What Are Complications of Fractures?

Patient Presentation
A 14-year-old female came to clinic with right foot pain. The pain began approximately 5 months earlier after a fall on ice. Radiographs at that time were negative. Since that time, there usually was no pain, but pain would return and increase with more activity. Over the past 2 weeks, she began recreational league soccer practices and would have pain that initially occurred at the end of practice and now occurs when she begins running at the beginning of practice. She also complains that it is more painful when she is going up stairs or just at the end of a regular day. She denies any other trauma. The review of systems was negative.

The pertinent physical exam revealed a healthy female with normal vital signs and growth parameters. Her extremity examination revealed pain over the proximal 5th metatarsal with palpation and also with supination and flexion of the foot. There was no erythema, bruising or edema. There was no other point tenderness and range of motion was normal in ankle and toes. The radiologic evaluation showed the diagnosis of a fracture of the proximal 5th metatarsal. The family was told by the pediatrician that this could represent a new fracture, one that hadn’t healed or a refracture and therefore the fracture may require surgical intervention. Orthopaedics was consulted and recommended a weight-bearing boot be placed for the next 3 weeks after which they would re-evaluate the patient.

Case Image

Figure 110 – AP and oblique radiographs of the left foot demonstrate 2 corticated fragments at the base of the fifth metatarsal, felt to represent a non-united chronic fracture.

Discussion
Fifth metatarsal fractures are a common fracture of the foot and are the most common metatarsal fracture in children > 5 years of age and adults. There is a peak age distribution in the second and fifth decades of life. Teenage boys in organized sports are one of the most common groups affected. In acute fractures, acute pain and inability to walk are common presentations, whereas in a stress fracture an increase in activity, or chronic repetitive forces are at play. Fifth metatarsal fractures have various classifications. Fracture locations from proximal to distal include avulsion fractures (a common acute fracture because of torque forces in the proximal diaphysis), Jones fracture, metaphyseal fractures (common location for stress fractures) and neck and head fractures. The Jones fracture is a specific type of 5th metatarsal fracture first described in 1902 by Sir Robert Jones. He described it in his own foot after dancing and in 4 other patients. It occurs at the diaphyseal-metaphyseal interface which has a watershed blood supply and therefore is prone to delayed or non-union fractures.

Treatment for 5th metatarsal fractures varies and includes non-operative management such as wraps, casts, boots, hard soled shoes with or without weight bearing and also electromagnetic field treatment or ultrasound. Operative management is usually by screw fixation, but also by tension band wiring and/or bone grafts. The prognosis is good overall for these fractures. Depending on several factors (including the initial treatment) and the end point used (i.e. clinical fracture union, return to sports) treatment may take weeks to months.

has been described as the “incomplete healing of a fracture where the cortices of the bone fragments do not reconnect.” Some people will also use the term delayed union. Malunion is a fracture that has healed with a deformity such as rotation, angulation or an incongruent joint surface. Common reasons for malunion include poor blood supply, poor bone fixation (i.e. too much movement) or apposition (i.e. fragments are too far away from each other), behaviors (e.g. smoking, excessive alcohol ingestion, and noncompliance with treatment) and underlying medical problems. Medications may impair healing of fractures. Certain body sites are more common for nonunion because of poor blood supply including the fifth metatarsal, tibia, hamate and scaphoid bones.

Learning Point
Fracture complications include:

  • Acute
    • Injuries to adjacent structures
      • Arterial
      • Nerve
      • Other organs
    • Compartment syndrome
    • Fracture blisters of the skin
    • Fat embolism
    • Open fracture
    • Thromboembolic disease
  • Chronic
    • Arthritis, post-traumatic
    • Complex regional pain syndrome
    • Delayed union
    • Malunion
    • Osteomyelitis
  • Life-threatening
    • Hemorrhage
    • Rhabdomyolysis
    • Thromboembolic disease

Questions for Further Discussion
1. How does the presence of a wound or bone infection affect the risk for delayed or of fractures?

