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SA Orthopaedics > Complications of fracture repair > Flashcards

Complications of fracture repair Flashcards

1
Q

Factors to be considered when dealing with fracture complications

A

Immobilisation

Biology (blood supply, bone viability, periosteum integrity, marrow cells)

Infection

Others (severity of the trauma, defect size, patient related factors)

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2
Q

Direct bone healing

A

Absolute stability (<2% interfragmentary strain)

No gap or very small gap (<1mm)

Will not result in callus formation

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3
Q

Indirect bone healing

A

Relative stability (10% interfragmentary strain)

Can occur with larger gaps

Will result in callus formation

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4
Q

How to calculate strain

A

Strain = deltal L / L

= Gap movement / fracture gap

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5
Q

Delayed union

A

A fracture that has not healed in the time normally expected for that fracture type to heal

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6
Q

Non-union

A

Fracture healing stops and union will not occur without surgical intervention

(non-progression for 3mo after fracture should have healed)

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7
Q

Clinical signs of a delayed or non-union

A

Painful motion at the fracture site
Pseudoarthritis
Progressive deformity
Disuse of the limb
Muscle atrophy
Joint stiffness

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8
Q

Causes of delayed and non-union

A

Inadequate immobilisation

Inadequate reduction

Loss of blood supply

Infection

Loss of bone from trauma

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9
Q

What is the commonest cause of delayed or non-union?

A

Inadequate immobilisation of the fracture

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10
Q

Radiological appearance of delayed union

A

A radiolucent gap between fracture fragments, with a feathery or chewed up appearance of the fracture ends and moderate callus

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11
Q

Radiographic appearance of non-union

A

No radiological evidence of healing - no callus, ends of bone segment are rounded and the marrow cavity is sealed with dense (sclerotic) trabecular bone.

Bone ends can be enlarged (elephant foot) or narrowed (atrophic).

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12
Q

Two main groups of non-unions

A

Biologically acitve/viable non-unions

Biologically inactive/non-viable non-unions

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13
Q

Types of biologically active or viable non-unions

A

Hypertrophic (elephant foot)

Slightly hypertrophic type (horses foot)

Oligotrophic type

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14
Q

Types of biologically inactive or non-viable non-unions

A

The dystrophic type (torsion wedge)

The necrotic type (necrotic segment)

The defect type (big gap)

The atrophic type

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15
Q

Causes of hypertrophic non-union (biologically active)

A

Usually a complication of IM pinning of humeral and femoral shaft fractures - caused by rotation at fracture site

Can be a complication of loose cerclage wires or sequestra

A well-developed elephant-foot shaped callus develops which does not bridge the fracture gap

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16
Q

Biology of a hypertrophic non-union

A

The gap contains cartilage and fibrous tissue

There is sclerosis of the bone ends and later the medullary cavity becomes sealed.

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17
Q

Treatment of hypertrophic non-union

A

Rigid immobilisation preferably with a compression plate or anti-rotational ESF.

Cartilage and fibrous tissue between bone ends rapidly ossifies so it is not as necessary to freshen the ends or use a bone graft

Remove loose implants or sequestra - necrotic bone is yellowish white in appearance

Following debridement flatten out the ends so they can be compressed

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18
Q

Slightly hypertrophic non-union (horses foot)

A

Instability following plate fixation

Minimal callus formation

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19
Q

Oligotrophic non-union

A

No callus formation and the fragments are usually widely separated and joined by fibrous tissue only e.g. avulsion fractures

May benefit from adjusting the biological or mechanical environment

20
Q

Dystrophic non-union (torsion wedge)

A

Seen as a complication of comminuted fractures where a poorly revascularised fragment or fragments impedes fracture healing

21
Q

Necrotic non-union

A

Seen in commoinuted or infected fractures where non-viable fragments or sequestra at the fracture site impede healing

22
Q

Defect non-union

A

A major defect in the bone caused by removal of fragments or sequestra which is too big to be bridged by the normal healing process.

Often seen after severe soft tissue injury or a loss of vascularity in the area - often become atrophic.

