Complications of fractures
Local complications is divided into early and late. Early complications may presents as part
of primary injury or may appear after a few days or weeks.
*Early complications
1-Visceral injury
Fractures around the trunk are often complicated by injuries to underlying viscera , the
most important being penetration of the lung following rib fractures and rupture of the
bladder or urethra in pelvic fractures.
2-Vascular injury
The fractures most often associated with damage to a major artery are those around the
knee and elbow, and those of the humeral and femoral shafts. The artery may be cut, torn,
compressed or contused, either by initial injury or by later on by jagged bone fragments .The
effects vary from transient decrease of blood flow to profound ischemia, tissue death and
peripheral gangrene.
The patient may complain of paraesthesia in the fingers or in the toes. The injured limb is
cold and pale, or slightly cyanosed, and the pulse is weak or absent. If vascular injury is
suspected an angiogram should be performed immediately, if it is positive, emergency
treatment must be started immediately. All bandages and splints should be removed. The
fracture is re-x-rayed and ,if the position of the bone suggests that the artery is compressed
prompt reduction is done. If there is no improvement in the circulation over the next half
hour, the vessel must be explored by operation. If vessel repair is undertaken, stable fixation
is a must and the fracture should be fixed internally if possible.
3-Nerve injury
Nerve injury is particularly common with fractures of the humerus or injuries around the
elbow or the knee .In closed injuries the nerve is seldom severed, and spontaneous recovery
should be awaited , it occurs in 90% within 4 months. If recovery has not occurred by the
expected time, and if nerve conduction studies and EMG fail to show evidence of recovery ,
the nerve should be explored.
With open fractures the nerve injury is more likely to be complete, so exploration and nerve
repairing must be done.
4-Compartment syndrome
Fractures of the arm or leg can give rise to severe ischemia, even if there is no damage to
major vessel. Bleeding , edema or inflammation may increase the pressure within one of the
osseofascial compartments, there is reduced capillary flow, which results in muscle
ischemia, further edema, still greater pressure and yet more profound ischemia- a vicious
circle that ends, a er 12 hours or less, in necrosis of the nerve and muscle within the
compartment. Nerve is capable of regeneration but muscle , once infracted, can never
recover and is replaced by inelastic fibrous tissue(Volkmann ischemic contracture).
High-risk injuries are fractures of the elbow , forearm bones , proximal third of the tibia, and
also multiple fractures of the hand or foot, crush injuries and circumferential burns. The
classic features of ischemia are:
a-pain
b-paraesthesia
c-pallor
d-paralysis
e-pulselessness
However in compartment syndrome the ischemia occurs at the capillary level , so pulses
may still be felt and the skin may not pale .The earliest features are pain , altered sensation
and paresis.
Ischemic muscle is highly sensitive to stretch. If the limb is unduly painful, swollen or tense ,
the muscles should be tested by stretching them. When the toes or fingers are passively
hyper extended, there is increased pain in the calf or forearm. Confirmation of the diagnosis
can be made by measuring the intracompartmental pressure.
The threatened compartment must be promptly decompressed. Casts, bandages, and
dressings must be completely removed and the limb should be nursed flat. A differential
pressure should be carefully monitored ; if it falls below 30 mmHg , immediate open
fasciotomy is performed.
5-Haemarthrosis
Fractures involving a joint may cause acute hemarthrosis .The joint is swollen and tense and
the patient resists any attempt at moving it. The blood should be aspirated before dealing
with the fracture.
6-Infection
Open fractures may become infected ; closed fractures hardly ever do unless they are
opened by operation .Post-traumatic wound infection is now the commonest cause of
chronic osteitis.
7-Gas gangrene
This is produced by clostridial infection(especially Clostridium welchii
perfringens
).These are
anaerobic organisms that can survive only in tissues with low oxygen tension ; so a dirty
wound with a dead muscle that have been closed without adequate debridement is the
favorite site.
Clinical features appear within 24 hours of the injury ; the patient complain from intense
pain and swelling around the wound and a brownish discharge may be seen ; gas formation
is usually not very marked .there is little or no fever but the pulse rate is increased and a
characteristic smell become evident. Rapidly the patient becomes toxemic and may lapse
into coma and death. It is important to distinguish this condition from anaerobic cellulitis, in
which gas formation is abundant but toxemia is slight.
The key to life –saving treatment is early diagnosis .General measures , such as fluid
replacement and intravenous antibiotics, are started immediately .Hyperbaric oxygen has
been used as a means of limiting the spread of gangrene. The mainstay of treatment is
prompt decompression of the wound and removal of all dead tissue. In advanced cases ,
amputation may be essential.