2. What are indications for orthopaedic consultation?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Fractures and Foot Injuries and Disorders.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Zwitser EW, Breederveld RS. Fractures of the fifth metatarsal; diagnosis and treatment. Injury. 2010 Jun;41(6):555-62.

Roche AJ, Calder JD. Treatment and return to sport following a Jones fracture of the fifth metatarsal: a systematic review. Knee Surg Sports Traumatol Arthrosc. 2013 Jun;21(6):1307-15.

Howe, AS. General Principles of Fracture Management: Early and Late Complications. UpToDate. Rev. 1/21/2014, cited 2/3/2014.

ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    6. Information technology to support patient care decisions and patient education is used.
    7. All medical and invasive procedures considered essential for the area of practice are competently performed.
    8. Health care services aimed at preventing health problems or maintaining health are provided.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Systems Based Practice
    23. Differing types of medical practice and delivery systems including methods of controlling health care costs and allocating resources are known.
    24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

  • What Are the Potential Side Effects of Iron Therapy?

    Patient Presentation
    A 15-month-old caucasian male came to clinic for his health supervision visit. He was developing and growing normally and his parents had no concerns. He was taking a mixed diet appropriate for his age with ~20 ounces of whole milk daily. The pertinent physical exam showed a healthy appearing male with growth parameters at the 75% and a normal examination. His screening laboratory evaluation showed a hemoglobin of 10.6 mg/dL.

    The new intern wasn’t sure how to manage the diagnosis of anemia and asked about how much iron to prescribe. His medical record review noted a normal neonatal screening test and normal complete blood count at birth done because of a maternal fever. After discussion with her attending physician, they decided that this presumably was iron deficiency anemia, and they would treat with supplemental iron for 1 month and then followup with repeat labs including a reticulocyte count. The attending noted that in general, additional iron in a healthy infant doesn’t cause problems, so he prescribes 3-6 mEq/kg of elemental iron rounding this up to an amount that is easy for the parent to give. He also told the intern that when the patient comes back she would be able to tell if the infant is getting the iron because his teeth will be non-permanently stained from the iron. The patient’s clinical course at one month showed a hemoglobin of 11.8 mg/dL and a reticulocyte count of 6.3%. His complete blood count was otherwise normal. He was to continue on the iron therapy for an additional 2 months.

    Discussion
    Anemia is a common problem in pediatrics with an estimated 25% of school age children worldwide being anemic. It can cause cognitive and developmental problems along with impaired immunity. It is defined as “a lower than normal value for the related measurements of hemoglobin, hematocrit, and number of red blood cells”, usually 2 standard deviations below the normal for age. Normal hematological values change with age. The most common type of anemia in childhood is iron deficiency commonly caused by inadequate stores (e.g. premature infant), inadequate intake (e.g. poor nutrition) or blood loss (e.g. menses). Anemia screening is recommended at age 9-12 months, and in adolescent males and females during routine health examinations. As iron deficiency is the most common cause, often a trial of therapeutic iron (2-6 mg/kg/day of elemental iron) is started and then a complete blood count is rechecked ~ 1 month later. If iron deficiency is the cause then there should be an increase of 10-20 g/L. If not other causes must be sought.

    For a review of iron deficiency anemia and lead poisoning, click here.
    For a review of non-correcting causes of anemia, click here.

    Learning Point
    Iron is an essential trace element needed mainly for heme synthesis, but also oxidative energy production, mitochrondrial respiration and DNA synthesis.

    Short term supplemental oral iron ingestion is known to cause nausea, emesis and abdominal pain due to presumed irritation of the gastrointestinal tract. These problems seem to be dose-dependent. Constipation and diarrhea can also be seen in approximately 6% of children but these problems seem to be less dose dependent. Other short term effects also include harmless discoloration of stools (black) and teeth (grey). For a review of differential diagnosis of abnormal tooth coloring click here or for different color stools click here.

