Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

General principles of fracture management: Early and late complications

Allyson S Howe, MD, FAAFP, CAQ Sports Medicine
Section Editors
Patrice Eiff, MD
Chad A Asplund, MD, FACSM, MPH
Deputy Editor
Jonathan Grayzel, MD, FAAEM


Fractures are associated with a range of potential complications. Acute complications occur as a direct result of the trauma sustained and can include damage to vascular structures, nerves, or soft tissue. Delayed complications may occur after initial treatment or in response to treatment. Therefore, reevaluation at regular intervals during healing is prudent in most cases.

Major acute and long-term complications of fractures are described here. The management of specific fractures and some specific complications are discussed in detail separately. (See "Acute compartment syndrome of the extremities" and "Treatment and prevention of osteomyelitis following trauma in adults" and "Clinical presentation and diagnosis of the nonpregnant adult with suspected deep vein thrombosis of the lower extremity".)


Certain fractures can cause severe hemorrhage or predispose to other life-threatening complications. Femur fractures that disrupt the femoral artery or its branches are potentially fatal [1]. Pelvic fractures can damage pelvic arteries or veins causing life-threatening hemorrhage; the more displaced the pelvic fracture, the greater the potential blood loss [2]. Hip fractures, particularly in the elderly, may prevent ambulation, resulting in potentially life-threatening complications, such as pneumonia, thromboembolic disease, and possibly rhabdomyolysis, if there is a prolonged period of immobility. Patients with multiple rib fractures are at substantial risk for pulmonary contusion and related complications. (See "Midshaft femur fractures in adults" and "Pelvic trauma: Initial evaluation and management" and "Hip fractures in adults" and "Initial evaluation and management of rib fractures".)


Arterial injury — Proper fracture healing requires adequate blood supply to the injured site. However, fractures can involve sharp bone fragments that injure adjacent arteries, causing hemorrhage and possibly disruption of distal blood supply to a limb, and potentially impairing bone healing. Certain fractures are associated with particular arterial injuries (table 1) [3]. In all cases, the distal and proximal pulses of any fractured extremity should be examined to determine the adequacy of arterial flow. Immediate reduction and immobilization is required for any fracture associated with neurovascular compromise. A detailed examination of the extremity should be documented at the initial presentation so that changes in the neurovascular status can be recognized.

In cases of high-velocity trauma, angiography may be needed to define vascular injury, as the presence of distal pulses does not always indicate intact proximal arteries. Signs of disrupted arterial flow may include a cool extremity, mottled skin color, and loss of sensation. (See "Overview of acute arterial occlusion of the extremities (acute limb ischemia)", section on 'Clinical presentations'.)  

