COMPLICATIONS OF

FRACTURES
FRACTURE

• A fracture is a break in the structural continuity of bone.

-May be no more than a crack, a crumpling or a splintering of the cortex; more often the break is
complete and the bone fragments are displaced.
• Closed (simple) fracture: the overlying skin remains intact.
• Open (compound) fracture: skin or one of the body cavities is breached, liable to
contamination and infection.
• Fractures result from:
1. A single highly stressful, traumatic incident. (fractures due to sudden trauma)
2. Repetitive stress of normal degree persisting to the point of mechanical fatigue (stress
or fatigue fractures)
3. Normal stress acting on abnormally weakened bone (pathological fracture)
FRACTURES DUE TO SUDDEN TRAUMA

• Caused by sudden and excessive force, which may be direct or indirect.

• Direct force: the bone breaks at the point of impact. (e.g. fracture of ulna caused by a
blow on the arm)
• Indirect force: the bone breaks at a distance from where the force is applied. (e.g. spiral
fractures of the tibia and fibula due to torsion of the leg, vertebral compression fractures
due to sudden, severe spinal flexion, and avulsion fractures due to violent traction by a
muscle, tendon or ligament.)
STRESS OR FATIGUE FRACTURES

• Due to repetitive stress

• Most often seen in the tibia or fibula or metatarsals, especially in athletes, dancers and
army recruits who go on long route marches.
PATHOLOGICAL FRACTURES

• In mechanically abnormal bone, for example:

 Generalised bone diseases
 Local benign conditions
 Primary malignant tumours
 Metastatic tumours
COMMON TYPES OF FRACTURES

a) ‘Greenstick’ fracture
b) Displaced transverse fracture
c) Oblique fracture
d) Spiral fracture
e) Segmental fracture
f) Compression fracture
g) Avulsion fracture
CLASSIFICATION OF FRACTURES

• Complete fractures
• Incomplete fractures
• Physeal fractures
COMPLETE FRACTURES

• The bone is completely broken into two or more fragments.

• Transverse fracture: fragment usually remain in place after reduction
• Oblique/spiral fracture: fragments tend to slip and displace even if the bone is splinted.
• Impacted fracture: fragments are jammed tightly together and the fracture line is
indistinct.
• Comminuted fracture: more than two fragments. Often unstable due to poor interlocking
of the fragments
INCOMPLETE FRACTURES

• Incompletely divided, periosteum remains in continuity

• Greenstick fracture: the bone is buckled or bent (like snapping a green twig). Reduction is
easy and healing is quick
• Stress fracture: may be incomplete. With the break initially appearing in only one part of
the cortex.
• Compression fracture: occurs when cancellous bone is crumpled. It happens in adults,
especially in the vertebral bodies.
PHYSEAL FRACTURES

• Fracture through the growing physis.

• Damage to the cartilaginous growth plate may give rise to progressive deformity out of
all proportion to the apparent severity of the injury.
 FRACTURE DISPLACEMET

• After complete fracture, the fragments usually become displaced, partly by the force of
injury, partly by gravity, partly by pull of muscles attached to them.
• Displacement usually described in terms of:
a. Translation (shift) - sideways, backwards, forwards
b. Alignment (angulation)
c. Rotation (twist)
d. Length- shortening of the bone
FRACTURE HEALING

• 2 methods:
- With callus
- Without callus

* Varies according to the type of bone involved and amount of movement at the fracture
site
HEALING WITH CALLUS

• In a tubular bone and in the absence of rigid fixation.

• 5 stages:
1. Haematoma (tissue damage and bleeding at the fracture site, the bone ends die back
for a few millimetres)
2. Inflammatory reaction and cellular proliferation (inflammatory cells appear in
haematoma)
3. Callus ( the cell population changes to osteoblasts and osteoclasts, dead bone is
mopped up and woven bone appears in the fracture callux.
4. Consolidation (woven bone is replaced by lamellar bone, the fracture has united)
5. Remodelling (the newly formed bone is remodelled to resemble the normal structure)
HEALING WITHOUT CALLUS

• Callus is the response to movement at the fracture site.

