complications of fractures-2

Complications of fractures
د.عادل الهنداوي Lecture -5-

Late complications:

Bone complications:
Delayed union: is undue prolongation of the time required for a given # to unite. (more than 3months of proper treatment)
Causes: 1-inadequate blood supply e.g. lower tibia, segmental, femoral neck, scaphoid &talus fractures.
2-infection, 3-incorrect splintage, 4-intact fellow bone,(e.g: . fractured tibia with intact fibula).
Clinically: the fracture site is still tender, if stress the bone, it is painful and may angulate.
X-ray shows the fracture line with little callus.
Treatment; treat the cause, like infection; correct the splintage.
Surgery: excise 2.5cm of the intact fellow bone e.g. fibula. If all fail treated by bone grafting.
Non union: in which no clinical and radiological evidence of bone healing of fracture after 6 months of proper treatment.
The causes are: 1-too large gap e.g. bone loss or excessive traction.
2-soft tissue interposition like muscle, periosteum or cartilage.
3-pathological lesion in the bone. 4- intra articular # due to synovial
fluid dissolving # hematoma. 5-same causes of delayed union.
Clinically: painless movement at the # site (psuedoarthrosis).
X-ray shows the # line smooth & sclerotic.
Types of non union: 1-Hypertrophic: with huge callus at both ends.
2-Atrophic: with no callus at bone ends.
Treatment: Conservative: some time is indicated especially in hypertrophic type by use functional bracing and electrical stimulation.
Operative: 1- refreshment:-by exploration of bone ends and excision of sclerotic and dead bone.
2- reactivation:- by use of bone graft on the bone ends to promote osteogenesis,especially in atrophic type.
3- reinforcement:-by use rigid fixation (internal or external).





Malunion:
It mean healing of fracture in an acceptable position due to inadequate reduction ,or inadequate immobilization.
Clinically: malunion may be evident, compares with other side is of help. X-ray is important for measurement of deformity.
Treatment: manipulation to acceptable alignment or if fully united, corrective osteotomy with internal or external fixation.

Avascular necrosis: bone ischemia and necrosis due to poor blood supply after injury, the usual sites are:
1- head of femur (after neck # or hip dislocation).
2- proximal part of scaphoid ( waist # ).
3- lunate (after dislocation).
4- talus body(following neck # ).
Clinically: after weeks or months, there will be nonunion or collapse of the affected bone causing pain & stiffness.
x-ray: increase density of the ischemic bone due to new bone ingrowth and disuse osteoporosis of the surrounding bones.

Myositis ossificans:
It means abnormal ossification in muscle following injury.
The usual sites is elbow or arm, sometimes, it occur without history of local trauma as in unconscious or elderly patients.
CF: early: pain, swelling & soft tissue tenderness. X-ray is normal.
At 3 weeks: the pain decrease & the joint become stiff.
X-ray shows fluffy calcifications.
At 8 weeks: a bony mass can be felt and seen on X-ray.
Treatment: rest the joint in position of function till pain subside, then start gentle active (not passive) exercise. Later, the bony mass, if limit the joint movement, can be excised.
Joint stiffness:
common sites: shoulder, elbow, knee &hands.
Causes:
1-intra articular causes: trauma to the joint causes haemarthrosis which cause synovial adhesions.
2-peri articular causes: edema in the capsule &soft tissues around the joint cause fibrosis& adhesion. 3-extra articular causes: adhesion of soft tissue &muscle to underlying bone causes limitation of movement.
Prevention: early exercise from the start and, if the joint has to be splinted, this should be in a position of function where the ligaments are at their longest (position of safety).
Treatment: physiotherapy, MUA, operative release of adhesion.


Osteoarthritis: causes:
1-intra articular # may damage the articular cartilage causing
early osteoarthritis( within months); or imperfect reduction of the # with irregularity of the joint surfaces causing late OA changes.
2-malunited shaft fracture may alter the mechanics of nearby joints causing late OA.
Treatment: early, conservative.
Late, operative(realignment osteotomy or joint replacement).

Reflex sympathetic dystrophy (algodystrophy, Sudeck s atrophy, complex regional pain syndrome): is due to peripheral sympathetic over activity.
Early: the patient get continuous burning pain, swelling,
redness and warmth of the affected part e.g. following
Colle s #, the hand is affected.
After few weeks: stiffness is more & the skin become atrophic.
X-ray shows patchy osteoporosis.
Treatment: elevation, active exercise, NSAID, severe cases may
get benefit from IV gaunithidine(sympatholytic drug).
Finally, sympathectomy may be required.



Paediatric fractures:

Fractures in children could be:
1-complete # like adult #,
2-green stick incomplete #, torus(buckle)#(in metaphysis)
3-plastic deformation(diaphyseal).
4-physeal injury.

physeal injuries:
About 10% of # in children occur through the physis
, if a # disturbance may occur. effect on growth which takes through proliferating layer, then premature fusion &later growth disturbance
(Salter-Harris) Classification of physeal injuries:
I- transverse # through the hypertrophied or calcified layer. Usually occur in infants, but also may occur at puberty like slipped upper femoral epiphysis. Prognosis is good.
II- transverse # through the physis, but at the edge it splits off a triangular fragment from the metaphysis. Prognosis is also good.
III- vertical # through the epiphysis then transversely through the physis splitting a segment off the epiphysis. This require accurate reduction to prevent growth disturbance.
IV- fracture that split the epiphysis & metaphysis. Prognosis is similar to typeIII.
V- longitudinal compression of the physis causing crushing which may end with growth arrest due to bony fusion. The # is not visible, so the diagnosis. is retrospective

Pathological fractures:
It means a fracture in abnormal bone ,occur without trauma or trivial trauma.
Causes:1-generalized bone disease:e.g; osteoporosis
2-local benign condition; bone cyst, infection
3- malignant bone tumor: osteosarcoma,secondary.