(Drfranky) Disboncongenietalease - 10 Agustus 2012

7/26/2019 (Drfranky) Disboncongenietalease - 10 Agustus 2012

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Friday 10/8Friday 10/813.40-15.2513.40-15.25

BONE AND BONE HEALINGCONGENITAL BONE DISEASE

Congenital Bone Disease

Plenary:

FRACTURE


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Congenital Bone Disease

1. COON NORAL !ARIATIONS IN C"ILDREN

Caused by Hypermobility of Joints (Joint Laxity

!lat feet"no#$ $nees

Caused by %orsional &eformities of 'ones%oein out%oein in'o) le

#. CONGENITAL ABNORALITIES

C%*+ (#onenital talipes e,uino arus &&H (deelopmental displa#ement of te ip

/CH&L// 6/!/7 &*/*

$. DISORDERS OF EPIP"%SIS AND EPIP"%SEAL GRO&T" PLATE

L*88-C/L+*-*%H* &*/* L*& 9* !*6/L *H:


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Congenital Bone Disease :

%end to improe spontanously%end to improe spontanously %e borderline bet)een te extremes of%e borderline bet)een te extremes of

normal ariation and te beinnin ofnormal ariation and te beinnin ofabnormal is not al)ays #learabnormal is not al)ays #lear

nly extremes needs spe#ifi# treatment su#nly extremes needs spe#ifi# treatment su#as #orre#tie soes; bra#esas #orre#tie soes; bra#es

1. COMMON NORMAL VARIATIONS IN CHILDREN


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!lat feet!lat feetloo$ flat only on )eit bearinloo$ flat only on )eit bearin

/r# support for extreme/r# support for extreme

"no#$ $nees"no#$ $nees

W or television positionW or television position

J% L/


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/lteration of epipyseal plates %oein out (external femoral torsion

Sleep face down %oein in (internal femoral torsion

Television position *xternal tibial torsion

Television position nternal tibial torsion

Sleeping on the knees with feet turned in 'o) les

nternal torsion of tibia and external torsion of femur

%/L &*!6%*

Congenital Bone Disease :Common Normal Variations In Children


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2. CONGENITAL ANORMALITIES

66

ay be defined as defe#ts in te deelopmentay be defined as defe#ts in te deelopment

of body form or fun#tion tat areof body form or fun#tion tat are present at thepresent at thetime of birthtime of birth

6ay be lo#ali=ed or enerali=ed6ay be lo#ali=ed or enerali=ed n#iden#e> 3? at birt to @ ? at 1st year (notn#iden#e> 3? at birt to @ ? at 1st year (not

dete#table or not defineable at birt; asdete#table or not defineable at birt; asAariationsBAariationsB

Caused by eneti#s defe#ts andorCaused by eneti#s defe#ts andorenironmental influen#esenironmental influen#es


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Congenital Bone Disease :Con!enital a"normalities

/plasia/plasia HypoplasiaHypoplasia &ysplasia&ysplasia

HypertropyHypertropy &upli#ation as olyda#tyly&upli#ation as olyda#tyly /rrested as pina bifida/rrested as pina bifida

&islo#ated as dysplasia of te ip (&&H&islo#ated as dysplasia of te ip (&&H Contra#ture as #onenital #lubfoot (C%*+Contra#ture as #onenital #lubfoot (C%*+

Localized Abnormalities


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Generalized Abnormalities

&eelopmental defe#ts of epipyseal ro)t plate&eelopmental defe#ts of epipyseal ro)t plateas in /#ondroplastyas in /#ondroplasty

mbalan#e bet)een bone deposition and resorptionmbalan#e bet)een bone deposition and resorption

as in steoenesis mperfe#taas in steoenesis mperfe#ta *rrors of metabolism as in efra#tory i#$ets*rrors of metabolism as in efra#tory i#$ets Hypermobile Doint as in #onenital enerali=edHypermobile Doint as in #onenital enerali=ed

