Assessment of Post-Traumatic Complications of Long Bone Fractures in Iraq: A Multicenter Prospective Study

Abstract Background: Long bone fractures are a major driver of orthopaedic trauma morbidity in Iraq, where high-energy mechanisms, constrained resources, and operative delays plausibly increase risks of infection and impaired union. Yet prospective multicenter estimates of complication burden and its determinants remain limited. We aimed to quantify the incidence and pattern of post-traumatic complications and to identify independent predictors following operative fixation of long bone fractures at three Iraqi tertiary referral hospitals. Methods: We conducted a prospective cohort study at 3 private hospitals in Baghdad city from January 2021 to December 2023. Adults (≥18 years) with femur, tibia, humerus, radius, or ulna fractures undergoing operative fixation within 72 hours of presentation were enrolled. Outcomes at 12 months were pre-specified: surgical site infection, delayed union/nonunion, malunion, compartment syndrome, implant failure, and amputation. Independent predictors of major complications were evaluated using multivariable binary logistic regression. Results: Of 912 screened patients, 847 were enrolled (mean age 34.7 ± 14.2 years; 76.3% male); 803 completed 12-month follow-up. Road traffic accidents accounted for 58.4% of injuries, and 43.2% of fractures were open. Overall, 38.6% developed at least one major complication (327/847). Surgical site infection was most common (18.9%), followed by delayed union/nonunion (12.9%), malunion (8.4%), and implant failure (6.7%); the amputation rate was 3.2%. Multidrug-resistant organisms were recovered in 54.4% of positive wound cultures. Independent predictors of major complications were Gustilo–Anderson type III open fracture (aOR 4.82; 95% CI 3.21–7.24), operative delay >24 hours (aOR 3.17; 95% CI 2.08–4.83), diabetes mellitus (aOR 2.94; 95% CI 1.76–4.91), blast/gunshot mechanism (aOR 2.63; 95% CI 1.59–4.35), and BMI >30 kg/m² (aOR 1.87; 95% CI 1.23–2.84). Conclusion: Major complications after operative fixation of long bone fractures are frequent in Iraqi tertiary trauma care, with infection and impaired union predominating and MDR pathogens common. Risk concentrates in type III open injury, delayed surgery, diabetes, high-energy penetrating/blast mechanisms, and obesity—factors that are partially modifiable at system and patient levels. Priorities include antibiotic prophylaxis at first contact, streamlined pathways to definitive surgery, and antimicrobial stewardship. Keywords: long bone fracture; postoperative complication; open fracture; surgical site infection; nonunion; antimicrobial resistance; Iraq