Complication of fracture

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  • Type I open fracture can be managed with non-operative approach and closed reduction.
  • may lead to irreversible damage of the life supporting organs.Thirst, rapid shallow breathing, the lips and skin are pale and the extremities feel cold,if the compansation fails….. impaired renal function test and decreased urinary output.
  • Dopamine (1-20g/kg/min)Dobutamine (1-20g/kg/min)Adrenaline (1-20g/min)Noradrenaline (1-20g/min)
  • DIVC
  • It’s a re-perfusion injury seen after the release of crushing pressure, there will be release of muscular breakdown products(myoglobin,k+,p) which have nephrotoxic effect on the kidneyFirst describe by Eric Bywaters
  • It’s a re-perfusion injury seen after the release of crushing pressure, there will be release of muscular breakdown products(myoglobin,k+,p) which have nephrotoxic effect on the kidneyFirst describe by Eric Bywaters
  • Petechial haemorrhage
  • 4C – Colour – blue-black purpleConsistency – MushyContractibility – unableCut – not capable to bleedDeep, penetrating wound in muscular tissue should be explored, ALL DEAD TISSUE SHOULD BE COMPLETELY EXCISED, if there is doubt about tissue viability, the wound should be left opened
  • Neuropraxia = misspellingNeurapraxia = neuro + a [no] + praxia [action]Axonotmesis = axon + tmesis [cut]Neurotmesis = Nerve + tmesis [cut]
  • Complication of fracture

    1. 1. FRACTURES<br />AnandkumarBalakrishna<br />Wong Poh Sean<br />MohdHanafiRamlee<br />
    2. 2. CONTENT<br />DEFINITION<br />PRINCIPLE MANAGEMENT<br />COMPLICATIONS<br />
    3. 3. DEFINITION<br />
    4. 4. CAUSES<br />Sudden trauma<br />direct(fracture of the ulna caused by blow on the arm)<br />indirect(spiral fractures of the tibia and fibula due to torsion of the leg, vertebral compression fractures, avulsion fractures)<br />Stress or fatigue-repetitive stress(athletes, dancers, army recruits)<br />Pathological(osteoporosis, Paget’s disease, bone tumour)<br />
    5. 5. TYPES OF FRACTURES<br />
    6. 6.
    7. 7.
    8. 8. COMPLETE FRACTURES<br />
    9. 9.
    10. 10.
    11. 11.
    12. 12. INCOMPLETE FRACTURE<br />
    13. 13.
    14. 14. FRACTURES DISPLACEMENT<br />After a complete fracture the fragments usually displaced:<br />partly by the force of injury<br />partly by gravity<br />partly by the pull of muscles attached to them.<br />4 types: <br />Translation/Shift<br />Alignment/Angulation<br />Rotation/Twist<br />Altered length<br />
    15. 15. SIDEWAYS<br />OVERLAP<br />IMPACTION<br />
    16. 16. HOW FRACTURES HEAL?<br />Healing by callus<br />Healing without callus<br />
    17. 17. Healing by callus<br />Callus is the response to movement at the fracture site to stabilize the fragments as rapidly as possible.<br />Steps:<br />
    18. 18.
    19. 19.
    20. 20. Healing without callus<br />For fracture that is absolutely immobile:<br />impacted fracture in cancellous bone.<br />fracture rigidly immobilized by internal fixation<br />New bone formation occurs directly between fragments.<br />Gaps between the fracture surfaces are invaded by new capillaries & bone forming cells growing in from edges.<br />For very narrow crevices(<200um), osteogenesis produces lamellar bone(mature).<br />For wider gaps, osteogenesis begins with woven bone (immature) first which is then remodelled to lamellar bone (mature bone).<br />
    21. 21. RATE OF REPAIR DEPENDS UPON:<br />
    22. 22. CAUSES OF DELAYED UNION OR NON-UNION OF THE FRACTURES <br />
    23. 23. FRACTURES- PRINCIPLE OF TREATMENT<br />
    24. 24. Management of Closed Fracture<br />
    25. 25. First aid management <br />Airway, Breathing and Circulation<br />Splint the fracture <br />Look for other associated injuries<br />Check distal circulation – is distal circulation satisfactory? <br />Check neurology – are the nerve intact?<br />AMPLE history- Allergies, Medications, Past medical history, Last meal, Events <br />Radiographs – 2 views, 2sides, 2 joints, 2 times. <br />
    26. 26.
