Complications

What are the potential complications of these fractures?

Complications are rare problems that make recovery from the injury longer or more "complicated". The intent of treatment is to keep these complications as rare as possible; that is why orthopaedic surgeons pay so much attention to them.

Compartment Syndrome

Bleeding from broken bones or torn muscles deep inside the foot may cause swelling inside the muscle compartment. This compartment cannot enlarge much so the pressure may rise high enough to cut off circulation to the living muscle that occupies this region. Now this muscle too is at risk of dying and swelling more in turn. This dangerous sequence causes severe pain when the muscles are moved actively or passively. If the condition is diagnosed early, before any muscle death occurs then surgery to open up the muscle compartments will save the situation and allow the muscle to heal normally. The treating staff are very much on the look out for this problem, even though it is rare. The observations getting you to move your toes right after surgery make sure that a compartment syndrome is not developing or that it is detected right away.

Malunion

When a bone heals with a deformity and looks different from the normal shape it is said to be mal-united. Malunion of a joint surface leaves it rough and irregular. Movement of the joint may then be limited or painful and there is a higher risk that the joint would wear out. The assessment of the injury and the choice of treatment including operation looks at the likelihood and consequences of malunion. Malunion in areas of the bone outside the joint may be better tolerated even if the bone heals with a "kink" in it.

If poor alignment is identified before the bone has healed (mal-alignment) it may be possible and desirable to improve the position either by manipulation or by surgery. If the bone has truly healed (malunion) the position can only be improved by cutting the bone and re-aligning it. It may not be worth doing something as elaborate as that.

Post Traumatic Arthritis (PTA)

PTA means that the joint has become painful and stiff because it has worn out. The joint wears out because it was injured or because it healed with deformity (malunion). This arthritis is the same process as normal wear-and-tear arthritis of old age (osteoarthritis), but is accelerated by the damage to the joint. The pain may be treated with medication, weight loss, and restriction of activities that hurt. If it is too much to bear, the painful arthritic joint may be treated by surgery.

In the foot, the surgery recommended to treat an arthritic, painful joint is usually an arthrodesis, or fusion of the joint. To perform a fusion, the remaining joint surface is removed, the bone ends are placed together and held until bone grows across the gap making two bones into one. This surgery aims to replace a painful joint with an immobile but painless one. Since many of the joints in the foot do not have to move much anyway, this type of operation is successful in improving foot function after post traumatic arthritis.

Nonunion

Nonunion implies that the fracture has failed to heal even though more than enough time has passed. There are often two main reasons – poor mechanics and/or poor biological environment. The mechanics are poor if the fracture is still mobile or if it moves when weight is placed on the foot. Any attempts to heal are therefore disrupted. If there is an infection, or if the blood supply is poor then the body cannot produce the healing reaction. Nonunions are most common with the fractures that are caused by fatigue (stress fractures). Fractures of the neck of the talus and Jones fracture also have a bad reputations.

You feel a nonunion as an aching pain made worse by walking. Most often the symptoms are severe enough to require intervention. Sometimes the nonunion will heal if the foot is rested for long enough. More often, surgery is required to improve the mechanics and the biology of the situation. This is done by rigidly fixing the two parts of the fracture together (mechanics) and by inserting bone graft or some other biologically active material to improve the biology. Nonunions generally heal with treatment, but it can sometimes take more than one attempt.

Avascular Necrosis

With some fractures the blood supply of one of the bone fragments is cut off and part of the bone dies. Even if the fracture heals the dead bone may not support the weight of the body and will crush down. This can occur with fractures of the neck of the talus. The dome of the talus which supports the ankle joint loses the blood supply that comes up through the neck.

If the fracture heals, new living bone may eventually replace the dead bone by a process called "creeping substitution". New blood vessels grow into the area and bring in new living bone cells. These bone cells then make new bone using the dead bone as a scaffold on which the new bone grows. This a long process and weight bearing needs to be restricted or avoided while this occurs to prevent collapse of the dead bone. If the bone does not grow back, the bone supporting the joint will eventually give way and the joint will need surgery (usually fusion).

Loss of blood supply may also affect other foot fractures, particularly where there has been a massive crush injury. The Jones fracture may disrupt blood supply to the proximal part of the 5th Metatarsal. This may cause the failure of healing seen frequently in this injury.