Fracture Complications

Original Editor - lucinda hampton

Top Contributors - Lucinda hampton, Naomi O'Reilly and Ewa Jaraczewska  

Introduction

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.

1. Early complications include wound healing problems, shock, fat embolism, compartment syndrome, deep vein thrombosis, thromboembolism (pulmonary embolism), disseminated intravascular coagulopathy, and infection.
2. Delayed complications include delayed union and nonunion, avascular necrosis of bone, reaction to internal fixation devices, complex regional pain syndrome, and heterotrophic ossification.

Early Complications

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
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.	Anxiety or Agitation. Cool, Clammy Skin or Sweating, Moist Skin Confusion Decreased or No Urine Output Generalised Weakness Pale Skin Color (Pallor) Rapid Breathing	Urgent Medical Team Review Management includes restoration of blood volume and circulation, relieving the patient’s pain, providing adequate splinting, and protecting the patient from further injury and other complications.
Rhabdomyolysis	Risk Factors: Crush Injury (resulting in muscle damage with byproducts damaging the kidneys) Timeframe: Usually occurs in the very acute phase (around 1-3 days) post-injury	Significant Muscle Pain Swelling Fever Vomiting Confusion Tea-colored urine Irregular heartbeat	Urgent Medical Team Review Requires immediate action from the medical team Management includes fluid resuscitation and the management of associated renal failure
Compartment Syndrome	Risk Factors: Tibial or Forearm Fractures High-energy Wrist Fractures Crush Injuries Timeframe: Usually occurs in the very acute phase, post-injury	Pain out of proportion to the associated injury Pain on passive movement of the muscles of the involved compartments Severe Swelling Neurovascular Changes - 5P’s	MEDICAL EMERGENCY Inform the surgeon immediately. Requires immediate action. Remove any cast, splint of circumferential dressing and elevate limb to heart level. May require emergency fasciotomy
Fat Embolism Syndrome	Risk Factors: Long Bone Fractures Pelvic Fractures Multiple Fractures Crush Injuries Young Adults (20 to 30 years of age) Older Adults with Proximal Femur Fracture Timeframe: Occurs Very Acute Phase Post-injury (24 to 72 hours) Rapid Onset	Hypoxia Tachypnea Tachycardia Pyrexia	Urgent Medical Team Review. Requires immediate action. Check Observations Administer oxygen if required and if this is within your scope of practice
Pulmonary Embolism	Risk Factors Serious Limb Injury Surgery Prolonged Bed Rest Static Lower Limb Posture for more than 6 hours Trauma and Spinal Cord Injury Smoking Oral Contraceptives Hormone Replacement Therapy Cancer Chemotherapy Pregnancy and Post-Partum Period Advanced Age (>40 years old) Immobilizer or Cast Central Venous Catheterization Timeframe: Patient is most at risk in the acute phase and first three months post-injury	Pyrexia Dyspnea and/or Tachypnea Crackles Second Heart Sound Pleuritic Chest Pain Profuse Sweating Haemoptysis Tachycardia Hypotension Lightheaded / Dizzy Syncope Cyanosis	Urgent Medical Team Review. Requires immediate action. Check Observations Administer oxygen if required and if this is within your scope of practice
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 Reduced Skeletal Muscle Contractions Bed Rest. Lower Limb Fractures Pelvic Fractures Timeframe: Patient is most at risk in the acute phase and first three months post-injury	Swollen, Hard, Painful Limb Tender to Touch Heat Discolouration (usually red but can be blueish-grey)	Inform Medical Team Check whether the team is happy for the patient to mobilise
Disseminated Intravascular Coagulopathy (DIC)	Group of bleeding disorders with diverse causes, including massive tissue trauma.	Ecchymoses Unexpected Bleeding after Surgery Bleeding from Mucous Membranes, Venipuncture Sites, Gastrointestinal and Urinary Tracts.	Urgent Medical Team Review. Requires immediate action. May require plasma, red blood cell and platelet transfusion and Anti-coagulant medication to prevent blood clotting.
Infection	Risk Factors Open Fractures Internal Fixation Surgical Wound Pin Sites	New or Increasing Pain Heat Redness Swelling Green or Cloudy Oozing/Discharge Tenderness	Inform the Medical Team Infections must be treated promptly. Antibiotic therapy must be appropriate and adequate for prevention and treatment of infection.

Sub-acute or Delayed Complications

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
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.	Fever Lethargy, Malaise or Irritability in Children Pain Swelling Redness Warm Sensation Over an Area of Bone Loss of Range of Movement	Urgent Medical Team Review
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.	Discomfort Pain Reduced Function in Affected Area	Orthopaedic Review In low resource, disaster or conflict settings where surgical patients may not be routinely followed up then arrange for orthopaedic review
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.	Discomfort Pain Deformity Reduced Function in Affected Area Swelling	Orthopaedic Review In low resource, disaster or conflict settings where surgical patients may not be routinely followed up then arrange for orthopaedic review
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.	Discomfort Pain Continued Movement at Fracture Site beyond Expected Healing Times Reduced Function in Affected Area Swelling	Orthopaedic Review In low resource, disaster or conflict settings where surgical patients may not be routinely followed up then arrange for orthopaedic review
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	Continuing Pain, Allodynia, or Hyperalgesia in which the pain is disproportionate to any known inciting event Oedema Changes in skin blood flow Abnormal Sudomotor Activity (Sweating, Abnormal Hair or Nail Growth) Reduced Range of Movement in the Region of Pain	Consult with Medical Team Develop Joint Treatment Plan
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).	Gradually worsening pain, in particular on weight bearing Reduced range of movement in the affected joint	Urgent Orthopaedic Review
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.	Discomfort Pain Reduced Function in Affected Area	Orthopaedic Review

Signs and Symptoms

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

Patient-Related Risk Factors

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.
• In delayed union and non-union identified risk factors include: age; lower limb > upper limb; open fractures; infection; diabetes; smoking; poor blood supply.
• 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.