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Abstract
Objective: Refracture is a serious
complication of fracture , cause of redisability and is
difficult to treatment. The purpose of this study was to
evaluate epidemiology and influencing factors of refracture.
Methods: From April 2002 to December 2004, patients with
refracture who were admitted in Babol Sahid Beheshti Hospital
were studied. Epidemiological features and influencing factors
of refracture were recorded .
Results: During this period, 40 patients were studied.
Frequency of refracture was 2.6%. Refracture was more common in:
men (80%), in the younger than 20 years old (40%), Overweight
(52.5%), light work (67.5%), low education (80%), fracture with
transverse pattern(47.5%), fractures caused by indirect and low
energy trauma(79.5%) , left side (57.5%), upper extremity
(57.5%), forearm bones (47.5%) and femur (37.5%). Rigid plate
fixation (42.5%), early weight bearing (76.5%) and improper
cooperation (67.5%) also were found as predisposing factors to
refracture .
Conclusion: There is correlation between gender, age,
weight, Job, level of education, type, pattern and mechanism of
fracture. Refracture is more common in left side, upper limb,
forearm and femur bones and it is more frequent after fixation
of fracture with rigid plate. Post operative early weight
bearing was found as influencing factors and most refracture
occurred in the first year post operative period (risk period).
Key words : Refracture , Epidemiology
, Influencing Factors
J.Orthopaedics 2005;2(5)e2
Introduction:
One of the serious complication of fractures
is refracture which occur after treatment, during and after
healing, and after removal of devices for fixation (1) .
Refracture usually occurs with minor trauma. The incidence of
refracture ranges 1 to 30% and differs according to age,
special bone and different methods of treatment (2-8) .
Treatment of refracture in comparison with
primary fracture is more difficult Knowing the epidemiology and
influencing factors of refractures may induce for reduction of
its occurrence. This study was conducted to evaluate the
epidemiology and influencing factors of refracture in our
department.
Material and Methods :
From April 2002 to December 2004, patients
with refracture who were attended to department of Orthopedics,
Shahid Beheshti Teaching Hospital, Babol Medical University were
studied. Gender, age, weight, Job, levels of education, type of
primary fracture in refracture cases (closed or opened), pattern
of fracture ( transverse, oblique, with butterfly fragment,
segmental and comminuted), mechanism of primary fracture (low or
high energy), and its side, limb, and involved bone were
recorded. Time of refracture after cast removal is classified to
less than 4 weeks, 4 to 6 weeks and more. Cooperation of
patients after post operation was classified as good, fair and
poor. The period between primary fracture treatment and
occurrence of refracture also were noted .
Results :
During this
period, 1522 patients with fracture were admitted. Among them,
40 cases had refracture (2.6% ).
Thirty-two (80%)
cases were males and in 52.5% cases, refracture occurred in
patients less than 20 years old. With regard to weight, 22.5%
had less than 40kg.Twenty-seven( 67.5%) had light work and 23.5%
had heavy work . regarding to educational status, twenty (50%)
cases were elementary educated (table 1).
Table 1;Chracteristics of patients with refracture
|
Patient characteristic |
No(%) |
|
Sex:
Male
Female |
32(80)
8(20) |
|
Age:
<20years
20-50 years
>50 years
|
21(52.5)
14(35)
5(12.5) |
|
Wieght:
<40 kg
40-70 kg
>70 kg
|
9(22.5)
10(25)
21(52.5) |
|
Job:
Light
Heavy |
25(67.5)
15(32.5)
|
|
Education:
Illitrate
Elementary
Diploma |
12(30)
20(50)
8(20) |
Thirty-nine
(97.5%) of primary fracture of these cases were closed. The
pattern of primary fractures were as follows: transverse 47.5%,
oblique 30%,comminuted 12.5%,each of segmental and butterfly
were 5%.Thirty-nine( 97.5%) of refracture caused by indirect low
energy trauma.
The fracture was
seen in the left side of 23(57.5%) cases and of the upper
extremity of 57.5%.
Forearm and
femur comprised 47.5% and 37.5% of refractured bones
respectively .
Twenty (50%) of
patient were treated with cast immobilization and 42.5% with
rigid plate fixation (Table 2).
Table 2.Sites of refractures and kinds
of primary fracture treatment
|
Patients characteristic |
No(%) |
|
Refractured bone
Femur
Leg
Forarm
Humerus
|
15(37.5)
2(5)
19(47.5)
4(10) |
|
Kind of primary frature treatment
Plating
IM Rod(non locking)
External fixator
Nonsurgical |
17(42.5)
2(5)
1(2.5)
20(50) |
Patients who
were treated with cast immobilization, sustained refracture 10%
,30% and 60% in < 4 weeks , 4 - 6 weeks and > 6 weeks after
removal of cast, respectively . Weight bearing in refracture
cases were began in 25.5% , 52.5% and 12.5% in the first ,
second and ≥2 months after treatment of primary fracture
respectively. Regarding to cooperation after treatment of
primary fracture,32.5% , 27.5% and 40% had good , fair and
poor cooperation respectively .The relationship between
occurrence of refracture and the time elapsed from primary
fracture treatment in surgically treated group was found as
follows:35% in the first 3 months , 30% in the second 3 months ,
22.5% in the second half of the first year , 10% in the second
year, and 2.5% later on after primary fracture treatment .
