These usually involve abnormalities of fracture union, namely malunion, non-union and delayed union. Even later sequelae are degenerative osteoarthrosis of the associated joints and tardy nerve palsy. Malunion can involve shortening of the affected limb or a residual deformity. In the younger age group, deformity may be reduced by remodelling an overgrowth of the bone; however, in adults, particularly with respect to rotational deformity, remodelling is extremely limited in its ability to correct residual deformity.
Epiphyseal plate injuries
These occur in the paediatric age group and may result in ongoing deformity if there has been disruption of the growth plate.
This commonly affects fractures where the blood supply to the bone is tenuous (e.g. fractures of the femoral neck, scaphoid and talus). As a result of the fracture, the blood supply to a segment of bone is disrupted and will not be reinstituted even with accurate reduction and appropriate immobilization; over a period of time the bone undergoes necrosis and ultimately collapses often leading to arthritis of the joint.
A not uncommon sequelae of fractures and their associated treatment is reflex sympathetic dystrophy or Sudeck's atrophy. Many names have been attributed to this condition and the most recent name in vogue is complex regional pain syndrome type II. This most commonly occurs following hand or wrist fractures, though it can occur in the lower limbs. The exact aetiology is unknown but it is thought to be related to autonomic nervous system dysfunction, particularly involving the sympathetic branch. It is difficult to predict which patients will be predisposed to developing this condition. The joints distal to the fracture are usually stiff and the affected part is usually swollen with shiny, smooth, mottled skin which may be excessively sweaty or cold to palpation depending on the stage of the condition. Skin creases are usually lost and the nails and hair become atrophic. Any attempted movements of the joints results in severe pain despite fracture union. Radiographically, there is marked osteopaenia of the involved bones. The patient is extremely reluctant to move the affected part because of the pain this induces and this triggers a vicious cycle of further lack of movement resulting in further pain, stiffness and swelling. Treatment usually revolves around braking this cycle by first relieving the patient's discomfort using guanethidine or regional sensory nerve blocks and then aggressive physiotherapy to mobilize the affected joints. If this proves unsuccessful, sympathectomy may be deemed necessary.
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