    27. 27. Principle Of Treatment<br />
    28. 28. The Fracture Quartet<br />
    29. 29. Outline<br />
    30. 30. Reduce<br />Aim for adequate apposition and normal alignment of the bone fragments<br />The greater contact surface area between fragments, the more likely is healing to occur<br />
    31. 31. However, there are some situations in which reduction is unnecessary:<br />When there is little or no displacement<br />When displacement does not matter (e.g. in some fractures of the clavicle)<br />When reduction is unlikely to succeed (e.g. with compression fracture of the vertebrae) <br />
    32. 32. Reduction<br />
    33. 33. Closed Reduction<br />Suitable for<br />Minimally displaced fractures<br />Most fractures in children<br />Fractures that are likely to be stable after reduction<br />
    34. 34. Most effective when the periosteum and muscles on one side of fracture remain intact<br />Under anaesthesia and muscle relaxation, a threefold manoeuvre applied:<br />Distal part of the limb is pulled in line of the bone<br />Disengaged, repositioned<br />Alignment is adjusted<br />
    35. 35.
    36. 36. Mechanical Traction<br />Some fractures (example fracture of femoral shaft) are difficult to reduce by manipulation because of powerful muscle pull<br />However, they can be reduced by sustained muscle mechanical traction; also serves to hold the fracture until it starts to unite<br />
    37. 37. Open Reduction<br />Operative reduction under direct vision<br />Indications:<br />When closed reduction fails<br />When there is a large articular fragment that needs accurate positioning<br />For avulsion fractures in which the fragments are held apart by muscle pull<br />When an operation is needed for associated injuries<br />When a fracture needs an internal fixation<br />
    38. 38.
    39. 39. Hold<br />
    40. 40. HOLD<br />
    41. 41. Sustained Traction<br /><ul><li>Traction is applied to limb distal to the fracture
    42. 42. To exert continuous pull along the long axis of the bone</li></li></ul><li>
    43. 43. Disadvantage and complications<br />Patient kept on bed for long time<br />Pressure ulcer<br />General weakness<br />Pulmonary infection<br />Contracture<br />Pin tract infection<br />Thromboembolic event<br />Methods<br />Traction by gravity<br />Balanced traction<br />Fixed traction<br />
    44. 44. Traction By Gravity<br />Example:<br /> Fracture of humerus<br /><ul><li>Weight of arm to supply traction
    45. 45. Forearm is supported in a wrist sling</li></li></ul><li>Balanced Traction<br />
    46. 46. Thomas’s Splint<br />
    47. 47.
    48. 48. Fixed Traction<br />Principle = balanced traction<br />Useful for when patient has to be transported<br />Thomas’s splint<br />
    49. 49. Cast Splintage<br />Methods:<br />Plaster of Paris <br />Fibreglass<br />Especially for distal limb # and for most children #<br />Disadvantage: joint encased in plaster cannot move and liable to stiffen<br />Can be minimized:<br />Delayed splintage (traction initially)<br />Replace cast by functional brace after few weeks<br />
    50. 50.
    51. 51. Complications<br />
    52. 52. Functional Bracing<br />
    53. 53.
    54. 54.
    55. 55. INTERNAL FIXATION<br />
    56. 56. Principle<br />
    57. 57. Indication<br />
    58. 58.
    59. 59. Type of internal fixation<br />
    60. 60.
    61. 61. advantages<br />
    62. 62.
    63. 63.
    64. 64.
