Late complications of fractures Medical ppt http://hastaneciyiz.blogspot.com

Outlines Delayed unioun Non union Malunion Avascular necrosis Osteoarthiritis Shortening

Normally fractures unite within 2 to 5 months. Average times for fracture healing Lower limb Upper limb 2-3 weeks Callus visible 8-12 weeks 4-6 weeks union 12-16 weeks 6-8 weeks consolidation

Delayed Union a fracture that has not healed after a reasonable time period (the time in which it was expected to heal) has passed. Delayed union means that there are no signs of beginning of union and the fragments are mobile 3 to 4 months after injury. Signs of union: Callus formation, less mobility, less pain, and medullary canal formation.

Delayed Union Causes - excessive traction Poor blood supply Severe soft tissue damage infection Treatment complication Excessive Periosteal stripping during internal fixation Imperfect splintage - excessive traction - excessive movement at fracture site Over rigid fixation

Delayed Union Signs: The fractured site is usually tender Acute pain when the bone is subjected to stress The fracture is not consolidated X-ray: - the fracture line remains visible - little or no callus formation or periosteal reacrtion - the bone ends are not sclerosed or atrophic ( there is still a chance for union )

Treatment: Operative : Conservative: (1) eliminate any possible cause of delayed union (2) Promote healing by providing the most appropriate biological environment. (3) immobilization (4) Union stimulus by encouraging muscular exercise and wieght bearing cast or brace Operative : Delayed union more than 6 months without signs of callus formation Internal fixation or bone grafting are indicated

Non-union Permanent failure of bone healing. After 6 months Movement can be elicited at the fracture site and pain diminishes The fracture gap turns into pseudarthrosis Delayed union may progress to Non – union if not treated in minority of cases.

Non-union X-ray : The fracture is clearly visible and the bone on either side of it may be either exuberant or rounded off. 2 types hypertrophic : bones ends are enlarged suggesting that oseogenesis is still active but not capable of bridging the gap. Atrophic :the bones tapered or rounded , osteogenesis ceased

Treatment Conservative: Operative Occasionally symptom less, needing no treatment Functional bracing may be sufficient to induce union Electrical stimulation promotes osteogenesis Operative Very rigid internal fixation with hypertrophic non-union Fixation with bone graft is needed in case of atrophic non union

Mal-union Fragments join in an unsatisfactory position ( unacceptable angulation, rotation or shortening) Causes: Failure to reduce a fracture adequately Failure to hold reduction while healing proceeds Gradual collapse of osteoporotic bone

Mal-union Clinical features: Deformity usually obvious , but sometimes the true extent of malunion is apparent only on x-ray Rotational deformity can be missed in the femur, tibia, humerus or forearm unless is compared with it’s opposite fellow X-ray are essential to check the position of the fracture while uniting during the first 3 weeks so it can be easily corrected

Treatement: In lower limb shortening In adults - fracture should be reduced as near to the anatomical position as possible, apposition is important for healing wherease alignment and rotation it’s important for function Angulation more than 10- 15 degrees in long bone or apparent rotational deformity may need correction by re-manipulation or by osteotomy and internal fixation In children angular deformity near the bone ends often remodel with time Rotational deformity will not In lower limb shortening Shortening less than 2 cm: compensated by shoe raise Shortening more than 2 cm: limb length equalization procedures

Avascular necrosis Certain regions are known for their propensity to develop ischemia and necrosis after injury. It’s Early complication because ischemia occurs during the first few hours but the clinical and radiological effects are seen until weeks or months later . Symptomless

Avascular necrosis Site Cause Head of the femur Fracture neck of the femur. Posterior dislocation of the hip Proximal pole of scaphoid Fracture through the waist of the scaphoid lunate Following dislocation Body of the talus Fracture through neck of the talus

Avascular necrosis Consequences:- Diagnosis Avascular necrosis causes deformation of the bone. This leads, a few years later, to secondary osteoarthritis and causes painful limitation of joint movement. Diagnosis X-ray – shows increase in bone density (consequence of new bone ingrowth in the necrotic segment and disuse osteoprosis in the surrounding parts ) Bone scan:- changes can be seen before X-ray changes, Visible as cold area on the bone.

Treatment:- Avascular necrosis can be prevented by early reduction of susceptible fractures and dislocations. Arthroplasty - Old people with necrosis of the femoral head. Realignment osteotomy or arthrodesis - for younger people with necrosis of the femoral head Symptomatic treatment for scaphoid or talus

Avascular necrosis

Avascular necrosis of the head of the femur (Bone scan)

osteoarthritis A fracture involving a joint may damage the articular cartilage and give rise to post traumatic osteoarthritis within a period of months. Even if the cartilage heals, irregularity of the joint surface may cause localized stress and so predispose to secondary osteoarthritis years later

osteoarthritis Treatment:- The goal of every treatment for arthritis is to:- reduce pain and stiffness, allow for greater movement, and slow the progression of the disease Anti-Inflammatory Medications Cortisone Injections Occupational and physiotherapy Weight Loss Activity Modification Diet: obesity is a risk factor for developing osteoarthritis

Shortening It is a common complications of fractures and results from:- Mal union of the long bones Crushing: Actual bone loss Growth defects: growth plate or epiphyseal injuries

Treatment:- Shortening of upper limbs goes unnoticed For lower limb treatment depends upon the amount of shortening: Shortening less than 2 cm: compensated by shoe raise Shortening more than 2 cm: limb length equalization procedures

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