LATE COMPLICATIONS OF FRACTURES

By: Akram Khatri Reg No.08M0005

Outlines
Local 1. Delayed union 2. Nonunion 3. Malunion 4. Joint stiffness 5. Contractures 6. Myositis ossificans 7. Avascular necrosis 8. Algodystrophy (or Sudeck's atrophy) 9. Osteomyelitis 10.Growth disturbance or deformity 1. 2. 3. Systemic Gangrene, tetanus, septicaemia Fear of mobilising Osteoarthritis

Delayed Union
Normally the fracture unites within 2-5 months Time taken for fracture healing

Upper Limb Callus visible Union Consolidation 2 - 3 weeks 4 6 weeks 6 8 weeks

Lower limb 2 3 weeks 8 12 weeks 12 16 weeks

NonUnion of fracture
Lack of complete bone healing in specified time frame generally 6 -8 months Non union occurs when further healing doesnt occur without intervention Time to heal depends on
1. 2. 3. 4. Bone involved Anatomical region Fracture pattern Method of treatment

 Cessation of oeriosteal and not the endosteal healing response prior to fracture bridging is non union at cellulae level

Presentation
Pain at fracture site Nonuse of extremity Tenderness and swelling Joint stiffness (prolonged >3 months) Movement around the fracture site (pseudarthrosis)

Pathophysiology in nonunion
Fracture specific factors
Open fracture with extensive soft tissue injury Sp. Bones involved Metaphysis> diaphysis High energy fracture

Host factor related to fracture

Age of patient Diabetis mellitus Smoking Malnutrition and immunocompromised state

Treatment factor
Stablity of fracture Technique of stablisation infection

Classification
Non union is of two type
Aseptic and septic

Furthur classified into

Atrophic Oligotrophic Hypertrophic Frank pseudarthrosis

Evaluation and Diagnosis

History and Examination Plain radiograph CT sacn Bone scan
Technetium 99 methylene diphosphonate bone scintigraphy Tc99 and Ga67 used to detect infection at fractered site

Treatment
Conservative
1.Elemination of any posible cause of delayed union 2.Promote healing by providing most apropriate biological environment 3.Immobilization 4.Healing stimulated by encouraging muscle exercise and weight bearing casts or braces

Operative management
Dealyed union for more than 6 months with no signs of callus formation Internal fixation and bone grafting are indicated Autogenous bone graft Bone graft subtitutes
Eg. Bone morphogenic proteins

MalUnion
Presents with a set of bone deformities Deformities can be in term of length, angulation, rotation and translation

Evaluation
Clinical
Review of medical history Evaluation of any medical history Manual stressing at malunion site, if it causes pain it signifies non healed fracture Movement of limb proximal and distal to malunion site

Plain radiograph
Both AP and lateral view also in flexion and extension It shows: limb alignment, joint orientation, anatomical and mechamical axes and CORA

Types of deformities
Length: shortening/lengthning Treatment
Acute traction/compression Autologus calcellous or cortical bone graft Vascularised auto graft Mesh cage bone graft construct Synontosis technique

Angulation
Treatment
Making osteotomy Obtaining realignment of bony segment Securing fixation during healing

Rotation
Treatment
Osteotomy Followed by rotational reallignment followed by stratification

Translational
Treatment(3 methods)
Single osteotomy, correction of translation and not angulation, length constant Single oblique osteotomy, restoration of alignment, length increased 2 wedge osteotomy, straightning, increased length

Joint stiffness
Most common sites:knee, elbow, sholder, small joints of hand Pathophysiology
Oedema and fibrosis of the capsule, the ligament and the muscle around the joint Adhesion of soft tissue to each other or to underling bone Damage to joint forming heamoarthrosis leading to syonial adhesion Prolonged immobilizaton of joint and joint heald in a position where the ligaments are in shortest position

Treatment
Prevention is better than cure When splintage is required the joint should be held in position of safety For already stiff joint: physiotherapy and regular exercise For intraarticular adhesion: gentle manipulation under anaesthesia to free the joint Adhered/ contracted tissur to be released by operation

Contracture of Joint
Usually seen following arterial injury or compartment syndrome There occurs ischemic contracture of affected muscle: volkmans ischemic contracture Most common affected site: forearm, hand, the leg and foot

Presentation
Wasting of the forearm and hand and clawing of the fingers Intrinsic hand muscle fibrosis and shorter, pulling the fingers into flexion at the metacarpophalyngeal joint, extension at interphalyngeal joint, thumb remains abducted (Bunnells intrinsic plus position)

Treatment
Detachment of flexors at there origin and along the interosseous membrane in forearm Pedicle nerve graft Tendon transfer