Complications of Surgical Management

Tim Coughlin

When considering the complications of fracture these should be considered, as with many surgical complication, into pre-operative, intra-operative and immediate, early and late post-operative complications.

Pre-operative Complications
These are issues which may occur as a result of the fracture itself. - Blood loss and vascular injury : It is important to remember that blood loss will occur as a consequence of a fracture irrespective of whether a vascular injury is sustained. This loss can be quite impressive in the case of long bone fractures with a femoral fracture leading to potential loss of 1.5l of blood. Fractures may also cause a concurrent vascular injury either with deformation causing a vascular occlusion or the fracture ends causing direct injury to the blood vessel wall. Arterial injuries as well as being life threatening as a consequence of blood loss are limb threatening. There is around a 6 hour time window to re-perfuse an ischaemic limb before it must be amputated. - Nerve Injury : Similarly to vascular structures, which often lie in close proximity to nerves a fracture can cause injury either by traction or transection of the structure. While not a dangerous to life or limb viability the potential for disastrous function impairment is signicant. Traction injuries can cause a neurpraxia with a temporary loss of function which gradually returns but transection has a bleak outlook. ! - Compartment Syndrome : Compartment syndrome is dened as an increase in pressure in a closed osteofascial compartment. Remember that tight dressings, plaster casts and the eschar from circumferential burns can all cause an increase in pressure similar to compartment syndrome. The increase in pressure from any cause will eventually cause ischaemia of all the affected tissues. Early on pain and neurologic symptoms are prominent signs with patients describing numbness and tingling in the affected area. ! This condition should be considered at any time from the point of injury in patients who display a disproportionate and unrelenting amount of pain which fails to settle with appropriate analgesia. Remember that pulses may still be palpable as it would be rare for the compartment pressure to exceed the systolic blood pressure. If the conditions is missed or diagnosis delayed an ischaemic contracture will eventually develop. - Articular Involvement : If the fracture has an intra-articular component it may have signicant implications for operative planning and the long term outcomes for the patient. From a pre-operative standpoint concerns over articular involvement may prompt further imaging such as CT scanning to fully demonstrate the extent of the injury. This is commonplace in fracture of the tibial plateau where plain X-rays may signicantly underestimate the injury.

Intra-operative Complications
The major intraoperative complications are nerve and vascular injuries. The implications of these are the same as above in terms of outcomes for the patient. It is critically important that any pre-operative neurovascular compromise is well documented as its presence will be attributed to the surgeon if it is not. Anaesthetic complications are also an issue but these will not be discussed here.

Post-operative Complications
Immediate - These are complications which arise in the hours following surgery. As we mentioned above one of the most important to recognise is compartment syndrome. Other complications relate to intraoperative blood loos which can be quite signicant and may need early transfusion. Early - Over the days following injury and operation myriad complications may arise. The most important are discussed:
Copyright 2010 Tim Coughlin. All rights reserved. www.learnorthopaedics.com

- Infection : Bacterial colonisation of a fracture can occur at any point from the initial injury. Despite the signicant precautions taken in theatre to minimise risk of infection it still develops in 1-2% of cases post operatively. Special consideration should be given to open fractures whose risk of subsequent infection is very high due to inoculation of the wound and bone ends with bacteria at time of injury. How infection is treated depends on the severity of the infection and the type of operation performed. If an infection simply affects the supercial layer of wound closure it can usually be successfully treated with a short course of intravenous antibiotics followed by a longer oral course. Infection which originates or spreads to deeper layers of closure can be signicantly more problematic. If a prosthetic implant or plate has been inserted infection affecting this can be a devastating complication which in the worse case may necessitate amputation of the affected limb. At the very least treatment will likely require a repeat operation to open the layers of closure with a thorough washout performed and then between 2-6 weeks on intravenous antibiotics. Thromboembolism : This is quoted as occurring most commonly at around day 6 in the post operative recovery but there should always be a high index of suspicion for the condition in any orthopaedic patient. Deep vein thrombosis (DVT) is estimated to occur in around 25% of all orthopaedics patients though this number are not usually clinically evident. The condition is caused by a blood clot forming in the deep venous system of the lower limbs. There are many risk factors for the condition including smoking, obesity, previous DVT/PE, prothrombotic clotting disorders, infection, malignancy and oral contraceptive use. ! These are all true of the orthopaedic patient, but are exacerbated by the propensity to be bed bound for a number of days post-operatively preventing the calf pump to move blood out of the lower limbs and by the fact that orthopaedic surgery on its own put patients at increased risk. ! Typical symptoms of a DVT are a swollen, warm erythematous limb. The symptoms occur due to venous congestion with the clot preventing venous return from the limb. Pulmonary Embolus (PE) is a life threatening condition occurring when part of the thrombus of a DVT dislodges from its position in the deep calf veins and travels through the circulation to the vascular bed of the lungs.

Copyright 2010 Tim Coughlin. All rights reserved. www.learnorthopaedics.com