PassFinals
Trauma & Orthopaedics

Complications of Fractures

Fracture complications range from immediate haemorrhage, neurovascular injury and compartment syndrome to later infection, venous thromboembolism and failure of union; serial assessment and rapid specialist escalation are the safety-critical skills.

In a nutshell

Fracture complications are time-dependent. Early threats include haemorrhage, neurovascular injury, compartment syndrome, open-fracture infection, fat embolism and VTE; later problems include infection, delayed or non-union, malunion, avascular necrosis and post-traumatic arthritis. Serial neurovascular examination and rapid escalation are central.

Classic presentation

After a tibial fracture, pain escalates despite analgesia and is severe on passive toe movement with a tense calf; compartment syndrome must be assumed until senior orthopaedic assessment proves otherwise.

Key points

  • Pain out of proportion, pain on passive stretch and increasing analgesia requirement are early compartment-syndrome clues; pulses may remain present.
  • A pulseless or persistently dysvascular limb needs immediate realignment, splinting and vascular or plastic-surgery escalation.
  • Open fractures need early IV antibiotics, orthoplastic referral and a planned debridement and soft-tissue pathway.
  • New hypoxaemia, confusion or collapse after major long-bone or pelvic injury needs urgent investigation for fat embolism, PE and other trauma complications.
  • Assess VTE and bleeding risk after lower-limb immobilisation and fracture surgery; give prophylaxis only through the current risk-based pathway.
  • Persistent pain, deformity or absent healing progression needs specialist assessment for infection, mechanical failure, non-union, malunion or osteonecrosis.

First-line investigation

ABCDE and serial neurovascular examination, with targeted radiographs, pressure monitoring when the compartment examination is unreliable, and urgent specialist imaging or sampling for vascular injury, VTE, infection or failed union.

Management

Stabilise, splint and reassess the injured limb

  • Use ABCDE trauma care, control bleeding, realign and splint, document pulses, perfusion, motor function and sensation, and repeat the examination after every intervention.11,2,4

Act immediately on compartment syndrome or limb ischaemia

  • Release restrictive dressings, obtain senior orthopaedic review and proceed to urgent decompression for diagnosed compartment syndrome; revascularise a persistently dysvascular limb without harmful imaging delay.3,2

Prevent infection and VTE through risk-based pathways

  • Give open-fracture antibiotics promptly, refer for orthoplastic care, assess VTE and bleeding risk, and follow local antimicrobial and thromboprophylaxis policies.4,8,12

Investigate systemic deterioration after major fracture

  • Treat respiratory or neurological deterioration as a critical illness and investigate fat embolism, pulmonary embolism, chest injury, sepsis and bleeding in parallel.7,10,11

Refer failed healing or infection to specialist reconstruction

  • Persistent pain, deformity, instability or absent healing progression requires specialist assessment for infection, fixation failure, non-union, malunion or osteonecrosis, followed by structured rehabilitation and safety-netting.5,6

Exam traps

  • A palpable distal pulse does not exclude compartment syndrome.
  • Do not wait for pallor, paralysis or pulselessness before escalating compartment syndrome; these are late or non-specific findings.
  • Do not use capillary refill or an isolated Doppler signal to exclude arterial injury in a dysvascular limb.
  • A negative initial radiograph or normal early inflammatory marker does not settle a suspected complication; use serial assessment and specialist review.
  • Do not give empiric antibiotics for a stable suspected fracture-related infection before a diagnostic plan and deep sampling unless sepsis makes treatment urgent.
  • Do not attribute new post-traumatic hypoxaemia or confusion to fat embolism without assessing pulmonary embolism, chest injury, sepsis and other reversible causes.

Illustrations

Scaphoid non-union before and after screw fixationPaired wrist radiographs showing a persistent scaphoid non-union and the subsequent appearance after internal fixation with a Herbert screw.Hellerhoff, Wikimedia Commons · CC-BY-SA-3.0
Avascular necrosis of the femoral headA radiograph or MRI of femoral-head osteonecrosis showing sclerosis and collapse of a fragment with a precarious blood supply.Jmarchn, Wikimedia Commons · CC-BY-SA-3.0

Key sources

  1. NICE NG37, Fractures (complex): assessment and management (Current NICE complex-fracture pathway, last updated November 2022, including arterial injury, compartment syndrome, open fractures, major trauma transfer and documentation)Published 17 Feb 2016
  2. BOASt, Diagnosis and management of arterial injuries associated with musculoskeletal trauma (Current UK BOA, BAPRAS and Vascular Society standard published and updated June 2026 for immediate haemorrhage control, clinical examination, CTA without harmful delay and emergency revascularisation)Published 10 Jun 2026
  3. BOASt, Diagnosis and Management of Compartment Syndrome of the Extremities (British Orthopaedic Association and BAPRAS standard last updated July 2025, including serial assessment, dressing release, pressure monitoring when uncertain, urgent decompression and soft-tissue follow-up)Published 1 Jul 2014
  4. BOASt, Open Fractures (UK orthoplastic standard for open long-bone, hindfoot and midfoot fractures, including early antibiotics, vascular and neurovascular checks, debridement, coverage and rehabilitation)Published 1 Dec 2017
  5. BOASt, Fracture Related Infections (UK orthopaedic standard for suspected early and late fracture-related infection, deep sampling, antimicrobial timing, multidisciplinary management and infected non-union)Published 1 Sept 2019
  6. British Limb Reconstruction Society and British Orthopaedic Association, Best practice in limb reconstruction surgery in the United Kingdom (Current UK specialist service and referral framework for fracture non-union, malunion, fracture-related infection, bone defects and complex trauma)Published 2 Dec 2025
  7. Luff and Hewson, Fat embolism syndrome, BJA Education (UK-authored specialist review describing clinical recognition, differential diagnosis and supportive critical-care management of fat embolism syndrome after trauma)Published 6 Jul 2021
  8. NICE NG89, Venous thromboembolism in over 16s (Current NICE VTE risk assessment and prophylaxis recommendations, last reviewed September 2024, including lower-limb immobilisation, orthopaedic surgery and fragility fractures)Published 21 Mar 2018
  9. NICE NG38, Fractures (non-complex): assessment and management (NICE assessment, management and follow-up pathway for selected non-complex fractures; no exceptional-review update was identified after the 2018 surveillance decision)Published 17 Feb 2016
  10. NICE NG158, Venous thromboembolic diseases: diagnosis, management and thrombophilia testing (Current NICE pathway for evaluating suspected DVT and PE, including the need to investigate rather than assume fat embolism after trauma)Published 26 Mar 2020
  11. NICE NG39, Major trauma: assessment and initial management (NICE major-trauma initial assessment, haemorrhage control and early management pathway)Published 17 Feb 2016
  12. BNF, current antithrombotic prescribing information (Current UK prescribing cross-check for LMWH, fondaparinux and other antithrombotic contraindications, interactions, renal dosing and perioperative safety; detailed BNF access is restricted in this environment)
  13. NICE NG51, Sepsis: recognition, diagnosis and early management (Current NICE sepsis recognition and immediate-treatment pathway used for infected fracture and fracture-related infection escalation)Published 13 Jul 2016
  14. BOASt, Outpatient and on-call services for people with fractures or musculoskeletal injury (Current BOA service standard published March 2026 for fracture follow-up, access, safety-netting and on-call pathways)Published 5 Mar 2026

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.