Doint laxity (6arfan7s syndromeDoint laxity (6arfan7s syndrome iid Doint as in /myoplasia #onenitaiid Doint as in /myoplasia #onenita

(/rtroryposis(/rtroryposis


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DiagnosisCongenital Bone Disease

/ntenatal/ntenatalby %issue samplin of amnion; uided by 9ltrasoundby %issue samplin of amnion; uided by 9ltrasoundas in open eural %ube &efe#tas in open eural %ube &efe#t

ostnatalostnatal*asy as in Clubfeet*asy as in Clubfeetpe#ifi# #lini#al examination as in &&Hpe#ifi# #lini#al examination as in &&H

Failure to recognize a congenital abnormality at theFailure to recognize a congenital abnormality at the

earliest possible time is an injusticeearliest possible time is an injustice


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TreatmentCongenital Bone Disease

EARL% RECOGNITION' EARL% TREATENT' COUNSELINGEARL% RECOGNITION' EARL% TREATENT' COUNSELING

TOTAL CARETOTAL CARE: (lannin)' *+ill,-l and (rln)ed: (lannin)' *+ill,-l and (rln)ed*-(eri*in*-(eri*in

TO CURE SOETIES' TO RELIE!E OFTEN ANDTO CURE SOETIES' TO RELIE!E OFTEN AND

TO COFORT AL&A%STO COFORT AL&A%S

1.1. !irst do no arm!irst do no arm2.2. 'ase treatment on an a##urate dianosis and pronosis'ase treatment on an a##urate dianosis and pronosis

3.3. ele#t treatment )it spe#ifi# aimsele#t treatment )it spe#ifi# aims

4.4. Cooperate )it te la)s of natureCooperate )it te la)s of nature5.5. 'e realisti# and pra#ti#al in your treatment'e realisti# and pra#ti#al in your treatment

@.@. ele#t treatment for your patient as an indiidualele#t treatment for your patient as an indiidual


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C8*%/L %/L* *E9-+/9

CTE! 2CLUBFOOT3alipes!Tal-* 4 an+le5 Pe* 4 ,6. E"uinus!4 7r*e

F6 67a6 i* in a (*i6in , (lan6ar ,lein a6 67e an+le' l+*

li+e 67a6 , 67e 7r*e.


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Congenital Bone Disease :Con!enital a"normalities #lub$oot %#E&'

T%PES:

ostural> minor and #ore#tablediopati#/#,uired (Central ere ysteme disease; /rtroryposis

INCIDENCE:##urs approximately in 2 of eery 1000 lie birt6ale are affe#ted in about 2< irls'ilateral #ases are as i as 50 ?8eneti# fa#tor in 10?

BASIC PAT"OLOG%:

ne-r9-*;-lar ;a-*estartin from te early stae ofembryoni# deelopment


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"ind ,6:E6alar =in63

Fre ,6:Add-;6in 2id 6ar*al =in63S-(ina6inCa-*

"ind ,6Fre,6

Cl->,6Nral ,6

Nral ,6

ort /#illes tendonHi and small eelo #reases beind Heel/bnormal #rease inmiddle of te foot

!oot is smallerCallositiesnternal torsion of leCalf mus#les )astin&on7t preent )al$in

#HA(A#E(I)I# DEFO(*I+ !

#lub$oot %#E&'

A>nral Tar*al Rela6inand S,6 Ti**-e Cn6ra;6-re

l " l


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(EA*EN !

8/L % '%/A FUNCTINA!" #AIN!$SS AN% N&'A!

A##$A&ANC$ ,LANIG(ADE FOO HA )ABLE O&E( I*E.

A.Nn *-r)i;al 6rea6en6 *7-ld >e)in *7r6ly a,6er >ir67:

8entle passie #orre#tionmmobili=ation>

1. )ee$ly for @ )ee$s2. %ape strappin)ee$ly for F )ee$s

plints to maintain #orre#tion for 3-@ monts &ennis 'ro)n splint rtopaedi# soes

uperision until end of ro)tPONSETI

ani(-la6in

and *erial ;a*6*

#lub$oot %#E&'

C i l B Di C i l " li i


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(EA*EN !

