Date: Fri, 22 Oct 2004 23:53:14 +0600
From: Alexander Chelnokov
Subject: Refracture? Hello All,
Is there any generally accepted definition of refracture?
A patient who broke his femoral shaft during usual walking, at the initial site, 6 months after plate removal - i was convinced that it is exactly what refracture is. But our vice-director returned the chart to me with note that she is not agree with the diagnosis. I'll ask what she means after the weekend but it would be nice to be prepared to the discussion so any references and citations with the definition would be greatly appreciated.
Best regards,
Alexander N. Chelnokov
Ural Scientific Institute of Traumatology and Orthopaedics
str.Bankovsky, 7. Ekaterinburg 620014 Russia
Date: Fri, 22 Oct 2004 22:59:29 EDT
From: Tadabq
Alex
There is no definition of "refracture" that I have ever seen. There are principles and concepts:
1. One key element is whether the fracture occurred at the same site within the bone as the original fracture.If so, refracture.
2. Another is whether or not the fracture was completely healed radiographically and retrospectively before the second episode.
3. Another is delineation of the difference between an unrecognized nonunion and a refracture. Related to #2. Not so much an issue after 6 months as in your case.
4. If the amount of force associated with the second fracture wasn't enough to expect a fracture (e.g. misstep walking and afemur shaft fracture)then a weakend bone and "refracture" would be more likely.
5. Fracture after plate removal issimilar but different from refracture, although the first4 items all apply. Implicating the plate removal as a contributor to the new fracture would include the new fracture line being through one of the screw holes or other stress riser from the plate removal, the amount of time after plate removal, the amount of bone that had filled in the various stress risers, the amount of bone remodelling that had occurred, the appearance of dead (avascular, not completely remodelled) or infected and weak bone (if any such).
Let us know what you and your department chairwoman's perspectives are on this.
Tom DeCoster
Date: Fri, 22 Oct 2004 13:15:33 -0500
From: anthony brown
i quickly scanned this,
they seem to be looking at refxs up to 12 years from original tx. don't know if it will help.
anthony brown
Date: Sat, 23 Oct 2004 09:55:01 +0600
From: Alexander Chelnokov
Hello Anthony,
ab> i quickly scanned this, they seem to be looking at refxs up to 12 years from original tx. don't know if it will help.
It seems to me the article is more about subsequent fractures in general rather than refractures.
Anyway thanks!
Best regards,
Alexander N. Chelnokov
Ural Scientific Institute of Traumatology and Orthopaedics
str.Bankovsky, 7. Ekaterinburg 620014 Russia
Date: Sat, 23 Oct 2004 13:44:14 +0600
From: Alexander Chelnokov
Hello Tom,
TAC> There is no definition of "refracture" that I have ever seen. There are principles and concepts:
1. One key element is whether the fracture occurred at the same site within [...] weakened bone and "refracture" would be more likely.
Agree completely.
I found an article in Russian referred to similar list of features cited from
TAC> 5. Fracture after plate removal is similar but different from refracture,
Yes, i would also inlcine to call this a new fracture though a pathologic one if it is because of local osteoporosis, screw hole or partial bone defect etc.
TAC> Let us know what you and your department chairwoman's perspectives are on this.
Our department chairmen are with me, the person is a step higher... It is a separate problem (maybe specific to local environment of xUSSR) whether such "top managers" should dictate clinical opinions...
Best regards,
Alexander N. Chelnokov
Ural Scientific Institute of Traumatology and Orthopaedics
str.Bankovsky, 7. Ekaterinburg 620014 Russia
Date: Sun, 24 Oct 2004 23:19:40 +0600
From: Alexander Chelnokov
Hello Tom,
TAC> There is no definition of "refracture" that I have ever seen.
Sometimes it is useful to RTFM. :-)
I checked a CD with AO's Principles of Fracture management and the definition was found at p.725:
==============================
Definition of refracture
All five of the following criteria must be fulfilled, without exception:
Definition of secondary fracture - At least one of the above criteria is invalid.
==============================
Best regards,
Alexander N. Chelnokov
Ural Scientific Institute of Traumatology and Orthopaedics
str.Bankovsky, 7. Ekaterinburg 620014 Russia
Date: Sun, 24 Oct 2004 17:06:53 EDT
From: Tadabq
Alex
Excellent definition and reference.
Is there some funtional point to all of this? Is a "refracture" considered a complication of the initial treatment and therefore a negative aspect of that particular form of treatment? Are "refractures" associated with any particular complications themselves, like nonunion, delayed union, further fractures...? Why would the vice-chair care whether or not you called this particular case a "refracture"? What difference does it make if you call it a refracture or not? If you don't call it a refracture, what other terms could it be? Secondary fracture? New fresh fracture? What is the significance of a "secondary fracture"? It sounds like it's a similar category but somehow not quite as "bad". Perhaps this concept is more commonly discussed in Europe or elsewhere?
TDeCoster
Date: Mon, 25 Oct 2004 07:50:28 +0600
From: Alexander Chelnokov
Hello Tadabq,
TAC> Is there some funtional point to all of this? Is a "refracture" considered a complication of the initial treatment and therefore a negative aspect of that particular form of treatment?
I am not sure. Of course meaning of phrase "technically perfect osteosynthesis" is not constant, and what earlier we took as the one like ideal open reduction of the shaft now is interpreted as a common mistake. Maybe it also should be considered as a variation of patient response?
TAC> Are "refractures" associated with any particular complications themselves, like nonunion, delayed union, further fractures...?
In my experience all refractures are quite well healed without any further problem.
TAC> Why would the vice-chair care whether or not you called this particular
I'll explore her view this week.
TAC> What is the significance of a "secondary fracture"? It sounds like it's a similar category but somehow not quite as "bad".
I also don't know, and have to search the manual and other literature for this - maybe it means fractures due to screw holes, local osteoporosis etc, including peri-implant ones?
TAC> Perhaps this concept is more commonly discussed in Europe or elsewhere?
No idea.
Best regards,
Alexander N. Chelnokov
Ural Scientific Institute of Traumatology and Orthopaedics
str.Bankovsky, 7. Ekaterinburg 620014 Russia
Date: Mon, 25 Oct 2004 23:15:28 +0600
From: Alexander Chelnokov
Hello Tom and colleagues,
Monday, October 25, 2004, 3:06:53 AM, you wrote:
TAC> fractures...? Why would the vice-chair care whether or not you called this particular case a "refracture"? What difference does it make if you call it a refracture
After a phone call things cleared - it was misunderstanding. She decided that the refracture was through a screw hole not the old fracture line. Real situation can easily be demonstrated on a pair of films what I plan to do this week. So i am awfully sorry for the "false alarm". Many thanks - the discussion was very interesting and useful. ;-)
Best regards,
Alexander N. Chelnokov
Ural Scientific Institute of Traumatology and Orthopaedics
str.Bankovsky, 7. Ekaterinburg 620014 Russia