Fracture Complications Overview

Fracture Complications

• Risk Factors:
  • Age
  • Nutritional status
  • Smoking
  • Alcohol use
  • Immobility
  • Diabetes (type 1 or 2)
  • Use of non-steroidal anti-inflammatory drugs (NSAIDs) within 12 months
  • Recent motor vehicle accident (within one month of fracture)
  • Estrogen-containing hormone therapy (may be a proxy for osteoporosis)

Types of Fracture Complications

• Early Complications:

  • Acute complications from initial trauma
  • Neurovascular and soft tissue damage
  • Blood loss
  • Localized contamination and infection

• Late Complications:

  • Delayed complications after treatment
  • Malunion (fracture doesn't heal in correct alignment)
  • Non-union (fracture doesn't heal)
  • Loss of function
  • Embolic complications
  • Osteomyelitis

• Iatrogenic Complications:

  • Complications from fracture treatment

Early Complications (Life-Threatening)

• Vascular damage: Disruption to femoral artery or its branches, damage to pelvic arteries (by pelvic fracture)
• Multiple rib fractures: Pneumothorax, flail chest, and respiratory compromise
• Hip fractures: Loss of mobility, potentially leading to pneumonia and thromboembolic disease

Systemic Life-Threatening Complications

• Shock

• Fat embolism

• Thromboembolism (pulmonary or venous)

• Exacerbation of underlying diseases (e.g., diabetes, coronary artery disease)

• Pneumonia

• Shock: Hemorrhagic, most common with pelvic or long bone fractures and polytrauma

  • Symptoms include firm, distended abdomen or extremities; extreme edema, tenderness, ecchymosis at injury site; increased heart and respiratory rates; decreased blood flow (BF); pallor; cold, clammy skin; and anxiety, agitation, or confusion

• Fat embolism: Often associated with long bone fractures; symptom onset within 24-27 hours

  • Symptoms include anxiety; feeling of impending doom; confusion; low blood oxygen (PO2 <60 mm Hg); rapid breathing rate; shortness of breath; blood-tinged sputum; chest pain; rapid heartbeat (tachycardia); and petechiae on the trunk, abdomen, sclera, or conjunctiva.

• Local Complications (Thromboembolism):

  • Vascular injury
  • Visceral injury (brain, lung, bladder)
  • Tissue, nerve, or skin damage
  • Hemarthrosis (blood in a joint)
  • Compartment syndrome
  • Wound infection
  • Fracture blisters

Compartment Syndrome

• Definition: Increased pressure within a confined myofascial space
• Pathophysiology: Leads to circulatory impairment, ischemia, and potential tissue necrosis
• Management: Ongoing pain management; surgical intervention (fasciotomy) to relieve pressure

Fracture Blisters

• Relatively uncommon complication of fractures in areas where skin adheres tightly to bone
• Examples include ankle, wrist, elbow, foot
• Risk factors include conditions that predispose to poor skin healing (e.g., diabetes, hypertension, smoking, alcohol excess, peripheral vascular disease)

Late Complications

• Local complications:

  • Delayed union (healing takes longer than normal)
  • Malunion (healing in abnormal alignment)
  • Non-union (failure to heal)
  • Joint stiffness
  • Contractures
  • Myositis ossificans
  • Avascular necrosis
  • Osteomyelitis
  • Growth disturbances or deformity

• Systemic Complications:

  • Gangrene
  • Tetanus
  • Septicemia
  • Fear of mobilization

Non-union

• No signs of healing after 3-6 months
• Failure of a fracture to consolidate within the expected time, dependent on the location and nature of the fracture
• Healing processes are still continuing, but the outcome is uncertain

Factors Predisposing to Delayed Union

• Severe soft tissue damage
• Inadequate blood supply
• Infection
• Insufficient Splinting
• Severe anemia
• Diabetes
• Low vitamin D
• Hypothyroidism
• Medications (NSAIDs, steroids)
• Complicated/compound fracture
• Osteoporosis

Presentation of Non-Union

• Persistent pain at the fracture site
• Non-use of the extremity
• Tenderness and swelling
• Joint stiffness
• Movement around the fracture site (pseudarthrosis)
• Palpable gap at the fracture site
• Absence of callus
• Radiological signs may show avascularity, or excessive bone formation on either side of the gap.

Management of Non-Union

• Non-surgical: Early weight-bearing and casting
• Non-surgical: Bone stimulation (pulsed ultrasonic or electromagnetic waves)
• Surgical:
  • Debridement
  • Bone grafting
  • Internal fixation

Iatrogenic Complications of Fracture Treatment

• Cast Application Complications:
  • Pressure ulcers
  • Thrombophlebitis
  • Thermal burns (during plaster hardening)
• Traction Application Complications:
  • Muscle wasting and weakness
  • Pressure ulcers
  • Thromboembolism
  • Pneumonia
  • Urinary tract infections
  • Permanent foot drop (peroneal nerve palsy)
  • Pin tract infection

External Fixation

• Problems:
  • Pin tract infection
  • Pin loosening or breakage
  • Interference with joint movement
  • Neurovascular damage
  • Misalignment
  • Psychological issues (altered body image, sense of disability)

Test your knowledge on the risk factors and types of complications associated with fractures. This quiz covers both early and late complications, as well as iatrogenic issues that may arise from treatment. Understand the critical aspects of managing fractures in a clinical setting.