axillary
- Humeral shaft fracture: Radial
- Humeral supracondylar fracture: Radial or median
- Elbow medial condyle: Ulnar
- Monteggia fracture-dislocation: Posterior interosseus
- Hip dislocation: Sciatic
- Knee dislocation: Peroneal
Indications for early exploration in nerve injury
- Nerve injury associated with an open fracture
- Nerve injury with fractures that need internal fixation
- Presence of concomitant vascular injury
- Nerve damage was diagnosed after manipulating the fracture
Compartment syndrome
- Pain: severe pain, ‘ bursting’ sensationParesthesiaPallorParalysisPulseness: pulse may still be present as occlusion is at the capillary level
***Muscles die within 4-6 hours of ischemia
High-risk injuries and precipitating factors for compartment syndrome
- Fractures
  - Elbow
  - Forearm
  - Proximal tibia
  - Multiple fractures of the hand or foot
- Injuries
  - Crush injuries
  - Circumferential burns
- Precipitating factors
  - Internal fixation
  - Infection
Hemarthrosis
- Fractures involving a joint
- Signs and symptoms: swollen joint, tense, patient resists moving it
- Aspirate blood before dealing with the fracture
Infection
- Open fractures carry a high risk
- Closed fractures rarely get infected unless ORIF is performed
Gas gangrene
- Culprit: Clostridium welchii, AKA Clostridium perfringens
- Signs and symptoms: intense pain and swelling around the wound, brownish discharge, gas formation not marked, little or no pyrexia, increased heart rate, characteristic smell, toxemia, coma, death
Fracture blister
- Tense, clear, fluid-filled vesicles (serous blisters) or blood-stained vesicles (hemorrhagic blisters)
- Reflects significant swelling and shearing of the dermal-epidermal junction. Commonly occur in areas with minimal soft-tissue padding.
- They should not be deroofed. Postpone internal fixation (temporary external fixation) until the blister re-epithelializes
Plaster and pressure sores
- Padd bony points
- Mould the wet plaster so pressure is distributed for soft tissue around bony points
- Signs and symptoms: localised burning pain

Reference Intervals ›

Biochemistry

ACTH	P: <80 ng/L
ALT	P: 5–35 U/L
Albumin	P: 35–50 g/L
Aldosterone	P: 100–500 pmol/L
Alk. phosphatase	P: 30–130 U/L
α-Amylase	P: 0–180 IU/dL
α-Fetoprotein	S: <10 kU/L
Angiotensin II	P: 5–35 pmol/L
ADH	P: 0.9–4.6 pmol/L
AST	P: 5–35 U/L
Bicarbonate	P: 24–30 mmol/L
Bilirubin	P: 3–17 μmol/L
BNP	P: <50 ng/L
CRP	P: <10 mg/L
Calcitonin	P: <0.1 mcg/L
Calcium (ionized)	P: 1.0–1.25 mmol/L
Calcium (total)	P: 2.12–2.60 mmol/L
Chloride	P: 95–105 mmol/L
Cholesterol	P: <5.0 mmol/L
VLDL	P: 0.128–0.645 mmol/L
LDL	P: <2.0 mmol/L
HDL	P: 0.9–1.93 mmol/L
Cortisol AM	P: 450–700 nmol/L
Cortisol Midnight	P: 80–280 nmol/L
CK ♂	P: 25–195 U/L
CK ♀	P: 25–170 U/L
Creatinine	P: 70–100 μmol/L
Ferritin	P: 12–200 mcg/L
Folate	S: 2.1 mcg/L
FSH	P: 2–8 U/L ♂; >25 menopause
GGT ♂	P: 11–51 U/L
GGT ♀	P: 7–33 U/L
Glucose (fasting)	P: 3.5–5.5 mmol/L
Growth hormone	P: <20 mu/L
HbA1C (DCCT)	B: 4–6%
HbA1C (IFCC)	B: 20–42 mmol/mol
Iron ♂	S: 14–31 μmol/L
Iron ♀	S: 11–30 μmol/L
Lactate (venous)	P: 0.6–2.4 mmol/L
Lactate (arterial)	P: 0.6–1.8 mmol/L
LDH	P: 70–250 U/L
LH	P: 3–16 U/L
Magnesium	P: 0.75–1.05 mmol/L
Osmolality	P: 278–305 mosmol/kg
PTH	P: 0.8–8.5 pmol/L
Potassium	P: 3.5–5.3 mmol/L
Prolactin ♂	P: <450 U/L
Prolactin ♀	P: <600 U/L
PSA	P: 0–4 mcg/mL
Protein (total)	P: 60–80 g/L
Red cell folate	B: 0.36–1.44 μmol/L
Renin (erect)	P: 2.8–4.5 pmol/mL/h
Renin (recumbent)	P: 1.1–2.7 pmol/mL/h
Sodium	P: 135–145 mmol/L
TBG	P: 7–17 mg/L
TSH	P: 0.5–4.2 mU/L
T4	P: 70–140 nmol/L
Free T4	P: 9–22 pmol/L
TIBC	S: 54–75 μmol/L
Triglycerides	P: 0.50–2.3 mmol/L
T3	P: 1.2–3.0 nmol/L
Troponin T	P: <0.1 mcg/L
Urate ♂	P: 210–480 μmol/L
Urate ♀	P: 150–390 μmol/L
Urea	P: 2.5–6.7 mmol/L
Vitamin B12	S: 0.13–0.68 nmol/L
Vitamin D	S: 50 nmol/L

