Local

Early

The important local early complications have already been dealt with, being injuries to surrounding structures including blood vessels and nerves.

Intermediate

Local problems occurring at an intermediate stage are listed in Table 9.7.

Compartment syndrome

This phenomenon generally occurs within hours of injury and is associated with injuries in certain areas. Whereas compartment syndrome is most commonly associated with fractures, this is not always the case, as it relates to soft tissue swelling. Swelling within a relatively fixed compartment (e.g. enclosed by bone and non-compliant fascia) results in compression of the soft structures within that compartment. Both blood vessels and nerves are squashed, reducing their blood supply and impairing their function. Tissue ischaemia results in tissue damage and oedema, and therefore further swelling, causing a vicious circle. This pathophysiology explains the symptoms, signs, sequelae and treatment of compartment syndrome.

The earliest symptom is of pain in the injured area. This might not seem terribly helpful but the pain of compartment syndrome is disproportionately great compared to the underlying injury and has a less-than-expected response to analgesics.

The area is exquisitely tender and pain is experienced on stretching (passively) any muscles that are also being squashed within the compartment, or whose blood supply is impaired. From these early features there is a spectrum to the late features of compartment syndrome that should not be seen (as treatment will have been instituted). The late features are classically described as the five Ps (Table 9.8).

A high level of suspicion allows monitoring and prevents occurrence. If compartment syndrome is developing, constricting dressings and traction should be removed and the area elevated to try to reduce oedema. If unresolving, it might be necessary to surgically decompress the compartment, for example by fasciotomy.

Infection

Infection can seriously impair the physiological process of fracture healing described above, and is one of the more common causes of malunion and non-union described below. Infection is much more common in open fractures and this is one of the main reasons they are treated differently.

Another risk factor for the development of infection is the insertion of foreign bodies. This is particularly important when considering the insertion of metal such as plates and screws.

Table 9.7 Local intermediate problems complicating fractures

Compartment syndrome Infection Delayed union Non-union

Table 9.8 The five Ps of compartment syndrome

Pale

Pulseless Paraesthesia Painful Paralysed

Delayed union

In delayed union, fracture healing takes longer than expected. This is predominantly a clinical diagnosis with persistent pain and excessive mobility at the fracture site. Even under normal circumstances, radiological union takes longer than clinical union.

There are numerous causes of delayed union and it is less common in cancellous bone than cortical bone. Infection is a common cause and the presence or absence of infection has an influence on management. Other important causes include poor alignment of the fracture (inadequate reduction), poor blood supply to the fracture site and excessive mobility at the fracture site.

Non-union

Causes are similar to those of delayed union, with the addition of interposition of soft tissues. A gap remains between the ends of the fracture, which is radiographically visible, and it might also be possible to see that the medullary cavities have sealed off. Clinically, the patient has persistent pain and mobility, with or without crepitus, on stressing the fracture site. The diagnosis is therefore both clinical and radiological.

Treatment of abnormal fracture union depends on whether there is infection present. Healing in the presence of pus and dead bone (sequestrum) is unlikely, and surgical debridement with antibiotic therapy is often required.

Delayed union is classified into fractures with hypertrophic callus and hypotrophic callus. Where there is excess callus, normal healing is the rule with a prolonged period of immobilisation. Where there is minimal or no callus, healing is likely to remain inadequate and operative treatment, for example with bone grafting may be indicated.

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