• It serves to stabilize the fragments as rapid as possible- a necessary precondition for
bridging by bone.
• However, if the fracture site is ABSOLUTELY IMMOBILE (e.g. an impacted fracture in
cancellous bone or fracture rigidly immobilized by internal fixation), there is no need for
callus.
RATE OF REPAIR

• Rate of repair depend upon:

a. Type of bones involved (cancellous bone heals faster than cortical bone)
b. Type of fracture (transverse fracture takes longer than spiral fractures)
c. State of blood supply (poor circulation means slow healing)
d. Patient’s general constitution (healthy bone heals faster)
e. Patients’ age (healing is almost twice as fast in children as in adults)
CAUSES OF DELAYED UNION AND NON-UNION

• Distraction and separation of the fragments

• Interposition of soft tissues between the fragments
• Excessive movement at the fracture site
• Poor local blood supply
• Severe damage to soft tissues which makes them non-viable (or nearly so)
• Infection
• Abnormal bone
APPROACH
TO
FRACTURE
 HISTORY

• Identification data :
- Name, Age , Sex, Occupation, Address, Date of admission
• History of Presenting Illness :
- What : mechanism of injury & force involved
- When : timing of fracture
- Where : situation of injury
- Why : circumstances of fracture (if due to fall, include before/during/after
fall history)
• Always enquire about symptoms of associated injuries :
- Pain?
- Swelling?
- Deformity?
- Movement restriction?
- Any locking, giving way?
- Any weakness, numbness, paresthesia?
- Skin pallor or cyanosis?
- Blood in the urine ?
- Breathing difficulties?
- Transient loss of consciousness?
• Past Medical & Surgical History
- Ask about any previous injuries/accidents?
- Any previous surgical intervention had done?
- Any co- morbidities? ( eg: epilepsy, dementia, Parkinsonism)
- A general medical history in preparation for anaesthesia or operation
• Social History
-Occupation : will the injury likely impact employment?
-Any hobbies likely to be impacted by injury?
-Which hand is dominant?
-Smoking/ alcohol intake/ recreational use
- Adequate financial support?
-How will independent living be impacted by injury and rehabilitation?

• Drug History
- in particular, any anticoagulants, steroids (osteopenia)
- any allergies
 CLINICAL EXAMINATION

• Always examine above and below of joints

• LOOK : 1) swelling & erythema

2) deformity
3) skin changes
FEEL : 1) tenderness
2) palpable deformity
3) temperature
4) effusion

MOVE : 1) Crepitus
2) Abnormal movement
3) Ask if the patient can move the joints distal to injury

- Vascular and peripheral nerve abnormalities should be tested for both before and after
treatment
 IMAGING

X-ray examination is mandatory & remember the rules of twos:

• Two views: At least two views MUST be taken.

• Two joints: The joints above and below the fracture MUST both be included on X-
ray film.
• Two limbs: In children, x-ray of uninjured limb are needed as the appearance of
immature epiphyses may confuse the diagnosis.
• Two injuries : when severe force causes injuries at more than one level
• Two occasions : some fractures are difficult to detect soon after injury, but another
x-ray a week later may show the lesion.
 • Where is the fracture?

• Situations: whether it is in the diaphysis,

metaphysis, epiphysis and the articular surface
ABOUT • Type of fracture line
PLAIN X -RAY • Look for alignment, angulation, displacement,
rotation

• Number: how many fragments are seen?

• Bone condition: normal or pathological?

• Joint involvement

• Soft tissue swelling

COMPLICATIONS
CLASSIFICATION
EARLY
• Visceral injury
• Vascular injury
• Nerve injury
• Compartment syndrome
• Haemarthrosis
• Infection
• Gas gangrene
• Fracture blisters
• Plasters and pressure sores
LATE
• Unification ( delayed, non, mal )
• Avascular necrosis
• Growth disturbance
• Bed sores
• Myositis ossificans
• Tendon lesions
• Nerve compression
• Muscle contracture
• Joint (instability, stiffness)
• Complex regional pain syndrome
• Osteoarthritis
EARLY COMPLICATION
VISCERAL INJURY

• Often from fractures around trunk

• Rib fracture -> penetrate lung -> pneumothorax
• Pelvic fracture -> bladder/ urethra rupture
• EMERGENCY TREATMENT
VASCULAR INJURY

• Associated with damage to a major artery

• Knee
• Elbow
• Humeral shaft
• Femoral shaft

• Artery can be cut, torn, compressed or contused

• Intima detached and vessels blocked by thrombus or spasm
CLINICAL FEATURES TREATMENT
• Patient may complaint of paraesthesia 1. Removed all bandages and splints
or numbness in the toes or fingers 2. Re xray fracture
• The injured limb is cold and pale or 3. If position suggest artery being
slightly cyanosed compressed or kinked, prompt reduction
• The pulse is weak or absent is necessary
4. Reassessed circulation repeatedly over half
hour
• X-ray and angiogram
5. If no improvement -> explored by
operation
• Cut vessel -> suture
• Thrombosed -> endarterectomy
COMMON VASCULAR INJURIES

