Chronic/Long-term sequelae of Extremity Trauma


Chronic problems as a result of extremity injury can occur months or years after the initial injury.  These problems include osteomyelitis (deep bone infection), nonunion (a fracture that hasn’t healed), and deformity such as bowing or excessive shortening, and wound healing problems. All of these chronic problems can put a limb in jeopardy of amputation.

Management of chronic problems after extremity trauma can involve one surgical specialist, or may require a team of specialists in order to manage the problem appropriately.  There are a number of surgical procedures that may be recommended to attempt to manage the problem.  An amputation may be recommended if a reasonable surgical result can’t be achieved or if function would be better with amputation. 

Osteomyelitis requires aggressive surgical debridement, appropriate antibiotic therapy, and surgical reconstruction once the infective organism has been managed. For more information about osteomyelitis and its management go to Osteomyelitis.

Nonunion of a fracture can be a difficult and frustrating problem.  A number of factors can contribute to development of a nonunion.     

  Smokers experience a 12-15% higher rate of nonunion than nonsmokers. In addition, the healing time for a fracture in a smoker is about 6 weeks longer than a non-smoker.1
  Diabetic patients can experience a higher nonunion rate as well as an increased time to fracture healing compared to non-diabetic patients. This is due to circulation problems, neuropathy and the nutritional compromise that a diabetic experiences.2
  Soft tissue damage at the fracture site can also contribute to nonunion. Open fractures (when the broken bone penetrates the skin) have a higher rate of nonunion than closed, and open comminuted (multiple fractures of the bone) fractures have the highest rate of nonunion.3

Deformity of a bone after a fracture has healed can also place a limb in jeopardy of amputation. If a bone has healed in a “bowed” shape, or if there is significant shortening because the fracture repair required shortening of the bone, a patient can experience difficulty with function or they may develop wounds or early joint degeneration due to abnormal pressure on soft tissues or joint.

Treatment of Chronic Problems related to Extremity Trauma

 

There is no “one size fits all” approach to treatment of any of the chronic problems listed above.  All vary in their severity so consultation with the appropriate specialist is the first step on the road to management.  
Some surgical options that might be discussed to treat these problems include:

 

  Hardware revision – where the orthopedic implants (such as plates, screws, or rods) used to treat the fracture and removed and new implants are utilized to correct the problem.
  Bone osteogenesis – for conditions where there is loss of bone in the area (either due to surgical removal or poor bone formation after initial treatment) an external fixator designed to take advantage of a bone’s ability to form more bone is used; the frame is also called a Taylor Spatial Frame or Ilizarov frame.
  Osteotomy – this involves removal of a piece of a bone in order to change the alignment.
  Vascularized bone flap – bones have a very good blood supply so surgeons take advantage of this characteristic in vascularized bone flap procedures where a small section of a bone is removed and moved to the area of a nonunion or where a significant piece of bone has been removed.
  Allograft reconstruction – a ‘tissue bank’ is an organization that receives donations of human bodies and processes the body for research or for medical use. An allograft bone is one that is received from a tissue bank after it has been appropriately processed. Allograft tissue is used quite commonly in orthopedic surgery. An allograft reconstruction involves the use of allograft bone to fill a gap where bone was removed. Plates and screws are utilized to hold the allograft in place.
  Amputation– there is always the possibility that amputation is the best option for a patient. If a patient’s function will be better with an amputation, or if surgery to treat a chronic extremity problem would be dangerous for the patient, then amputation may be the best choice for treatment.

Before any decision regarding treatment is reached, it is important that a patient (and their family) understand the extent of the treatment as well as the potential functional outcome. Whenever possible, taking some time to consider the options recommended.


References
1.  Schenker M, et al. "Blowing smoke: a meta-analysis of smoking on fracture healing and postoperative infection" AAOS 2013; abstract 591
2. Loder RT. The influence of diabetes mellitus on the healing of closed fractures. Clin Orthop 1988;232:210–16
3. Gustilo et al; Problems in the management of type III (severe) open fractures: a new classification of type III open fractures;  Journal of Trauma, 1984 Aug;24(8):742-6