7-Fracture blisters
Two distinct blister types are seen after fractures: clear fluid –filled vesicles and blood –
stained ones. There is no advantage to puncturing the blisters.
8-Plaster and pressure sores
Plaster sores occur where skin press directly onto bone .They should be prevented by
padding the bony points and molding the plaster around the bony points. If plaster sores
occurs ; there will be localized burning pain. A window must be cut in the plaster.
Even traction on a Thomas splint requires skills in nursing care; careless selection of the ring
size , excessive fixed traction, and neglect can lead to pressure sores around the groin and
iliac crest.
Late complications
1-Delayed union
If the time which is taken for a fracture to unite and consolidate is unduly prolonged, the
term delayed union is used.
Factors causing delayed union are:
*Biological
a-Inadequate blood supply, a badly displaced fracture of a long bone will cause tearing of
both the periosteum and interruption of intramedullary blood supply.
b-Severe soft tissue damage will decrease effectiveness of muscle splintage, damage local
blood supply and diminish the osteogenic input from mesenchymal stem cells within the
muscle.
c-Periosteal stripping during internal fixation.
*Biochemical
a-Imperfect splintage , excessive traction or excessive movement at fracture site will delay
ossification in the callus.
b-Over rigid fixation , because the fixation device holds the fragments so securely that the
fracture seems to be uniting .
c-Infection, both biology and stability are hampered by active infection.
*Patient related
On x-ray, the fracture line remains visible and there is very little or incomplete callus
formation or Periosteal reaction. However, the bone ends are not sclerosed or atrophic.
The treatment either conservative or operative ; in conservative treatment two principles
are important 1-to eliminate any possible cause of delayed union and 2-to promote healing
by providing the most appropriate environment.
In operative treatment , each case should be treated on its merits ; however, if union is
delayed for more than 6 months and there is no sign of callus forma on , internal fixa on
and bone grafting are indicated.
2-Non-union
In a minority of cases delayed union gradually turns into non-union- that is becomes
apparent that the fracture will never unite without intervention. Movement can be elicited
at fracture site and pain diminished; the fracture gap becomes a type of pseudoarthrosis.
In x-ray, the fracture is clearly visible but the bone on either side of it may show either
exuberant callus or atrophy.
The causes of non- union are:
a-Contact-was there sufficient contact between the fragments?
b-Alignment-was the fracture adequately aligned, to reduce the shear?
c-Stability-was the fracture held with sufficient stability?
d-Stimulation-was the fracture sufficiently stimulated?
There are , of course , also biological and patient-related reasons that may lead to non-
union: a-poor soft tissue b-local infection c-associated drug abuse ,anti-inflammatory or
cytotoxic immunosuppressant medications and d- non-compliance on the part of the
patient.
Non-union is occasionally symptomless, needing no treatment or , at most , a removable
splint. Even if symptoms are present, operation is not the only answer; with hypertrophic
non-union, functional bracing may be sufficient to induce union.
Sometimes operative treatment is necessary, with hypertrophic non-union and in the
absence of deformity , very rigid fixation alone may lead to union. With atrophic non-union ,
fixation alone is not enough. Fibrous tissue in the fracture gap , as well as the hard , sclerotic
bone ends is excised and bone grafts are packed around the fracture.
3-Malunion
When the fracture fragments joins in an unsatisfactory position , the fracture is said to be
malunited. Causes are failure to reduce a fracture adequately , failure to ho0ld reduc on
while healing proceeds, or gradual collapse of comminuted or osteoporotic bone.
The deformity is usually obvious , but sometimes the extent of malunion is apparent only on
x-ray. Rotational deformity of the femur ,tibia, humerus or forearm may be missed unless
the limb is compared with its opposite fellow.
X-rays are essential to check the position of the fracture while it is uniting. This is particularly
important during the first 3 weeks.
In adults, fractures should be reduced as near to the anatomical position as possible
.Angula on of more than 10-15 degrees in a long bone or a noticeable rotational deformity
may need correction by re-manipulation, or by osteotomy and fixation.
In children, angular deformities near the bone ends will usually remodel with time ;
rotational deformities will not.
In the lower limb, shortening of more than 2 cm is seldom acceptable to the pa ent and a
limb length equalizing procedure may be indicated.+
4-Avascular necrosis
Certain regions are prone to develop ischemia and bone necrosis after injury .They are:
a-head of femur.
b-the proximal part of the scaphoid.
c-the ulna.
d- the body of the talus.
The clinical and radiological effects are not seen until weeks or even months later.
There are no symptoms associated with avascular necrosis , but if the fracture fails to unite
or if the bone collapses the patient may complains from pain. X-ray shows the characteristic
increase in density.
