Complications

What are the potential complications in these types of fractures?

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

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A Patient's Guide to Guide to Adult Fractures

Malunion

Malalignment is common in fractures of the metacarpals and phalanges. If the fracture heals with deformity it is called malunion. Some malunion is well tolerated - for example in the Boxer's fracture. But in other situations it can cause a significant problem. Rotational malalignment of the metacarpal or the phalanges makes it difficult to make a fist or grip things. One finger is likely to override another.

If these symptoms are not acceptable, the only way to improve the situation is surgery. The bone must be cut, rotated into the correct position and fixed with internal fixation until it heals. This operation sounds simple but because angular and rotational deformity are often both present, it is not.

Nonunion

Scaphoid and lunate fractures are very prone to nonunion - meaning failure to heal. Treatment of these problems can be complex and almost always will require surgery. Different techniques are used depending on the bone involved. Bone grafting, internal fixation and, in some cases, electrical stimulation to promote healing all play a role in the tratment of this complication. Nonunion is unusual in the other bones of the hand but may occur is there has been surgery or infection. In these cases the infection must be treated and an operation performed to fix the fracture and bone graft it.

Avascular Necrosis

This term implies loss of the blood supply to all or part of the bone. When this happens the bone dies and healing of the fracture is delayed or halted. Eventually the dead bone is replaced by living bone but the bone may crumble before this happens and be distorted. Avascular necrosis (AVN) most commonly occurs in parts of the bone which are covered with articular cartilage because no blood vessels pass through this tissue. The problem is most common following fractures of the scaphoid and lunate but can occur with metacarpal head fractures and other intraarticular fractures.

AVN often goes along with non-union and the treatment usually is to bone graft and fix the fracture. If the fracture has healed but the bone is distorted the surgeon would probably leave it and see if it caused symptoms. Late reconstruction for this problem is complex and might include stiffening (fusion) of the joint if it was painful.

Stiffness

You may refer to pain when you move a joint as "stiffness". But when doctors talk about stiffness they mean that the joint will not move at all or will move only through a limited range of movement. This may or may not be painful. Stiffness frequently results from contracted or tethered tendons and ligaments. This in turn is the result of immobilizing the joints of the hand or finger while the bone heals.

One of the most difficult management problems in the treatment of a hand fracture is the balance between holding everything still so that it heals and getting everything to move so that the hand does not get stiff. It is often possible later to overcome the loss of range of motion by a combination of stretching exercises and splinting to stretch out the scar tissue. Where the flexor tendons are scarred down, surgical procedures may be necessary to free them up or graft replacement tendons.

Painful stiffness after a hand fracture is more commonly the result of damage to the surface of a joint and premature arthritis. This is a rare situation and the treatment is individualized to the particular case. If the pain is unbearable, one option is to undergo an operation to make the joint painless by stiffening it completely (fusion); another would be some form of artificial joint (arthroplasty) replacement.

Infection

Open fractures in which the bone comes out through the skin are quite common in hand injuries. These injuries need surgical treatment to wash out the contamination and remove dead tissue. In spite of this bacteria do remain in the wound and can multiply to form an infection. Surgical site infection can also occur after an operation to fix a fracture. Thirdly, the pins sometimes used to fix the fracture may come out through the skin and form a pathway for bacteria to cause a pin track infection.

Infection is signaled by redness, swelling and tenderness of the wound and by a high temperature. Pus may drain from the wound or pin site. Treatment depends on the case but would usually include culturing any pus and starting high doses of antibiotics. The antibiotic may be changed based on the result of the bacterial culture. The doctor will chose a drug to which the bacteria is very sensitive. Most often the wound would be opened up and the infected dead tissue removed.

With aggressive early treatment of surgical site infections, the outcome is good with both the infection and the bone healing. However, the risk of scarring and stiffness of the hand is greater following an infection because of the need for further surgery and the prolonged treatment time.

Nerve Injury

One of the main functions of the hand is feeling things. If a nerve is injured as part of a complex hand injury the loss of sensation may be one of the most serious long term disabilities. It is important to work out whether the injury is partial or complete. Partial injuries usually recover better than the best results of surgery.

If the nerve injury is complete and affects a significant area (like a fingertip) then an operation may be necessary to see what the damage is. If the nerve sheath is still intact then it is better to leave the nerve alone to regenerate. If the nerve is completely severed then an operation to join up the ends would give a better result. Some of the nerve fibers will grow back down the existing nerve sheath and supply sensation to the skin of the hand or finger again. This sensation will not be as good as it was, with a noticeable reduction in fine discrimination.

Tendon Injury

Laceration of a tendon is a rare element in hand fractures. If the two occur together it is usually in the setting of a massive hand injury like getting caught in machinery. The injury to the muscles, tendons and ligaments may be more important than the fractures in this scenario. A tendon might be damaged during surgery for a hand fracture or the internal fixation may damage a tendon. Most often this type of damage is repaired at once, but it may affect the rehabilitation of the hand and increase the risk of stiffness.