tbl 1: orthopedic trauma husna, izzati, ili safia, aqilah & safiyyah
TRANSCRIPT
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TBL 1: Orthopedic TBL 1: Orthopedic TraumaTrauma
Husna, Izzati, Ili Safia, Aqilah & Safiyyah
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TBL TriggerTBL TriggerA 24 year old man was involved
in a road traffic accident.He was a pedestrian when a
motorcycle knocked him down when he was crossing the road.
Following that incident, he complained of pain of the left leg and was unable to bear weight on his left lower limb.
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In A&E, physical examination was performed:◦Revealed swollen, tender and deformed
proximal region of the left leg. ◦No limb threatening injury noted. ◦No wound overlying the deformed
region. An X-ray of the left leg done
reported transverse fracture proximal of the left fibula.
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He was admitted to the ward:◦The left leg was elevated on the
Bohler Braun frame awaiting for the swelling to subside and to observe for Compartment syndrome.
◦He was told the fracture is best treated with internal fixation but he opted for conservative treatment.
◦Full leg POP cast was applied after 3 days of admission.
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Follow up visit (6 weeks post-trauma):◦X ray was done and it showed no healing
signs.◦The earlier cast was removed and changed
to patellar tendon bearing cast for another six weeks.
Follow up visit (12 weeks post-trauma):◦Revealed mobility to the fracture site –
painless. ◦He was told to have problem with the
fracture healing and needs surgical treatment.
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Learning IssuesLearning IssuesAnatomy of the Leg.Fracture – Definition, Classification
and Patterns.Principle of Fracture Management.Acute Complications of Fracture.Process of Fracture Healing.Late Complications of Fracture.Non Union Fracture – Definition,
Classification and Management.
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Anatomy of the LegAnatomy of the Leg
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i. Bonesii. Muscles
◦ Compartmentsiii. Blood Supplyiv. Nerve Supply
The LegThe Leg
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i. Bonesi. Bones
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Anterior
Lateral
Fibula
Superficial Posterior
Deep Posterior
Tibia
Tibialis post.
FHLFDL
TA
ELHEDL
PL & B
ii. Muscles and ii. Muscles and compartmentscompartments
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Leg compartmentsLeg compartments
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Anterior compartment
Walls : i. Interosseous membraneii. Tibiaiii. Fibula
Contents : i. Extensor muscles of the toesii. Anterior tibial arteryiii. Deep peroneal nerveiv. Most susceptible to compartment
syndrome.
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Lateral compartment
Walls : i. Fibulaii. Intermuscular septums
Contents: i. Peroneal muscles ii. Superficial peroneal nerve
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Superficial Posterior compartment
Walls:i. Transverse intermuscular septum
Contents :i. Gastrocnemius ii.Soleus muscles
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Deep Posterior compartment
Walls :i. Transverse intermuscular septumii.Interosseous membrane
Contents: i. Flexor muscles of the footii.Tibial arteryiii.Tibial nerve
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Compartments
Muscles Vessels NervesSensory Distributi
on
AnteriorExtensor
muscles of toes
Anterior tibial artery
Deep peroneal
nerve
Web space of first & second
toes
Deep posterior
Deep flexor muscles
Posterior tibial artery
Tibial nerve
Heel
Superficial posterior
Superficial flexor
muscles (gastrocnem
ius and soleus)
LateralPeroneal muscles
Superficial
peroneal nerve
Lateral dorsum of
foot
Summary Summary
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Nerve and Nerve and ArteriesArteries
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Fracture – Definition, Fracture – Definition, Classification and PatternsClassification and Patterns
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Definition of FractureDefinition of Fracture
A break in the structural continuity of bone.
- Apley’s System of Orthopedics & Fractures, 8th Edition
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i. Open (Compound) i. Open (Compound) FractureFractureBreakage in the bone that
breaches the skin or one of the body cavities.
Usually due to high-energy injuries e.g. MVA, falls, sports injuries.
Liable to contamination and infection hence require immediate treatment and surgery to clean the area.
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Open Fracture Fracture of tibia-fibula with soft-tissue injury
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ii. Closed (Simple) ii. Closed (Simple) FractureFractureBreakage in the bone with the
overlying skin still intact.3 types:
◦Compression fracture Occurs when 2 or more bones are
compressed against each other – commonly in the spine bone.
Due to falling in a standing or sitting position, advanced osteoporosis.
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◦Avulsion fracture Occurs when a piece of bone is broken off
by a sudden forceful contraction of a muscle.
Common in young athletes.
◦Impacted fracture Occurs when pressure is applied to both
ends of one bone causing it to split into fragments that collide with each other.
Similar to compression fracture, only it is within one bone.
