1. Late complications of fractures
Medical ppt

2. Outlines Delayed unioun Non union Malunion Avascular necrosis
Osteoarthiritis
Shortening

3. 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

4. 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.

5. 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

6. 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 )

8. 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

9. 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.

10. 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

12. 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

13. 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

14. 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

15. 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 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

16. 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

17. 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

18. 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.

19. 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

20. Avascular necrosis

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

22. 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

24. 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

25. 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

26. 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

27. Thank you
Medical ppt