Compound fractures are not just a type of fracture, but have a completely different entity, when it comes to managing their symptoms and complications. Not only are they prone to develop several complications, but they have some peculiar symptoms, which if noted, herald the onset of a multitude of interventions by several specialist surgeons. Treatment measures have to be tailored according to the type of compound fracture and the patients general condition to tolerate them. An unsuitable match between these variables can even lead to outcomes more disastrous than the initial injury.
Compound Fracture Symptoms
Symptoms of compound fractures are mainly due to the open wound and the broken bones within the wound.
Certain warning signs and symptoms are to be kept in mind when dealing with compound fractures. These specific symptoms herald the onset of life threatening complications or long term consequences and so indicate a transfer to the ER of a multi-speciality hospital at the earliest. The following list of warning signs can be used for quick reference in case of an emergency.
Stretch Pain is the earliest and most definitive sign of compartment syndrome. It necessitates immediate intervention by a multitude of specialists, including a radiologist or sonologist for accurate diagnosis, trauma care surgeon for fasciotomy (Picture 1) ( a surgery which cuts open the affected compartment of the limb and relieves the increased compartment pressure), and a vascular surgeon or plastic surgeon for an opinion regarding viability of the limb.
Picture 1: Fasciotomy for Compartment Syndrome
(Source: Wikimedia Commons)
Compartment syndrome causes the muscles of the affected limb to contract and become tender, which causes fingers or toes to curl or bend and forcible straightening causes severe pain. This is a common occurrence in neglected compound fractures of the forearm or leg, irrespective of the size of the wound. Compartment syndrome is a limb threatening emergency and its consequences are life long in the form of fibrosis of muscles or in the worst senario, amputation of the limb.
Pale Pulseless extremity after a compound fracture is a sign of arterial injury. This deprives the part of the limb beyond the injured blood vessel to be unable to maintain itself with loss of viability(death of the tissues) within 2-3 hours. Hence, immediate intervention by a radiologist or sonologist for confirming the diagnosis, and repair of the injured vessel by a vascular surgeon, followed by temporary stabilization of the fracture by an orthopedic surgeon becomes necessary. If not this can lead to permanent loss of muscle fibers and fibrosis of the affected muscles.
Foul Odor resembling rotten fish or an extremely offensive odor from the wound, should arouse the suspicion of gas gangrene, which is a life threatening infection due to contamination of the wound by bacteria from soil at the time of the accident. This infection is mainly caused by clostridium perfringens species of bacteria and the toxins produced by this bacteria can cause rapid deterioration of the patients condition. The only way to control an established infective focus is by amputation of the infected limb. Hence, preventive measures in the form of injection AGGS (anti gas gangrene serum) have to be excised primarily during the initial management of compound fractures along with anti tetanus injection.
Apart from these warning signs, there are some routine symptoms of compound fractures, like
- Pain, which is apparently more due to the added anxiety of the visual shock from seeing the blood loss and wounds.
- Bleeding from the wound causing soaked dressing and bedsheets is a common occurrence and should not lead to panic. It is mainly fluids from the exposed and injured muscles which makes up most of the oozing and which mixes up with blood to give a wrong impression of the amount of blood loss.
Compound Fracture Treatment
The initial assessment of compound fractures, includes a variable amount of investigations, depending on the location and severity of the injury. Minor puncture wounds with fractures along the extremity can be treated after just a simple x-ray, whereas, large open wounds may require assessment of blood loss, and ruling out the possibility of bone loss, contamination, circulatory shock and so on. Needless to say this takes a lot of time, which may make one may feel that the patient is being dodged from several doctors without any definitive management of the injury. However, the opinion of several doctors from various fields of specialization is essential for giving accurate treatment. Hence, it is important that one remains calm during this process and also comforts the patient to help them understand and tolerate it better.
After the primary investigations, when the complications have been ruled out and a provisional diagnosis is established, the treatment plan is initiated depending on the requirement of the patient. A through washing of the wound with normal saline and antiseptic (povidone iodine) solution, is the first step to clean the contaminated wound and reduce the number of infecting organisms. The wound cannot be repaired immediately, due to chances of development of gas gangrene. Thus, one has to allow the wound to heal normally before permanent fixation of the fractured bones. But the absence of skeletal support to the wound causes a delay in wound healing. Hence, a temporary fixation of the fractured bones by an external fixator device in undertaken on an emergency basis. There are three types of external fixators, uni-planar, bi-planer, and ring fixator (Illizarov’s technique), which are chosen depending on the injury. The advantages of each of these are as follows,
Uni-planar external fixation is generally used when there is a significant wound, but the edges of broken bones are stable.
Bi-planar external fixation is reserved for unstable fractures with a significant wound.
Ring fixation with Illizarov’s technique is used for compound fractures with bone loss or extreme instability, where apart from wound healing, there is also the need for bone lengthening.
The external fixation is maintained until the open wound heals and is removed at the time of permanent fixation surgery. However, if the wound takes more than 6 weeks to heal completely then the patient may not require permanent fixation. Temporary fixation of bones prevents injury to important soft tissues, like blood vessels and nerves, and even facilitates their repair if the need be. Temporary fixation is a minor orthopedic surgery and can be accomplished under local anesthesia, if the patient is unfit for other types of anesthesia.
Compound Fracture Complications
Several immediate complications of compound fractures have been mentioned in detail above along with their management. Hence, in this section we will discuss the delayed complications of compound fractures.
Chronic osteomyelitis is a severe bone infection, which invades and remains in the bone tissue for months to years after a compound fracture. This infection usually causes pus to exude out of the bone cavity continuously, from a wound that does not heal even after months of daily dressing. Oral antibiotics are ineffective for this type of long term infection due to micro-organisms taking shelter in the tough bone tissue. Hence, the infected bone tissue has to be completely removed and the cavity is filled with a bone graft to stimulate bone healing.
Non healing fracture is a fractured bone, which does not heal even after 9 months of conservative or surgical treatment. This is more likely in the case of an infected wound or bone loss from the compound fracture. Repeat trauma at the same site during the healing phase of the fracture can also lead to a non healing fracture. Treatment of this condition consists of electrical stimulation, removal of infection, and bone grafting with fixation of the broken ends with a metal plate, to provide a scaffolding until the fracture heals.
Delayed wound healing is a frequent concern for compound fractures as it delays the permanent fixation of the bony injury. Regular wound culture and antibiotic sensitivity tests to ensure the use of correct antibiotics, helps to counter infective organisms. Wound healing in an otherwise healthy wound can be expedited by performing a skin graft surgery. The use of an appropriate topical antibiotic and preparations containing nascent oxygen are also known for faster wound healing.