Common in falls and MVA.**View video http://video.about.com/orthopedics/Fractures-2.htm for
better understanding.
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Closed fracture
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Compression fracture of the spine
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Avulsion fracture of the phalanges
Impacted fracture of the femur
Impacted fracture of the tibia
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iii. Pathological Fractureiii. Pathological FractureBreakage of bone in an area that is
weakened by another disease process either by:◦Changing the structure i.e. osteoporosis,
Paget’s disease.◦Presence of lytic lesion i.e. bone cyst or
metastasis.◦Infection.
Usually occur during normal daily activities bone unable to withstand even the normal stresses.
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Bone cyst resulting in pathological fracture in
the neck of femur
Multiple myeloma of humerus with pathological
fracture
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iv. Stress Fractureiv. Stress FractureUsually fractures are caused by
acute, high force to the bone i.e. MVA, fall.
In Stress facture, the force applied is much lower but it happens repetitively for a long period of time.
Rarely occur in the upper extremity because weight bearing is by lower extremity – common site shin and foot.
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Contributing factors:◦Athletes
High demand of activity repetitively.
◦Diet abnormalities Poor nutrition e.g. in aneroxia, bulimia.
◦Menstrual irregularities Irregular cycles/amenorrhea signify lack
of estrogen which results in lower bone density.
Common in female athletes.
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Stress fractures of the tibia-fibula
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i. Incomplete Fracturei. Incomplete FracturePattern Mechanism of
InjuryImages
Hairline fracture-A crack in the bone that does not extend all the way through.
Minor injury e.g. minor fall, minor blunt trauma.
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Pattern Mechanism of Injury
Images
Greenstick fracture-Only one side of the bone break resulting in the bone buckling or bending (like snapping a green twig).
-Common in children as bone more springy than adult.
-Similar to this is Plastic deformity – also common in children.
Minor fall, minor blunt trauma.
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i. Complete Fracturei. Complete FracturePattern Mechanism of
InjuryImages
Transverse fracture-Fracture straight across the bone.
Tension due to high energy direct trauma.
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Pattern Mechanism of Injury
Images
Short Oblique fracture-A fracture which goes at an angle to the axis.
Compression.
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Pattern Mechanism of Injury
Images
Spiral fracture-A fracture which runs around the axis of the bone.
-S-shaped.
Twisting.
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Pattern Mechanism of Injury
Images
Comminuted fracture-A fracture in which bone is broken, splintered or crushed into a number of pieces.
-A fracture is considered comminuted when there are more than 2 bone fragments.
-Also known as triangular ‘butterfly’ pattern.
Bending.
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Pattern Mechanism of Injury
Images
Segmental fracture-A fracture in two parts of the same bone.
- Also known as double fracture.
Severe direct force.
**View video http://video.about.com/orthopedics/Fractures-1.htm for better understanding.
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Principles of Fracture Principles of Fracture ManagementManagement
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FIRST FIRST GENERAL RESUSCITATIONGENERAL RESUSCITATION
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At the HospitalAt the HospitalExamine HEAD TOELevel of consciousness GCSRemember:
Airway
Ensure clear airway
Breathing
Examine chest (atelactasis, pneumothorax)Supplemental O2
ABG if necessary
Circulation
Control bleedingAsses for signs of shockFBC and electrolytes
Secondary Survey
X-rays
Re-evaluation Monitor vital signs
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Fractures – Principles of Fractures – Principles of TreatmentTreatment Manipulation – improve position
of fragments. Splintage – hold.
WHILST:
Preserving the joint movement and function – exercise and weight bearing.
