Major Potential Complications of Fracture Fixation
Introduction (Jacob):
This research report will discuss major potential complications when it comes to fracture fixation. The topics of the essay will be the pathophysiology of the complication, how they are treated and prevented, and the specific relation to fracture fixation along with a description for each disease. Deep Vein Thrombosis, Pulmonary Emboli, Fat Emboli, Infection, Compartment Syndrome, Skin Ulcer, and Nonunion/Delayed Union are the complications that will be discussed in this report.
DVT (Makayla):
A DVT (Deep Vein Thrombosis) is a blood clot (thrombus) in a deep vein that usually occurs in the legs. Deep vein thrombosis can cause leg pain or swelling, but also can occur without symptoms. It can develop if the individual has certain medical conditions that affect the blood clots. It can also happen if they patient does not move around for a long time. For example, it usually affects 1% to 2% of hospitalized patients because they have had surgery that requires bed rest. These clots are very dangerous because the clot can break loose and travel through the bloodstream and eventually go into the lungs, blocking the blood flow which results in pulmonary embolism. There is a 30%-50% occurrence of DVT in trauma patients with lower extremity fractures. If the patient is older than 55 years it can result from complex pelvic and long bone fracture. This can be prevented by exercising the lower leg muscles to improve circulation in the legs.
For diagnosis, diagnostic tests such as duplex ultrasonography or venography and laboratory tests such as a serum concentration test or a (WBC) white blood cell count are performed. Traditional treatments consist of IV heparin (anti-clotting) medication. The pathophysiology is vessel trauma stimulating the clotting cascade. Then the platelets aggregate at the site particularly when venous stasis is present, the platelets and fibrin form the initial clot which causes the RBC to be trapped in the fibrin meshwork. The thrombus grows in the direction of the blood flow and the inflammation cascade is triggered, causing tenderness, swelling, and erythema. Pieces of thrombus that break loose and travel through the circulation are called emboli. Fibroblasts eventually invade the thrombus, scarring the vein wall and destroying valves.
Pulmonary Emboli (Makayla):
A pulmonary embolism is a blockage in one of the pulmonary arteries in the lungs. This is caused by blood clots that travel to the lungs from the legs or to other parts of the body. Because the clots block the blood flow to the lungs, it can be life-threatening, but treatment reduces the risk of death.When a leg fracture or other injury that requires the legs to be immobile is sustained it can raise the risk of a clot forming in the leg.
The pathophysiology occurs when the venous thrombi originate in venous valve pockets and at other sites of venous stasis. To reach the lungs, thromboemboli travel through the right side of the heart. The common signs and symptoms are shortness of breath, chest pain, cough and leg pain. The portions of lung served by each blocked artery do not get blood and may die, which is known as pulmonary infarction. This makes it difficult for your lungs to provide oxygen to the rest of the body. Blockages in the blood vessels are not only caused by blood clots, they can be made up of fat from the marrow of a broken long bone, collagen, part of a tumor, or air bubbles.
Risk factors for this disease are history of heart disease, cancer, surgery, bed rest or extended travel. Some complications may be life-threatening. Undiagnosed and untreated patients may not survive. A pulmonary embolism can lead to pulmonary hypertension, which is a condition in which the blood pressure in the lungs and in the right side of the heart is too high. To prevent any of that happening treatment includes blood thinners (anticoagulants), lower extremity elevation and compression with stockings that help blood flow improve and exercise.
Fat Emboli (Carolina):
A fat embolus is an embolus made up of fatty acids. It is a glob of fat that gets into the bloodstream and lodged in a blood vessel. This condition is hard to diagnose and is common following a major injury or trauma. When a fracture is fixed by intramedullary rodding it can cause cause the fat that has been built up in the bone to move into the blood and cause a fat embolism. The release of a fat embolism leads to microvasculature triggering inflammatory response that can cause pulmonary and neurologic dysfunction.
Treatments such as heparin, dextran and steroids have been tested but have not been shown to help reduce the morbidity and mortality of fat emboli. Methylprednisolone may have beneficial effects. Prevention can be by the use of a membrane stabilizer, which may reduce the incidence. The use of heparin has been shown to reduce the degree of pulmonary compromise despite risk of a hemorrhage in some studies.
Infection (Jacob):
Infection occurs after surgery has been completed. Usually this is uncommon, although when a fracture is infected it is because bacteria enters the body during the event that caused the fracture or bacteria will enter during surgery. When the fracture is a compound fracture this allows for bacteria to easily get inside the body since the bone has broken in such a way that causes the skin to tear and allow entry. Once inside, the bacteria will grow rapidly and form a biofilm which makes them more difficult for the immune system to fight. In any case healthy patients rarely get infected and as a precaution doctors will prescribe antibiotics. If infection does occur it can result in permanent functional loss or amputation of the limb that is infected. There is less knowledge regarding how to treat infections with current practices such as retained hardware, irrigation, debridement, and antibiotic suppression.
