Complications of Fractures | 49
• Persistent pain
• Pain on stressing the fracture
• Mobility (in non-union)
• Increasing deformity at the fracture site (in non-
union).
The following are some of the radiological features
suggestive of these complications:
• Delayed union: The fracture line is visible. There
may be inadequate callus bridging the fracture
site.
• Non-union: The fracture line is visible. There is
little bridging callus. The fracture ends may be
rounded, smooth and sclerotic. The medullary
cavity may be obliterated.
It is sometimes very difficult to be sure about
union of a fracture where internal fixation has
been used. Evaluation of serial X-rays may help
detect subtle angulation, non-progress of bridging
callus, resorption of callus, loosening of screws and
bending of the nail or plate. Excessive rotation may
be the only abnormal mobility in a case with intra-
medullary rod in situ. Oblique views, done under
fluoroscopy may show an unhealed fracture better
than conventional AP and lateral X-rays. It may be
possible to demonstrate mobility at the fracture by
stress -rays or weight bearing -rays. 3-D CT scan
is sometimes helpful in differentiating between
delayed and non-union.
Treatment: Most fractures in delayed union
unite on continuing the conservative treatment.
Sometimes, this may not occur and the fracture
may need surgical intervention. Bone grafting
with or without internal fixation may be required.
Treatment of non-union depends upon the site
of non-union and the disability caused by it. The
following possibilities of treatment should be
considered, depending upon the individual cases.
• en re t on nternal fi at on an bone grafting:
This is the commonest operation performed for
non-union. The grafts are taken from iliac crest.
Internal fixation is required in most cases.
• Excision of fragments: Sometimes, achieving
union is difficult and time consuming compared
to excision of one of the fragments. This can only
be done where excision of the fragment will not
cause any loss of functions. An excision may or
may not need to be combined with replacement
with an artificial mould (prosthesis). For
example, the lower-end of the ulna can be
https://kat.cr/user/Blink99/
excised for non-union of the fracture of the
distal-end of the ulna without much loss. In
non-union of fracture of the neck of femur in an
elderly, the head of the femur can be replaced
by a prosthesis (replacement arthroplasty).
• No treatment: Some non-unions do not give
rise to any symptoms, and hence require no
treatment, e.g., some non-unions of the fracture
scaphoid.
• Ilizarov’s method: Prof. Ilizarov from the former
SSR designed a special external fixation
apparatus for treating non-union (see page 33).
MALUNION
When a fracture does not unite in proper
position, it is said to have malunited. A slight
degree of malunion occurs in a large proportion
of fractures, but in practice the term is reserved
for cases where the resulting disability is of
clinical significance.
Causes: Improper treatment is the commonest
cause. Malunion is therefore preventable in most
cases by keeping a close watch on position of the
fracture during treatment. Sometimes, malunion is
inevitable because of unchecked muscle pull (e.g.,
fracture of the clavicle), or excessive comminution
(e.g., Colles’ fracture).
Common sites: Fractures at the ends of a bone always
unite, but they often malunite e.g., supracondylar
fracture of the humerus, Colles’ fracture etc.
Consequences: Malunion results in deformity,
shortening of the limb, and limitation of movements.
Treatment: Each case is treated on its merit. A
slight degree of malunion may not require any
treatment, but a malunion producing significant
disability, especially in adults, needs operative
intervention. The following treatment possibilities
can be considered:
a) Treatment required: Malunion may re uire
treatment because of deformity (e.g.,
supracondylar fracture of the humerus),
shortening (e.g., fracture of the shaft of the
femur) or functional limitations (e.g. limitation
of rotations in malunion of forearm fractures).
Some of the methods for treating malunion are
as follows:
50 | Essential Orthopaedics
• Osteoclasis (refracturing the bone): It is used
for correction of mild to moderate angular
deformities in children. nder general an-
aesthesia the fracture is recreated, the angu-
lation corrected, and the limb immobilised
in plaster.
• Redoing the fracture surgically: This is the
most commonly performed operation for
malunion. The fracture site is exposed,
the malunion corrected and the fracture
fixed internally with suitable implants.
Bone grafting is also performed, in addition,
in most cases e.g., malunion of long
bones.
• Corrective osteotomy: In some cases, redoing
the fracture, as discussed above may not be
desirable due to variety of reasons such as
poor skin condition, poor vascularity of bone
in that area etc. In such cases, the deformity
is corrected by osteotomy at a site away from
the fracture as the healing may be quicker at
this new site, e.g. supra-malleolar corrective
osteotomy for malunion of distal-third tibial
fractures.
• Excision of the protruding bone: In a fracture
of the clavicle, a bone spike protruding
under the skin may be shaved off. Same may
be required in a spikey malunion of fracture
of the shaft of the tibia.
b) No treatment: Sometimes malunion may not
need any treatment, either because it does not
cause any disability, or because it is expected
to correct by remodelling. Remodelling of a
fracture depends on the following factors.
• Age: Remodelling is better in children.
• Type of deformity: Sideways shifts are well
corrected by remodelling. Five to ten degrees
of angulation may also get corrected, but
mal-rotation does not get corrected.
• Angulation in the plane of movement of the
adjacent joint is remodelled better than that
in other planes e.g., posterior angulation in
a fracture of the tibial shaft remodels better.
• Location of fracture: Fractures near joints
remodel better.
Cross union is a special type of malunion which
occurs in fractures of the forearm bones, wherein
the two bones unite with each other. For details
please refer to page 110.
SHORTENING
Causes: It is a common complication of fractures,
resulting from the following causes:
• Malunion: The fracture unites with an overlap
or marked angulation e.g., most long bone
fractures.
• Crushing: Actual bone loss e.g., bone loss in
gunshot wounds.
• Growth defect: Injury to the growth plate may re-
sult in shortening (see Salter-Harris classification
of epiphyseal injuries, page 5 ).
Treatment: A little shortening in upper limbs goes
unnoticed, hence no treatment is required. For
shortening in lower limbs, treatment depends upon
the amount of shortening.
• Shortening less than 2 cm is not much noticeable,
hence can be compensated by a shoe raise.
• Shortening more than 2 cm is noticeable. In elderly
patients, it may be compensated for by raising
the shoe on the affected side. In younger patients,
correction of angulation or overlap by operative
method is necessary. Limb length equalisation
procedure is required to correct shortening in an
old, healed, remodelled fracture.
AVASCULAR NECROSIS
Blood supply of some bones is such that the
vascularity of a part of it is seriously jeopardized
following fracture, resulting in necrosis of that part.
Common sites: Some of the sites where avascular
necrosis commonly occurs are given in Table– .5.
Consequences: Avascular necrosis causes
deformation of the bone. This leads to secondary
Table– . : Common sites of avascular necrosis
Site Cause
• Head of the femur Fracture neck of the femur.
Posterior dislocation of the hip
• Proximal pole of Fracture through the waist
scaphoid of the scaphoid
• Body of the talus Fracture through neck of the talus
osteoarthritis a few years later, thus causing painful
limitation of joint movement.