INJURY VESSELS
First rib fracture Subclavian
Shoulder dislocation Axillary
Humeral supracondylar fracture Brachial
Elbow dislocation Brachial
Pelvic fracture Presacral and internal iliac
Femoral supracondylar fracture Femoral
Knee dislocation Popliteal
Proximal tibial Popliteal and its branches
NERVE INJURY

• CLOSED
• Seldom severed and spontaneous recovery (90% in 4months)
• If not recover within expected time, and nerve conduction studies + EMG fail -> do
exploration

• OPEN
• Complete nerve injury, nerve should be explored during debridement and repaired

• ACUTE NERVE COMPRESSION

• Complaints of numbness or paresthesia in the distribution of the nerve
COMMON NERVE INJURY

INJURY NERVE

Shoulder dislocation Axillary

Humeral shaft fracture Radial

Humeral supracondylar fracture Radial or Median

Elbow medial condyle Ulnar

Monteggia fracture-dislocation Posterior-interosseous

Hip dislocation Sciatic

Knee dislocation Peroneal

COMPARTMENT SYNDROME

• Bleeding, eodema or inflammation may increase the pressure within one

of the osseofascial compartments
• There is reduced capillary flow -> muscle ischemia, worsen oedema,
greater pressure -> more profound ischemia -> viscous cycle -> 12h
necrosis of nerve and muscle within compartment
 Nerve can regenerate
 Muscle replaced by inelastic fibrous tissue ( Volkmann’s ischemic
contracture)
CLINICAL FEATURES

• High risk injury : elbow, forearm bones, procimal third of the tibia, multiple fractures
of the hand or foot, crush injuries, cicumferential burns, internal fixation operation
and infections
• Classic features of ischemia (5P)
1. Pain
2. Paraesthesia
3. Pallor
4. Paralysis
5. Pulselessness
• Ischemic muscle is highly sensitive to stretch
• Conformation diagnosis : intracompartmental pressure (ΔP<30mmHg)
TREATMENT

1. Remove casts, bandages and dressings

2. Limb should be flat
3. Monitor ΔP, if below 30mmHg -> immediate open fasciotomy
4. The wound should be left open and inspected 2 days later
• If muscle necrosis -> wound debridement
• Healthy tissue -> suture wound/ skin grafted
HAEMARTHROSIS

• Fracture involving joint

• Affected joint is painful, swollen, and warm, and range of motion is
reduced
• Joint swollen and tense -> resists movement
• Treatments of general benefit include immobilization, ice, and compression
initially; analgesia; and arthrocentesis.
JOINT ASPIRATION

• Synovial fluid obtained from a patient with a

hemarthrosis may appear red, pink, or brown. (middle
genicular artery)

• The presence of lipid globules strongly suggests

an intraarticular fracture, resulting in leakage of
marrow fat into the synovial fluid.
• A true bloody effusion usually fails to clot due to
chronic fibrinolysis, while blood from a traumatic
aspiration generally does coagulate.
• If X bloody effusion seen? Gout, pseudogout, arthritis, RA, degenerative
meniscus

• Hx to rule out non-trauma related conditions (haemophilia, anemia)

RADIOLOGICAL FINDINGS

• Stage 1: Soft tissue swelling – This is characterized by swelling secondary to direct bleeding, both into the joint and into the
adjacent tissues.
• Stage 2: Osteoporosis – The second stage is characterized by the development of osteoporosis and/or epithelial overgrowth
secondary to inflammatory hyperemia, especially marked in the knee and elbow.
• Stage 3: Osseous lesions – The third stage is characterized by disorganization of the joint with overgrowth of the epiphysis,
squaring of the patella, and widening of the articular notch of the knee and the trochlea of the ulna; the articular cartilage
remains intact.
• Stage 4: Cartilage destruction – The fourth stage is characterized by destruction and secondary joint space narrowing.
• Stage 5: Joint disorganization – The fifth stage is due to chronic disease that leads to complete loss of cartilage spaces, and
considerable bony erosion and irregularity.
GAS GANGRENE

• Caused by clostridial infection (Clostridium welchii) G+ve GAStrep, Staph a.