B. S-r)i;al 6rea6en6 if failure re#urren#e of #onseratie treatmt

S,6 6i**-e (era6in* are best performed at 3 to @ monts; but stilleffe#tie until te first 5 years>

release of contractures"

tenotom("

tendon elongation)transfer"

restoration of bon( relationship

Bny (era6in* at 5 to 10 years > (9sually a##ompanied )it soft

tissue operation>

osteotomy;

)ede ex#ision artrodesis;

salae operation to restore sape

#lub$oot %#E&'

C it l B Di C it l " liti


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&*+*L6*%/L &L/C*6*% ! %H* H

(&&HC&H

A PROGRESSI!E DEFORATIONOF PRE!IOUSL% NORALL%FORED STRUCTURES DURINGT"E EBR%ONIC PERIOD

NOTa malformation of oranoenesis

DDH-#DH



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%e most #ommon disorder affe#tin te ip in%e most #ommon disorder affe#tin te ip in

#ildren#ildren

Hip nstability at 'irt > 0.5 G 1 ? of infantsHip nstability at 'irt > 0.5 G 1 ? of infants

Classi# &&H > 1.5 in 1000 infants; bilateral inClassi# &&H > 1.5 in 1000 infants; bilateral in

more tan alf and irls F x more fre,uentmore tan alf and irls F x more fre,uent

9p to 50 ? of ip artritis in ladies; ae9p to 50 ? of ip artritis in ladies; ae

underlyin ip dysplasiaunderlyin ip dysplasia

6ost fre,uent amon te Canadian ndian (due to6ost fre,uent amon te Canadian ndian (due to

titly )rapped blan$et ; follo)ed by tetitly )rapped blan$et ; follo)ed by te

Cau#assian; and less amon te CineseCau#assian; and less amon te Cinese

DDH-#DH



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EIOLOG+ !DDH-#DH

1. P7y*il)i; ,a;6r*: liament laxity (ormonal; familial

#. Gene6i; ,a;6r*: female; mono=yote$. e;7ani;al ,a;6r*:bree# position; s)addlin?. Eniren6al ,a;6r* : strappin

DD" PATIENTS AT RIS@:

ositie !amily History/ baby irl'ree# resentation%orti#ollis

Cal#aneoalus I metatarsus addu#tus of te footHyperextension I dislo#ation of te $nee

&"EN RIS@ FACTORS ARE PRESENT:%e infant sould be examined repeate.ly

%e ip sould be imaed ( by 9 or


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NEONAAL #LINI#AL E/A*INAION !

LOO@ :LOO@ :

*xternal rotation attitude*xternal rotation attitude Laterali=ed #ontourLaterali=ed #ontour ide perineum in bilateral &&Hide perineum in bilateral &&H /symmetri# ti folds/symmetri# ti folds ortenin ( not in neonates>ortenin ( not in neonates>

8alea==y sin8alea==y sin

DDH-#DH



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FEEL :

*mpty roin

ea$ !emoral pulse

O!E :

Hip instability in early infan#y

Limited ip abdu#tion in flexion -later

if K@00on bot sides> re,uest imain

DDH-#DH



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Feel a Cl-n+Feel a Cl-n+

N6 7ear a ;li;+ N6 7ear a ;li;+

ORTOLANIby already dislo#ated ip

BARLO& 2(r;a6in 6e*63byeery infant to see$ out te instability

DDH-#DH

Congenital Bone Disease :Con!enital a"normalities DDH-#DH


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T"OAS TEST (Hip !lexion &eformity:

Loss of fixed flexion deformity (!!& of ips (in earlyinfan#y

!!&ormal

o !!&&&H

DDH-#DH



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"ASTRING STRETC" SIGN:!lex ip and $nee 00ea#."eep ip flexed and radually extend te $neeormally a resistan#e is felt to)ards te end of $nee extension

(#aused by te amstrins )i# are pulled from bot endsn #ases of &&H; no resistan#e is felt

()en te ip is dislo#ated; te oriin of te amstrins arenot pulled by ip flexion

DDH-#DH



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TRENDELENBURGTRENDELENBURG>> unilateral bilateral ()addlinunilateral bilateral ()addlin

DDH-#DH



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(ADIOG(A,H+ !

