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Essay On Fracture Complications
Essay On Fracture Complications
Time of complication
General
External
Internal.
Local
General
Local
General
Local
1. Delayed and non - union . Malunion, i.e. union in a bad position (see
below).
2. Late wound sepsis with skin breakdown.
3. Failure of internal fixation , e.g. breakage or cutting out of plates or nails
(Fig. 6.1 ).
4. Joint stiffness and contracture .
5. Regional pain syndrome (previously variously known as refl ex
sympathetic dystrophy, Sudek ’ s atrophy or algodystrophy) — a condition
in which the limb becomes painful, swollen and discoloured, with obvious
circulatory changes and X - rays showing diffuse, patchy porosis of the
bones. It is thought to be due to a sympathetic malfunction, but is ill -
understood. It appears to be precipitated by trauma, either external or
surgical. It is a distressing condition, but usually settles after several weeks
or months. During this period it is important that the patient understands
the condition and is encouraged to exercise the limb. There is evidence
that treatment with calcitonin and sympathetic nerve blocks may shorten
the course of the condition in some patients. Neuro modifying drugs are
frequently used, such as gabapentin.
6. Osteoarthritis resulting from joint damage or occasionally from
malaligment of the limb.
Complications of fracture healing
Delayed union
Many fractures take longer to unite than the average times suggested, and
protection may still be needed from full load - bearing beyond these times,
even though union may apparently have occurred.
Non union
A decision to treat delayed union is usually made before true non - union
occurs. It is usually apparent after 4 – 5 months that union is not occurring, but in
most cases the decision can be made long before this.
Malunion
This expression means that the fracture has united in an unsatisfactory
position from either a functional or cosmetic point of view. It should not occur if
management of the fracture has been adequate, but circumstances are not always
favourable and some patients are left with a degree of deformity or shortening of
the limb. In children, considerable compensatory remodelling can be expected and
even length defects often correct by the end of growth. In adults, much less
correction can be expected, although when the swelling and thickening associated
with the fracture have settled, the appearance may be much more satisfactory than
might at first have been expected. In some cases, a corrective osteotomy or even
bone lengthening with an external fixator may have to be considered. This is a
hazardous procedure and in most cases shortness, which is usually only a problem
in the lower limb, can be compensated for by modifications to the shoes.
1. Hypertrophic , i.e. with much callus at the bone ends, often as a result
of excessive fracture site mobility (Fig. 2b ) or
2. Atrophic , i.e. with no obvious callus, often as a result of poor blood
supply to the fracture site (Fig. 2b ).
The atrophic non - union also requires firm fixation, but healing tends to
proceed more quickly if a bone graft is used to stimulate bone formation. Bone
graft (if from the patient it is an autograft) is usually taken from the iliac crest.
Bone graft serves a number of functions: induces dormant cells to produce bone
(osteo - induction), provides a scaffold over which new bone forms (osteo -
conduction) and can provide structural support for bone defects. Harvest of bone
graft from the iliac crest is often painful for the patient.
Infected fracture
Union will rarely occur until the infection is overcome. Firm fixation of
the fracture and excision of bone which is obviously dead will often eliminate or
reduce the infection, enabling a subsequent bone graft to be carried out. If the
defect after removal of dead tissue is large, a considerable quantity of bone may
be needed to bridge the gap. Immobilization of the fracture needs to be continued
until solid union occurs. In severely infected non - unions, an external fixation
frame, devised by Ilizarov, is safer than implanting metal plates or nails (see Fig.
3 ). Securing union in such cases can take many months or even years, and in
some patients amputation may be a better option.