Fifth Stage Orthopedics Dr. Haider – Lecture 51
L a te C o m p lic a tio n s of F racturesDelayed union and non union :
When the fracture takes more time than expected to unite then it is delayed union
When the fracture fail to unite . For diagnosis of non union , 6 months of follow up
should pass without clinical and \or radiological signs of union.
Ca uses :
— Biological : - inadequate blood supply
- severe soft tissue damage
- excessive periosteal stripping
— Biomechanical : - inadeqaute reduction
- unstable fixation
— Patient related : - medical conditions like DM
- non compliant patie nt
Diagnosis :Delayed union : fracture tenderness persist , fracture
line in the xray with very little or no callus
Non union : pain diminished , movement in the
fracture site (pseudarthrosis or pseudojoint ) , xray show
atrophic or hypertrophic bone ends
Treatment :Delayed union : look for and treat the cause .
Non union : treated mainly by surgical fixatio n with
bone graft ( in Atrophic non union or without bone
graft in cased of hypertrophic Non union.
When the fragments join in an unsatisfactory position (unacceptable angulation,
rotation or shortening) the fracture is said to be malunited.
Causes are failure to reduce a fracture adequately, failure to hold reduction while
Treatment of malun ited fracture:In adults, Angulation of more than 10 –15 degrees in a long bone or a noticeable
rotational deformity may need correction by re - manipulation, or by osteotomy and
In children, angular deformities near the bone ends (and especially if the
deformity is in the same plane as that of movement of the nearby joint) will usually
remodel with time; rotationa l deformities will not
Shortening malunion may be treated by bone lengthening procedure.
Avascular necrosis :Certain regions are problematic for their
tendency to dev elop ischemia and bone
necrosis after injury.
- the head of the femur (after fracture of the
femoral n eck or dislocation of the hip);
- the proximal part of the scaphoid (after
fracture through its waist);
- the bo dy of the talus (after fracture of its
— Accurately speaking, this is an early
complication of bone injury, because
ischemia occurs during the first few
hours following fracture o r dislocation.
However, the clinical an d radiological effects
are not seen until weeks or even months
Clinical features of AVN :- Pain
- Increased bone density in the radiography
Tr eatment :
- Femoral head AVN – total hip arthroplasty
- Scaphoid or talus – conservative treatment or joint arthrodesis
Joint stiffness :— Commonly occurs in the knee, elbow, shoulder and (worst of all) small joints of the
— Due to oedema and fibrosis of the capsule, ligaments and muscles around the
joint, or adhesions of the soft tissues to each other or to the underlying bone.
— M ade worse by prolonged immobilization
— What is important is to prevent stiffness and to insist on skilled physiotherapy
until normal function is restored.
Treatment of joint sti ffness :
- Extensive physiotherapy
- Arthroscopic release of adhesions
- Open surgical release of adhesions ( ex. Stiff knee )
Sudeck’s atrophy :Algodystrophy , reflex sympathe tic
dystrophy , complex pain regional syndrome
( all refer to same entity )
C.F . :
— Continuous ‘ burning ‘ pain. local
swe lling, redness and warmth, and
— After few weeks the skin becomes pale
and atrophic, movements are
— X-rays characteristically show patchy
rarefaction of the bone.
- Elevation and active exercises are
essential to prevent and to treat CRPS.
- antiinflammatory drugs and adequate
analgesia are helpful.
- use of drugs like amitriptyline,
carbamazepine , gabapentin and
calcium channel blockers may help.
Ischemic contracture :Following arterial injury or compartment syndrome, the patient may develop
ischaemic contractures of the affected muscles ( Volkmann’s ischaemic contracture ).
The sites most commonly affected are the forearm and hand, leg and foot.
Myositis ossificans :— Heterotopic ossification in the muscle s
— Common sites : elbow or a blow to the brachialis, deltoid or quadriceps. especially
in unconscious or paraplegic patients
— x-ray may show fluffy calcification in the
— The joint should be rested in the position
of function until pain subsides; gentle
active movements are then begun.
— Months later, when the condition has
stabilized, it may be helpful to excise the
— Indomethacin or radiotherapy shoul d be
given to help prevent a recurrence.
Degenerative arthritis (osteoarthritis ) :A fracture involving a joint may severely damage
the articular cartilage and give rise to post -traumatic
Even if the cartilage heals, irregularity of the joint
surface may ca use localized stress and so predispose
to secondary osteoarthritis years later..
Thank You ,,,