    65. 65. Implant failureMetal is subjected to fatigue<br /><ul><li>Metal is subjected to fatigue
    66. 66. So, undue stress should therefore be avoided until the fragment has united.
    67. 67. Pain at the site of fracture site is a danger signal.</li></li></ul><li>Refracture<br /><ul><li>It is important not to remove the metal implant too soon
    68. 68. A year is minimum and 18 to 24 month is safer
    69. 69. For several weeks after the implant removal the bone is weak so full weight-bearing should be avoided</li></li></ul><li>EXTERNAL FIXATION<br />
    70. 70. Principle<br />
    71. 71. Indication<br />
    72. 72. (a)The patient was fixed with a plate and screw but did not unite (b) external fixation was applied<br />
    73. 73. Advantages<br />
    74. 74.
    75. 75.
    76. 76.
    77. 77.
    78. 78. Exercise<br />Prevention of edema<br />active exercise and elevation<br />Active exercise also stimulates the circulation. Prevents soft-tissue adhesion and promotes fracture healing.<br />Preserve the joint movement<br />Restore muscle power<br />Functional activity<br />
    79. 79. Management of Open Fractures<br />Abreakin skin and underlying soft tissues leading directly to communicating with the fracture<br />
    80. 80. Open Fracture<br />
    81. 81. First Aid & Management of the Whole Patient<br />
    82. 82. 1. Emergency Management of Open Fracture<br />A,B,C <br />Splint the limb <br />Sterile cover - prevent contamination<br />Look for other associate injury <br />Check distal circulation – is distal circulation satisfactory?<br />Check neurology – are the nerve intact?<br />AMPLE history- Allergies, Medications, Past medical history, Last meal, Events<br />Radiographs – 2 view, 2sides, 2 joints, 2 times. <br />Relieve pain <br />Tetanus prophylaxis<br />Antibiotics<br />Washout / Irrigation<br />Wound debridement <br />fracture stabilisation<br />80<br />
    83. 83. Open Fractures Classification<br />
    84. 84. Preoperative Assessment<br />
    85. 85. Preoperative Assessment<br />
    86. 86. Treatment- Outline<br />
    87. 87. 1) Analgesic + Antibiotic + AntitetanusProphylaxis<br />
    88. 88. Antibiotic<br /><ul><li>GustiloGrade I- first generation of cephalosporin for 72 hours
    89. 89. Gustilo Grade II- first generation cephalosporin for 72 hours + Gram negative coverage (gentamicin) for at least 72 hours
    90. 90. Gustilo Grade III- first generation cephalosporin +G –ve coverage for at least 72 hours
    91. 91. For soil contamination- penicillin is added for clostridial coverage</li></li></ul><li>2) Irrigation<br />
    92. 92. 3) Debridement<br />
    93. 93. Surgical Debridement<br />Type II and type III require surgical debridement. <br />Important aspect of wound management.<br />Reduce bacteria, remove foreign bodies, remove devitalized tissue. <br />Removal of dead tissue reduces bacterial burden and accelerate healing. <br />89<br />
    94. 94. 4) Wound Closure<br />
    95. 95. Wound Closure<br />Uncontaminated I & II can be sutured – provided without tension<br />All other wounds left open, packed with moist sterile gauze, to be inspected 24-48 hours – primary delayed closure<br />If wound cannot be closed without tension – skin grafting<br />
    96. 96. 5) Fracture Stabilization<br />
    97. 97. Stabilization of the fracture<br />To reduce infection and assist recovery of soft tissue<br />Depends on:<br />degree of contamination<br />length of time from injury to operation<br />amount of soft tissue damage<br />If <8 hours: up to IIIA treated as closed fractures:<br />Splintage<br />Intramedullary nailing<br />Plating <br />External fixation<br />Others: External fixation<br />
    98. 98. Aftercare<br />
    99. 99. COMPLICATION OF FRACTURE<br />
    100. 100. GENERAL<br />BONE<br />JOINT<br />SOFT TISSUE<br />
