1	Fracture Complications L C Bainbridge Hand Surgeon Derbyshire Royal Infirmary UK
2	"Failure of Bone healing" Failure of Bone healing Infection Malunion Tendon and joint stiffness Cast disease and RSD Post Traumatic Arthritis Implant failure Amputation
3	Failure of Bone healing Delayed union 3 months is definition 4 weeks is limit of immobilisation Non union stable versus unstable pseudarthrosis
4
5	Signs of nonunion persistent or expanding fracture line sclerosis of margins submarginal cyst medullary sealing with cortical bone rounding of fracture ends OR lack of reaction
6	Causes of non union extensive trauma closed <1% versus 6-7% with grade III bone loss soft tissue interposition unstable fixation premature mobilisation infection traumatic or inherent poor blood supply old age
7	Management of nonunion stable nonunion eg some scaphoid nonunions, ulnar styloids, distal phalanx Symptomatic nonunion Reassess blood supply bone stock age skin cover
8	Fixation + Bone Graft Kirschner wires Jupiter 1985, Wray and Glunk 1989 K-wires + bone graft O’Brien 1988 Rigid plates for Hypertrophic non union Segmuller 1977 Plates and bone graft Heim 1979 I prefer the appropriate size plate with iliac crest bone. Usually cortico- cancellous
9	Other modalities Electrical stimulation rarely used Ohl and Smith 1988 Artificial bone grafts BMP Extracorporeal Shock wave therapy Used extensively in the German speaking countries for lower limb fractures
10
11	Infection Local Vs Systemic
12	Local Contamination Delayed treatment Tissue necrosis Soft tissue stripping Wrong size implants
13	Systemic Diabetes Auto immune disorders Drug abuse including smoking Peripheral vascular disease (VWF) Sickle cell Immune compromise
14	Risk Closed K-wiring 6-7% incidence Belsky et al, Botte et al 0.5% incidence of osteomyelitis K-wires produce heat Regularly reaches above 50deg C Increases with blunt wires
15	Risk ORIF closed fractures very rare Open fractures upto 5% Osteomyelits 0-5%
16	Management Antibiotics, Broad spectrum as per hospital policy Beware Steptococci “flesh eating bugs” Stability Drainage Debridement Antibiotics Reconstruction blood supply flaps graft
17	Malunion “Union with deformity” Legal connotations Functional Loss Fifth Metacarpal neck Corrective osteotomy Wedge osteotomy Derotation osteotomy
18	Osteotomies Site of greatest deformity metaphyseal - diaphyseal junction adjacent to above base of metacarpal for £25deg rotation
19
20
21
22	Tendon and joint stiffness Initial injury operative treatment insufficient treatment overtreatment failure to initiate early digital motion
23	Tendon and joint stiffness Initial injury operative treatment insufficient treatment overtreatment failure to initiate early digital motion
24	Tendon and joint stiffness Initial injury operative treatment insufficient treatment overtreatment failure to initiate early digital motion
25	Treatment Common muscle belly and Intrinsics Aggressive Physio and OT Surgery Tenoarthrolysis resect collateral ligaments flexor and extensors simultaneously? Adcon gel? CPM? Continuous interscalene blocks
26	Cast disease and RSD Pain Tenderness Swelling Progressive trophic changes Increasing allodynia
27	Post Traumatic Arthritis Interposition arthroplasty Silastic arthroplasty Total joint replacement Cemented pyrocarbon Arthrodesis
28	Implant failure Fatigue failure Implant loosening
29	Amputation Not always a failure! A short, pain free digit always beats a dysaesthetic, cold intolerant, immobile digit