LATE COMPLICATIONS OF FRACTURES LATE COMPLICATIONS Delayed union

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LATE COMPLICATIONS OF FRACTURES

LATE COMPLICATIONS OF FRACTURES

LATE COMPLICATIONS • • Delayed union Non-union Malunion Joint stiffness Myoisitis ossificans Avascular necrosis

LATE COMPLICATIONS • • Delayed union Non-union Malunion Joint stiffness Myoisitis ossificans Avascular necrosis Algodystrophy Osteoarthritis • Joint instability • Muscle contracture (Volkmann’s contracture) • Tendon lesions • Nerve compression • Growth disturbance • Bed sores

DELAYED UNION • Fracture that has not healed in the expected time for type

DELAYED UNION • Fracture that has not healed in the expected time for type of fracture, patient and method of repair • Causes Ø Inadequate blood supply Ø Severe soft tissue damage Ø Periosteal stripping Ø Excessive traction Ø Insufficient splintage Ø Infection

PERKINS’ TIME TABLE Upper Limb Lower Limb Callus visible 2 -3 wks Union 4

PERKINS’ TIME TABLE Upper Limb Lower Limb Callus visible 2 -3 wks Union 4 -6 wks 8 -12 wks Consolidation 6 -8 wks 12 -16 wks

§ Clinical features ØPersistent pain at fracture site ØInstability at fracture site ØNon weight

§ Clinical features ØPersistent pain at fracture site ØInstability at fracture site ØNon weight bearing ØDisuse muscle atrophy § X-Ray Ø Visible fracture line Ø Very little callus formation or periosteal reaction

 • Treatment Ø Conservative - To eliminate any possible cause - Immobilization -

• Treatment Ø Conservative - To eliminate any possible cause - Immobilization - Exercise Ø Operative - Indication : Union is delayed > 6 mths No signs of callus formation - Internal fixation & bone grafting

treatment of delayed union fractures • If alignment is adequate implants are stable but

treatment of delayed union fractures • If alignment is adequate implants are stable but motion exists at fracture sites: apply rigid fixation • If alignment is poor: straighten and apply rigid fixation • If reduction is inadequate: treat as nonunion

NON-UNION • Fracture has not healed and is not likely to do so without

NON-UNION • Fracture has not healed and is not likely to do so without intervention • Healing has stopped. Fracture gap is filled by fibrous tissue (pseudoarthrosis)

causes of nonunion • Instability at fracture site – inadequate method of stabilization, inadequate

causes of nonunion • Instability at fracture site – inadequate method of stabilization, inadequate postop care • Inadequate blood supply at fracture – Poor surgical technique following open reduction, following trauma at time of frature • Infection • Excessive gap at fracture site – Bone loss, distracting force not counteracted by method of fixation, bone loss from ischemia or infection • Excessive postop use of limb • Use of improper metals or combinations of dissimilar metals • Excessive quantities of implants

Clinical features § Painless movement at the fracture site §No pain at fracture site

Clinical features § Painless movement at the fracture site §No pain at fracture site §Instability at fracture site §May be weight bearing with pseudoarthrosis § X-Ray Ø Fracture is clearly visible ØFracture ends are rounded, smooth and sclerotic ØAtrophic non-union : - Bone looks inactive (Bone ends are often tapered / rounded) - Relatively avascular Hypertrophic non-union : - Excessive bone formation ` - on the side of the gap - Unable to bridge the gap

Hypertrophic nonunion Atrophic non-union

Hypertrophic nonunion Atrophic non-union

treatment of the 2 types of nonunion fractures. • Vascular nonunion – Rigid immobilization

treatment of the 2 types of nonunion fractures. • Vascular nonunion – Rigid immobilization – Open reduction and compression of fracture with cancellous bone graft • Avascular nonunion – Surgery required – Open medullary canal, debride sclerotic bone – Apply rigid fixation – Cancellous bone graft

MALUNION • Condition when the fragments join in an unsatisfactory position (unaccepted angulation, rotation

MALUNION • Condition when the fragments join in an unsatisfactory position (unaccepted angulation, rotation or shortening) • Causes Ø Failure to reduce a fracture adequately Ø Failure to hold reduction while healing proceeds Ø Gradual collapse of comminuted or osteoporotic bone.