    101. 101. General Complications<br />Shock<br />Diffuse coagulopathy<br />Respiratory dysfunction<br />Crush syndrome<br />Venous thrombosis & Pulmonary embolism<br />Fat embolism<br />Gas Gangrene<br />Tetanus<br />
    102. 102. General 1: Shock<br />Altered physiologic status with generalized inadequate tissue perfusion relative to metabolic requirements.  irreversible damage to vital organs<br />
    103. 103. 1500-3000ml<br />500-1000ml<br />1500-3000ml<br />100-300ml<br />1000-2000ml<br />1000-2000ml<br />VOLUME DISTRIBUTION<br />
    104. 104. General 1: Shock<br />
    105. 105. General 2: DIFFUSE COAGULOPATHY <br />
    106. 106. General 3: RESPIRATORY DYSFUNCTION <br />
    107. 107. General 4: Crush Syndrome[traumatic rhabdomyolitis]<br />Serious medical condition characterized by major shock & renal failure following a crushing injury to skeletal muscles or tourniquet left too long<br />Bywaters’ Syndrome<br />
    108. 108. General 4: Crush Syndrome<br />
    109. 109. General 5: Deep vein thrombosis and pulmonary embolism.<br />Virchow’s triad factor  Clot formation in large vein  thrombus breaks off  Emboli<br />Site: leg, thigh and pelvic vein.<br />Risk factors:<br />
    110. 110. General 5: Management Deep vein thrombosis and pulmonary embolism.<br />Anticoagulation<br />Ambulate patient<br />Established thrombosis/embolism<br />Limb elevation<br />Heparinization<br />Thrombolysis<br />Oxygenation or ventilation<br />PREVENTION<br />Correct hypovolemia<br />Calf muscle exercise<br />Proper positioning<br />Well fitting bandages & cast<br />Limb elevation<br />Graduated compression stockings<br />Calf muscle stimulation<br />
    111. 111. General 6: Fat Embolism<br />Fat globules from marrow pushed into circulation by the force of trauma that causing embolic phenomena<br />
    112. 112. General 6: Fat Embolism <br />
    113. 113. General 6: Fat Embolism<br />SKIN: Fat droplets  obstruct alveolar capillaries  thromboplastin release  consumption of coagulation fx & platelets  DIVC/Skin necrosis  Petechia<br />LUNG: Fat droplets  obstruct alveolar capillaries  thromboplastin release  alter membrane permeability / lung surfactant  oedema  respiratiory failure [V/Q Mismatch]<br />BRAIN: Fat droplets  obstruct capillaries  confusion  coma/fits  death<br />
    114. 114. General 7: Gas Gangrene<br />Rapid and extensive necrosis of the muscle accompanied by gas formation and systemic toxicity due to clostridium perfringens infection<br />
    115. 115. General 7: Gas Gangrene<br />Prevention: ALL DEAD TISSUE [4C] SHOULD BE COMPLETELY EXCISED, <br />
    116. 116. General 8: Tetanus<br />A condition after clostridium tetani infection that passes to anterior horn cells where it fixed and cant be neutralized later produces hyper-excitability and reflex muscle spasm <br />
    117. 117. Early Complications<br />Visceral Injury<br />Vascular Injury<br />Compartment Syndromes<br />Nerve injury<br />Haemarthrosis<br />Infection<br />
    118. 118. Early 1: Visceral injury<br />Fractures around the trunk are often complicated by visceral injury.<br />E.g. Rib fractures  pneumothorax / spleen trauma / liver injuries.<br />E.g. Pelvic injuries  bladder or urethral rupture / severe hematoma in the retro-peritoneum .<br />Rx: Surgery of visceral injuries<br />
    119. 119. Early 2: Vascular injury<br />Commonly associated with high-energy open fractures. They are rare but well-recognized.<br />Mechanism of injuries:<br />The artery may be cut or torn. <br />Compressed by the fragment of bone. <br />normal appearance, with intimal detachment that lead to thrombus formation.<br />segment of artery may be in spasm.<br />It may cause<br />Transient diminution of blood flow<br />Profound ischaemia<br />Tissue death and gangrene<br />
