Open Fractures: Complications and Recovery After Surgery

Q: Open Fractures: Complications and Recovery After Surgery

Hello： Based on your description, the so-called "external fixation pins (that are placed on the skin)" refer to percutaneous pins that are partially exposed through the skin. <br>Due to friction between the pins and the skin, there may often be serous fluid leakage, which can be

Open fracture

I suffered a comminuted fracture in my hand due to a car accident, and after surgery on July 13, the doctor used steel pins and plates, as well as an external pin (inserted through the skin).
About a week after the surgery, I noticed some discharge that resembled pus and returned for a follow-up.
The attending physician said it was tissue fluid from the friction between the pin and the skin and that it was nothing to worry about.
Four days later, I experienced severe pain in my hand, and during the follow-up, the attending physician did not take an X-ray and attributed the pain to excessive movement, sending me home without medication.
That night, the pain was so intense that I had to take painkillers.
I then sought a second opinion at another hospital, where the doctor questioned why I had not been given a cast or a brace.
They took an X-ray, found no significant issues, prescribed medication, changed my dressings, and advised me on what to watch for.
They also provided compression for my hand to reduce swelling and gave me a brace.
After taking the medication, my headache eased, but the next evening, the area around the pin began to show signs of pus.
I returned to the same hospital two days later, but saw a different doctor (Doctor B) on August 3.
The doctor indicated that the discharge was a common postoperative infection and mentioned that the pin could be removed.
However, I thought it was supposed to stay in for a month.
The doctor insisted it could be removed and did so without anesthesia, which was extremely painful.
Afterward, I continued to take painkillers, and the pus decreased, but I was also prescribed antibiotics.
On August 8, I noticed a bulge above my wrist.
I returned to see Doctor A, who took an X-ray and said that the ligament had not yet healed properly and was slightly bulging.
He instructed me to keep my palm facing up and apply pressure to prevent the bulge and promote healing.
However, I am confused because the steel pin inside should prevent excessive movement, and I also have a titanium plate above the ligament.
Shouldn't that restrict rotation? Why did Doctor A advise me to rotate my hand? Could it be that Doctor B removed the pin too early, leading to these issues?

JYURI, 20~29 year old female. Ask Date: 2018/08/09

Dr. Li Wenhong reply Orthopedics

Hello: Based on your description, the so-called "external fixation pins (that are placed on the skin)" refer to percutaneous pins that are partially exposed through the skin.
Due to friction between the pins and the skin, there may often be serous fluid leakage, which can be managed by changing the dressing.
If the physician suspects an infection, they may prescribe oral antibiotics.
The decision to prescribe medication and whether to use a cast is determined by the attending physician based on the clinical situation.
Typically, exposed pins are removed after about 4 to 8 weeks, and this procedure usually does not require anesthesia.
If the pins become loose and cannot maintain fixation, or if there is a suspicion of deep infection, they may be removed earlier; these decisions are also made by the physician based on clinical circumstances.
Please follow up with your attending physician for further treatment.
Changhua Hospital, Orthopedics, Dr.
Li Wen-Hong.

Reply Date: 2018/08/09

More Info

Open fractures, particularly those that are comminuted (or "粉碎性骨折"), present unique challenges in both treatment and recovery. Your situation, involving the use of internal fixation devices such as steel plates and screws, as well as external fixation, is a common approach to stabilize the fracture and promote healing. However, complications can arise, as you've experienced.

Understanding Open Fractures and Their Complications
An open fracture occurs when the bone breaks and pierces through the skin, exposing the fracture site to the external environment. This increases the risk of infection, which can complicate recovery. In your case, the presence of pus-like discharge and subsequent infection is a common concern following surgery. The friction between the hardware (like screws and plates) and the surrounding tissue can lead to irritation and inflammation, which may manifest as pain and swelling.

Infections following surgery can be classified as superficial or deep. Superficial infections may involve the skin and subcutaneous tissue, while deep infections can affect the bone itself, leading to more severe complications. The fact that your initial doctor did not provide a cast or protective brace may have contributed to the discomfort and swelling you experienced, as immobilization is often crucial in the early stages of recovery to allow for proper healing.

Recovery Timeline and Rehabilitation
The recovery timeline for open fractures, especially comminuted ones, can vary significantly based on several factors, including the severity of the fracture, the quality of surgical intervention, and the patient's overall health. Generally, bone healing can take anywhere from three to nine months, depending on the complexity of the fracture and the patient's adherence to rehabilitation protocols.

After surgery, it is essential to follow a structured rehabilitation program. This typically includes:
1. Initial Rest and Protection: After surgery, the affected area should be immobilized to allow for initial healing. This may involve the use of a cast or brace.

2. Gradual Mobilization: Once the initial healing has occurred, physical therapy can begin. This often starts with gentle range-of-motion exercises to prevent stiffness and promote circulation.

3. Strengthening Exercises: As healing progresses, more intensive strengthening exercises can be introduced to restore function and mobility.

4. Monitoring for Complications: Regular follow-ups with your orthopedic surgeon are crucial to monitor the healing process through X-rays and clinical evaluations.

Concerns About Hardware Removal and Mobility
Regarding your concerns about the timing of the hardware removal, it is essential to understand that the decision to remove screws or plates is often based on the surgeon's assessment of the healing process. If the bone is not healing adequately or if there is significant irritation from the hardware, removal may be warranted. However, premature removal can lead to instability, which may hinder recovery.

Your doctor’s recommendation to perform certain movements, even with hardware in place, is likely aimed at promoting circulation and preventing stiffness. However, it is crucial to follow your doctor's specific instructions, as they will tailor their advice based on your unique situation.

Conclusion
In summary, open fractures, especially those that are comminuted, require careful management to prevent complications such as infection and delayed healing. Your experience underscores the importance of clear communication with your healthcare providers and adherence to rehabilitation protocols. If you have concerns about your recovery or the decisions made regarding your treatment, it is advisable to seek a second opinion or discuss these issues directly with your orthopedic surgeon. They can provide clarity on your specific case and help you navigate the recovery process effectively.

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