 • Clinical features Ø Deformity & shortening of the limb Ø Limitation of

• Clinical features Ø Deformity & shortening of the limb Ø Limitation of movements § Treatment Ø Angulation in a long bone (> 15 degrees) → Osteotomy & internal fixation Ø Marked rotational deformity → Osteotomy & internal fixation Ø Shortening (> 3 cm) in 1 of the lower limbs → A raised boot OR Bone operation

JOINT STIFFNESS • Common complication of fracture Treatment following immobilization • Common site :

JOINT STIFFNESS • Common complication of fracture Treatment following immobilization • Common site : knee, elbow, shoulder, small joints of the hand • Causes Ø Oedema & fibrosis of the capsule, ligaments, muscle around the joint Ø Adhesion of the soft tissue to each other or to the underlying bone (intra & peri-articular adhesions) Ø Synovial adhesions d/t haemarthrosis

 • Treatment ØPrevention : - Exercise - If joint has to be splinted

• Treatment ØPrevention : - Exercise - If joint has to be splinted → Make sure in correct position ØJoint stiffness has occurred: - Prolonged physiotherapy - Intra-articular adhesions → Gentle manipulation under anaesthesia followed by continuous passive motion - Adherent or contracted tissues → Released by operation

MYOSITIS OSSIFICANS • Heterotopic ossification in the muscles after an injury • Usually occurs

MYOSITIS OSSIFICANS • Heterotopic ossification in the muscles after an injury • Usually occurs in Ø Dislocation of the elbow Ø A blow to the brachialis / deltoid / quadriceps § Causes Ø (thought to be due to) muscle damage Ø Without a local injury (unconscious / paraplegic patient)

 • Clinical features ØPain, soft tissue tenderness ØLocal swelling ØJoint stiffness ØLimitation of

• Clinical features ØPain, soft tissue tenderness ØLocal swelling ØJoint stiffness ØLimitation of movements ØExtreme cases: - Bone bridges the joint - Complete loss of movement (extra-articular ankylosis) § X-Ray ØNormal ØFluffy calcification in the soft tissue

 • Treatment ØEarly stage : Joint should be rested ØThen : Gentle active

• Treatment ØEarly stage : Joint should be rested ØThen : Gentle active movements ØWhen the condition has stabilized : Excision of the bony mass ØAnti-inflammatory drugs may ↓ joint stiffness

AVASCULAR NECROSIS • Circumscribed bone necrosis • Causes Ø Interruption of the arterial blood

AVASCULAR NECROSIS • Circumscribed bone necrosis • Causes Ø Interruption of the arterial blood flow Ø Slowing of the venous outflow leading to inadequate perfusion • Common site : Ø Femoral head Ø Femoral condyls Ø Humeral head Ø Capitulum of humerus Ø Scaphoid (proximal part) Ø Talus (body) Ø Lunate

 • Conditions associated with AVN ØPerthes’ disease ØEpiphyseal infection ØSickle cell disease ØCaisson

• Conditions associated with AVN ØPerthes’ disease ØEpiphyseal infection ØSickle cell disease ØCaisson disease ØGaucher’s disease ØAlcohol abuse ØHigh-dosage corticosteroid

 • Clinical features ØJoint pain, stiffness, swelling ØRestricted movement § X-Ray Ø↑ bone

• Clinical features ØJoint pain, stiffness, swelling ØRestricted movement § X-Ray Ø↑ bone density ØSubarticular fracturing ØBone deformity

 • Treatment ØAvoid weight bearing on the necrotic bone ØRevascularisation (using vascularised bone

• Treatment ØAvoid weight bearing on the necrotic bone ØRevascularisation (using vascularised bone grafts) ØExcision of the avascular segment ØReplacement by prostheses

ALGODYSTROPHY (COMPLEX REGIONAL PAIN SYNDROME) • Previosly known as Sudeck’s atrophy • Post-traumatic reflex

ALGODYSTROPHY (COMPLEX REGIONAL PAIN SYNDROME) • Previosly known as Sudeck’s atrophy • Post-traumatic reflex sympathetic dystrophy • Usually seen in the foot / hand (after relatively trivial injury) • Clinical features ØContinuous, burning pain ØEarly stage : Local swelling, redness, warmth ØLater : Atrophy of the skin, muscles ØMovement are grossly restricted

 • X-Ray ØPatchy rarefaction of the bones (patchy osteoporosis) Osteoporosis Algodystrophy

• X-Ray ØPatchy rarefaction of the bones (patchy osteoporosis) Osteoporosis Algodystrophy

§ Treatment ØPhysiotherapy (elevation & active exercises) ØDrugs - Anti-inflammatory drugs - Sympathetic block

§ Treatment ØPhysiotherapy (elevation & active exercises) ØDrugs - Anti-inflammatory drugs - Sympathetic block or sympatholytic drugs (Guanethidine)

OSTEOARTHRITIS • Post-traumatic OA ØJoint fracture with severely damaged articular cartilage ØWithin period of

OSTEOARTHRITIS • Post-traumatic OA ØJoint fracture with severely damaged articular cartilage ØWithin period of months § secondary OA ØCartilage heals ØIrregular joint surface may caused localized stress → secondary OA ØYears after joint injury

 • Clinical features Ø Pain Ø Stiffness Ø Swelling Ø Deformity Ø Restricted

• Clinical features Ø Pain Ø Stiffness Ø Swelling Ø Deformity Ø Restricted movement • Treatment Ø Pain relief : Analgesics Anti-inflam agent Ø Joint mobility : Physiotherapy Ø Load reduction : wt reduction Ø Realignment osteotomy (young pt) Ø Arthroplasty (pt > 60 yr)

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