Complications of Trauma

Abstract

Early stabilization of long bone fractures significantly decreases the risk of pulmonary complications, ARDS, fat embolism, and thromboembolic disease

These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

FormalPara Take-Home Message

• Early stabilization of long bone fractures significantly decreases the risk of pulmonary complications, ARDS, fat embolism, and thromboembolic disease

• DVT prophylaxis must balance the risk of bleeding with the risk of thromboembolic disease

• No regimen of DVT prophylaxis has been shown to decrease the rate of fatal pulmonary embolism

1 Nonunions

• Arrest in the fracture healing process with no evidence of progression in bone healing over 4–6 months

• Risk factors: inadequate fracture stabilization, poor blood supply (scaphoid, distal tibia, fifth metatarsal, intercalary fragments in segmental fractures), infection, smoking, poor nutritional status, immunocompromise

• Classification

  • Hypertrophic nonunion: inadequate fracture stability with adequate blood supply, elevated type II collagen, typically heals with improved mechanical stability

  • Oligotrophic nonunion: poor reduction with fracture fragment displacement

  • Atrophic nonunion: inadequate immobilization and inadequate blood supply

  • Septic nonunion

  • Pseudarthrosis

• Presentation

  • Pain with mechanical loading

  • Failure of fracture fixation

  • Radiographs are the primary study to assess fracture healing

  • May consider CT scan if the presence of union is unclear

• Treatment

  • Identify and treat infection, if present

    • May require staged approach

  • Provide stability for hypertrophic nonunions

  • Provide biology for atrophic nonunions

    • Remove dysvascular bone

    • Autologous iliac crest bone graft (gold standard, osteogenic), BMPs (osteoinductive), osteoconductive agents

  • No strong evidence for the use of ultrasound or electromagnetic devices to stimulate bone healing

2 Heterotopic Ossification (HO)

• Ectopic bone that forms in soft tissues

  • Most commonly occurs as a sequelae of trauma or surgical dissection

  • Closed head injury significantly increases the risk of HO

• Risk factors: male, closed head injury, increased ISS, spinal cord injury, ankylosing spondylitis, DISH, Paget’s disease

• Common in hip, elbow, and shoulder fractures and any fracture with extensive muscle injury

• Presentation

  • Loss of range of motion, ankylosis, contractures

  • Chronic regional pain syndrome symptoms

  • Inflammation with warm, swollen painful joint or fever

  • Labs: elevated serum alkaline phosphatase, CRP, and CK

• Prophylaxis

  • Radiation: 700 rad 4 h preoperatively or within 72 h postoperatively

    • Inhibits the differentiation and proliferation of osteoprogenitor cells

  • NSAIDS: Indomethacin 75 mg/day ×6 weeks

  • Bisphosphonates: inhibit mineralization but not osteoid matrix formation, HO may become evident with discontinuation of bisphosphonates

• Treatment

  • Sufficiently symptomatic HO may be excised once mature

    • Timing of resection is controversial

    • May consider bone scan or stable appearance of disease on serial radiographs to determine maturity of heterotopic bone

    • Risk of recurrent HO

3 Acute Respiratory Distress Syndrome (ARDS)

• Acute lung injury leads to non-cardiogenic pulmonary edema, respiratory distress, refractory hypoxemia with poor gas exchange, and decreased lung compliance

  • Ultimately results in acute respiratory failure

• Presents with tachypnea, dyspnea, and hypoxemia

• Diagnostic work-up: CXR with bilateral diffuse fluffy infiltrates, arterial blood gas measurements

• Supportive care with high PEEP ventilation and treatment of the underlying pathology

  • Risk of pneumothorax with high PEEP ventilation

  • Steroids not proven to be effective

• Associated with late sepsis and MSOF

• High mortality of 50 % despite critical care

• Early stabilization of long bone fractures significantly decreases the risk of pulmonary complications

