Complications of fracture

Presented by :- Dr. Momin Mohammad Farhan

Moderator :- Dr. Girish Keri
Classification of complications of
fracture
Complications of fractures

Immediate complications Early complications Late complications

1.Hypo 1.Avasc
volaemi ular
c shock necrosi
1. 2.ARD s
Imperfect 2.Short
Injury S
Systemic Local Systemic Local union of Others
ening
to 3.Fat
fracture 3.Joint
major embolis
vessels. m stiffnes
2.Injury 4.DVT 1.Delay 4.sudec
1.Infect k’s
to and ed
ion dystrop
1.Hypo muscles pulmon union
2.Comp hy
volaemi and ary 2.Malu
artment 5.Ischa
c shock tendons embolis nion
syndro emic
. m 3.Non-
me contract
3.Injury 5.Asept union
to ic ure
joints. traumat 6.Myos
4.Injury ic fever itis
to 6.Septic ossifica
viscera aemia ns
 Immediate complications
Systemic
Hypovolaemic shock :-
• This type of shock is due to blood loss due to vascular
injury. The vessels may be injured by the fracture pieces or
in open fractures
• The cause of hypovolaemia could be external or internal
haemorrhage
• External haemorrhage may result from a compound fracture
with or without an associated injury to a major vessels.
• Internal haemorrhage is more difficult to diagnosed, it is
usually massive bleeding in the body cavities such as lungs
and abdomen.
 Immediate complications
Systemic
Hypovolaemic shock :-
• There will be reduction in the circulating volume causing
reduction in venous return and cardiac output.
• The patient usually; severely pallor, shivering, rigor,
hypotensive and sometimes comatose.
• Hypovolaemic shock is the commonest cause of death
following fractures of major bones such as the pelvis and
femur.
• Blood loss in fractures of the major bones like the pelvis
(1500-2000 ml), and femur ( 1000- 1500ml).
• Treatment is by control of hemorrhage (may require
surgery), restoration of circulating blood volume.
 Immediate complications
Local :-
 Injury to major blood vessels:-

• Blood vessels lie in close proximity to bones, and hence are

liable to injury with different fractures and dislocation
• The vessels may be damaged by the object causing the
fracture or by a sharp edge of a bone fragment.
• Obstruction to blood flow will not always lead to gangrene.
If collateral circulation of the limb around the site of
vascular injury is good, there will be no adverse effect of
the vascular injury.
 Immediate complications
Local :-
 Injury to major blood vessels:-
• If collaterals do not provide adequate blood supply to the
muscle, this results in ischaemic muscle necrosis, followed
by contracture and fibrosis of necrotic muscle leading to
deformities ( eg. Volkmans ischaemic contracture).
• If blood supply is grossly insufficient, gangrene occurs.
• The pulses distal to the injury should be examined in every
cases of fractures and dislocations.
• Features which suggest a possible vasscular injury of a limb
are
1) Signs at fracture site
 Rapidly increasing swelling
 Massive external bleeding
 A wound in the normal anatomical path of the vessel
 Immediate complications
 Local :-
 Injury to major blood vessels:-
1) Signs in the limb distal to the fracture
 Pain- cramp like
 Pulse- absent
 Pallor
 Paraesthesias
 paralysis
• Some commonly injured vessels in skeletal trauma are
NO
VESSELS INJURED SKELETAL TRAUMA

1 FEMORAL ARTERY # LOWER THIRD OF FEMUR

2 POPLITEAL ARTERY SUPRACONDYLAR # OF THE FEMUR
3 POSTERIOR TIBIAL # TIBIA, DISLOCATION OF THE KNEE
ARTERY
4 SUBCLAVIAN ARTERY # OF THE CLAVICLE
5 AXILLARY ARTERY # -DISLOCATION OF SHOULDER JOINT

