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LATE COMPLICATIONS OF FRACTURES

LATE COMPLICATIONS OF FRACTURES. 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.

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LATE COMPLICATIONS OF FRACTURES

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  1. LATE COMPLICATIONS OF FRACTURES

  2. 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 LATE COMPLICATIONS

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

  4. PERKINS’ TIME TABLE

  5. Clinical features • Persistent pain at fracture site • Instability at fracture site • Non weight bearing • Disuse muscle atrophy • X-Ray • Visible fracture line • Very little callus formation or periosteal reaction

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

  7. 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

  8. 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)

  9. 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

  10. 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 • Fracture is clearly visible • Fracture ends are rounded, smooth and sclerotic • Atrophic 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

  11. Hypertrophic non-union Atrophic non-union

  12. 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

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

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

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

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

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

  18. Clinical features • Pain, soft tissue tenderness • Local swelling • Joint stiffness • Limitation of movements • Extreme cases: - Bone bridges the joint - Complete loss of movement (extra-articularankylosis) • X-Ray • Normal • Fluffy calcification in the soft tissue

  19. Treatment • Early stage : Joint should be rested • Then : Gentle active movements • When the condition has stabilized : Excision of the bony mass • Anti-inflammatory drugs may ↓ joint stiffness

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

  21. Conditions associated with AVN • Perthes’ disease • Epiphyseal infection • Sickle cell disease • Caisson disease • Gaucher’s disease • Alcohol abuse • High-dosage corticosteroid

  22. Clinical features • Joint pain, stiffness, swelling • Restricted movement • X-Ray • ↑ bone density • Subarticular fracturing • Bone deformity

  23. Treatment • Avoid weight bearing on the necrotic bone • Revascularisation (using vascularised bone grafts) • Excision of the avascular segment • Replacement by prostheses

  24. 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 • Continuous, burning pain • Early stage : Local swelling, redness, warmth • Later : Atrophy of the skin, muscles • Movement are grossly restricted

  25. X-Ray • Patchy rarefaction of the bones (patchy osteoporosis) Osteoporosis Algodystrophy

  26. Treatment • Physiotherapy (elevation & active exercises) • Drugs - Anti-inflammatory drugs - Sympathetic block or sympatholytic drugs (Guanethidine)

  27. OSTEOARTHRITIS • Post-traumatic OA • Joint fracture with severely damaged articular cartilage • Within period of months • secondary OA • Cartilage heals • Irregular joint surface may caused localized stress → secondary OA • Years after joint injury

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

  29. Thank You

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