4 Fat Embolism

• Inflammatory response to embolized fat and marrow elements

• Incidence: 1–4 % of isolated long bone fractures, 10–15 % of polytrauma patients

• Onset: 24–48 h post-injury

• Diagnostic criteria

  • Major: hypoxemia (PaO₂ <60), CNS confusion/depression, petechial rash, pulmonary edema

  • Minor: tachycardia, pyrexia, retinol emboli, fat in urine or sputum, thrombocytopenia, decreased hematocrit

• Supportive care with high PEEP ventilation

• 10–15 % mortality rate

• Early stabilization of long bone fractures is the most important factor in prevention

5 Systemic Inflammatory Response Syndrome (SIRS)

• Generalized response to trauma with increased cytokines, complement, and hormones

• SIRS criteria

  • Heart rate >90 bpm

  • WBC <4 or >10

  • Respirations <20 breaths per minute with PaCO₂ <32 mm

  • Temperature <36 °C or >38 °C

• Associated with disseminated intravascular coagulopathy (DIC), ARDS, renal failure, shock, and multisystem organ failure

6 Thromboembolic Disease

• Virchow’s Triad: venous stasis, hypercoagulability, intimal injury

• Risk factors: history of thromboembolism, obesity, malignancy, oral contraceptives, smoking, blood disorders that create a hypercoaguable state, immobilization, paralysis, pregnancy

• Thromboplastin triggers the coagulation cascade and is released in large amounts during orthopedic procedures

• High incidence of DVT in trauma patients not receiving prophylaxis

  • Pelvis/acetabular fractures: 20 %

  • Polytrauma patients: 35 %

  • Hip fractures: 60 %

  • Spine fracture with paralysis: 100 %

• Early fracture stabilization lowers incidence

• Prophylaxis

  • Mechanical prophylaxis prevents venous stasis and increases fibrinolytic activity

  • Many options for chemical prophylaxis

  • Prophylactic treatment should be determined by balancing the risk of bleeding with risk of thromboembolic disease

  • Consider vena cava filter in high-risk patients (pelvic trauma, polytrauma, bleeding diathesis) with contraindication to chemical prophylaxis

• Diagnosis

  • Clinical suspicion: extremity pain, swelling, and Homan’s sign

  • Assess with venography, duplex ultrasonography, CT scan

• Pulmonary embolus

  • Symptoms: tachypnea 90 %, tachycardia 60 %, EGC changes 25 %, pleuritic chest pain

  • Diagnostic studies: ECG, CXR, arterial blood gas, ventilation-perfusion scan, pulmonary angiography (gold standard)

  • Risk of upper extremity DVT embolization: ~5 %

  • Risk of lower extremity DVT embolization: ~20 %

  • No regimen of DVT prophylaxis has been shown to lower the incidence of fatal PE

Bibliography

• 1. Browner BD, Jupiter JB, Levine AM, Trafton PG, Krettek C. Skeletal trauma. 4th ed. Philadelphia: Saunders; 2009. p. 177–92, pp 199–214.

• 2. Falck-Ytter Y, Francis CW, Johanson NA, Curley C, Dahl OE, Schulman S, Ortel TL, Pauker SG, Colwell CW Jr, American College of Chest Physicians. Prevention of VTE in orthopedic surgery patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2 Suppl):e278S–325.

• 3. Knudson MM, Collins JA, Goodman SB, McCrory DW. Thromboembolism following multiple trauma. J Trauma. 1992;32(1):2–11.

• 4. Miller MD, Thompson SR, Hart JA. Review of orthopaedics. Philadelphia: Elsevier; 2012. p. 20, 105–109, 698–703.

• 5. Pape HC, Lehmann U, van Griensven M, Gänsslen A, von Glinski S, Krettek C. Heterotopic ossifications in patients after severe blunt trauma with and without head trauma: incidence and patterns of distribution. J Orthop Trauma. 2001;15(4):229–37.