    120. 120. Early 2: Vascular injury<br />X-ray: suggest high-risk fracture.Angiogram should be performed to confirm diagnosis.<br />
    121. 121. Early 2: Vascular injury<br />muscle ischaemic is irrevesible after 6 hours.<br />Remove all bandages and splint & assess circulation<br />Skeletal stabilization – temporary external fixation.<br />Definitive vascular repair.<br />Vessel sutured<br />endarterectomy<br />
    122. 122. Early 3: Compartment Syndrome<br />A condition in which increase in pressure within a closed fascial compartment leads to decreased tissue perfusion. <br />Untreated, progresses to tissue ischaemia and eventual necrosis<br />
    123. 123. Early 3: Compartment Syndrome<br />Most common sites (in ↓ freq): leg (after tibial fracture) -> forearm -> thigh -> upper arm. Other sites: hand, foot, abdomen, gluteal and cervical regions.<br />High risk injuries:<br /># of elbow, forearm bones, and proximal 3rd of tibia (30-70% after tibial #)<br />multiple fracture of the foot or hand<br />crush injuries<br />circumferential burns<br />
    124. 124. Early 3: Compartment Syndrome [aetiology]<br />
    125. 125. Early 3: Compartment<br /> Syndrome <br />Vicious cycle<br />↑ fluid content<br />Constriction of compartment<br />↑ INTRACOMPARTMENTAL PRESSURE<br />Capillary basement membranes become leaky -> oedema<br />Obstruct venous return<br />Vascular congestion<br />Muscle and nerve ischaemia<br />Further ↑ intracompartmental pressure<br />↓ capillary perfusion<br />Compromise arterial circulation<br />-> PROGRESSIVE NECROSIS OF MUSCLES AND NERVES !!<br />
    126. 126.
    127. 127. A vicious circle that ends after 12 hours or less<br />Necrosis of the nerve and muscle within the compartment<br />Nerve<br />-capable to regenerate<br />Muscle<br />-infarcted<br />Never recover<br />Replaced by inelastic fibrous tissue<br />( Volkmann’s ischaemic contracture)<br />
    128. 128. Investigations of compartment sydromes<br />Intra-compartment Pressure Measurement (ICP)<br />Use of slit catheter; quick and easy<br />Indications:<br />Unconscious patient<br />Those who are difficult to assess<br />Concomitant neurovascular injury<br />Equivocal symptoms<br />Especially long bone # in lower limb<br />Perform as soon as dx considered<br />> 40mmHg – urgent Rx! (normal 0 – 10 mmHg)<br />
    129. 129. Investigations of compartment syndromes<br />Other Ix – limited value; +ve only when CS is advanced<br />Plasma creatinine and CPK<br />Urinanalysis – myoglobinuria<br />Nerve conduction studies <br />Ix to establish underlying cause or exclude differentials<br />X-ray of affected extremity <br />Doppler US/arteriograms – determine presence of pulses; exclude vascular injuries and DVT<br />PT/APTT – exclude bleeding disorder<br />
    130. 130. Management<br />Prompt DECOMPRESSION of affected compartment<br />Remove all bandages, casts and dressings<br />Examination of whole limb<br />Limb should be maintained at heart level<br />Elevation may ↓ arterio-venous pressure gradient on which perfusion depends<br />Ensure patient is normotensive. <br />Hypotension ↓ tissue perfusion, aggravate the tissue injury.<br />
    131. 131. Management<br />Measure intra-compartment pressure<br />If > 40mmHg<br />Immediate open fasciotomy<br />If < 40mmHg<br />Close observation and re-examine over next hour<br />If condition improve, repeated clinical evaluation until danger has passed<br />Don’t wait for the obvious sings of ischemia to appear. If you suspect <br />An impending compartment syndrome, start treatment straightaway<br />
    132. 132. Fasciotomy<br />Opening all 4 compartments<br />Divide skin and deep fascia for the whole length of compartment<br />Wound left open<br />Inspect 5 days later<br />If muscle necrosis, do debridement<br />If healthy tissue, for delayed closure or skin grafting<br />
    133. 133.