6 BRACHIAL ARTERY SUPRACONDYLAR # OF THE

HUMERUS
 Immediate complications
Local :-
 Injury to nerves:-
• Nerves lies in close proximity to bones and hence are
liable to damage in different fractures and dislocation
• A nerve may be damaged in one of the following way
• By the agent causing fracture
• By direct pressure by fracture ends
• Traction injury at the time of fracture, when fracture is being
manipulated or during skeletal traction.
• Entrapment in callus at the fracture site.
 Immediate complications
Local :-
 Injury to nerves:-
• Damage to the nerve may be neurapraxia, axonotmesis and
neurotmesis.
• Neurapraxia - physiological disruption of conduction in nerve fibre,
- spontaneous and complete recovery in few weeks
 Axonotmesis - Axons & myelin sheath damaged but nerve is preserved
- partial spontaneous recovery in months.
 Neurotmesis - cutting/ scarring of the nerve
- no spontaneous recovery, requiring nerve repair.
 Immediate complications
Local :-
 Injury to nerves:-
• Treatment depend upon the type of fracture, whether
it is closed or open.
• If the nerve injury is associated with closed fractures,
the type of damage is generally neurapraxia or
axonotmesis and nerve recovery is good with
conservative treatment.
• If the nerve injury is associated with open fractures,
the type of damage is often neurotmesis , and the
nerve should be explored and repaired.
 Immediate complications
Local :-
 Injury to nerves:-
• Some commonly injured narves in skeletal trauma are
No Nerve Trauma Effect
1. Axillary nerve Dislocation of the shoulder Deltoid paralysis
2. Radial nerve # shaft of the humerus Wrist drop
3. Median nerve Supracondylar # of humerus Pointing index
4. Ulnar nerve # medial epicondyle of humerus Claw hand
5. Sciatic nerve Posterior dislocation of hip Foot drop due to
weakness of
dorsiflexors of the
foot
6. Common peroneal Knee dislocation, # of neck of the Foot drop
nerve fibula
 Immediate complications
Local :-
 Injury to muscles and tendons:-
• Some degree of damage to muscle and tendons occurs with
most fractures, it may result from the object causing the
fracture or from the sharp edges of the fractured bone.
• For partial rupture, rest to the injured muscle and analgesic is
enough and complete rupture requires repair.
Injury to joints:-
• Fractures near a joint may be associated with
subluxation or dislocation of that joint.
 Immediate complications
Local :-
Injury to viscera:-
• Visceral injuries are seen in pelvic fractures, rib fractures,
abdominal compression.
• Pelvic fractures may cause rupture to the urethra, urinary
bladder and perforation of the rectal wall.
• In abdominal compression or crushing( eg. Run-over injuries)
may cause rupture of spleen, kidney , liver and intestine.
• Paralytic ileus is occasionally seen following fractures of the
pelvic and lumbar spine, due to disturbance of the autonomic
control of the bowel from retroperitoneal haematoma.
 Early complications
 Systemic :-
 Fat embolism:-
• This is one of the most serious complications, it is thought to be due to
escaping of the microglobules of the marrow fat into the circulation from
the region of the fracture and lodging primarily in the lung parenchyma.
• It occurs most frequently after fractures of femoral shaft and pelvis.
• The major features are:-
1. Respiratory insufficiency- increased frequency of respiration (RR>
35), dyspnoea, and use of accessory muscles of respiration.
2. Cerebral involvement- the patient become confuse, dissoriented,
drowsy, aggressive or comatose.
3. The occurrence of the petechial haemorrhages in the skin. Theses
appear most frequently in the axilla, anterior chest wall and the
conjuntiva.
◦ The minor features are pyrexia, tachycardia, jaundice, retinal changes
and renal insufficiency.
 Early complications
Systemic :-
 ARDS:-
• ARDScan be a sequele of trauma with subsequent
shock.
• It is supposed to be due to release of inflammatory
mediators which causes disruption of microvasculature
of the pulmonary system.
• The onset is usually after 24 hours after injury.
• The patient develops tachypnoea, and laboured
breathing.
• X-ray chest shows diffuse pulmonary infiltrates.
• Management consist of 100 percent oxygen and
assisted ventilation
 Early complications
Systemic :-
 DVT and Pulmonary emboli:-
• DVT is a common complication associated with
lower limb injuries and with spinal injuries.
• Immobilisation following trauma leads to venous
stasis which results in thrombosis of veins.
• DVT proximal to knee is a common cause of life
threatening complication of pulmonary embolism.
 Early complications
Systemic :-
 DVT and Pulmonary emboli:-
• The group of the patient at risk include the elderly
and obese patients.
• Leg swelling and calf tenderness are usual signs.
• The calf tenderness may get exaggerated by passive
dorsiflexion of the ankle ( Homan’s sign ).
• Treatment of DVT is elevaion of limb, elastic
bandage and anticoagulant therapy. For pulmonary
embolism respiratory support and heparin therapy is
to be done.
 Early complications
 Systemic :-
 Crush syndrome:-
• This syndrome results from massive crushing of the
muscles, commonly associated with crush injuries
sustained during earthquake, mining, and other accidents.
• A similar effect follow the application of torniquet for an
excessive period.
• Crushing of muscles results in entry of myohaemoglobin