5-Growth disturbance
In children, damage to the physis may lead to abnormal or arrested growth. A transverse
fracture through the growth plate is not always disastrous; the fracture runs through the
hypertrophic and calcified layers and not through the germinal layer , there may not be any
disturbance of growth. However fractures that split the epiphysis inevitably traverse the
growing portion of the physis and so further growth may be asymmetrical and if the entire
physis is damaged , there may complete cessation of growth.
6-Bed sores
Bed sores occurs in elderly or paralyzed patients. The skin over the sacrum and heels is
especially vulnerable. Careful nursing and early activity can usually prevent bed sores ; once
they have developed, treatment is difficult –it may be necessary to excise the necrotic tissue
and apply skin grafts.
7-Myositis ossificans
Heterotopic ossification in the muscles sometimes occur after injury , particularly dislocation
of the elbow or a blow to the brachialis, deltoid or quadriceps. It is thought to be due to
muscle damage , but it also occurs without a local injury in unconscious or paraplegic
patients.
8-Tendon lesion
Tendinitis may affect the tibialis posterior tendon following medial malleolar fractures. It
should be prevented by accurate reduction. Rupture of the extensor pollices longus tendon
may occur 6-12 weeks a er fracture of lower radius. It is treated by transferring the
extensor indicis tendon to the distal stump of the ruptured thumb tendon.
9-Nerve compression
Nerve compression may damage the lateral popliteal nerve if an elderly or emaciated
patient lies with the leg in full external rotation. Radial palsy may follow the faulty use of
crutches .Both conditions are due to lack of supervision.
Bone or joint deformity may result in local nerve entrapment with typical features such as
numbness, loss of power and muscle wasting in the distribution of the affected nerve.
Common sites are: a-the ulnar nerve – following malunited lateral condylar fracture or
supracondylar fracture b- the median nerve –due to injuries around the wrist c- posterior
tibial nerve following fractures around ankle.
10- Muscle contracture
Following arterial injury or compartment syndrome , the patient may develop ischemic
contracture of the affected muscles (Volkmann ischemic contracture).Nerve injured by
ischemia sometimes recover , at least partially ; thus the patient presented with deformity
and stiffness, but numbness is inconstant .The sites most commonly affected are the
forearm and the hand, leg and foot .
In a severe case affecting the forearm , there will be wasting of the forearm and hand , and
clawing of the fingers. If the wrist is passively flexed , the patient can extend the fingers ,
showing that the deformity is largely due to contracture of the forearm muscles.
Detachment of the flexors at their origin and along the interosseous membrane in the
forearm may improve the deformity , but function is no better if sensation and active
movement are not restored. A pedicle nerve graft and tendon transfers are sometimes
necessary.
11-Joint instability
Following injury a joint may give way and may also lead to recurrent dislocation. Causes
include the following: a-ligamentous laxity b-muscle weakness c-bone loss
12-Joint stiffness
Joint stiffness after a fracture commonly occurs in the knee, elbow, shoulder, and small
joint of the hand. Sometimes the joint itself has been injured; a hemoarthrosis forms and
lead to synovial adhesions .More often the stiffness is due to edema and fibrosis of the
capsule , ligaments and muscles around the joint , or adhesion of the soft tissue to each
other or to the underlying bone.
The best treatment is prevention-by exercises that keep the joints mobile from the outset.
If a joint has to be splinted, make sure that it is held in the position of safety. Joints that are
already stiff take time to mobilize, but prolonged and patient physiotherapy can work
wonders. Sometimes adhesions need to be released by arthroscopy or operation.
13-Complex regional pain syndrome (Algodystrophy)
It is characterized by painful osteoporosis of the hand .The same condition sometimes
occurs after fractures of the extremities and for many years it was called Sudeck atrophy. It
is now recognized that this advanced atrophic disorder is the late stage of a post traumatic
reflex sympathetic dystrophy, which may follow relatively trivial injury.
The patient complains of continuous pain, local swelling , redness and warmth, tenderness
and moderate stiffness of the nearby joints. Later on skin become pale and atrophic and
fixed deformities may occur. X-rays characteristically show patchy rarefaction of the bone.
Elevation and exercises are essential also anti –inflammatory drugs and adequate analgesia
are helpful.
14-Osteoarthritis
A fracture involving a joint may severely damage the articular cartilage and give rise to
post-traumatic osteoarthritis within a period of months. Even if the cartilage heals ,
irregularity of the joint surface may cause localized stress and so predispose to secondary
osteoarthritis years later. If the step-off in the articular surface involves a large fragment in a
joint that is readily accessible to surgery , intra-articular osteotomies and re-positioning of
the fragments may help. Often though the problem arises from areas that were previously
comminuted and depressed- little can be done once the fracture has united.