Professional Documents
Culture Documents
Outlines
Local 1. Delayed union 2. Nonunion 3. Malunion 4. Joint stiffness 5. Contractures 6. Myositis ossificans 7. Avascular necrosis 8. Algodystrophy (or Sudeck's atrophy) 9. Osteomyelitis 10.Growth disturbance or deformity 1. 2. 3. Systemic Gangrene, tetanus, septicaemia Fear of mobilising Osteoarthritis
Delayed Union
Normally the fracture unites within 2-5 months Time taken for fracture healing
NonUnion of fracture
Lack of complete bone healing in specified time frame generally 6 -8 months Non union occurs when further healing doesnt occur without intervention Time to heal depends on
1. 2. 3. 4. Bone involved Anatomical region Fracture pattern Method of treatment
Cessation of oeriosteal and not the endosteal healing response prior to fracture bridging is non union at cellulae level
Presentation
Pain at fracture site Nonuse of extremity Tenderness and swelling Joint stiffness (prolonged >3 months) Movement around the fracture site (pseudarthrosis)
Pathophysiology in nonunion
Fracture specific factors
Open fracture with extensive soft tissue injury Sp. Bones involved Metaphysis> diaphysis High energy fracture
Treatment factor
Stablity of fracture Technique of stablisation infection
Classification
Non union is of two type
Aseptic and septic
Treatment
Conservative
1.Elemination of any posible cause of delayed union 2.Promote healing by providing most apropriate biological environment 3.Immobilization 4.Healing stimulated by encouraging muscle exercise and weight bearing casts or braces
Operative management
Dealyed union for more than 6 months with no signs of callus formation Internal fixation and bone grafting are indicated Autogenous bone graft Bone graft subtitutes
Eg. Bone morphogenic proteins
MalUnion
Presents with a set of bone deformities Deformities can be in term of length, angulation, rotation and translation
Evaluation
Clinical
Review of medical history Evaluation of any medical history Manual stressing at malunion site, if it causes pain it signifies non healed fracture Movement of limb proximal and distal to malunion site
Plain radiograph
Both AP and lateral view also in flexion and extension It shows: limb alignment, joint orientation, anatomical and mechamical axes and CORA
Types of deformities
Length: shortening/lengthning Treatment
Acute traction/compression Autologus calcellous or cortical bone graft Vascularised auto graft Mesh cage bone graft construct Synontosis technique
Angulation
Treatment
Making osteotomy Obtaining realignment of bony segment Securing fixation during healing
Rotation
Treatment
Osteotomy Followed by rotational reallignment followed by stratification
Translational
Treatment(3 methods)
Single osteotomy, correction of translation and not angulation, length constant Single oblique osteotomy, restoration of alignment, length increased 2 wedge osteotomy, straightning, increased length
Joint stiffness
Most common sites:knee, elbow, sholder, small joints of hand Pathophysiology
Oedema and fibrosis of the capsule, the ligament and the muscle around the joint Adhesion of soft tissue to each other or to underling bone Damage to joint forming heamoarthrosis leading to syonial adhesion Prolonged immobilizaton of joint and joint heald in a position where the ligaments are in shortest position
Treatment
Prevention is better than cure When splintage is required the joint should be held in position of safety For already stiff joint: physiotherapy and regular exercise For intraarticular adhesion: gentle manipulation under anaesthesia to free the joint Adhered/ contracted tissur to be released by operation
Contracture of Joint
Usually seen following arterial injury or compartment syndrome There occurs ischemic contracture of affected muscle: volkmans ischemic contracture Most common affected site: forearm, hand, the leg and foot
Presentation
Wasting of the forearm and hand and clawing of the fingers Intrinsic hand muscle fibrosis and shorter, pulling the fingers into flexion at the metacarpophalyngeal joint, extension at interphalyngeal joint, thumb remains abducted (Bunnells intrinsic plus position)
Treatment
Detachment of flexors at there origin and along the interosseous membrane in forearm Pedicle nerve graft Tendon transfer