    134. 134. Complications<br />Volkmann’s ischaemiccontracture <br />Motor/sensory deficits<br />Kidney failure from rhabdomyolysis (if very severe)<br />Infection – fasciotomy converts closed # to open #<br />Loss of limb<br />Delay in bone union<br />Prognosis<br />excellent to poor, depending on how quickly CS is treated and whether complications develop<br />
    135. 135. Early 4: Nerve Injury<br />It’s more common than arterial injuries.<br />The most commonly injured nerve is the radial nerve [in its groove or in the lower third of the upper arm especially in oblique fracture of the humerus]<br />Common with humerus, elbow and knee fractures<br />Most nerve injuries are due to tension neuropraxia.<br />
    136. 136. Early 4: Nerve Injury<br />Damaged by laceration, traction, pressure or prolonged ischaemia<br />
    137. 137. Early 4: Nerve Injury<br />Investigations<br />Electromyography<br />Nerve conduction study<br />May help to establish level and severity of lesion<br />Clinical features<br />Numbness and weakness<br />Skin smooth and shiny but feels dry<br />Muscle wasting and weakness<br />Sensation blunted<br />Tinel’s sign +ve<br />
    138. 138. Early 4: Nerve Injury<br />
    139. 139. Early 5: Haemarthrosis<br />Bleeding into a joint spaces.<br />Occurs if a joint is involved in the fracture.<br />Presentation:<br />swollen tense joint; the patient resists any attempt to moving it<br />treatment:<br />blood aspiration before dealing with the fracture; to prevent the development of synovial adhesions.<br />
    140. 140. Early 6: INFECTION<br />Closed fractures – hardly ever<br />Open fractures – may become infected<br />Post traumatic wound – may lead to chronic osteomyelitis<br />
    141. 141. Late Complications<br />Delayed Union<br />Non-union<br />Mal-union<br />Avascular Necrosis<br />Osteoarthritis<br />Joint Stiffness<br />
    142. 142. Late 1: DELAYED UNION <br />Union of the upper limbs - 4-6 weeks<br />Union of the lower limbs - 8-12 weeks(rough guide)<br />Any prolong time taken is considered delayed<br />
    143. 143.
    144. 144. Late 1: DELAYED UNION<br />Factors are either biological or biomechanical<br />Biological :<br />Poor blood supply<br />Tear of periosteum, interruption of intramedullary circulation<br />Necrosis of surface# and healing process will take longer<br />Severe soft tissue damage<br />Most important factor<br />Longer time for bone healing due less inflammatory cell supply<br />Infection: bone lysis, tissue necrosis and pus <br />Periosteal stripping<br />Less blood circulation to bone<br />
    145. 145. Mechanical <br />Over-rigid fixation-fixation devise<br />Imperfect splintage<br />Excessive traction creates a gap#(delay ossification in the callus)<br />Late 1: DELAYED UNION <br />
    146. 146. Clinical features:<br />Tenderness persist<br />Acute pain if bone is subjected to stress*<br />( * ask pt to walk, move affected limb)<br />X RAYS -visible line# and very little callus<br /> formation/periosteal reaction<br /> - bone ends are not sclerosed/ atrophic<br /> (it will eventually unite)<br />Late1: DELAYED UNION <br />
    147. 147. Tx: conservative and operative<br />Eliminate possible causes of delay<br />Promote healing<br />Immobilization should be sufficient to prevent movement at # site(cast / internal fixation)<br />Not to neglect # loading so, encourage muscle exercise and weight bearing in the cast/brace<br />Operation<br />> 6 mths & no signs of callus formation<br />Internal fixation and bone graffting<br />(operation-least possible damage to the soft tissue)<br />Late 1: DELAYED UNION <br />
