Complications of Fracture MCQs

Whenever perfusion to an extremity is inadequate (e.g., trauma or poor perfusion), hypoxic edema develops, producing swelling. When this occurs in a compartment, tissue pressures rise, decreasing capillary perfusion. Symptoms of compartment syndrome include extreme pain unrelieved by analgesics, paresthesias, paralysis, and pallor. Extensive rhabdomyolysis may develop as well as permanent nerve and muscle injury in the compartment. Because the problem is at the tissue level, pulses and capillary refill may still be present. Treatment includes fasciotomy to relieve the elevated pressure Reference: Barash: Clinical Anesthesia, ed 7, p 1514; Miller: Miller's Anesthesia, ed 8, p 2450.

Compartment syndrome is defined as the elevation of pressure in a closed fascial compartment causing a decrease in perfusion to the limb leading to irreversible muscle and neurovascular damage. So in compartment syndrome, by definition there must be a closed fascial compartment for the pressure to build up and rise. In a gun shot injury, there will be bullet wounds, making the fascial compartments open, and hence making compartment syndrome unlikely. Reference: J. Maheshwari's 5th Edition of Essential Orthopaedics page no. 47

The earliest sign of compartment syndrome pain on passive stretch. Compartment syndrome is defined as the elevation of pressure in a closed fascial compartment causing a decrease in perfusion to the limb leading to irreversible muscle and neurovascular damage. The clinical features of compartment syndrome are summarized as the 6 Ps of compartment syndrome, which are Pain Pallor Pulselessness Paresthesia Paralysis Pain on passive stretch (earliest and most important) Reference: J. Maheshwari's 5th Edition of Essential Orthopaedics page no. 47

The most common complication of reamed intramedullary nailing is anterior knee pain (57%). The knee pain is activity related (92%) and exacerbated by kneeling (83%). Although knee pain is the most common complication, most patients rate it as mild to moderate and only 10% are unable to return to previous employment. The incidence of the other complications is: infection 0% to 3%, nonunion 0% to 6%, and malunion 2% to 13%. Compartment syndrome is rare after nailing. Reference- https://pubmed.ncbi.nlm.nih.gov/31315794/#:~:text=Introduction%3A%20The%20treatment%20of%20choice,47.4%25%20in%20meta%2Danalyses.

Scaphoid is the most commonly fractured carpal bone. These patients present with pain & swelling over the radial aspect of the wrist following fall on out stretched hand. The most important clinical sign is tenderness in the anatomical snuff box. Oblique view of the wrist is the best radiographic view to diagnose it. Scaphoid is most commonly fractured at its waist (at the junction of anterior & mid one thirds) in adults while the commonest site for fracture in a child is the distal pole. Very important point to note is that, the common complications of scaphoid fractures- nonunion and AVN usually occur most often in proximal pole fractures. Reference: Maheshwari, Orthopaedics, 5th ed page no 95

Pain typically severe and out of proportion to the injury, represents the first and most sensitive symptom of compartment syndrome. Pain, however, is extremely nonspecific . A better sign is pain on passive stretch, which by itself can be used as an indication to do fasciotomy. Pulselessness represents a very late finding, and therefore the finding of a palpable pulse should not exclude compartment syndrome in your differential diagnosis. Reference- Maheshwari Ortho 5th edition, page number 47.

Cubitus varus deformity can be treated with lateral closing wedge osteotomy or medial opening wedge osteotomy. A named lateral closing wedge osteotomy is French osteotomy. Cubitus valgus is treated with medial closing wedge osteotomy or lateral opening wedge osteotomy Closing wedge osteotomies are preferred as it avoids complications related to bone healing such as nonunion which is seen in open wedge osteotmies. Reference: Paediatric Orthopaedics: A System of Decision-Making, Second Edition By Benjamin Joseph, P141

Fracture of the scaphoid is notorious for AVN. Scaphoid fracture can occur at 3 sites – distal pole, waist and proximal pole. All complications of scaphoid fracture, be it non union or AVN occurs maximally in proximal pole fractures, followed by waist # and distal pole. This I so because of the abnormal blood supply of the scaphoid, where the blood vessel enters distally and goes proximally, thereby making the proximal pole the least vascular part of the scaphoid. If proximal pole of scaphoid was given in the options, it would have been the answer. But from the available options, the best choice would be waist of scaphoid #. Reference- Maheshwari ortho 5th edition, page no 115