Late complications of fractures

Outlines
Delayed unioun Non union Malunion Avascular necrosis Osteoarthiritis Shortening

 Normally fractures unite within 2 to 5 months. Average times for fracture healing
Upper limb Lower limb

Callus visible union consolidation

2-3 weeks 4-6 weeks 6-8 weeks

2-3 weeks 8-12 weeks 12-16 weeks

Delayed Union
a fracture that has not healed after a reasonable time

period (the time in which it was expected to heal) has passed. Delayed union means that there are no signs of beginning of union and the fragments are mobile 3 to 4 months after injury.

Signs of union: Callus formation, less mobility, less pain,

and medullary canal formation.

Delayed Union
Causes
1. 2. 3. 4.
Poor blood supply Severe soft tissue damage infection Treatment complication Excessive Periosteal stripping during internal fixation Imperfect splintage

excessive traction excessive movement at fracture site

Over rigid fixation

Delayed Union
Signs:
The fractured site is usually tender Acute pain when the bone is subjected to stress The fracture is not consolidated X-ray:
- the fracture line remains visible - little or no callus formation or periosteal reacrtion - the bone ends are not sclerosed or atrophic ( there is still a chance for union )

Treatment:

(1) (2) (3) (4) Conservative: eliminate any possible cause of delayed union Promote healing by providing the most appropriate biological environment. immobilization Union stimulus by encouraging muscular exercise and wieght bearing cast or brace

Operative :
-

Delayed union more than 6 months without signs of callus formation Internal fixation or bone grafting are indicated

Non-union

Permanent failure of bone healing. After 6 months Movement can be elicited at the fracture site and pain diminishes The fracture gap turns into pseudarthrosis Delayed union may progress to Non union if not treated in minority of cases.

Non-union
X-ray : The fracture is clearly visible and the bone on either side of it may be either exuberant or rounded off. 2 types
hypertrophic : bones ends are enlarged suggesting that oseogenesis is still active but not capable of bridging the gap. Atrophic :the bones tapered or rounded , osteogenesis ceased

 Treatment
Conservative:
1.Occasionally symptom less, needing no treatment 2.Functional bracing may be sufficient to induce union 3.Electrical stimulation promotes osteogenesis

Operative
1.Very rigid internal fixation with hypertrophic non-union 2.Fixation with bone graft is needed in case of atrophic non union

Mal-union
Fragments join in an unsatisfactory position (
unacceptable angulation, rotation or shortening) Failure to reduce a fracture adequately Failure to hold reduction while healing proceeds Gradual collapse of osteoporotic bone

Causes:

Mal-union
Clinical features:

Deformity usually obvious , but sometimes the

true extent of malunion is apparent only on x-ray Rotational deformity can be missed in the femur, tibia, humerus or forearm unless is compared with its opposite fellow

X-ray are essential to check the position of the fracture while uniting during the first 3 weeks so it can be easily corrected

 Treatement:
In adults - fracture should be reduced as near to the anatomical position as possible, apposition is important for healing wherease alignment and rotation its important for function Angulation more than 10- 15 degrees in long bone or apparent rotational deformity may need correction by remanipulation or by osteotomy and internal fixation In children

angular deformity near the bone ends often remodel with time Rotational deformity will not

In lower limb shortening

1. Shortening less than 2 cm: compensated by shoe raise 2. Shortening more than 2 cm: limb length equalization procedures

Avascular necrosis
Certain regions are known for their propensity to

develop ischemia and necrosis after injury. Its Early complication because ischemia occurs during the first few hours but the clinical and radiological effects are seen until weeks or months later . Symptomless

Avascular necrosis
Site
Head of the femur Proximal pole of scaphoid lunate

Cause Fracture neck of the femur. Posterior dislocation of the hip

Fracture through the waist of the scaphoid Following dislocation

Body of the talus

Fracture through neck of the talus

Avascular necrosis
Consequences:Avascular necrosis causes deformation of the bone. This leads, a few years later, to secondary osteoarthritis and causes painful limitation of joint movement.

Diagnosis

X-ray shows increase in bone density (consequence of new bone

ingrowth in the necrotic segment and disuse osteoprosis in the surrounding parts ) Bone scan:- changes can be seen before X-ray changes, Visible as cold area on the bone.

 Treatment: Avascular necrosis can be prevented by early reduction

of susceptible fractures and dislocations. Arthroplasty - Old people with necrosis of the femoral head. Realignment osteotomy or arthrodesis - for younger people with necrosis of the femoral head Symptomatic treatment for scaphoid or talus

Avascular necrosis

Avascular necrosis of the head of the femur (Bone scan)

osteoarthritis
A fracture involving a joint may damage the articular
cartilage and give rise to post traumatic osteoarthritis within a period of months.

Even if the cartilage heals, irregularity of the joint

surface may cause localized stress and so predispose to secondary osteoarthritis years later

osteoarthritis
Treatment:The goal of every treatment for arthritis is to:1.reduce pain and stiffness, 2.allow for greater movement, and 3.slow the progression of the disease Anti-Inflammatory Medications Cortisone Injections Occupational and physiotherapy Weight Loss Activity Modification Diet: obesity is a risk factor for developing osteoarthritis

Shortening
It is a common complications of fractures
and results from:1.Mal union of the long bones 2.Crushing: Actual bone loss 3.Growth defects: growth plate
or epiphyseal injuries

 Treatment:Shortening of upper limbs goes unnoticed For lower limb treatment depends upon the
amount of shortening:
1.Shortening less than 2 cm: compensated by shoe raise 2.Shortening more than 2 cm: limb length equalization procedures

Thank you