Complications of Fractures

Complications are considered by:

1. Time of complication — immediate, intermediate and late

2. Site of complication — general or local
3. Complications specifi c to the fracture healing.

Time of complication

Immediate complications ( i .e. occurring at the time of injury)

General

1. Shock from severe haemorrhage either:

 External
 Internal.

2. Injury to important internal organs — brain, lung, liver, etc.

Local

1. Injury to local nerves or vessels.

2. Skin loss or damage.

Intermediate complications ( i .e. occurring during the period of treatment)

General

1. Deep vein thrombosis and pulmonary embolism . The former may

occur in the immobilized leg or elsewhere. It is commoner in patients
confined to bed. There is no general agreement as to the best form of
prophylaxis. Many patients with hip fractures, for example, receive
low molecular weight heparin or aspirin.
2. Chest infection .
3. Renal calculus, acute retention and other urinary tract problems .
4. Fat embolism syndrome , usually occurring 3 – 10 days after fractures
of long bones, and particularly after major trauma. The cause is
unknown. It was originally thought to be caused by fat released into
the circulation from the fracture site, but it is now thought to be a
 metabolic phenomenon associated with a period of circulatory
insufficiency. It manifests itself as confusion and respiratory diffi culty
(often detected by a lowered arterial oxygen tension), and a petechial
rash which varies in severity. It may lead to acute respiratory distress
syndrome (ARDS). It is sometimes fatal, but its severity can be
diminished by correct fl uid replacement, early immobilization of the
fracture and intensive respiratory care.
5. Crush syndrome ’ — this is usually associated with extensive soft -
tissue damage or ischaemia of a large volume of tissues, e.g. following
occlusion of the femoral artery. Its cause is complicated; various
factors such as fl uid loss, release of toxic materials from the site of
damage, and possibly diffuse intravascular coagulation, all contribute
to an effect on the kidneys, resulting in acute tubular necrosis with
renal failure. It may be prevented by removal of the damaged tissue
before severe renal changes have occurred, e.g. by amputation of the
limb. If the renal changes become established, dialysis may be
necessary in anticipation of recovery of renal function.

Local

1. Compartment syndrome . This is commonest after tibial fractures

where swelling in the tightly bound compartments causes venous
engorgement in the compartment, further raising pressure and
subsequently causing muscle necrosis. This presents as increasing pain
some hours after the injury, and paraesthesia and pain on passive
movement of the toes. Loss of arterial pulses is a late sign. If
suspected, surgical decompression of the compartments is a mandatory
emergency (see Chapter 2 , p. 18).
2. 2Gangrene from vascular damage or external pressure.
3. Pressure sores and nerve palsies from splintage or traction.
4. Infection and wound breakdown .
5. .Loss of alignment . Failure of internal fixation (Fig. 1 ).
6. Tetanus and gas gangrene .
Figure 1. Failed Fixation of the Wrist

Late Complications

General
Post traumatic psychological disturbances.

Local

1. Delayed and non - union . Malunion, i.e. union in a bad position (see
below).
2. Late wound sepsis with skin breakdown.
3. Failure of internal fixation , e.g. breakage or cutting out of plates or nails
(Fig. 6.1 ).
4. Joint stiffness and contracture .
5. Regional pain syndrome (previously variously known as refl ex
sympathetic dystrophy, Sudek ’ s atrophy or algodystrophy) — a condition
in which the limb becomes painful, swollen and discoloured, with obvious
circulatory changes and X - rays showing diffuse, patchy porosis of the
bones. It is thought to be due to a sympathetic malfunction, but is ill -
understood. It appears to be precipitated by trauma, either external or
surgical. It is a distressing condition, but usually settles after several weeks
or months. During this period it is important that the patient understands
the condition and is encouraged to exercise the limb. There is evidence
that treatment with calcitonin and sympathetic nerve blocks may shorten
the course of the condition in some patients. Neuro modifying drugs are
frequently used, such as gabapentin.
6. Osteoarthritis resulting from joint damage or occasionally from
malaligment of the limb.

Complications of fracture healing

The decision as to whether a fracture is united or not is essentially a

clinical one: it depends on the disappearance of the original signs of the
fracture, i.e. pain, tenderness, abnormal mobility, swelling etc. Once a fracture
is stable, most of these signs diminish. There is usually some residual loss of
function after a period of immobilization, so this is not a helpful physical sign
in diagnosing union where limbs have been immobilized. X-rays are helpful in
that they may show callus (Fig. 6.2a ). This may be visible as early as 3
weeks after a shaft fracture, but when rigid internal fixation is used, callus
may be minimal. Even profuse callus may not mean that the fracture is stable,
but it is usually an indication that union is proceeding. It can be difficult to
assess whether movement is still occurring, but for lower limb fractures
significant pain on weight bearing suggests instability.

Delayed union

Absence of callus with mobility at the fracture site is an indication of

delayed union. This means delay beyond the normal time which would
normally be expected for the fracture to unite, but still with the possibility of
union if immobilization is continued. When the fracture has been rigidly fixed
with plates, it may be difficult to judge when union has occurred on clinical
and radiological grounds, and the decision to allow unprotected load - bearing
may have to be made on the basis of average union times. Occasionally, this
leads to load - bearing on a non - united fracture and in these circumstances
the fixation device will usually break or cut out of the bone.