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Nov 2017. | This topic last updated: Feb 23, 2017.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. Cary DV. Management of traumatic femoral shaft fractures. JAAPA 2005; 18:50.
  2. Grainger MF, Porter KM. Life threatening haemorrhage from obturator vessel tear as a result of pubic ramus fracture. Injury 2003; 34:543.
  3. Schlickewei W, Kuner EH, Mullaji AB, Götze B. Upper and lower limb fractures with concomitant arterial injury. J Bone Joint Surg Br 1992; 74:181.
  4. McKay SD, MacDermid JC, Roth JH, Richards RS. Assessment of complications of distal radius fractures and development of a complication checklist. J Hand Surg Am 2001; 26:916.
  5. Turner RG, Faber KJ, Athwal GS. Complications of distal radius fractures. Orthop Clin North Am 2007; 38:217.
  6. Townsend, CM, Beauchamp, et al. Hand surgery: trauma. In: Sabiston Textbook of Surgery, 18th, Saunders, Philadelphia 2008.
  7. Blick SS, Brumback RJ, Poka A, et al. Compartment syndrome in open tibial fractures. J Bone Joint Surg Am 1986; 68:1348.
  8. Okike K, Bhattacharyya T. Trends in the management of open fractures. A critical analysis. J Bone Joint Surg Am 2006; 88:2739.
  9. FLOW Investigators, Bhandari M, Jeray KJ, et al. A Trial of Wound Irrigation in the Initial Management of Open Fracture Wounds. N Engl J Med 2015; 373:2629.
  10. Gustilo RB, Mendoza RM, Williams DN. Problems in the management of type III (severe) open fractures: a new classification of type III open fractures. J Trauma 1984; 24:742.
  11. Bowen TR, Widmaier JC. Host classification predicts infection after open fracture. Clin Orthop Relat Res 2005; :205.
  12. Giordano CP, Koval KJ, Zuckerman JD, Desai P. Fracture blisters. Clin Orthop Relat Res 1994; :214.
  13. Strauss EJ, Petrucelli G, Bong M, et al. Blisters associated with lower-extremity fracture: results of a prospective treatment protocol. J Orthop Trauma 2006; 20:618.
  14. Giordano CP, Koval KJ. Treatment of fracture blisters: a prospective study of 53 cases. J Orthop Trauma 1995; 9:171.
  15. Varela CD, Vaughan TK, Carr JB, Slemmons BK. Fracture blisters: clinical and pathological aspects. J Orthop Trauma 1993; 7:417.
  16. Gross T, Kaim AH, Regazzoni P, Widmer AF. Current concepts in posttraumatic osteomyelitis: a diagnostic challenge with new imaging options. J Trauma 2002; 52:1210.
  17. Paluska, SA. Osteomyelitis. Clinics in Family Practice 2004; 6:127.
  18. Zura R, Xiong Z, Einhorn T, et al. Epidemiology of Fracture Nonunion in 18 Human Bones. JAMA Surg 2016; 151:e162775.
  19. Pountos I, Georgouli T, Blokhuis TJ, et al. Pharmacological agents and impairment of fracture healing: what is the evidence? Injury 2008; 39:384.
  20. Jee WS, Park HZ, Roberts WE, Kenner GH. Corticosteroid and bone. Am J Anat 1970; 129:477.
  21. Kim SG, Chung TY, Kim MS, Lim SC. The effect of high local concentrations of antibiotics on demineralized bone induction in rats. J Oral Maxillofac Surg 2004; 62:708.
  22. Haleem AA, Rouse MS, Lewallen DG, et al. Gentamicin and vancomycin do not impair experimental fracture healing. Clin Orthop Relat Res 2004; :22.
  23. Li J, Mori S, Kaji Y, et al. Effect of bisphosphonate (incadronate) on fracture healing of long bones in rats. J Bone Miner Res 1999; 14:969.
  24. Odvina CV, Zerwekh JE, Rao DS, et al. Severely suppressed bone turnover: a potential complication of alendronate therapy. J Clin Endocrinol Metab 2005; 90:1294.
  25. Kwiatkowski TC, Hanley EN Jr, Ramp WK. Cigarette smoking and its orthopedic consequences. Am J Orthop (Belle Mead NJ) 1996; 25:590.
  26. Furr AM, Schweinfurth JM, May WL. Factors associated with long-term complications after repair of mandibular fractures. Laryngoscope 2006; 116:427.
  27. King AR, Moran SL, Steinmann SP. Humeral nonunion. Hand Clin 2007; 23:449.
  28. Lee JJ, Patel R, Biermann JS, Dougherty PJ. The musculoskeletal effects of cigarette smoking. J Bone Joint Surg Am 2013; 95:850.
  29. Murray IR, Foster CJ, Eros A, Robinson CM. Risk factors for nonunion after nonoperative treatment of displaced midshaft fractures of the clavicle. J Bone Joint Surg Am 2013; 95:1153.
  30. Scolaro JA, Schenker ML, Yannascoli S, et al. Cigarette smoking increases complications following fracture: a systematic review. J Bone Joint Surg Am 2014; 96:674.