Compartment Syndrome (Abigail):
Compartment Syndrome is when the muscle tissue exceeds the normal pressure limits and can cause muscle and nerve ischemia (when there is not enough blood supply to an organ). Compartment syndrome occurs after a fracture or other traumatic event. Circulation in that body part is delayed or even completely obstructed, which causes the muscle to be unable to excrete waste or get proper blood flow. This in turn causes pain and decreased feeling in the area. If not treated it can increase until there is no pulse in the extremity, complete loss of feeling, weakness and eventually tissue death. Untreated compartment syndrome can also affect the kidney, because the body is not able to filter and excrete the waste from that limb. The kidney will try to work too hard and eventually this can lead to renal failure.
Compartment syndrome results from increased intracompartmental pressure. There are two types of compartment syndrome, one resulting from trauma (significant one-time trauma) and the other is called exertional compartment syndrome (repetitive micro-trauma from a physical activity). Compartment syndrome from fractures are an example of trauma.
The most successful and chosen treatment for compartment syndrome is early decompression. If the syndrome is too far progressed decompression will be unsuccessful and the doctors may perform an emergency fasciotomy (removal of the diseased tissue) which can save the limb. After these procedures the doctor will reduce the fracture and do any necessary vascular repair.
Compartment syndrome can have multiple causes such as crush injuries, burns, tight casts, blood vessel surgery, or extremely vigorous exercise. If a cast is placed too tight it can cause swelling and eventually compartment syndrome. Fractures can cause compartment syndrome by cutting off blood supply to the muscle near them.
Skin Ulcer (Abigail):
A skin ulcer or pressure ulcer is skin and soft tissue damage that results from constant localized pressure. The injury can come from pressure on a bony prominence or medical device. Patients can be more prone to ulcers if they have had significant diet or weight change, bowel habits change, muscle contractures, medication allergies, drug use, an incorrect choice of bed, and a decreased level of independence. Ulcers cause pain, and they can have a strong foul odor and discharge. In the case of fractures, they are usually caused by a cast being placed too tight and without proper padding to give the skin enough room so there is constant pressure.
There are six stages of skin ulcers. The first stage is a non blanchable erythema of unbroken skin. The second is partial-thickness skin loss (exposed dermis). The third is complete skin loss. The fourth is skin and tissue loss. Unstageable ulcers are characterized by obscured view of the skin and tissue. Finally, a deep pressure injury is a persistent non blanchable ulcer with red and purple discoloration.
Skin ulcers result from impaired blood flow to the soft tissue, which keeps the capillaries from being able to get the blood/oxygen that they need. With any pressure and friction slightly above the normal levels for a long period of time the skin will start to break down and die (necrosis).
First the healthcare professional needs to verify where the ulcer has resulted from, then they need to do everything they can to remove what is causing it. For example, if the cast was too tight, they need to remove it and replace it with a looser one, or use a different fracture fixation method. Now that the pressure is off the skin, if the ulcer has broken the skin the providers need to debride the wound. They can use medicine and clarifying agents, they can cut away the affected tissue or they can use irrigation. They need to continue to give antibiotics to prevent infection because of the open wound.
Skin ulcers can result from prolonged time in bed, having medical equipment close to the body constantly or having a cast on too tight. When a doctor places a cast without the correct padding or room for the extremity to move slightly the constant elevated pressure can cause skin ulcers and if the wound is not caught early enough the ulcer can continue to break down tissue all the way to bone. If an ulcer is suspected it is best to quickly replace the cast with one that is correctly wrapped.
Nonunion/Delayed Union (Carolina):
This complication can be caused by casting or external fixtures. A delayed union or nonunion is when a broken bone does not heal at all or it takes longer to heal than it should. Delayed union is a term used for a fracture that has not united within a certain period of time. A fracture is considered a nonunion after three to five months that the bone(s) have yet to unite.
Treatment for a nonunion or delayed union can be treated with surgically or non-surgically. The most common nonsurgical treatment is a bone stimulator which is a device that delivers a pulse of electromagnetic waves to stimulate healing. Surgical treatment is used when nonsurgical treatment fails. Options for surgical treatments include a bone graft, internal fixation, or external fixation.
Conclusion (Jacob):
After explaining all the complications it is clear how severe they can be, anywhere from having partial skin loss to a complete amputation of a limb. This essay reviews complications from bone fractures including deep vein thrombosis, pulmonary embolism, fat embolism, infection, compartment syndrome, skin ulcers and delayed union.