Complications of Fracture

A. General (Systemic) Complications

Source: S Das A Manual on Clinical Surgery, 13th Ed; Rosen's Emergency Medicine, 9th Ed

B. Local Complications

I. Early (Immediate/Recent) Local Complications

1. Injury to Joints

2. Nerve Injury

• Usually neuropraxia (heals spontaneously); occasionally axonotmesis from overzealous manipulation.
• Neurotmesis is rare with closed fractures.
• Classic nerve-fracture associations:
  • Spinal cord / cauda equina - fracture-dislocation of the spine
  • Axillary nerve - fracture neck of humerus, shoulder dislocation
  • Radial nerve - fracture shaft of humerus (spiral fracture at radial groove)
  • Ulnar/median/radial nerve - supracondylar fracture of humerus
  • Sciatic nerve - posterior dislocation of hip, subtrochanteric fracture of femur
  • Common peroneal nerve - fracture neck of fibula
• Late nerve injury: "Tardy ulnar palsy" - delayed ulnar nerve involvement in malunited supracondylar fracture causing cubitus valgus.

3. Vascular Injury

• Vessels classically damaged:
  • Middle meningeal vessels - fracture of skull (extradural haemorrhage)
  • Brachial artery - supracondylar fracture of humerus
  • Popliteal artery - supracondylar fracture of femur
• Mechanism: thrombosis, spasm, oedema, compression by displaced fragment, or (rarely) complete division.
• Untreated vascular injury leads to gangrene (severe) or ischaemic contracture (partial/late).

4. Muscle Complications

• Torn muscle fibres may become adherent to the fracture site or joint capsule, causing joint stiffness.
• Disuse atrophy from prolonged immobilisation.

5. Tendon Complications

• Immediate: Torn quadriceps expansion in fracture of the patella.
• Late rupture: Extensor pollicis longus after Colles' fracture; long head of biceps after fracture neck of humerus.
• Tendinitis: Tibialis posterior tendon after medial malleolus fracture (rare).

6. Visceral Injury

• Pelvic fracture: Urinary bladder and urethra injury
• Sacral fracture: Rectal injury
• Rib fractures: Lung (pneumo/haemothorax), liver, spleen
• Skull fracture: Brain injury

7. Infection (Compound Fractures)

• Osteomyelitis with sequestrum formation.
• The most dreadful complications are gas gangrene (Clostridium perfringens) and tetanus.

8. Compartment Syndrome

• Raised pressure within a closed fascial compartment compromises perfusion.
• High risk with tibial shaft fractures (1.5-11% incidence) and forearm fractures.
• "Volkmann's ischaemia" is compartment syndrome of the forearm after supracondylar fractures.
• 5 P's: Pain (especially on passive stretch), Pallor, Paraesthesia, Pulselessness, Paralysis (late).
• Treatment: urgent fasciotomy.

II. Late Local Complications

1. Delayed Union

• Causes: Inadequate immobilisation, internal fixation (disturbs haematoma scaffold, strips periosteum), intact companion bone (one bone of forearm/leg acts as splint preventing compression at fracture site).

2. Non-Union

• Causes:
  • Infection
  • Interposition of soft tissue (periosteum or muscle) between bone ends
  • Inadequate blood supply (e.g., lower third of tibia)
  • Wide separation of fragments (patella, olecranon - or excessive traction)
  • Untreated delayed union

3. Mal-Union

• Causes: Inadequate reduction; redisplacement within plaster; growth disturbance from epiphyseal injury.
• Common sites: Neck/supracondylar fracture of humerus, Colles' fracture, fractures through condyles of tibia.
• Mal-union can cause limb shortening, cosmetic deformity, and later osteoarthritis (especially in weight-bearing joints where stress transmission becomes abnormal).

4. Avascular Necrosis (AVN)

• The affected fragment shows increased radiodensity on X-ray (does not share in disuse osteoporosis), appearing 1-3 months post-fracture.
• Leads to non-union and osteoarthritis of the involved joint.
• Classic sites:
  • Fracture neck of femur - femoral head
  • Fracture of scaphoid - proximal pole
  • Fracture neck of talus - body of talus
  • Dislocation of lunate - entire lunate

5. Volkmann's Ischaemic Contracture

• Mechanism: Ischaemia → muscle death → fibrosis → contracture. Nerves recover (regenerate); muscles do not.
• Classically: Flexor muscles of forearm after supracondylar fracture of humerus with brachial artery occlusion.
• Early signs: Absent radial pulse, inability to fully extend fingers, pain on passive extension.
• Established: Flexion deformity of wrist and fingers ("intrinsic minus hand").

6. Myositis Ossificans Traumatica

• Despite the name, it is not true inflammation of muscle; it is ectopic bone formation in the connective tissue.
• Common after elbow injuries (especially dislocation + fracture) and dislocations of the hip.
• X-ray shows fluffy calcification/ossification in soft tissues around the joint.
• Can cause severe restriction of joint movement.

7. Joint Complications (Late)

• Joint stiffness: Due to haemarthrosis, periarticular adhesions, prolonged immobilisation.
• Joint instability: Ligamentous laxity or malunited intra-articular fracture.
• Osteoarthritis: Follows intra-articular fractures (irregular joint surface), malunion (abnormal stress transmission), or AVN.
• Sudeck's Osteodystrophy (Complex Regional Pain Syndrome / CRPS): Pain, stiffness of fingers, hyperaesthesia, moistness (vasomotor changes). X-ray shows patchy rarefaction. More common after hand/wrist injuries.
• Unreduced dislocation: Leads to permanent joint stiffness; often requires open reduction or osteotomy.

Summary Classification Table

Complications of Fracture
│
├── GENERAL (Systemic)
│   ├── Shock / Haemorrhage
│   ├── Fat Embolism Syndrome
│   ├── DVT / Pulmonary Embolism
│   ├── Fracture Fever
│   ├── Hypostatic Pneumonia
│   ├── Tetanus (compound fractures)
│   └── Delirium / Accident Neurosis
│
└── LOCAL
    ├── EARLY
    │   ├── Joint injury (dislocation/ligament)
    │   ├── Nerve injury (neuropraxia → neurotmesis)
    │   ├── Vascular injury → gangrene
    │   ├── Muscle / Tendon injury
    │   ├── Visceral injury
    │   ├── Infection / Osteomyelitis / Gas Gangrene
    │   └── Compartment Syndrome (→ Volkmann's)
    │
    └── LATE
        ├── Delayed Union
        ├── Non-Union
        ├── Mal-Union → Osteoarthritis / Deformity
        ├── Avascular Necrosis
        ├── Volkmann's Ischaemic Contracture
        ├── Myositis Ossificans Traumatica
        ├── Joint Stiffness / Instability / OA
        └── Sudeck's Osteodystrophy (CRPS)

• S Das A Manual on Clinical Surgery, 13th Ed, pp. 177-181 (dedicated chapter on complications of fractures and dislocations)
• Rosen's Emergency Medicine, 9th Ed, Box 41.5 - Complications of Fractures
• Campbell's Operative Orthopaedics, 15th Ed (2026) - specific fracture complications
• Rockwood and Green's Fractures in Adults, 10th Ed (2025) - compartment syndrome and adverse outcomes