    Iron overload can occur in patients with underlying disease states especially those that require blood transfusions including β-thalassemia, sickle cell anemia and other congenital anemias and often with cancer treatment. Iron overload can lead to chronic complications including cardiac toxicity with arrhythmias and congestive heart failure, hepatotoxicity with inflammation, fibrosis and cirrhosis, and endocrine problems including delayed puberty, growth failure, diabetes, hypoparathyroidism and hypothyroidism. Cardiac toxicity is the most common cause of death for patients with β-thalassemia. There have been some studies which showed an increased risk of malaria in patients taking iron supplementation. A 2011 Cochrane Collaboration review and the World Health Organization both recommend treating patients for iron deficiency anemia with iron supplementation in malaria-endemic areas.

    Questions for Further Discussion
    1. What is your general management plan for anemia found on routine screening?
    2. When do you order iron studies and which studies do you order?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

    Information prescriptions for patients can be found at MedlinePlus for these topics: Anemia and Iron.

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    To view videos related to this topic check YouTube Videos.

    Schumann K, Ettle T, Szegner B, Elsenhans B, Solomons NW. On risks and benefits of iron supplementation recommendations for iron intake revisited. J Trace Elem Med Biol. 2007;21(3):147-68.

    Kwiatkowski JL. Oral iron chelators. Pediatr Clin North Am. 2008 Apr;55(2):461-82, x.

    Okebe JU, Yahav D, Shbita R, Paul M. Oral iron supplements for children in malaria-endemic areas. Cochrane Database Syst Rev. 2011 Oct 5;(10):CD006589.

    Low M, Farrell A, Biggs BA, Pasricha SR. Effects of daily iron supplementation in primary-school-aged children: systematic review and meta-analysis of randomized controlled trials. CMAJ. 2013 Nov 19;185(17):E791-802.

    World Health Organization Iron supplementation in children in malaria-endemic regions.
    Available from the Internet at http://www.who.int/elena/titles/iron_infants_malaria/en/ (rev. 1/22/14, cited 1/31/14).

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    7. All medical and invasive procedures considered essential for the area of practice are competently performed.
    8. Health care services aimed at preventing health problems or maintaining health are provided.
  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
    16. Learning of students and other health care professionals is facilitated.

  • Systems Based Practice
    23. Differing types of medical practice and delivery systems including methods of controlling health care costs and allocating resources are known.
    24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

  • How Long Before Gastroparesis Improves?

    Patient Presentation
    A 5-year-old male came to clinic with a history of ~ 7 days where he would have emesis. The episodes occurred at random times usually at least 1 or more hours after he had eaten. He denied nausea and was still hungry but he would not eat as much as usual. The emesis did not have blood or mucous and was of the food and beverages he had consumed. Some of the food was ingested 12-18 hours previously. The episodes occurred twice a day at least and at any time of the day. They usually did not occur over night, but parents said that one time he had an episode about 5 AM in the morning. They were not sure if he was already awakened and then had emesis or if he was awoken by it. He did have some abdominal pain especially around the time of the emesis but was able to play normally. They also noted that his abdomen seemed to be slightly larger. He had normal urination but his bowel movements were less frequent. He still was having a normal soft stool at least daily to every other day without diarrhea. He denied any bad tastes in the back of his throat other than when he had emesis. The family denied any self-gagging behaviors and had a common variety of over-the-counter medications in the home. They also denied any social stressors, recent illnesses, trauma or foreign body ingestions. The past medical history revealed a healthy male with some minor illness and no surgeries. He had been a “spitty” baby, but had not had gastrointestinal problems since. The family history was positive for gastroesophageal reflux disease in a maternal aunt. The review of systems was negative including no fever or rashes.

    The pertinent physical exam showed a thin male in no distress. Vital signs were normal. His weight was 10% and was down 250 grams from a weight earlier in the month. His height was 25-50%. HEENT including his teeth, heart and lungs were normal. His abdomen was slightly enlarged overall with increased tympani with percussion. Bowel sounds appeared normal in all quadrants. There was no specific tenderness and no hepatosplenomegaly. The left upper quadrant seemed “fuller” on palpation but no specific mass was palpated. His genitourinary examination was normal as was his neurological examination. His hands did not show any bite marks. The diagnosis of emesis without an obvious cause was made. The work-up included a complete blood count, electrolytes, BUN, creatinine and urinalysis that were all negative. The radiologic evaluation of an abdominal radiograph showed an enlarged fluid filled stomach displacing the transverse colon inferiorly.

