Complications of limb injury
The
complications of injuries can be divided into early and late, local and
systemic, and those specific to certain methods of fixation (Table
21.6).
Early
local
The
key complication is the loss of circulation distal to the injury. A second
commonly missed problem is degloving of the skin and subcutaneous fat, which
lose their blood supply as they are torn from the deeper tissues. This injury is
easy to miss, but if a careful check is made for loss of sensation and capillary
filling, and there is a high coefficient of suspicion from the history, then
appropriate action can be taken as all of the dead tissue needs to be removed
and skin cover is urgently needed. Compartment syndrome is a condition which
develops if an injured muscle swells inside a compartment bounded by an
inelastic fascia. The most common sites for this problem are the forearm and the
muscle compartments surrounding the tibia and fibula. As the muscle swells the
pressure within the compartment rises until it becomes so high that it actually
cuts off the blood supply to the limb. If urgent action is not taken the muscle
dies and scars up, producing Volkmann’s
contracture (Fig. 21.18). An identical situation can be created if a
dressing is put on too tight or if
These
are a side effect of the soft tissue trauma (Fig. 21.19). They are fragile and
quickly burst, creating an open wound which is contaminated. They are a
contraindication to internal fixation because of the risk of infection.
Swelling
Soft-tissue
swelling is commonly association with fractures. If it severe it is a hindrance
to open reduction and internal fixation (ORIF) because the swelling may make it
impossible to close the wound at the end of operation. If severe swelling is
expected (it is very common with ankle fractures) there is a short window within
hours of the accident when surgery may be feasible; after that there may be a
period of several days when surgery is impossible. During that time every effort
should be made to reduce the swelling as quickly as
Early
systemic
The
main complications arise secondary to hypovolaemic shock. The second problem is
that injuries come in clusters, and so a careful search must be made for other
injuries to the patient, including those to soft tissues and vital organs, such
as the lungs.
Late
local
Limbs
that are injured tend not to be moved. In limbs that are not moved the joints
become stiff, the muscles waste and the circulation deteriorates, so that the
healing of the limb may be compromised.
Osteomyelitis
If
wounds were not cleaned properly or surgery became contaminated the fracture may
become infected. Once infection is established it can be very difficult to
eradicate, in fact some would say that chronic osteomyelitis is never cured as
it can break out again at any time.
The
principles of management are to remove all dead and infected bone, then to try
to achieve union with strong bone and adequate soft-tissue cover. The amount of
bone that needs to be removed is always difficult to estimate and more than you
had originally hoped.
Fractured
bones which have lost their blood supply, either because of the energy involved
at the time of injury or because of the handling of soft tissues at the time of
surgery, may go on to atrophic nonunion. The
bone ends become thin and pointed, and there is no sign of any attempt at union.
If
the fracture moves too much then a hypertrophic
nonunion may result (overabundant callus), but with a persisting fracture
cleft held open by excessive movement at the fracture site. If the fracture
unites in a bad position (malunion) the
limb may look very ugly, but may also not work properly. If the radius and ulna
unite in a poor position the forearm will lose all ability to pronate and
supinate (Fig. 21.20). A common cause for malunion is a failure to supervise the
healing of a fracture adequately. If protection is removed too soon, or the
patient is not seen often enough, then the fracture may slip and then unite in a
poor position. Avoid calling a patient back as an outpatient more than
absolutely necessary, but while the fracture is still uniting be sure that the
next appointment occurs before union has occurred, so that if there is a slip
there is time for a correction of reduction and to secure fixation. Intra-articular
fractures which are not anatomically reduced will lead to rapid onset of
osteoarthritis. Accurate reduction can be difficult to
Late
systemic
The
late systemic complications can be divided into organic and psychiatric. The
initial period of hypovolaemia, and even hypoxia, in polytrauma can lead to
irreversible damage locally and systemically. The key to the management of these
conditions is prevention. Early aggressive management of the trauma with
oxygen and fluids should minimise the time and severity of the insult. If there
has been a significant injury then there is a high risk of multiorgan failure
which is best managed on an intensive care unit. If there is an open wound with
muscle necrosis and this dead tissue is not excised, there is a risk of
infection including gas gangrene. Even if the dead tissue does not become
infected, there will be a release of muscle degradation products into the
bloodstream as the tissue revascularises. These products include myoglobin,
which darkens the urine to a dark-brown colour, but also clogs the glomeruli,
causing renal failure. The treatment once again is prevention. First, where
possible, tissues should not be allowed to become ischaemic. Trapped limbs
should be released as quickly as possible, and patients should be kept well
oxygenated
and well perfused. Dead muscle should be excised and wounds left open for
further inspection and excision until cleared of all dead and contaminated
tissues. The patient should be given plenty of fluids to maintain diuresis. It
is thought that rapid flow of fluids through the kidneys may reduce the build-up
of myoglobin and reduce the risk of renal failure.
Shocked
lung
This
condition develops in patients who have been involved in major trauma. Over the
days after the trauma the patient’s oxygenation deteriorates despite adequate
ventilation and perfusion. The lungs become stiffer and more difficult to
ventilate, and chest X-ray shows diffuse clouding. The condition appears to be
more likely to occur if the patient is
Psychiatric
disorders
Patients
who survive a suicide attempt may remain deeply psychiatrically disturbed. As
soon as they are conscious a psychiatric opinion needs to be sought. If when they
start to be mobile they continue to want to take their lives special measures
may need to be taken, especially if the orthopaedic wards are not on the ground
floor.
Patients
who were not psychiatrically disturbed at the time of the accident may become
depressed afterwards. This is especially true if the patient lost a close
relative or friend in the accident, or if there are awkward questions over who
was to blame. It can also occur if treatment takes some time, or the patient is
severely scarred, requires an amputation or is left in continuous pain. The
modern limb reconstruction techniques, involving multiple plastic and
orthopaedic operations which are so time-consuming and technically demanding,
can leave a patient physically capable
but
a mental invalid. You should give careful consideration to the possibility that
early amputation with rapid return to normal life in a well-fitting prosthesis
could give a better result for a patient with a mangled limb than many months
spent reconstructing a limb which could end up useless, painful and ugly.