Discussion :
In this study,
the frequency of refracture was 2.6%. There is not any report
about the frequency of refracture in the medical literature. But
the incidence of refracture in special bones in adults, forearm
bones after removal of plate was 1-30% (2,9) and of femur after
removal of plate was 13% (10). Refracture in childrens forearm
bones was reported 4.9% (11) and of femur after removal of
external fixator was reported between 3- 21.6% (12,3).
In this study,
we found that 80% of patients were men and 52.5% were in under
20 years old. Our findings were in contrast to the report of
Robinson et al which was reported in higher age groups(13). The
high frequency of refracture in men and very young patients in
our study may be related to susceptibility to injury and over
activity of this gender and their age. More than fifty-two
percent of our patients were relatively overweight (> 70 kg).
With regard to gender and age group (men, very young and
overactive) overweight seem to increase the chance of recurrent
injuries and refracture. More than sixty-seven of cases had
light work and, it seems that light work decreases physician's
and patient's attention and sensitivity to post operation care
and moreover individuals with light job usually have more low
musculoskeletal strength and skill . Therefore they are more
susceptible to injury and possibly refracture. Patients who were
illiterate or low educated included in 80% of refractured
patients in our study . This emphasizes the importance of
education on the outcome of disease and fracture .
In 47.5% of
patients , primary fracture pattern were transverse, this
pattern of fracture usually is associated with periosteal and
endosteal blood supply damage of bone which may consequently
delay union and predispose to refracture. The primary fracture
of 97% of the cases was closed. However, closed fracture usually
heal uneventfully and have good prognosis, this finding is
incompatible with general consensus. All of primary fracture and
97.5% of refracture in our cases caused by indirect trauma.
Indirect trauma causes extensive damage to the soft tissues
which may delay healing of fracture and predispose it to
refracture. Almost two third of primary and all of refracture
were caused by low energy trauma . Robinson et al found that
refracture was occurred in patients over forty five years old
with sustained a low energy trauma(13).
Left side was
involved more than right side (57.5%) which may be due to its
disability to resist against trauma. Upper limb was involved
more than lower limb which may be attributed to the high
frequency of refracture in forearm bones. Forearm bones and
femur with refracture rate of 47.5% and 37.5% respectively
comprised the most common refractured bones . This rate is
significantly higher than those previously reported in
literature ( 2 , 9 ). But in view of relative frequency to other
bones it is consistent with previous reports . In 42.5% of
refractured patients, primary fracture was treated with rigid
plate fixation . Refracture after removal of plate is an
established issue. Osteopenia of cortex beneath of the plate is
supposed to be the predisposing factor for occurrence of
refracture. Formerly this phenomenon was attributed to the
regional osteoporosis resulted from stress shielding effect of
plate but at present, impaired periosteal blood supply and
degree of plate contact with bone is thought to be the main
cause (14,15).
Screw holes are
known to act as stress elevator in bone and predisposing to
refracture. However the histological evidence showed that the
screw holes benefit from being filled with bone graft material
at the time of screw removal (16). Also the imperfect spatial
disposition of the microscopic elements of bone tissue may
significantly contribute to refracture of a long bone after
removal of screws from plated or unplated long bone fracture
(17) .
Internal
fixation with a rigid plate may lead not only to osteopnenia of
the cortex under the plate but also to disorganization of the
cortex in which the mineral column and collagen fibers were
oriented in randomized pattern. The regional osteoporosis could
recover gradually after removal of the rigid plate. However the
restoration of normal bone structure occurred later than that of
the bone mass . Delayed restoration of bone structure might be
one of the potential causes of refracture of the plated bone
(18). So, refracture remains the greatest risk following
hardware removal , which is not necessary for all patients
(19). Sixty percent of patients which were treated with cast
immobilization sustained refracture more than 6 weeks after
removal of cast. In previous report the median time to
refracture was 8 weeks after discontinuing cast
immobilization(11). Diaphyseal fracture were eight time likely
to refracture than metaphyseal fracture. Mid shaft forearm
fracture are at risk of refracture for sixteen weeks from cast
removal. The risk of refracture was inversely proportional to
the duration of cast immobilization (12).
More than fifty
two percent of patients with refracture of lower extremity
started to weight bearing 2 months after operation . Early
weight bearing with combination of other factors may lead to
refracture .
About two third
of patients with refracture had improper cooperation post
operatively. This finding denotes of importance of patient's
cooperation on the outcome of fracture. Bostman et al reported
that patients noncompliance with post operation regimen could be
suspected to have been major cause of the failure (20).
Eighty seven and
half percent of patients sustained refracture one year after
primary fracture. Thus, this period may be called “ risk period
for refracture occurrence ”.
Conclusions
In our knowledge,
related factors of refracture are insufficiency and inadequacy
of external and internal immobilization (1,12,21), location of
fracture (12,22), method of fixation (2,7,8) unsuccessful
reduction and compression, radiological nonunion, muscular
weakness with or without plate (1). The findings of this study
emphasize the role of gender, age, job, level of education, type
and pattern and mechanism of fracture, cooperation of the
patient and the period between primary fracture and refracture
which we named as “ Risk period “ are risk factors on the
occurrence of refracture.
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