Fracture Complications
Original Editor - lucinda hampton
Top Contributors - Lucinda hampton, Naomi O'Reilly and Ewa Jaraczewska
Introduction[edit | edit source]
Most bone injuries heal normally. But some patients do experience complications during the healing process. Complications of fractures fall into two categories: early and delayed.
- Early complications include wound healing problems,[1] shock, fat embolism, compartment syndrome, deep vein thrombosis, thromboembolism (pulmonary embolism), disseminated intravascular coagulopathy, and infection.
- Delayed complications include delayed union and nonunion, avascular necrosis of bone, reaction to internal fixation devices, complex regional pain syndrome, and heterotrophic ossification.[2]
Early Complications[edit | edit source]
Early complications include wound healing problems, shock, compartment syndrome, fat embolism, thromboembolism (pulmonary embolism), deep vein thrombosis, disseminated intravascular coagulopathy, and infection.
Intervention | Description | Signs and Symptoms | Action to Take |
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Shock | Hypovolemic or traumatic shock resulting from hemorrhage and from loss of extracellular fluid into damaged tissues may occur in fractures of the extremities, thorax, pelvis, or spine. Because the bone is very vascular, large quantities of blood may be lost as a result of trauma, especially in fractures of the femur and pelvis. |
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Rhabdomyolysis | Risk Factors:
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Compartment Syndrome | Risk Factors:
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Fat Embolism Syndrome | Risk Factors:
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Pulmonary Embolism | Risk Factors
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Deep Vein Thrombosis | Usually in the calf but can also occur in upper limbs. This can progress to a Pulmonary Embolism, which may cause death several days to weeks after injury. (see above)
Risk Factors
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Disseminated Intravascular Coagulopathy (DIC) | Group of bleeding disorders with diverse causes, including massive tissue trauma. |
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Infection | Risk Factors
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Sub-acute or Delayed Complications[edit | edit source]
Delayed complications include osteomyelitis, delayed union, malunion, non-union, avascular necrosis of bone, reaction to internal fixation devices, complex regional pain syndrome, and heterotrophic ossification can occur at a later stage in the healing process
Intervention | Description | Signs and Symptoms | Action to Take |
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Osteomyelitis | An acute or chronic inflammatory process involving the bone and its structures secondary to infection with pyogenic organisms including bacteria (mostly Staphylococcus), fungi, and mycobacteria.
Acute osteomyelitis is the clinical term for a new infection in bone that can develop into a chronic reaction when intervention is delayed or inadequate. |
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Delayed Union | Occurs when the bone does not heal at a normal rate for the location and type of fracture. Delayed union may be associated with distraction of bone fragments, systemic or local infection, poor nutrition, or comorbidity (eg, diabetes; autoimmune disorders). Eventually, the fracture heals. |
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Malunion | Occurs when bone heals but not in the right position. You may have never had treatment for the broken bone. Or, if you did have treatment, the bone moved before it healed. |
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Non-Union | Results from failure of the ends of a fractured bone to unite. The patient complains of persistent discomfort and abnormal movement at the fracture site. Factors contributing to union problems include infection at the fracture site, interposition of tissue between the bone ends, inadequate immobilization or manipulation that disrupts callus formation, excessive space between bone fragments (bone gap), limited bone contact, and impaired blood supply resulting in avascular necrosis. |
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Complex Regional Pain Syndrome (CRPS) | Abnormally severe pain and reduced function that develops following injury.
Type 1 following injury or immobilisation without nerve injury Type 2 following injury with nerve injury) Diagnosis is based on the exclusion of other conditions that would otherwise account for the degree of pain and dysfunction |
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Avascular Necrosis | The death of bone due to loss of blood supply. It may occur after a fracture with disruption of the blood supply, especially in femoral neck. The patient develops pain and experiences limited movement. X-ray reveal calcium loss and structural collapse. Treatment generally consists of attempts to revitalise the bone with bone grafts, prosthetic replacement, or arthrodesis (joint fusion). |
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Reaction to Internal Fixation Device | Some patient may have a reaction to the Internal fixation devices. The device may be removed after bony union has taken place. In most patients, however, the device is not removed unless it produces symptoms. Pain and decreased function are the prime indications that a problem has developed.[2] |
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Signs and Symptoms[edit | edit source]
It’s important to know the warning signs of a bone healing complication. Receiving prompt care is critical to treating complications. S &S include:
- Chronic pain
- Drainage from a Wound
- Fever
- Swelling
- Limping[3]
Patient-Related Risk Factors[edit | edit source]
Certain patient-related characteristics influence the development of fracture-healing complications in general, even though specific healing complications may differ by their mechanism.
- Diabetes, NSAID use, and a recent motor vehicle accident are most consistently associated with an increased risk of a fracture-healing complication, regardless of fracture site or specific fracture-healing complication. [4]
- In delayed union and non-union identified risk factors include: age; lower limb > upper limb; open fractures; infection; diabetes; smoking; poor blood supply[5].
- Fractures in obese children have a higher rate of complications independently from conservative or surgical treatment. Surgical indications are more common than in normal weighted children and are generally more invasive. [6]
References[edit | edit source]
- ↑ Gougoulias N, McBride D, Maffulli N. Outcomes of management of displaced intra-articular calcaneal fractures. Surgeon. 2021 Oct;19(5):e222-e229.
- ↑ 2.0 2.1 2.2 Brunner LS, Smeltzer SC, Suddarth DS. Brunner & Suddarth's textbook of medical-surgical nursing; Vol. 1. Language. 2010;27:1114-2240p. Available:https://www.brainkart.com/article/Fracture-Healing-and-Complications--Early-and-Delayed-_32596/ (accessed 27.10.2021)
- ↑ Henry Ford Health Systems Bone Healing Complications Available:https://www.henryford.com/services/orthopedics/broken-bones-trauma/complications-healing-bones (accessed 27.10.2021)
- ↑ Hernandez RK, Do TP, Critchlow CW, Dent RE, Jick SS. Patient-related risk factors for fracture-healing complications in the United Kingdom General Practice Research Database. Acta orthopaedica. 2012 Dec 1;83(6):653-60. Available:https://pubmed.ncbi.nlm.nih.gov/23140093/ (accessed 27.10.2021)
- ↑ Coughlin T. Initial Management of Trauma.Available: http://www.learnorthopaedics.com/Learn_Orthopaedics/Musculoskeletal_Trauma_files/Fracture%20Complications.pdf(accessed 27.10.2021)
- ↑ Donati F, Costici PF, De Salvatore S, Burrofato A, Micciulli E, Maiese A, Santoro P, La Russa R. A Perspective on Management of Limb Fractures in Obese Children: Is It Time for Dedicated Guidelines? Front Pediatr. 2020 May 8;8:207.