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Closed Fractures
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1. Closed Fractures – REDUCE1. Closed Fractures – REDUCEAim Aim adequate apposition and normal alignment of the adequate apposition and normal alignment of the bone fragmentsbone fragments
Methods:1. Manipulation
- Closed manipulation for minimally displaced fractures- Under anaesthesia and muscle relaxation:1.Distal part is pulled in the line of the bone2.Reposition fragments (reverse original direction of force)3.Adjust alignment
2. Mechanical traction
- Hold the fracture until it starts to unite
3. Open operation
Indications:1.Closed reduction fails2.Large articular fragment3.For avulsion fractures (fragments held apart by muscle pull)4.Operation needed for associated injuries5.When fracture anyhow need internal fixation to hold it
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2. Closed Fractures – HOLD 2. Closed Fractures – HOLD Aim Aim splint fracture splint fracture
Methods:1. Sustained traction
- Exert continuous pull in the long axis of the bone- Counterforce needed - Used in spiral fractures of long bone shafts- Types : traction by gravity, balanced traction, fixed traction
2. Cast splintage - E.g Plaster of Paris- Movement restricted- Complications: tight cast(vascular compression, pain), pressure sores, skin abrasions/lacerations (on removal), loose cast
3. Functional bracing
- Use POP or lighter materials while permitting fracture splintage and loading- Joint movements are less restricted- Usually applied only when the fracture is beginning to unite 3-6 weeks
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Transfixing pin passes to:Transfixing pin passes to:1. Proximal tibia – hip, thigh 1. Proximal tibia – hip, thigh and knee injuriesand knee injuries2. Distal tibia/calcaneum – 2. Distal tibia/calcaneum – tibial fracturestibial fractures
Balanced skin traction
Braun’s frame
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Internal Fixation
Indications:1.Fractures that cannot be reduced except by operation2.Fractures that are unstable (prone to re-displacement)3.Fractures that unite poorly and slowly (e.g femoral neck fracture)4.Pathological fractures5.Multiple fractures6.Patients with nursing difficultiesTypes – screws, wires, plates&screws, intramedullary nailsComplications:(due to poor techniques, poor equipment operating conditions) – infection, non-union, implant failures, refracture
External fixation
Principle – bone is transfixed above and below the fractures with screws/pins/wires which are clamped to a frameIndications:1.Fractures associated with severe soft tissue damage2.Severely comminuted and unstable fractures3.Pelvic fracture4.Fractures a/w nerve or vessel damages5.Infected fractures6.Ununited fracturesComplications:-Damage to soft-tissue structures-Over-distraction-Pin-tract infection
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3. Closed Fractures – EXERCISE3. Closed Fractures – EXERCISEAim Aim restore function restore function
1. Prevention of edema2. Active movement/exercise –
stimulate circulation, prevents soft tissue adhesion and promote healing
3. Assisted movement – restore muscle power
4. Functional activity – guide patient in performing normal daily acitivities
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Open Open FracturesFractures
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Gustilo’s ClassificationGustilo’s Classification
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Principles of TreatmentPrinciples of Treatment
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Debridement Skin graft
Stabilization
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Acute Complications of Acute Complications of FractureFracture
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Complications of FractureComplications of Fracture
EARLY LATE
i. Underlying Visceral injury
ii. Vascular injuryiii. Nerve injuryiv. Compartment
syndromev. Haemarthrosisvi. Infectionvii.Gas gangrene
i. Delayed unionii. Malunioniii. Non unioniv. Avascular
necrosisv. Muscle
contracturevi. Joint instabilityvii.Osteoarthritis
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i. Underlying Visceral i. Underlying Visceral InjuryInjuryOften in fractures around the trunk.
◦Rib fractures penetration of lung life-threatening pneumothorax .
◦Pelvic fractures rupture of bladder or urethra.
Require emergency treatment, before treating fracture.
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ii. Nerve Injuryii. Nerve InjuryCommon in fractures of the humerus,
injuries around elbow & knee.Look for tell tale signs:Closed injuries
◦ Nerve seldom severed wait for spontaneous recovery (90% in 4 months).
◦ Recovery x occur/nerve studies shows no recovery explore nerve.
Open fracture◦ Likely complete nerve lesion.◦ Explore during debridement/secondary
procedure repaired.
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iii. Vascular Injuryiii. Vascular InjuryFracture around knee and elbow,
humeral and femoral shafts ↑ ass. w. damage to major artery.
Cut, torn, compressed, contused by initial injury/jagged bone fragments.
N outward appearance intima may be detached, vessel blocked by thrombus, spasm.
Effects vary : transient diminutive of blood flow, profound inchaemia, tissue death, peripheral gangrene.
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Clinical featuresParaesthesia /numbness of toes/fingersCold, pale, slightly cyanosed weak/absent
pulseX ray shows high risk fractures
ManagementAngiogramRemove bandages/splintX ray – kinking or compressed reductionReassess circulationNo improvement explore via operation
◦Torn Suture/ replace by vein graft◦Thrombosed endarterectomy to restore
blood flow
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iv. Compartment iv. Compartment SyndromeSyndromeA group of conditions that result
from ↑ pressure within a limited anatomic space (limb compartments), acutely compromising the microcirculation and leading to ischaemia of the muscle.
Causes : high risk fractures, infection, operation.
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Bleeding, oedema or inflammation↓
↑ Tissue pressures in a compartment↓
Compromise perfusion↓
Tissue hypoxia ↓
Damage to the structures coursing through that compartment (nerves & muscles)
↓Prolonged muscle hypoxia
↓ Necrosis and permanent posttraumatic muscle
contracture (Volkmann's ischemia)
12 hours or less
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PathophysiologyPathophysiology
VICIOUS CYCLE OF VOLKMANN’S
ISCHAEMIA
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Clinical FeaturesClinical Features Ischaemia (5 Ps):
◦Pain : Earliest symptom bursting sensation
◦Paraesthesia◦Pallor◦Paralysis◦Pulselessness
Muscles sensitive to touch ↑ calf/forearm pain when is hyper-extended.