into circulation, which precipitate in renal tubules, leading
to acute renal tubular necrosis
• Acute tubular necrosis produces signs of deficient renal
functions such as scanty urine, apathy, restlessness and
delirium.
 Early complications
 Local :-
 Compartment syndrome:-
• The limb contains muscles in compartments enclosed
by bones, fascia and interosseous membrane.
• A rise in pressure within these compartment due to any
reason may hamper the blood supply to the muscles
and nerves within the compartment, resulting in
compartment syndrome.
• The rise in compartment pressure can be due to any of
the following reason:
• Any injury leading to oedema of muscle.
• Fracture haematoma within the compartment.
• Ischaemia to the compartment , leading to muscle edema.
 Early complications
Local :-
 Compartment syndrome:-
• The increased pressure within the compartment
compromises the circulation leading to further
muscle ischaemia. A vicious cycle is thus initiated
and continues until the total vascularity of the muscle
and nerves within the compartment is jeopardized.
• This results in ischaemic muscle necrosis and nerve
damage.
• The necrotic muscle undergo healing with fibrosis,
leading to contractures. Nerve damage may result in
motor and sensory loss.
 Early complications
Local :-
 Compartment syndrome:-
• Clinical findings are pain out of proportion to injury,
pain on passive movements of fingers or toes, diffuse
tenderness over the muscles of the compartment,
pallor, paraesthesia, loss of pulse, progressive
paralysis of the muscles of the compartment.
• Injuries with a high risk of developing compartment
syndromes are-
• Supracondylar fracture of the humerus
• Forearm bone fractures
• Closed tibial fractures
• Crush injuries to leg and forearm
 Early complications
 Local :-
 Compartment syndrome:-
• It is considered that when intracompartmental pressure
exceeds 30 mmhg then operative intervention is
indicated.
• Measurement of differential pressure ( diastolic pressure
minus intracompartmental pressure) is prefered- if it is <
30 mmhg , then fasciotomy is indicated, for fascial
compartment of hand, if it is < 15-20 mmgh.
• Early surgical deompression is necessary
• Fasciotomy – the deep fascia of the compartment is slit
longitudinally.
• Fibulectomy – the middle third of the fibula is excised in order
to decompress all compartments of the leg.
 Early complications
Local :-
 Infection ( Osteomyelitis ) :-
• Bone infection is a feared complication of open
fractures, and is also seen on occasion after the
internal fixation of closed fractures.
• The increasing use of operative methods in the
treatment of fractures is responible for the rise in the
incidence of infection of the bone, often years later.
• The sign and symptoms are , prolonged pain,
recurrent pyrexia, local tenderness and swelling.
 Late complications
Imperfect union of the fracture :-
 Delayed union :-
• When healing progresses more slowly than average,
the slow progress is referred to as delayed union
• Union is considered delayed when healing has not
advanced at the average rate for the location and type
of fracture. (usualy 3-6 months)
• May occur from causes of delayed wound healing in
general such as, infection, inadequate blood supply,
poor nutrition, movement and old age
 Late complications
Imperfect union of the fracture :-
 Non-union :-
• Failure of bone healing, or nonunion, results from an
arrest of the healing process
• It may result if there is a soft tissue interposed
between fractured end.
• In 1986, an FDA panel defined nonunion as
‘‘established when a minimum of 9 months has
elapsed since injury and the fracture shows no visible
progressive signs of healing for 3 months.’’
• But this criterion cannot be applied to every fracture.
 Late complications
Imperfect union of the fracture :-
 Non-union :-
 Two types of non-union are
recognised:
1. Hypertrophic non-union
- A large volume of callus
around the fracture site
- the fracture line is clearly
visible A‘‘Elephant foot’’ nonunion. B,
‘‘Horse hoof’’ nonunion.C,
- the gap being filled with Oligotrophic nonunion
cartilage and fibrous tissue
cell
 Late complications
Imperfect union of the fracture :-
 Non-union :-
2. Atrophic non-union
- Where little or no callus
forms and bone resorption
occurs at the fracture site
- there is no evidence of
cellular activity at level of
fracture A, Torsion wedge nonunion. B,
Comminuted nonunion. C,
- bone ends are narrow , Defect nonunion. D, Atrophic nonunion
rounded and osteoporotic,
they are frequently
avascular
 Late complications
Imperfect union of the fracture :-
 Non-union :-
• causes of delayed and non-union are
• Causes related to patient – common in old age, associated
systemic illness ( malignancies, osteomalacia)
• Causes related to fracture – distraction of the fracture site
( muscle pulling the fragment), soft tissue interposition,
bone loss at the time of fracture, infection from an open
fracture, damage to blood supply of fracture fragment,
pathological fracture.
• Causes related to treatment – inadequate reduction,
inadequate immobilisation, distraction during treatment.
 Late complications
 Imperfect union of the fracture :-
 Malunion :-
• Any fracture which has unitedin less than anatomical position.
• Where a fracture has united in a position of persistent
angulation or rotation which is of a degree that gives the limb a