Arterial Blood Gases

pH	7.35–7.45
PaCO₂	4.7–6.0 kPa
PaO₂	>10.6 kPa
Base excess	±2 mmol/L

Urine

Cortisol (free)	<280 nmol/24h
Hydroxyindole acetic acid	16–73 μmol/24h
Hydroxymethylmandelic acid	16–48 μmol/24h
Metanephrines	0.03–0.69 μmol/mmol cr.
Osmolality	350–1000 mosmol/kg
17-Oxogenic steroids ♂	28–30 μmol/24h
17-Oxogenic steroids ♀	21–66 μmol/24h
17-Oxosteroids ♂	17–76 μmol/24h
17-Oxosteroids ♀	14–59 μmol/24h
Phosphate (inorganic)	15–50 mmol/24h
Potassium	14–120 mmol/24h
Protein	<150 mg/24h
Protein/creatinine ratio	<3 mg/mmol
Sodium	100–250 mmol/24h

Haematology

WCC	4.0–11.0 ×10⁹/L
RBC ♂	4.5–6.5 ×10¹²/L
RBC ♀	3.9–5.6 ×10¹²/L
Hb ♂	130–180 g/L
Hb ♀	115–160 g/L
PCV ♂	0.4–0.54 L/L
PCV ♀	0.37–0.47 L/L
MCV	76–96 fL
MCH	27–32 pg
MCHC	300–360 g/L
RDW	11.6–14.6%
Neutrophils	2.0–7.5 ×10⁹/L (40–75%)
Lymphocytes	1.0–4.5 ×10⁹/L (20–45%)
Eosinophils	0.04–0.44 ×10⁹/L (1–6%)
Basophils	0–0.10 ×10⁹/L (0–1%)
Monocytes	0.2–0.8 ×10⁹/L (2–10%)
Platelets	150–400 ×10⁹/L
Reticulocytes	0.8–2.0% / 25–100 ×10⁹/L
Prothrombin time	10–14 s
APTT	35–45 s

Paediatric

Pulse Rate (bpm)
Neonate	140–160
Infant <1yr	120–140
1–5 years	110–130
5–12 years	80–120
>12 years	70–100
Respiratory Rate (tachypnoea)
0–2 months	≥60/min
2–12 months	≥50/min
1–5 years	≥40/min
>5 years	≥30/min
Blood Pressure (mmHg)
Term	65/45
1 year	75/50
4 years	85/60
8 years	95/65
10 years	100/70
Weight Formulas
3–12 months	(a + 9)/2 kg
1–6 years	2a + 8 kg
>6 years	(7a − 5)/2 kg
Haemoglobin (g/dL)
Term newborn	13–20
1 month	11–18
2 months	10–15
1–2 years	10–13
>2 years	11–14
MUAC (6 months–5 years)
Obese	>17.5 cm
Normal	13.5–17.4 cm
At risk	12.5–13.4 cm
Moderate malnutrition	11.5–12.4 cm
Severe malnutrition	<11.5 cm
Developmental Milestones
Social smile	1.5 months
Head control	4 months
Sits unsupported	7 months
Crawls	10 months
Stands unsupported	10–12 months
Walks	12–13 months
Talks	18 months
CSF WBC (/mm³)
Term newborn	0–25
>2 weeks	0–5

Calculator ›

Complications of Fractures

Some Selected Complications of Fractures

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