Many fractures take longer to unite than the average times suggested, and
protection may still be needed from full load - bearing beyond these times,
even though union may apparently have occurred.

Non union
 Non union, like union, is a clinical and radiological diagnosis. It is
commoner in open fractures, infected fractures and characteristic fracture
types in which there is poor blood supply, such as the scaphoid bone. Usually
the X-ray shows an obvious gap between the bone ends (Fig.2b ). True
radiological union, characterized by trabeculae crossing the fracture site, is
often not evident until long after clinical union has occurred and remodelling
may continue for many months after that (Fig. .2c ). Non - union is commoner
with fractures through cortical bone than with fractures of cancellous bone
which are often impacted.

Figure 2. Problems of Union

A decision to treat delayed union is usually made before true non - union
occurs. It is usually apparent after 4 – 5 months that union is not occurring, but in
most cases the decision can be made long before this.

Malunion

This expression means that the fracture has united in an unsatisfactory

position from either a functional or cosmetic point of view. It should not occur if
management of the fracture has been adequate, but circumstances are not always
favourable and some patients are left with a degree of deformity or shortening of
the limb. In children, considerable compensatory remodelling can be expected and
even length defects often correct by the end of growth. In adults, much less
correction can be expected, although when the swelling and thickening associated
with the fracture have settled, the appearance may be much more satisfactory than
might at first have been expected. In some cases, a corrective osteotomy or even
bone lengthening with an external fixator may have to be considered. This is a
hazardous procedure and in most cases shortness, which is usually only a problem
in the lower limb, can be compensated for by modifications to the shoes.

Treatment of delayed or non union

The management depends on whether the non union is infected or not. An

infected non - union usually fails to heal on antibiotic treatment alone because of
the presence of dead bone, either as a separate fragment (sequestrum) or still
attached to the living bone.

Non infected fracture

Non union is sometimes classified as:

1. Hypertrophic , i.e. with much callus at the bone ends, often as a result
of excessive fracture site mobility (Fig. 2b ) or
2. Atrophic , i.e. with no obvious callus, often as a result of poor blood
supply to the fracture site (Fig. 2b ).

The hypertrophic type will often unite if the fracture is rigidly

immobilized, usually by fixation, e.g. by a plate, nail or external fixator. A
compression plate gives particularly firm fixation.

The atrophic non - union also requires firm fixation, but healing tends to
proceed more quickly if a bone graft is used to stimulate bone formation. Bone
graft (if from the patient it is an autograft) is usually taken from the iliac crest.
Bone graft serves a number of functions: induces dormant cells to produce bone
(osteo - induction), provides a scaffold over which new bone forms (osteo -
conduction) and can provide structural support for bone defects. Harvest of bone
graft from the iliac crest is often painful for the patient.

Recently, much interest has been shown in the use of synthetically derived
bone morphogenic proteins (BMP), which can be introduced into non unions to
promote union. They have been shown to be as effective as autograft in some
situations. Their use is still being evaluated and currently they are very expensive,
but it is likely that they will become more extensively used and thus cheaper in
the future.

Infected fracture

Union will rarely occur until the infection is overcome. Firm fixation of
the fracture and excision of bone which is obviously dead will often eliminate or
reduce the infection, enabling a subsequent bone graft to be carried out. If the
defect after removal of dead tissue is large, a considerable quantity of bone may
be needed to bridge the gap. Immobilization of the fracture needs to be continued
until solid union occurs. In severely infected non - unions, an external fixation
frame, devised by Ilizarov, is safer than implanting metal plates or nails (see Fig.
3 ). Securing union in such cases can take many months or even years, and in
some patients amputation may be a better option.

Figure 3. Circular frame of Illizaroy

Factors Influencing Union

1. Age. This is a favourable factor

in children, especially young
children and babies. In adults,
 age affects union very little, even into old age, unless the patient is
severely malnourished.
2. Fracture site . Here the important feature is usually the blood supply,
especially when one fragment is rendered avascular by the fracture,
e.g. scaphoid and femoral neck fractures.
3. Degree of violence. Comminuted fractures with much soft - tissue
damage can be expected to unite slowly.
4. Infection . Severe infection, with osteomyelitis, usually delays union.
5. Immobilization. Some fractures need more immobilization than others.
Fractures of the clavicle, for example, usually unite rapidly with
minimal immobilization. In the early stages following the injury,
excessively rigid fixation may delay union, but rigid fixation is often
used later as a method of treating delayed union.
6. Bone or generalized disease . Local pathology may prejudice union,
e.g. malignant disease or infection. Generalized bone disease may or
may not matter, e.g. osteoporosis does not necessarily impair healing.
Severe malnutrition, vitamin deficiency or steroid excess may interfere
with union.
7. Distraction of the bone ends is harmful and is usually avoidable.
Interposition of soft tissue may delay or prevent union. If there is
evidence that the bone ends are being held apart by soft tissues, it is
usually advisable to carry out an open reduction (but not necessarily
internal fixation).