    The diagnosis of gastroparesis was made. A pediatric gastroenterologist was consulted by telephone and thought that it was most likely due to a virus that was not recognized and the patient was started on erythromycin for its prokinetic effects. The patient was scheduled for an upper gastrointestinal examination to rule out other potential causes of the emesis 5 days later that was normal. On followup at 10 days after treatment initiation, the history showed that the patient had had a slow diminution in the emesis that had completely stopped 3 days previously. He occasionally would still complain of abdominal pain and occasional bloating but his parents felt this was also decreasing. At his health supervision visit 2 weeks later his parents said that all the symptoms had resolved at least 1 week previously.

    Case Image

    Figure 109 – Upright abdominal radiograph shows an air fluid level in the fundus of an enlarged fluid filled stomach that is displacing the transverse colon inferiorly.

    Discussion
    [Gastroparesis] (GP) is a motor and sensory disorder of the stomach characterized by delayed gastric emptying in the absence of mechanical obstruction. Symptoms classically include nausea, vomiting, early satiety, bloating, postprandial fullness, abdominal pain and weight loss….GP is often not recognized and thus can remain untreated in children.”
    In the adult population, the age adjusted prevalence of GP is 9.6 (for men) and 37.8 (for women) per 100,000. There is no specific prevalence data available for children. It appears from some data that GP identification is rising and some data suggests that this is not due to increased incidence but due to increased awareness of the problem and more accurate classification.

    In one study, girls presented later than boys (9 versus 6.7 years), vomiting and abdominal pain occurred in more than 50% of patients and the delayed stomach emptying was more often characterized as mild.
    The most common causes in this study were idiopathic (70%), drugs (18%) and post-surgical (12.5) and post-viral (5%). In another study post-viral GP accounted for 18% of cases. It is possible that the some of the idiopathic cases are actually post-viral, and some sources quote idiopathic and post-viral as the two most common causes of gastroparesis in children.

    Treatment often include dietary changes (such as decreasing dietary fat or consuming lactose-free diets, having small frequent meals) and medications and rarely surgery.
    Medications include proton pump inhibitors and promotility agents (such as tegaserod, metoclopramide and erythromycin).

    Learning Point
    The good news about gastroparesis is that most patients resolve within weeks to a few months. In one study of the outcome of GP, “…the overall rate of symptom resolution was 52%, which was achieved at a median of 14 months from the time of diagnosis. In those patients in whom symptoms ultimately resolved, 84% did so by 12 months and all resolved by 36 months.”
    Factors associated with symptom resolution included younger age (infants > children > adolescents) male, postviral gastroenteritis, short duration of symptoms and response to prokinetic agents.

    Questions for Further Discussion
    1. What is in the differential diagnosis of emesis?
    2. When should a gastric-emptying study be considered for possible gastroparesis?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

    Information prescriptions for patients can be found at MedlinePlus for this topic: Stomach Disorders

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    To view videos related to this topic check YouTube Videos.

    Rodriguez L, Irani K, Jiang H, Goldstein AM. Clinical presentation, response to therapy, and outcome of gastroparesis in children. J Pediatr Gastroenterol Nutr. 2012 Aug;55(2):185-90.

    Waseem S, Islam S, Kahn G, Moshiree B, Talley NJ. Spectrum of gastroparesis in children. J Pediatr Gastroenterol Nutr. 2012 Aug;55(2):166-72.

    Nusrat S, Bielefeldt K. Gastroparesis on the rise: incidence vs awareness? Neurogastroenterol Motil. 2013 Jan;25(1):16-22.

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    7. All medical and invasive procedures considered essential for the area of practice are competently performed.
    8. Health care services aimed at preventing health problems or maintaining health are provided.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.

  • Systems Based Practice
    23. Differing types of medical practice and delivery systems including methods of controlling health care costs and allocating resources are known.
    24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital