General principles of fracture management: Early and late complications
- Allyson S Howe, MD, FAAFP, CAQ Sports Medicine
Allyson S Howe, MD, FAAFP, CAQ Sports Medicine
- Assistant Professor of Family and Sports Medicine
- Tufts University
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 "Approach to the diagnosis and therapy of lower extremity deep vein thrombosis".)
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 . Pelvic fractures can damage pelvic arteries or veins causing life-threatening hemorrhage; the more displaced the pelvic fracture, the greater the potential blood loss . 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) . 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'.)
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- LIFE-THREATENING CONDITIONS
- ACUTE COMPLICATIONS
- Arterial injury
- Nerve injury
- Compartment syndrome
- Thromboembolic disease
- Fat embolism syndrome
- Open fractures
- Fracture blisters
- NON-ACUTE COMPLICATIONS
- Nonunion and malunion
- Complex regional pain syndrome
- Post-traumatic arthritis
- SUMMARY AND RECOMMENDATIONS