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Fracture Repair 2 > Bone Healing: Assessment and Complications > Flashcards

Bone Healing: Assessment and Complications Flashcards

1
Q

What should be performed after # stabilisation?

A

Xrays

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2
Q

What should be assessed in post stabilisation xrays?

A

The 4 As

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3
Q

What are the 4 as?

A
  • Alignment
  • Apposition
  • Apparatus
  • Activity
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4
Q

What is the purpose of the four as?

A

to help assess, reliably and consistently, the treatment and its effects comprehensively.

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5
Q

What needs to be looked at for post op alignment? (3)

A
  • Above and below joint
  • Angular/torional alignment relative to normal
  • Aim is to return to normal alignment
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6
Q

What is looked at during apposition evaluation?

A

fragment apposition

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7
Q

What does the desired amount of apposition depend on?

A

Fixation method

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8
Q

What is assessed with “apparatus” in post op xrays?

A

Appropriateness of implants chosen and the positioning of the implants (e.g., implants do not penetrate the joint, screws are bicortically placed, size of IM pin etc.).

Evaluate each individual implant for evidence of current or impending failure.

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9
Q

When is “activity assessed on xrays? (1) what is looked for? (2)

A

When - follow up xrays

Assess biological activity of bone in response to fixation (i.e., callus formation).

Evaluate the fracture site for evidence of lysis and periosteal new bone formation.

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10
Q

What information is needed to assess “activity” on xrays? (4)

A
  • Age
  • Time since repair
  • Infect?
  • Other wounds?
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11
Q

How can the surgeon use mechanical strategies for enhance healing? (2)

A
  • Realign # fragments
  • Attenuating motion at # site
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12
Q

How can the surgeon use biological strategies for enhance healing? (2)

A
  • Use of growth factors/cells
  • Preserve soft tisssue/vasculature
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13
Q

Inadequate mechanical or biological environment leads to….

A

Delayed union, non-union or malunion.

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14
Q

What does unsuccessful healing mean?

A

Non-union

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15
Q

What does retarded healing mean?

A

Delayed union

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16
Q

What does improper healing mean?

A

Malunion

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17
Q

With inadequate stabilisation (mechanics), treatment is..

A

removal of loose and/or infected implants, complete revision of fixation or the use of additional fixation.

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18
Q

With inadequate biological environment (growth factors and cells), treatment is aimed at

A

preserving/enhancing the soft tissue and vasculature in addition to the application of bone grafts.

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19
Q

Define delayed healing

A

fracture healing is ‘slower than expected’.

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20
Q

Can delayed union heal?

A

Can eventually heal without specific intervention

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21
Q

What is the worst case end of a delayed union?

A

Non union

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22
Q

In the diagnosis of delayed union, what factors need to be considered? (3)

A
  • Age
  • Bone type
  • Biomechanical environment
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23
Q

How can we find out if a delayed union will likely heal or be at risk of becoming a non-union? (3)

A

Stability
Biology
Infect

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24
Q

How to assess fracture stability? (3)

A

Any signs of implants loosening?

Other signs of implant failure?

Loss of reduction/apposition/alignment?

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25
Q

How to assess fracture biology? (2)

A

Look for evidence of healing;

Assess callus formation.

26
Q

How to look for infection? (2)

A

Radiographic signs (but these typically lag behind the clinical signs);

Sample – FNA, biopsy.

27
Q

Infection causes implant loosening and reduces what? What does this result in?

A

Reduces oxygen tension
Results in persistent inflammation

28
Q

T or F:
Bone can heal in the presence of infection when stability is provided, and the infection is being suppressed by antibiotic treatmen

A

True

29
Q

For reducible fractures, apposition equals…

A

Reduction

30
Q

Delayed union is generally treated by

A

extending the postoperative confinement, (provided fracture stability and vascularity are satisfactory and no implant-related complications are seen)

31
Q

Treatment methods for delayed union fractures (and non-unions): (6)

A
  • bone graft
  • Revision of the fracture fixation may be required if implants are loose or broken
  • Growth factors
  • Extracorporeal Shock Wave Therapy (ESWT)
  • Low-Intensity Pulsed U/S (LIPUS)
  • Pulsed Electromagnetic Field (PEMF)
32
Q

What is Pulsed Electromagnetic Field (PEMF)?

A

A rapidly changing magnetic field induces an electric field in a conductive medium. These electric fields generate small currents that are thought to induce activity of bone tissues and healing callus.

33
Q

The effect of ESWT on bone?

A

both direct and indirect stimulation of bone activity.

