FRACTURE COMPLICATIONS:
(Mainly from McRae/Esser)
COMPLICATIONS OF
1) FRACTURE:
a. SITE
b. LIMB
c. VISCERA
2) PATIENT:
a. TRAUMA
b. ANAESTHETIC/SURGERY
c. IMMOBILITY
FRACTURE COMPLICATIONS
1) FRACTURE
a. SITE
i. UNION
1. NON-UNION
a. Hypertrophic: bone ends flare out, XS bone
b. Atrophic: bone ends narrow, round, osteoporotic
2. SLOW UNION
a. Does not heal within expected time
b. Mx: wait!
3. DELAYED UNION
a. If # not united by 4 months
b. Commonest cause: inadequate fixation
4. MALUNION
a. United in less than anatomical position
b. Eg: persistent angulation/rotation
c. May have cosmetic or functional effects
d. Around joints may predispose to OA
ii. BONE
1. SHORTENING
a. Usually due to malunion
b. NB: Injured limb usually grows longer than noninjured
c. Femur/tibia: usually compensated by pelvic tilt
d. Radius/ulna: May causes major disability @
wrist
2. TRAUMATIC EPIPHYSEAL ARREST
a. Leads to limb length discrepancy
b. May occur unevenly in epiphysis
i. Leads to joint angulation
3. AVASCULAR NECROSIS
a. Seen in:
i. Scaphoid
ii. Femoral head
iii. Talus
iv. Lunate – can be atraumatic or after
dislocation
b. Cx: Pain, stiffness, secondary OA
c. DISTINCT FROM NON-UNION
i. Ie in most avascular necrosis: # HAS
UNITED
d. NATURAL Hx
i. Slow revascularisation of necrotic bone
from periphery
ii. Takes 6-18 mths
iii. Secondary OA inevitable
4. MYOSITIS OSSIFICANS (Heterotopic Ossification)
i. Commonest at elbow
ii. Eg radial head or supracondylar #, due to
brachialis haematoma
iii. Also: shoulder, hip (acetabulum)
iv. Prophylaxis: indomethacin
v. Early excision = BAD = massive
recurrence
5. OSTEOMYELITIS
a. Closed # (systemic spread)
b. Open # (direct contamination)
c. ORIF
b. LIMB
1. COMPARTMENT SYNDROME
a. SEE OTHER NOTES
2. NERVE
a. ACUTE
i. NEUROPRAXIA/PALSY
1. Stretching  local ischaemia  nerve
dysfunction/rupture
2. Most injuries (neuropraxia) resolves
within 6 weeks
ii. NERVE DIVISION
1. RARE usually penetrating injury
b. DELAYED
i. TARDY ULNAR NERVE PALSY
1. Supracondylar, Monteggia
2. Can be years later
ii. MEDIAN NERVE PALSY
1. Months after Colle’s
2. Equivalent to Carpal tunnel
c. COMPLEX REGIONAL PAIN SYNDROME:
d. GROUP I: Sudeck’s atrophy/reflex symp dystrophy
i. Sensitisation of :
1. pain pathways
2. sympathetic pathways
ii. do not follow course of peripheral nerve
iii. Severe pain, sweating, vascular effects, dusky
iv. Hyperalgesia
e. Commonest after COLLE’S
i. Espec with eg median n. compression
f. Often not recognised until after POP removed
g. CAN OCCUR AFTER ANY FRACTURE
i. Often also seen in ANKLE # & even
SPRAIN!
h. GROUP II
i. Injury to major peripheral nerve
ii. Eg gunshot wound/amputation affecting
sciatic n.
iii. Syx/Signs as above
3. VASCULAR
a. ARTERIAL
i. KINKING  correct deformity
ii. RUPTURE/LACERATION
iii. SPASM – may be due to intimal damage
iv. ANEURYSM
b. REMEMBER: DOPPLER
c. FAT EMBOLISM
4. TENDON
a. DELAYED TENDON RUPTURE
b. EPL AFTER COLLE’S
5. JOINT
a. STIFFNESS
c. VISCERA
i. Chance # - duodenal rupture
ii. Pelvic # - bladder/urthethra, diaphragm, ileus
2) PATIENT
a. TRAUMA
i. LOCAL
1. BLEEDING (+/- SHOCK)
2. INFECTION
ii. SYSTEMIC
1. FAT EMBOLISM
2. RHABDO
3. ELECTROLYTE IMBALANCE
b. ANAESTHETIC/SURGERY
c. IMMOBILITY
i. Pneumonia
ii. Pressure sores
iii. UTI
iv. DVT/PE
v. Muscle wasting
vi. Skeletal decalcification
vii. Nerve palsies (eg common peroneal, ulnar)
viii. CCF
ix. Psych eg depression
NB: When writing answer – not all complications will apply to all fractures
Need to tailor it to case
Eg: Don’t write: Traumatic epiphyseal arrest in adult!
