Complications

What are the potential complications of this fracture?

Complications are problems with the process of healing your fracture. None of them are particularly common. We pay a lot of attention to complications in these Guides because doctors manage the treatment of fractures in order to avoid complications. This explains many of the mysterious things that happen to patients. When you are urged to move a sore elbow which you would much rather keep still, it is to avoid the long term problems of stiffness in the joint. Here we will consider the complications with most relevance to elbow fractures.

Malunion

If the bone heals but the fragments are not in the correct position the fracture is said to be mal-united. Often this can be accepted, but in the case of joints, malunion is something we prefer to avoid. Ridges, steps or other irregularities in the joint surface are very likely to cause wear-and-tear arthritis (post traumatic arthritis) down the road. Surgery has the best chance of avoiding this complication and this is why surgery is so often recommended for intra-articular fractures. However it is not guaranteed that the surgeon can restore the joint surface to smoothness or that the fixation will hold everything in place. Trying to achieve perfection through surgery may lead to even more problems and it may be necessary to compromise in order to get the best overall result. Malunion of the joint gives varying symptoms of clunking, catching, or giving way. It may be quite silent clinically and only be evident from examination of the x-rays.

The management of malunion is complex and depends very much on the individual case. If there is early failure of fixation and it is clear that the joint surface will be irregular if it heals in the current position, a re-operation may be indicated. Once everything has healed it is a major undertaking to take down a united fracture and recreate the joint surface. That procedure amounts to a new fracture and would not be undertaken lightly. More often one would accept the malunion and later treat any symptoms that arose because of it (see Post traumatic arthritis below).

Infection

Open fractures cause contamination of the broken bone fragments and often the joint. Even with the appropriate treatment of antibiotics and debridement there is risk of infection developing in the wound. Even clean surgical wounds have a 2% chance of getting infected. The wound is tender, red, and swollen and may discharge pus. The patient runs a fever and feels unwell. Tests may show bacteria in the blood stream or pus.

High doses of antibiotics are needed for a prolonged period of time. The wound needs to be re-operated on with all infected and dead tissue being removed. Infections do better if the pressure is high so drainage of the wound to keep the pressure low is desirable. Pus is also toxic to articular cartilage draining the joint is often necessary. Antibiotic beads can be placed in the wound to keep the local concentration of the drug high. If the fracture has been fixed the fixation may be left in place until the fracture has healed. Prevention of long-term infection of the bone and joint is the primary focus but it is also important to get the fracture to heal. A combination of infection and not healing (infected nonunion) is a very difficult problem.

Overall the outcome following an infection is quite favorable. It needs repeat surgery and close attention to detail but usually the infection can be healed or suppressed and the fracture goes on to heal with good function.

Heterotopic Ossification (HO)

Under certain circumstances scar tissue in injured muscle turns into bone. The exact reason for this is not known; it seems to be an inflammatory process because the area is swollen and tender before bone appears. Other risk factors include surgery and seeding the area with bone fragments and immobility. Since elbow fractures tear muscle, spread bone fragments into the muscle, and are frequently followed by surgery it is not surprising that this complication is relatively common at the elbow. The patient experiences pain and swelling at the elbow in excess of normal but does not have signs of infection. There is increasing stiffness and eventually bone shows up on x-ray in the tissues outside the normal area. The pain and inflammation settle down but the bone remains and may block movement. However, any further surgery risks flaring up the process.

Methods to avoid this complication include Non Steroidal Anti Inflammatory medication (NSAIDs) and radiation. Both these have side effects to a degree that they are not used routinely to protect against heterotopic ossification. They may be used in high risk cases. Management consists of maintaining as much movement as possible until the inflammatory period has passed. After about 18 months surgery to remove the bone can be done without flaring up more HO.

Post Traumatic Arthritis

This complication has been mentioned frequently in this discussion. If the elbow joint suffers damage to the articular cartilage, if the joint surface is irregular with pits, ridges, or gaps, or if the elbow is kept immobile for a prolonged period wear-and-tear arthritis of the joint is speeded up. The joint becomes aching and painful to move; it may lose range of motion and may grind or grate. An x-ray shows loss of the gap between the bones and spur formation. Loose bodies may form in the joint. In functional terms the elbow becomes painful to use, weaker, swollen, and stiff.

The first line of treatment of elbow arthritis is medication, pain relievers, and NSAIDs. Sometimes an operation to remove spurs and loose bodies is helpful. In progressive cases an elbow replacement is the best solution.

Related Document: A Patient's Guide to Adult Fractures