    148. 148. Late 2 : NON-UNION<br />In a minority of cases, delayed union--non-union<br />Factors contributing to non-union:-<br />inadequate treatment of delayed union <br />too large gap<br />interposition of soft tissues between the fragments<br />The growth has stopped and pain diminished- replaced by fibrous tissue - pseudoarthrosis<br />Treatment :-<br />conservative / operative<br />atrophic non-union – fixation and grafting <br />hypertrophic non-union – rigid fixation<br />
    149. 149. Late 2: NON UNION<br />bone ends are rounded off or exuberant<br />Hypertrophic non union<br />Bone ends are enlarged, osteogenesis is still active but not capable of bridging the gap<br />‘elephant feet’ on X ray<br />Atrophic non union<br />Cessation of osteogenesis<br />No suggestion of new bone formation<br />
    150. 150. Non-union<br />X- ray<br />A – Atrophic non- union<br />B – Hypertrophic non- union<br />A<br />B<br />
    151. 151. Late 2: Non union<br />Tx:<br />Mostly symptomless<br />Conservative<br />Removable splint<br />For hypertrophic non-union, functional bracing-induce union<br />Pulsed electromagnetic fields and low frequency pulsed u/s can also be used to stimulate union.<br />Operative<br />Hypertrophic--Rigid fixation (internal or external)<br />Atrophic--Excision of fibrous tissue ,sclerotic tissue at bone end, bone grafts packed around the fracture <br />
    152. 152.
    153. 153.
    154. 154. Late 3: MALUNION <br />Factors:-<br />failure to reduce the fracture<br />failure to hold the reduction while healing proceed<br />gradual collapse of comminuted / osteoporotic bone<br />
    155. 155. MALUNION<br />
    156. 156. Late 3: Mal-union<br /> X-ray are essential to check the position of the fracture while uniting. important- the first 3 weeks so it can be easily corrected <br />Clinical features:<br />Deformity usually obvious , but sometimes the true extent of malunion is apparent only on x-ray<br />Rotational deformity can be missed in the femur, tibia, humerus or forearm unless is compared with it’s opposite fellow<br />
    157. 157. Treatment<br />Decision about the need for re-manipulation and correction-difficult<br />
    158. 158. Late 4: AVASCULAR NECROSIS<br />Certain region-known for their propensity to develop ischaemia and bone necrosis<br />Head of femur <br />Proximal part of scaphoid<br />Lunate<br />Body of talus<br />(Actually this is an early complication however the clinical and radiological effects are not seen until weeks or even months)<br />No clinical feature of avascular necrosis but if there is a failure to unite or bone collapse-pain<br />
    159. 159. A<br />B<br />The cardinal X-ray feature – increased bone density in the weight-bearing part of the joint(new bone ingrowth in necrotic segment)<br />
    160. 160. Treatment:- <br />Avascular necrosis can be prevented by early reduction of susceptible fractures and dislocations. <br />Arthroplasty - Old people with necrosis of the femoral head.<br />Realignment osteotomy or arthrodesis - for younger people with necrosis of the femoral head <br />Symptomatic treatment for scaphoid or talus <br />
    161. 161. Late 5: OSTEOARTHRITIS<br />A fracture-joint may damage the articular cartilage and give rise to post traumatic osteoarthritis within a period of months.<br />Even if the cartilage heals, irregularity of the joint surface may cause localized stress and so predispose to secondary osteoarthritis years later<br />
    162. 162.
    163. 163. Late 6: JOINT STIFFNESS<br />Commonly occur at the joints close to malunion or bone loss eg: knee, elbow, shoulder <br />Causes of joint stiffness<br />haemarthrosis -> lead to synovial adhesion<br />oedema and fibrosis <br />adhesion of the soft tissues<br />Worsen by prolong immobilization<br />Treatment <br />prevented with exercise<br />physiotherapy <br />
    164. 164. THANK YOU!!!!<br />

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