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Pain: What types of pain after fractures are abnormal?

Abnormal Pain

If all goes well the bone unites and stops hurting, the soft tissue forms scar tissue which binds the injured parts together and restores function; finally the tissue remodels to transform into something very close to the original tissue. The normally painful parts of this process are the acute pain of the injury (hours), the post treatment pain from surgery or manipulation (days), the pain from the swelling and inflammatory phase of healing (weeks) and the aching from the re-building, remodeling phase (months). These pains are an inevitable consequence of the injury. The rest of this section deals with pain that is not inevitable and which may be a sign of trouble. The medical term for these processes is "complications" - which is more self explanatory than most jargon. Although there is some overlap, I have divided these subjects into early, medium term, recurring, and late pain, and painful fixation.

A word of warning. This account is for general knowledge and information. It is not for self-diagnosis. Most of these complications are rare. If your leg hurts for a time after a fracture most likely this is normal - ask anyone on the dicussion board! Do not use this account as a "shopping list" of problems and symptoms. You would do yourself a disservice, irritate and deceive your OS and diminish the value of the whole effort. Absolutely the last things you need are an increase in anxiety or treatment for a problem that doesn't exist; so please be careful in taking these accounts personally. These complications are rare. Less that 5% of patients with a broken leg will experience symptoms from any of these conditions. Each topic will be treated in depth in a separate page. This page treats the topics very briefly.

Early Painful Complications

These are problems that may occur to increase pain within days of the injury and its treatment. Since the leg is expected to hurt during that stage these problems may not be easy to diagnose.

Acute compartment syndrome
The pressure in the tissue compartments rises to the point where circulation to the muscles is compromised.
Infection
Acute infection occurs when pathogenic bacteria become established and grow in the wound or fracture site
Loss of fixation or position
If the fracture fragments are still mobile the fracture will be unusually painful
Neuro/vascular complications
Damage to nerve trunks or pressure on nerves will cause a burning pain and numbness or pins and needles sensation. Vascular injury may cause pain and numbness of the extremity.
Tight dressings/casts
Dressings or casts which dig into the leg may cause pain.
Deep Vein Thrombosis (DVT)
Blood clots forming inside veins may produce painful thrombo-phlebitis (translation: inflammation of the veins due to blood clotting)

Medium Term Painful Complications

These conditions must be considered if the "normal" pain that occurs with a fracture continues into the 3rd or 4th week post injury.

Infection
Unresolved deep infections caused by bacteria are painful and often also cause redness, tenderness and swelling of the region and the wound.
DVT
Although blood clots form at the time of the injury they may not produce symptoms of pain until later
Reflex Sympathetic Dystrophy (RSD)
This problem is a disturbance of the control of blood supply to an injured region. Normally there is a (reflex) increase in blood supply following the injury. As the inflammation settles the blood supply decreases. For some reason this decrease fails to occur in some people and the blood supply remains increased for many weeks. The result is throbbing, pain and stiffness.
Causalgia
Injury or pressure on a nerve causes a characteristic burning aching pain, often accompanied by sensitivity in the area of distribution of the nerve.
Delayed Union
A fracture which is not uniting may still be mobile and painful
Failure of Fixation
If the hardware is not strong enough for the stresses placed on the leg it will bend or break
or the screws will pull out. If fixation is lost in this way the fracture will be mobile and painful again.
Re-fracture

If a healing fracture is re-injured it will be painful again.

Recurring Painful Complications

In some situations the leg becomes painful again after a relatively pain free period.

Infection
Indolent or non virulent infections can smolder on for a long time with minimal symptoms then flare up.
Nonunion
A fracture which has failed to unite is most often painful.
Chronic Compartment Syndrome
Sometimes after injuries the muscles swell when you exercise and cause pain. This occurs quite late because you aren't able to exercise the muscles until the bone is well healed.

Late Painful Complications

Infection
Persistent infection is persistently painful
Compartment Syndrome
Unresolved compartment syndrome results in scarring and contracture of the affected muscle which usually causes long term pain.
Nonunion
A fracture which has failed to unite is most often painful.
Post Traumatic Arthritis
If the joint surface adjacent to the fracture was injured and rough as a result, the joint will wear down, causing painful post traumatic arthritis. This is a very common late complication of intra-articular fractures, particularly of the knee and ankle.
RSD
Persistent Reflex Sympathetic Dystrophy is a rare but serious cause of long term pain after injury
Stiffness

If joints fail to recover normal movement they may become painful or they may place stress on the next joint up and make that painful.
Avascular Necrosis of the Hip
After some types of hip fracture a small percentage lose the blood supply to the femoral head. Even if the fracture heals the dead bone may cause a long term problem with pain and arthritis. A similar problem can occur with fractures of the talus.


From: Katie

Avascular Necrosis can affect other joints as well - There's a knee condition called Osteochondritis which is similar, often caused by overstressing of the knee joint (often seen in sports-playing teenagers). It can turn up after fractures of the knee, particularly the condyles. The bad news is that it only shows up in MRI scans after the damage has been done. And it takes AGES to heal up. 12 months + 1 surgery so far... I'll let you know when I find out how long it does take...


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 29 August 2014
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