• Anaerobic organisms that can survive and multiply in tissue with low O2
tension Dirty wound with dead muscle that closed without adequate
debridement
• Toxin produced by the organism lead to tissue necrosis and distribution
of O2 to the body
• Complains of intense pain and swelling around the wound and a
brownish discharge may be seen
• Characteristic smell becomes evident
TREATMENT

• Fluid replacement and IV anti-biotics STAT

• Antibiotic treatment should include gram-
positive (penicillin or cephalosporin), gram-
negative (aminoglycoside, third-generation
cephalosporin, or ciprofloxacin), and anaerobic
coverage (clindamycin or metronidazole)

• Hyperbaric oxygen
• Prompt decompression of wound and
removal of all dead tissues
• Amputation may be essential
FRACTURE BLISTERS

• Tense vesicles or bullae that arise on markedly swollen skin

directly overlying a fracture.
• Anatomical sites with thinner skin without the underlying
protection of muscle or adipose tissues
• ankle, wrist, elbow, foot, and distal tibia

• Any conditions that predispose to poor wound healing:

• peripheral vascular disease, collagen vascular disease, hypertension,
smoking, alcoholism, diabetes mellitus, and lymphatic obstruction.

• Types
• Clear fluid filled vesicles
• Blood stained
OSTEOMYELITIS

• Infection of the bone – Staph. Aureus

• results from haematogenous spread, although direct extension from
trauma and/or ulcers.
• Formation of Sequestrum > Not connected to haversian system > AB
cannot reach the sequestrum > Involucrum forms around the
sequestrum
• Treatment: Open the involucrum >
LATE COMPLICATIONS
Complications Causes Clinical feature Treatment

1. Delayed union Biological  Tenderness – if Conservative

- fracture takes longer  Inadequate blood supply – badly displaced fracture → bone subjected to 2 imp. principle
than expected time to tearing of both periosteum → interruption of intramedullary stress, pain may be i. Eliminate any
heal blood supply acute possible causes
 Severe soft tissue damage – affects fracture healing by of delayed union
i. Reducing the effectiveness of muscle splintage  X-ray ii. Promote healing
ii. Damaging the local blood supply - Fracture line by providing
iii. Diminishing/ eliminating osteogenic input from remain visible most appropriate
mesenchymal stem cells within muscle - Presence of very environment
 Periosteal stripping – over- enthusiastic stripping of little/ incomplete
periosteum during internal fixation callus formation or → immobilization
periosteal reaction (cast or internal
Biomechanical - Bone ends NOT fixation)
 Imperfect splintage – excessive traction or excessive sclerosed or
movement at the fracture site → delay ossification in the atrophic Operative
callus If,
 Infection – bone lysis, necrosis & pus formation i. Union delayed >
6mnths
Patient-related ii. no sign of callus
formation

→ internal fixation
and bone grafting
Complications
2. Non-union
- fracture will never unite
without intervention
- Minority cases of delayed
union gradually turns into
non-union
Types
Pseudoarthrosis / false joint •
- Movement can be elicited
and pain diminishes • Alignment – adequately
Hypertrophic non-union
- bone ends are enlarged,
suggesting that
osteogenesis is still active
but not quite capable of
bridging the gap
Atrophic non-union
- osteogenesis seems to have
ceased. The bone ends are
tapered or rounded with no
suggestion of new bone
formation
Causes
Contact – sufficient
contact btwn fragments?
aligned?
• Stability – fracture held
with sufficient stability
• Stimulation – sufficiently
stimulated? (e.g. by
encouraging
weightbearing).
Others
 Poor soft tissue (from
either injury or surgery)
 Local infection
 Drug abuse
 Non-compliance patient
Treatment
Conservative
- Mostly treatment not
needed
- At most, removable splint
Operative
Hypertrophic non-union & in
the absence of deformity
→ rigid fixation (internal or
external)
Atrophic non-union - fixation
alone is not enough
→ Fibrous tissue in the
fracture gap, as well as the
hard, sclerotic bone ends is
excised
→ bone grafts are packed
around the fracture
Complications Causes Clinical features Treatment

3. Malunion • Failure to  Deformity is obvious • Incipient/developing

- Reduce fracture but sometimes true malunion may call for
- Fragments join in adequately extent of malunion is treatment before
unsatisfactory position - Hold reduction apparent only on x-ray. fracture fully united.
(unacceptable angulation, while healing • May use internal
rotation or shortening) proceeds fixation
• Gradual collapse of
comminuted or Guidelines for treatment
osteoporotic bone → Apley’s page 719
4. GROWTH DISTURBANCE 5. Bed sores

• In children, damage of physis/growth plate/

epiphyseal plate • Elderly or paralysed patients

• Transverse fracture through the • Skin over sacrum and heels

growth plate • Once developed, treatment is difficult
- Fracture runs through hypertrophic & • Tx – excise the necrotic ts & apply skin graft
calcified layers but NOT throught germinal
zone
- acutely reduced → may not be disturbance
of growth
• Fracture that split the epiphysis
- Growth may be asymmetrical
- If entire physis damaged → slowing or
complete cessation of growth
 6. NERVE COMPRESSION

Bone or joint deformity results in local nerve entrapmet with typical features
- Numbness
- Paraesthesia
- Loss of power
- Muscle wasting
Common sites
- Ulnar nerve - malunited lateral condyle or supracondylar fracture
- Median nerve – injuries around wrist
- Posterior tibial nerve – fracture around ankle
Treatment
- Early decompression of the nerve
7. AVASCULAR NECROSIS
DESCRIPTION CLINICAL IMAGING MANAGEMENT
FEATURES

• Also known as • Pain in or near joint • X-ray -Increase bone • old people -
osteonecrosis (normally only density Arthroplasty
• Bone does not during certain • MRI- band like low • young people-
receive adequate movement) intensity signal on Realigment
blood supply • Click in the joint T1-weighted SE osteotomy /
• Head of femur • Swelling image arthodesis
• Proximal part of • Movement restricted • Vascularised bone
scaphoid grafting
• Lunate
• Body of talus
 8. MYOSITIS OSSIFICANS
DESCRIPTION CLINICAL IMAGING MANAGEMENT
FEATURES
• Heterotopic • Pain • After injury X-ray • Joint rested in
ossifications in • Local swelling normal position of function
muscles • Soft-tissue • After 2-3 weeks until pain subside
• Dislocation of elbow, tenderness fluffy calcification in • After pain subside,
blow to brachialis, • Over 2-3 weeks pain soft tissue gentle active
deltoid or subside but joint • 8 weeks- defined movement
quadriceps movement limited bony mass • Excise bony mass
• Due to muscle • By 8 wekks bony • Indomethacin and
damge mass easily palpable radiotheraphy given
• Also occur without to prevent
local injury in recurrence.
unconscious or
paraplegic patient
9. JOINT STIFFNESS
DESCRIPTION CLINICAL FEATURE MANAGEMENT
• Knee, elbow,shoulder • Tenderness • Exercise to keep joint
and small joints of hand • Progressive stiffness of mobile
• Joint itself injured distal joints • If intraarticular
haemarthrosis adhesion then gentle
formation manipulation through
synovial adhesion anesthesia can free the
• Oedema and fibrosis of joint
capsule,ligaments and
muscle around joint
10. MUSCLE CONTRACTURE
DESCRIPTION CLINICAL MANAGEMENT
FEATURES
• following arterial • Wasting of arm • Pedicle nerve
injury or and forearm graft- using
compartment • Clawing of proximal
syndrome fingers segment of
• ischamic • Loss of sensation median and ulnar
contracture of • Loss of function nerve
affected muscle • Bunnells intrinsic • Tendon release
(Volkmann’s plus position and transfer
ischaemic • Claw-toe
contracture) deformity
• Forearm, hand,
leg, foot
11. JOINT INSTABILITY

DESCRIPTION CLINICAL FEATURES

• Ligamentous laxity- knee,
ankle, MCP
• Muscle weakness- due to
excessive splintage
• Bone loss- gunshot fracture
• Persistent discomfort at joint
• Weakness of joint
• Recurrent dislocation
12. ALGODYSTROPHY

DESCRIPTIO CLINICAL IMAGING MANAGEME

N FEATURES NT
• Complex • Continous, • Patchy • Elevation
regional pain burning pain rarefaction and active
syndrome • Local of bone exercise
• Painful swelling • Anti
osteoporosis • Redness inflammator
after warmth y drugs
fractures of • Tenderness • Amitriphylin
extremities • Moderate e for pain
stiffness control
• Skin become
pale and
atropic
• Restricted
movement
13. OSTEOARTHRITIS
DESCRIPTION CLINICAL FEATURES
• Following trauma articular • Pain during or after movement
cartilage damages and give rise • Tenderness on light pressure
to osteoarthritis within months • Loss of flexibility
• healed cartilage with irregular
joint surface cause localised
stress and lead to secondary
osteoarthritis years later
REFERENCE

• Apley’s system of orthopaedics and fractures 9th edition