23
Q

Treatment of viable non-union

A

Remove loose implants

Rigid immobilisation - preferably with a compression plate or with anti-rotational ESF

Biomechanical stimmuli (e.g. shockwave therapy) can stimulate bone healing

Don’t need ends freshening or bone grafts

24
Q

Treatment of non-viable non-unions

A

Harder

Fracture site debridement - remove loose implants, sequestra, or unhealthy callus

Exposing viable bone ends - cut back 2-3mm creating two flat surfaces

Compression with DC plate

Opening medullary cavity

Bone graft

Stem cell therapy

Biomechanical stimuli

25
Q

Malunion

A

Defined as a fracture that has healed or is healing in an abnormal position - usually caused by improper immobilisation or reduction during healing

26
Q

Classifications of malunions

A

Overriding

Angular

Rotational

Translational

27
Q

What disease can axial and rotational deviations (malunions) predispose to?

A

DJD

28
Q

Osteomyelitis

A

Any inflammatory condition of the bone which involves the haversian systems, volkmanns, cortex, and generally the marrow and periosteum

29
Q

Osteitis

A

Inflammation of the bone only

30
Q

Discospondylitis

A

Inflammation of the disc only

31
Q

Epiphysitis

A

Inflammation of the epiphysis only

32
Q

Source of infection of osteomyelitis

A

Iatrogenic

Haematogenous

Extension

Open fracture/external trauma

Nosocomial

33
Q

What % of osteomyelitis cases are iatrogenic?

A

70%

34
Q

What can cause osteomyelitis by haematogenous spread?

A

Spread from another infective focus in the body e.g. endocarditis

35
Q

Osteomyelitits from an open fracture/external trauma

A

Any trauma causing a pathway from the outside of the body to the bone.

Extraneous sources can include bites, foreign bodies, and even following radiation of neoplasms

Primary bacterial contamination occurs in about 1/3 of open fractures and necrotic tissue left in the wound serves as a nidus for bacterial multiplication

Secondary bacterial infection occurs after 6-8hrs

36
Q

Nosocomial infections

A

Infections acquired by patients during the course of hospitalisation

37
Q

Pre-disposing factors to osteomyelitits (14)

A

Vascular compromise

Iatrogenic contamination

Dead space haematoma at fracture site

Destructive fixation devices (IM pins)

Immunosuppression (corticosteroids)

Systemic problems

Break in sterility

Length of surgery

Remote infections

Old age

Length of hospitalisation

Antimicrobial therapy

Surgical drains, urinary catheters, IV cannulas

Diagnostic procedures

38
Q

Causative organisms of osteomyelitis

A

Bacteria - commonest
- Staph aureus
- Streps
- Coliforms
- Proteus
- Pasteurella
- Pseudomonas
- Corynebacterium
- Fusiformis necrophorus
- Nocardia

Tuberculosis - rare

Mycoses
- Cryptococcus
- Aspergillus

39
Q

History of acute osteomyelitis

A

Recent fracture repair of arthroplasty

40
Q

Clinical signs of acute osteomyelitis

A

Severe pain, swelling, pyrexia, lameness, tenderness and possibly a sub-periosteal abscess.

Discharge at the surgical wound may be visible

41
Q

Radiographic appearance of acute osteomyelitis

A

No bony changes identifiable on radiographs

42
Q

Treatment of acute osteomyelitis

A

Loose implant needs to be revised

Antibiotics (broad spec)

Bacterial culture and sensitivity

Min antibiotic course - 6wks

If not responding - surgical debridement and antibiotic implantation (beads)

43
Q

History of chronic osteomyelitis

A

Months or even years after surgery

44
Q

Clinical signs of chronic osteomyelitis

A

Systemic signs are rare
Less severe lameness

45
Q

Radiographic appearance of chronic osteomyelitis

A

Evident radiographic changes

Periosteal reaction (new bone in unhealthy formation)

Focal bone lucencies and osteopaenia

Wide spread bone lysis in more chronic cases

Sequestra develop

Sclerosis of surrounding bone

Implant lossening if present

46
Q

Treatment of chronic osteomyelitis

A

Surgical debridement and lavage and/or implant removal/revision surgery

Surgical drain or wound left to heal by second intention

Regular bacterial swab for C&S

Antibiotic loaded beads or bone cement

SA Orthopaedics (14 decks)

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