Union and consolidation
- Fracture repair is a continuous process
- The stages into which it is divided is an arbitrary process
- Union should be regarded as incomplete repair
- Present when an ensheathing callus is formed
- Fracture site is still tender
- Minimal movement at the fracture site is present
- Consolidation should be regarded as complete repair
- Radiologically fracture line is obliterated
- Fracture site is non-tender
- No movement is possible at the fracture site
- Time to union and consolidation depends on many factors including
- Age
- Fracture type
- Blood supply
- Fractures heal quicker in children
- Upper limb fractures heal quicker than lower limb
- Spiral fractures heal quicker than transverse fractures
Delayed union
- Delayed union is the prolongation of time to fracture union
- No definite timetable to define delayed union exists
- Delayed union is due to
- Inadequate blood supply
- Infection
- Incorrect splintage
- Intact fellow bone
Clinical features
- Fracture site remains tender
- Bone may still move when stressed
- On x-ray the fracture remains visible
- May be little callus formation or periosteal reaction
Management
- Usually continue previous treatment of fracture
- May need to replace cast or reduce traction
- Functional bracing promotes bone union
- For tibial fracture may need to excise portion of fibula
- It union is delayed more than 6 months may need to consider
- Internal fixation
- Bone grafting
Non-union
- Non-union has many causes including:
- Bone or soft tissue loss
- Soft tissue interposition
- Poor blood supply
- Infection
- Pathological fracture
- Poor splintage or fixation
- Fracture distraction
Clinical features
- Movement remains present at the fracture site
- Movement is often relatively painless
- Radiologically the fracture is still visible
- Bone ends on either side of the fracture are sclerosed
- Non-union can be either hypertrophic or atrophic
Management
- Non-union is occasionally symptomless
- Asymptomatic non-union may not require active treatment except splintage
- For hypertrophic non-union internal or external fixation may lead to union
- For atrophic non-union bone grafting is often required
Myositis ossificans
- Due to heterotopic ossification with an muscle
- Elbow is the commonest joint involved
- Seen following dislocation or muscle rupture
- Also occurs without injury in unconscious or paraplegic patients
- Pain is an early symptom
- Stiffness and reduced range of movement are late features
- In the late stage of the process a bony lump is often palpable
- Early x-ray shows fluffy calcification
- Late x-ray shows none formation
Management
- Rest joint in position of function
- Once pain settles begin mobilisation
- After several months consider excision of bony mass
Avascular necrosis
- Certain bony regions are prone to bone ischaemia and necrosis
- These areas include
- Head of femur
- Proximal scaphoid
- Body of the talus
- Interruption of blood supply by a fracture results in avascular necrosis
- Pain due to fracture non-union is the main symptom
- X-ray shows increase in bone density
Management
- Surgical intervention required if there is a reduction in function
- May require arthrodesis or arthroplasty
Bibliography
Beiner J M, Jokl P. Muscle contusion injury and myositis ossificans traumatica. Clin
Orthop 2002; 402 (Suppl): S110-119.
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