CAN DIVIDE INTO:
ACUTE FRACTURE COMPLICATIONS:
1) Trauma: pain, haemorrhage, infection, metabolic
2) Neurovascular problems
a. Arterial: kinking, rupture/laceration, aneurysm, spasm
b. Compartment syndrome
c. Neuropraxia, nerve division
3) Fat embolism
4) Visceral complications
5) Complications of treatment: morphine (n/v), plaster too tight
DELAYED FRACTURE COMPLICATIONS
1) Union: Non, Slow, Delayed, Malunion
2) Traumatic epiphyseal arrest
3) Joint Stiffness
4) Avascular necrosis
5) Complex regional pain syndrome
6) Myositis ossificans
7) Osteomyeltits
8) Delayed tendon rupture
COMPLICATIONS:
1) ANY TRAUMA
a. Bleeding
b. Infection (open wounds)
c. Metabolic eg rhabdo, electrolyte probs
2) PROLONGED IMMOBILITY
a. Pneumonia
b. Pressure sores
c. UTI
d. DVT/PE
e. Muscle wasting
f. Skeletal decalcification
g. Nerve palsies (eg common peroneal, ulnar)
h. CCF
i. Psych eg depression
3) ANAESTHESIA & SURGERY
a. Anaesthetic side effects
b. Bleeding
c. Infection
d. Failure
COMPLICATIONS SPECIFIC TO FRACTURES
1) RATE & QUALITY OF UNION
a. NON-UNION
i. Hypertrophic: bone ends flare out, XS bone
ii. Atrophic: bone ends narrow, round, osteoporotic
b. SLOW UNION
i. Does not heal within expected time
ii. Mx: wait!
c. DELAYED UNION
i. If # not united by 4 months
ii. Commonest cause: inadequate fixation
d. MALUNION
i. United in less than anatomical position
ii. Eg: persistent angulation/rotation
iii. May have cosmetic or functional effects
iv. Around joints may predispose to OA
e. SHORTENING
i. Usually due to malunion
ii. NB: Injured limb usually grows longer than non-injured
iii. Femur/tibia: usually compensated by pelvic tilt
iv. Radius/ulna: May causes major disability @ wrist
f. TRAUMATIC EPIPHYSEAL ARREST
i. Leads to limb length discrepancy
ii. May occur unevenly in epiphysis
1. Leads to joint angulation
g. JOINT STIFFNESS
i. Intra-articular adhesions: eg Haemarthrosis
ii. Mechanical restriction: joint surface #, loose bodies
1. NB Loose bodies = bad = abrade/erode joint surfaces
iii. OA
iv. Peri-articular:
1. Capsules/muscles/tendons injury
2. Persistent angulation – loss of ROM
3. Tethering of muscles/tendons: espec phalanges
4. Volkmann’s ischaemic contracture
a. Muscle blood supply interrupted
b. Distal contracture/restriction of movement
5. Splinting/plaster
2) COMPLEX REGIONAL PAIN SYNDROME:
a. GROUP I: “Sudeck’s atrophy, reflex sympathetic dystrophy”
i. Sensitisation of :
1. pain pathways
2. sympathetic pathways
ii. do not follow course of peripheral nerve
iii. Severe unremitting pain
iv. Sweating
v. Vascular effects: dusky colour
vi. Hyperalgesia
vii. Later:
1. Skin changes: smooth, shiny
3)
4)
5)
6)
2. Nails grow fast, brittle
3. Hair growth stimulated
b. Commonest after COLLE’S
i. Espec with eg median n. compression
c. Often not recognised until after POP removed
d. Clinical:
i. Hand/fingers swollen, pink warm skin
ii. Diffuse wrist tenderness
iii. Marked restriction of finger movement
e. XRay: # united, diffuse osteoporotic mottling of carpus
f. CAN OCCUR AFTER ANY FRACTURE
i. Often also seen in ANKLE # & even SPRAIN!
g. GROUP II
i. Injury to major peripheral nerve
ii. Eg gunshot wound/amputation affecting sciatic n.
iii. Syx/Signs as above
h. TREATMENT:
i. Intensive physio
ii. Most cases resolve in 4-12 months
iii. May be permanent
iv. Can try SYMPATHETIC BLOCKADE
v. Sympathetic antagonists: eg guanethidine infusion
AVASCULAR NECROSIS
a. Seen in:
i. Scaphoid
ii. Femoral head
iii. Talus
iv. Lunate – can be atraumatic or after dislocation
b. Cx: Pain, stiffness, secondary OA
c. DISTINCT FROM NON-UNION
i. Ie in most avascular necrosis: # HAS UNITED
d. NATURAL Hx
i. Slow revascularisation of necrotic bone from periphery
ii. Takes 6-18 mths
iii. Secondary OA inevitable
MYOSITIS OSSIFICANS (Heterotopic Ossification)
i. Commonest at elbow
ii. Eg radial head or supracondylar #, due to brachialis haematoma
iii. Also: shoulder, hip (acetabulum)
iv. Prophylaxis: indomethacin
v. Early excision = BAD = massive recurrence
OSTEOMYELITIS
a. Closed # (systemic spread)
b. Open # (direct contamination)
c. ORIF
NEUROVASCULAR PROBLEMS:
a. ACUTE ARTERIAL ARREST
1. KINKING  correct deformity
2. RUPTURE/LACERATION
3. SPASM – may be due to intimal damage
4. ANEURYSM
5. COMPARTMENT SYNDROME – see below
ii. REMEMBER: DOPPLER
iii. COMPARTMENT SYNDROME
1. See separate notes
b. ACUTE NEUROLOGICAL DISTURBANCE
i. Stretching  local ischaemia  nerve dysfunction
ii. Severe stretching  rupture of neural tubes
iii. Nerve division = RARE usually PENETRATING injury
iv. Most injuries (neuropraxia) resolves within 6 weeks
c. DELAYED NEUROLOGICAL DISTURBANCE
i. Tardy ulnar nerve palsy
1. Supracondylar, Monteggia
2. Can be years later
ii. Median nerve palsy
1. Months after Colle’s
2. Equivalent to Carpal tunnel
7) DELAYED TENDON RUPTURE
a. EPL after Colle’s (can’t extend thumb)
8) VISCERAL COMPLICATIONS
a. Chance # - duodenal rupture
b. Pelvic # - bladder/urthethra, diaphragm, ileus
9) FAT EMBOLISM