Late complications of fractures can include delayed or non-union of bone fragments, malunion resulting in deformity, joint stiffness, heterotopic ossification, avascular necrosis of bone, complex regional pain syndrome, osteoarthritis, and others. Treatment depends on the specific complication but may involve immobilization, physiotherapy, manipulation, surgery to repair bone or remove extra bone, joint replacement, or management of pain.

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 2-3 wks
Union 4-6 wks 8-12 wks
Consolidation 6-8 wks 12-16 wks

5.  Clinical features
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
 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
 Deformity & shortening of the limb
 Limitation of movements
 Treatment
 Angulation in a long bone (> 15 degrees)
→ Osteotomy & internal fixation
 Marked rotational deformity
→ Osteotomy & internal fixation
 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 :
- 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
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
• 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
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)
Osteoporosis Algodystrophy

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

29. OSTEOARTHRITIS
• Post-traumatic 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
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