displeasing appearance or affects its function.
• Improper treatment is the commonest cause of malunion.
• Malunion results in deformty , shortening of the limb and
limitation of movement.
 Cross union:-
• Special type of malunion which occurs in fractures of the
forearm bones, wherein the two bones unite with each other.
• It is likely to develop in acase where the two fractures are at the
same level.
• It results in complete limitation of forearm
 Late complications
Others :-
 Avascular necrosis :-
• Blood supply of some bone in such that the vascularity of a
part of it is seriously jeopardized following fracture, resulting
in necrosis of that part.
• AVN causes deformation of the bone. This leads to secondary
OA a few years later, thus causing painful limitation of joint
movement.
• Some common sites of avascular necrosis are-
No Site causes
1. Head of femur # neck of femur, posterior dislocation of the hip.
2. Proximal pole of # through the waist of scaphoid
scaphoid
3. Body of talus # through neck of the talus
 Late complications
Others :-
 Avascular necrosis :-
• Once the AVN has occurred , following treatment options
remain-
• Delayed wieght bearing on the necrotic bone until it is
revascularised.
• Revascularisation procedure by using vascularised bone
grafts ( eg. Vascularised bone pedicle graft from greater
trochanter in an avascular femoral head in fracture of the
neck of the femur).
• Excision of the avascular segment of bone where doing so
does not hamper functions ( eg. Fracture of the scaphoid)
• Total joint replacement or arthrodesis may be required once
the patient is disabled because of pain from OA secondary
 Late complications
 Others:-
 Shortening :-
• It is a common complication of fractures, resulting from the
following causes:
• Malunion- the fracture unite with an overlap or marked angulation
• Crushing- actual bone loss
• Growth defect – injury to the growth plate may result in shortening
• A little shortening in upper limbs goes unnoticed, hence no
treatment is required. For shortening in lower limb, treatment
depend upon the amount of shortening.
• < 2cm is not much noticeable, compensated by shoe raise
• >2cm is noticeable- in yelderly, compensated by shoe raise
- in younger, correction of angulation or overlap is
necessary
 Late complications
 Others :-
 Joint stiffness :-
• It is a common complication of fracture treatment. Shoulder,
elbow, and knee joints are particularly prone to stiffness.
• Causes:
• Intra-articular and peri-articular adhesions secondary to immobilisation,
mostly in intra-articular fractures
• Contracture of the muscles around a joint because of prolonged
immobilisation.
• Myosistis ossificans
• Treatment is by heat therapy ( hot fomentation , wax bath,
diathermy)
• Surgical intervention is required I
• Intra-articular adhessions
• To excise an extra articular bone block
• To lengthen contracted muscle
 Late complications
 Others :-
 Sudeck’s dystrophy (Reflex sympathetic dystrophy) :-
• It is a painful condition observed as a sequel of trauma.
• The trauma is sometimes relatively minor, and hence symptoms
and signs are out of proportion to the trauma.
• Clinical features include pain, hyperesthesia, tenderness and
swelling.
• Skin become red, shiny and warm in early stages.
• Progressive atrophy of the skin, muscle andnails occurs in later
stage.
• Treatment-
• Physiotherapy
• Sympathetic block or sympatholytic drugs
 Late complications
 Others :-
 Ischaemic contracture:-
• This is the sequel of injury to major blood blood
vessels. If the collaterals do not provide adequate blood
supply to the muscle.
• That results in ischaemic muscle necrosis.
• The ischaemic muscles are gradually replaced by
fibrous tissue, which contracts and draws the wrist and
fingers into flexion ( volkman’s ischaemic contracture).
 Late complications
 Others :-
 Osteoarthritis:-
• Joint movement may be restricted as a result of
secondary OA.
• This may be caused by
• Irregularity of joint surface ( eg. Displacement of a fracture
which runs into a joint,
• AVN (produced as result of damage to blood supply of an
intra-articular fragment of bone).
• Malnion of a fracture ( leads to abnormal stresses on the joint
from persistent angulation)
 Late complications
 Others :-
 Myositis ossificans:-
• This is ossification of haematoma around a joint,
resulting in the formation of a mss of bone restricting
joint movements, often completely.
• Occurs in cases with severe injury to joint, especially
when the capsule and the periosteum have been
stripped from the bone.
• It is most common in children because in them the
periosteum is loosely attached to the bones.
• The commonest site is elbow.
• Massage following trauma is a factor known to
aggravate myositis.
 Late complications
 Others :-
 Myositis ossificans:-
• The bone formation leads to stiffness of joint, either
due to thickening of the capsule or due to bone
blocking movement.
• In extreme cases, the bone bridges the joint resulting in
complete loss of movements.
• Treatment-
• Early stage- limb should be rested and NSAIDS is given.
• Late stage – physiotherapy
• Once the myositic mass matures – surgical excision of the
bone mass.
Reference :

1. Practical fracture trauma (Ronald McRae, Max Esser)

2. Rockwood and Greens Fractures in Adults ( 8th edition )
3. Essential orthopaedics ( Maheshwari & Mahaskar)
Thank you