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Fifth Stage Orthopedics Dr. Haider – Lecture 5

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L a te C o m p lic a tio n s of F ractures

Delayed 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
- infection
— Biomechanical : - inadeqaute reduction
- unstable fixation
- infection
— 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.

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Malunion:
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
healing proceeds

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
fixation .
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.
They are:
- 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
neck).
— Accurately speaking, this is an early
complication of bone injury, because
ischemia occurs during the first few
hours following fracture o r dislocation.

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However, the clinical an d radiological effects
are not seen until weeks or even months
later .

Clinical features of AVN :

- Pain
- Increased bone density in the radiography
Tr eatment :
- Femoral head AVN – total hip arthroplasty
or arthrodesis
- 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
hand.
— 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
tenderness.

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— After few weeks the skin becomes pale
and atrophic, movements are
increasingly restricted.
— X-rays characteristically show patchy
rarefaction of the bone.
Treatment :
- 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

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— x-ray may show fluffy calcification in the
soft tissues.
— 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
bony mass.
— 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
osteoarthritis.
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 ,,,


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