34
Q

In its early stage each non union is a ..?

A

Delayed union

35
Q

Radiographic features of a non union?

A
  • Fracture gap that does not progress over time
36
Q

What time is given to define a non union?

A

In pets, considering their bone sizes and associated healing times, a shorter time would appear adequate (e.g., 3 months), but no universally agreed time has been defined.

37
Q

How can non unions be sub classified?

A

Viable and non-viable

38
Q

How can viable non unions be further classified? (3)

A

Hypertrophic
Slightly (or moderately) hypertrophic
Oligotrophic

39
Q

Most common type of viable non union?

A

Hypertrophic - Elephant foot

40
Q

Slightly hypertrophic viable non union:
A) Another name?
B) Instability following.?
C) Amount of calus?
Commonly seen where? in who?

A

A) Horses hoof
B) Plate fixation
C) Minimal
D) Cats - radius/ulna #

41
Q

Oligotrophic viable non union:
A) Amount of callus formation?
B) How are fragments separated and joined?

A

A) No
B) Widely separated and joined by fibrous tissue only e.g. avulsion #

42
Q

Hypertrophic viable non union:
A) Seen where? (4)

A

Non surgical external fixation
After in adequate IM pining (rotational in stability),
Loose cerculage wire
Broken plate.

43
Q

Hypertrophic viable non union:
A) Amount of callus formation?
B) What causes and forms a seal?

A

A) Excessive (Gap contains cartilage and fibrous tissue)
B) Sclerosis of the bone ends and later the medullary cavity becomes sealed.

44
Q

What are viable non unions often caused by?

A

Inappropriate mechanical environemnt

45
Q

Treatment of non viable? (3)

A

Remove loose implants.

Rigid immobilisation Preferably with a compression plate or with an antirotational ESF.

Biomechanical stimuli (e.g. extracorporeal shock wave therapy (ESW) ) proven to stimulate bone healing.

46
Q

What should be doen with the cartilage and fibrous tissue between bone ends with viable non-union?

A

Cartilage and fibrous tissue between bone ends rapidly ossifies so it is not necessary neither to freshen the ends nor to use a bone graft.

47
Q

Are viable non unions biologically active or inactive?

A

Active

48
Q

How do dystrophic (torsion wedge) happen? What is it often a complication of

A

Intermediate fragment has healed at one end and not at the other end (one side is avascular).

Result of comminuted #

49
Q

Necrotic non viable non union:
A) Where is it seen?
B) How does it happen?

A

A) Comminuted fractures.
B) Non-viable fragments or sequestra at the fracture site prevent healing. Infection is not uncommon.

50
Q

Types of non viable non union?

A
  • Dystrophic (torsion wedge)
  • Necrotic
  • Defect
  • Atrophic
51
Q

What is a “defect” non viable non union?

A

Traumatic, congenital or post surgical resection bone defect that is too large to heal spontaneously.

52
Q

What is the most common non viable non union?

A

Atrophic

53
Q

What are atrophic non viable and non union commonly seen with? (type of # and who)

A

A complication of radius & ulna fractures in small & toy breeds.

54
Q

How does atrophic non vialbe/non union form?

A

Loss of blood supply, instability at the fracture site lead to loss of osteogenic activity, osteoporosis and eventually osteolysis.

55
Q

What are characteristics of atrophic non viable non union? (3)

A

Rounded bone ends
Gap
Absence of callus

56
Q

Treatment of non viable non union? (6)

A

Fracture site debridement via removal of loose implants, sequestra or unhealthy callus if any.

Exposing viable bone ends via cutting back 2-3mm to give two flat surfaces. The created gap can be opposed and compressed with DC-plate (rigid immobilisation).

Opening medullary cavity (marrow cells).

Bone graft (autologous vs allogenic - cancellous vs cortical) or bone graft substitute is essential to achieve healing (biology boost up).

Stem cell therapy , local delivery of growth factors to be considered.

Biomechanical stimuli (e.g. extracorporeal shock wave therapy (ESW)) proven to stimulate bone healing.

57
Q

Define malunion?

A

A fracture that has healed or is healing in an abnormal position

58
Q

What are malunions usually caused by?

A

improper immobilisation or reduction

59
Q

How are malunions described + classified (2,2)

A

Functional vs non functional
Extra articular vs intra articular

60
Q

Treatment of a funtional malunion?

A

No Tx

61
Q

Treatment of non functional malunion?

A

Revision surgery, including corrective osteotomy,

Fracture Repair 2 (10 decks)

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