Complications of Fractures, a Lecture by Dr. Peter Schosheim, M.D., F.A.C.S.:

There are numerous complications associated with fractures that can require future treatments, surgical interventions, and/or result in permanent debilitation. One of the most frequent complications is trau­matic arthritis. This injury can affect virtually any joint within the body. Fractures don't necessarily have to occur through, or even near a joint for traumatic arthritis to develop within the joint.

In order to understand traumatic arthritis, one must understand the anatomy of the joint. Most joints consist of thick, shock-absorbing articu­lar cartilage covering smooth articular bone. The joint itself is by ligaments that contain an inner lining of synovium that helps secrete fluids that lubricate the joint. During a traumatic event fractures can oc­cur though the joint or the joint surfaces can simply be driven together resulting in injuries to the articular cartilage and/or underlying articular bone. This trauma initiates a series of events that results in varying de­grees of breakdown of the articular cartilage, abnormal growth of the ar­ticular and underlying bone, and the development of excessive synovium. This condition is prone to continue to worsen overtime and may ultimate­ly require joint fusion or replacement.

Another frequent complication of fractures is the development of a "non-union." Fractures typically heal as a result of a callus forming between the fracture fragments, which is eventually re­placed by bone. When non-unions occur, the callus is replaced by fibrous tissue. The fibrous tissue at the fracture site allows for movement at the fracture site that typically is associated with a great deal of pain. Surgical intervention is often required to address nonunions. The surgical procedure typically involves exposure of the area of the nonunion, removing the fibrous tissue and underlying bone to essentially create new, bleeding fracture ends, the fixation of the fragments to allow for good callus formation and bone growth.

"Malunions" are another complication of fractures. In the case of malunions, the bones heal, but the fracture fragments were malaligned during healing so that the bone is abnormally angled, rotated, or in some other way abnormally aligned. Sig­nificant areas and amounts of malunion may require future sur­gical interventions. This procedure essentially involves creating a new "fracture" line surgically, realigning the bone fragments, and refixating them for eventual healing.

In other situations, the blood supply to a bone or bone fragment may be disrupted as a result of trauma. The scaphoid bone of the wrist, the talus bone of the ankle, and the head of the femur in the hip joint are particularly vulnerable to avascular necrosis. Because the blood supply to the bone is disrupted, it is not only unable to heal, but the bone itself breaks down and collapses.

This complication requires excision of the necrotic bone and placement of bone graft in an attempt to restore the bone reconstruction. In some situations, joint fusion or replacement may be necessary.

A rarer complication associated with fractures is "heterotopic bone growth" or "myositis ossificans." Opposed to nonunions, the bone growth fails to bridge the fracture and excessive development of bone may grow. Under these conditions, the bone around the fracture site extends into the muscles, liga­ments and other soft tissues. As one might expect, this leads to a pain and limited mobility. In some situations the excessive bone growth may be resorbed; however, in others, surgical intervention may be required.