1. LATE COMPLICATIONS OF FRACTURES

2. LATE COMPLICATIONS 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

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 Upper Limb Lower Limb Callus visible 2-3 wks Union
Consolidation
6-8 wks
12-16 wks

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

16. 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

17. Treatment Prevention : Joint stiffness has occurred: - 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

18. 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)

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

20. 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

21. AVASCULAR NECROSIS Circumscribed bone necrosis Common site : 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

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

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

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

26. 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

27. X-Ray Patchy rarefaction of the bones (patchy osteoporosis)
Algodystrophy

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

29. OSTEOARTHRITIS Post-traumatic OA secondary 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

30. Clinical features Treatment 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)

31. Thank You