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Pressure of fascial compartment:◦Introduce catheter into compartment measure P close to compartment.
◦Diastolic P – compartment P.◦Differential less than 30 mmHg.
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TreatmentTreatmentDecompression
◦Remove bandage, casts, dressings.
Fasciotomy
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v. Haemarthrosisv. HaemarthrosisJoint is swollen, tense.Pt resists any attempt to move it.
Aspirate blood first.
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vi. Infection vi. Infection Common in open fractures,
unless closed fracture is opened.Chronic osteomyelitis.Slow union, w ↑ chance of re-
fracturingImflamed wound, w seropurulent
discharge.Send for C&S.Start antibiotic.
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vii. Gas gangrenevii. Gas gangreneProduced by clostridial infection esp
Clostridum welchii in dirty woundsDestroy cell walls necrosis
spread of diseaseAppear within 24 hours on injuryIntense pain,swelling,brownish
discharge, ↑ HR, characteristic smell, gas formation
Toxaemic coma death
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Process of Fracture Process of Fracture HealingHealing
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TISSUE DISTRUCTION
AND HEMATOMA FORMATION
INFLAMMATION AND
CELLULAR FORMATION
CALLUS FORMATION
REMODELLING
How Fracture How Fracture Heal?Heal?
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Stage 1: start few days after injury and continue for about a month.
Stage 2: starts within a week or two and continues for many months.
Stage 3: continues for many month to a few years.
Fracture Healing Fracture Healing ProcessProcess
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Late Complications of Late Complications of FractureFracture
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Local ComplicationLocal ComplicationDeformityOsteoarthritis of adjacent /
distant joint Aseptic necrosis Traumatic ChondomalaciaReflex sympathetic dystrophy
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Local Complication (cont’)Local Complication (cont’)Contractures Myositis ossificans Avascular necrosis Algodystrophy (or Sudeck's
atrophy) Osteomyelitis
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Systemic ComplicationSystemic ComplicationGangreneTetanusSepticemia Fear of mobilizing Osteoarthritis
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Non Union Fracture – Non Union Fracture – Definition, Classification Definition, Classification
and Managementand Management
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What is mobility to the What is mobility to the fracture site but painless?fracture site but painless?
A sign of non-union (pseudoarthorsis)
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Non- UnionNon- UnionThe fracture will never unites
without intervention
Clinical features: Movement can be elicited at the fracture
site Pain diminishes
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Causes: Distraction and separation of
fragments Interposition of soft tissues between
the fragments excessive movements at the fracture
site Poor local blood supply Severe damage to soft tissues Infection Abnormal bone
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Classification: Hypertrophic (hypervascular) Oligotrophic Atrophic (avascular)
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Hypertrophic Non- Union
Features Callus formation initially okayRich of blood supply at the end of fragmentsBut bridging of the fracture gap is failedBone ends are enlarged (X-ray) suggesting osteogenesis Union is still possible if bone fragments are apposed and held immobile
Management Stimulate union:Pulsed electromagnetic fieldLow-frequency pulsed ultrasound
Operative:Rigid fixation (external/internal)
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Oligotrophic Non- Union
Features Not hypertrophicCallus is absentHowever there’s intact blood supply Inadequate healing process
Management
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Atrophic Non- Union
Features Osteogenesis is ceasedNo sign of attempted bridging Inert and incapable of biologic rxnPoor blood supply to the ends of fragmentsCold bone scanBone ends are tapered or rounded (X-ray)
Management Rigid fixationExcised the sclerotic end of bone ends and the fibrous tissue that filled the gapBone graft around the fracture
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Delayed Union Delayed Union The period in which the fracture
is expected to unite and consolidate is prolonged
Causes (as non-union)
Clinical features: Tenderness persists Mobilization at the fracture site
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X-ray: Fracture line visible Little callus formation Bone ends not sclerosed or atrophic The appearance suggests the fracture
has not united but eventually will
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Treatment:◦Conservatives
Eliminate possible causes of delayed union
Promote healing i.e. immobilization◦Operative
Internal fixator & bone grafting are indicated when there is delayed > 6 months & no sign of callus formation
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Take Home Message!Take Home Message!
• Read up the Anatomy!• Fracture – Types and Patterns• Reduce! Hold! Exercise!• Acute and Late Complications• Process of Fracture healing• Non Union Fracture – Classification, Clinical features and Management