3 - Late Complications of Fractures - D3

8/4/2019 3 - Late Complications of Fractures - D3

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Late complications of fractures


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Outlines

Delayed unioun

Non union

Malunion

Avascular necrosis

Osteoarthiritis

Shortening


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Normally fractures unite within 2 to 5 months.

Average times for fracture healing

Lower limbUpper limb

2-3 weeks2-3 weeksCallus visible

8-12 weeks4-6 weeksunion

12-16 weeks6-8 weeksconsolidation


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Delayed Union a fracture that has not healed after a reasonable time

period (the time in which it was expected to heal) haspassed.

Delayed union means that there are no signs of beginning

of union and the fragments are mobile 3 to 4 monthsafter injury.

Signs of union: Callus formation, less mobility, less pain,and medullary canal formation.


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Delayed Union

Causes1. Poor blood supply2. Severe soft tissue damage

3. infection4. Treatment complication

Excessive Periosteal stripping during internal fixation Imperfect splintage

- excessive traction- excessive movement at fracture site

Over rigid fixation


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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 periostealreacrtion

- the bone ends are not sclerosed or atrophic

( there is still a chance for union )


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Treatment: 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


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Non-union

Permanent failure of bone healing.

After 6 months

Movement can be elicited at the fracture site and paindiminishes

The fracture gap turns into pseudarthrosis

Delayed union may progress to Non union if nottreated in minority of cases.


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Non-union

X-ray :

- The fracture is clearly visible and the bone on eitherside 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 ofbridging the gap.

Atrophic :the bones tapered or rounded , osteogenesisceased


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TreatmentConservative:

1.Occasionally symptom less, needing no treatment2.Functional bracing may be sufficient to induce union

3.Electrical stimulation promotes osteogenesis

Operative

1.Very rigid internal fixation with hypertrophic non-union

2.Fixation with bone graft is needed in case of atrophicnon union


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Mal-union

Fragments join in an unsatisfactory position (unacceptable angulation, rotation or shortening)

Causes:Failure to reduce a fracture adequatelyFailure to hold reduction while healing

proceeds

Gradual collapse of osteoporotic bone


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X-ray are essential to check the position of the fracture whileuniting during the first 3 weeks so it can be easily corrected

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 comparedwith its opposite fellow

Mal-union


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Treatement: In adults

- fracture should be reduced as near to the anatomical

position as possible, apposition is important for healingwherease alignment and rotation its important for function

Angulation more than 10- 15 degrees in long bone orapparent 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 shortening1. Shortening less than 2 cm: compensated by shoe raise

2. Shortening more than 2 cm: limb length equalizationprocedures


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Avascular necrosis

Certain regions are known for their propensity todevelop ischemia and necrosis after injury.

Its Early complication because ischemia occurs during

the first few hours but the clinical and radiologicaleffects are seen until weeks or months later .

Symptomless

v


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Site Cause

Head of the femur

Fracture neck of the femur.

Posterior dislocation of thehip

Proximal pole ofscaphoid

Fracture through the waistof the scaphoid

lunate Following dislocation

Body of the talus Fracture through neck ofthe talus

Avascular necrosis


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Avascular necrosis

Consequences:-

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 boneingrowth in the necrotic segment and disuse osteoprosis in the

surrounding parts )

Bone scan:- changes can be seen before X-ray changes, Visible ascold area on the bone.


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Treatment:- Avascular necrosis can be prevented by early reduction

of susceptible fractures and dislocations.

Arthroplasty - Old people with necrosis of the femoralhead.

Realignment osteotomy or arthrodesis - for younger

people with necrosis of the femoral head Symptomatic treatment for scaphoid or talus


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Avascular necrosis


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


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osteoarthritis

A fracture involving a joint may damage the articularcartilage and give rise to post traumatic osteoarthritiswithin a period of months.

Even if the cartilage heals, irregularity of the jointsurface may cause localized stress and so predispose tosecondary osteoarthritis years later


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osteoarthritis

Treatment:-The goal of every treatment for arthritis is to:-

1.reduce pain and stiffness,

2.allow for greater movement, and3.slow the progression of the disease

Anti-Inflammatory Medications

Cortisone Injections

Occupational and physiotherapy

Weight LossActivity Modification

Diet: obesity is a risk factor for developing osteoarthritis


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Shortening

It is a common complications of fracturesand results from:-

1.Mal union of the long bones2.Crushing: Actual bone loss3.Growth defects: growth plate

or epiphyseal injuries


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Treatment:-Shortening of upper limbs goes unnoticed

For lower limb treatment depends upon theamount of shortening:

1.Shortening less than 2 cm: compensated by shoe raise

2.Shortening more than 2 cm: limb length equalizationprocedures


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Thank you

3 - Late Complications of Fractures - D3

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