*arly infan#y>*arly infan#y> not reliablenot reliable 'y 2-3 monts of ae>'y 2-3 monts of ae> reliablereliable

/ ie)/ ie) - neutral position- neutral position

- dra) referen#e lines- dra) referen#e lines - a#etabular index - in early infan#y- a#etabular index - in early infan#y

K 30K 30oo > normal > normal

3030ooG 40G 40oo> ,uestionable> ,uestionable

M 40M 40oo > abnormal > abnormal

+on osen ie)+on osen ie) > 45> 45ooabdu#tionabdu#tion

DDH-#DH



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(EA*EN !

AIS:AIS: btain and 6aintain #on#entri# redu#tionbtain and 6aintain #on#entri# redu#tion n an atraumati# fasionn an atraumati# fasion itout disruptin of te blood supplyitout disruptin of te blood supply

"O&:

6etod depends on ae> te earlier started; te easier

te treatment and te better te results

S7-ld >e de6e;6ed EARL%

Most resolve spontaneously in neonatal period

DDH-#DH



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DIAGNO)I) AND (EA*EN !

CLINICAL DIAGNOSIS

*/%* (9 % 3 6%H >nstability rtolani-'arlo)%omas test

3-1F 6%H >Limited abdu#tionortenin ( 8alea==i Hamstrin stret# sin

1F6-5 :*/ >Limited abdu#tion

ortenin ( 8alea==i Hamstrin stret# sin%rendelenbur

M 5 :*/ >%rendelenbur

Hamstrin stret# sin

TREATENT

*/%* (9 % 3 6%H >8entle redu#tion I ali$ orplaster ip spi#a3-1F 6%H >-Continous tra#tion;-/ddu#tor tenotomy; entle redu#tionand AumanB ip spi#a for @ monts-pen redu#tion1F 6-5 :*/>-Continous tra#tion;

-/ddu#tor tenotomy Iopen redu#tion-nnominate osteotomy

M5 :*/>-pen redu#tion;

-nnominate osteotomy and or femoralsortenin

DDH-#DH



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18 n67* year*:

Bir67 $ n67*: Pali+ 7arne**


(EA*EN !

$9 18 n67*: "-an 7i( *(i;a

DDH-#DH



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/CH&L// D&ARFIS> / failure of lonitudinal

ro)t in te #artilae of te epipysealplate of all bones tat form byendo#ondral ossifi#ation

##urs in about one in eery 25;000 birts Hae a normal mentality and life

expe#tan#y

/#ondroplasia is ard to lie )it be#auseof lun infe#tions and )al$in diffi#ulties.

Currently is no )ay to normali=e s$eletaldeelopment (een )it ormonal or

lli=arof surery



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#LINI#AL FEA0(E) !Achon.roplasia

AAitout #artilae formationB; te limbs areitout #artilae formationB; te limbs are

disproportionately sorter tan te trun$; )it te totaldisproportionately sorter tan te trun$; )it te total

eiteit NN4 feet4 feet

/ sort stature in a lon narro) trun$ )it sort/ sort stature in a lon narro) trun$ )it sortbo)ed extremities and #ured spine; lare ead )itbo)ed extremities and #ured spine; lare ead )it

frontal bossin; ypoplasia of te midfa#e; trident finersfrontal bossin; ypoplasia of te midfa#e; trident finers

and de#reased mus#le toneand de#reased mus#le tone

/n autosomal dominant disorder; sporadi# as te result of/n autosomal dominant disorder; sporadi# as te result of

a ne)a ne)mutation in a erm #ell.mutation in a erm #ell.



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6/!/7 :&6* / eritable #ondition tat affe#ts te #onne#tie tissue

)it an ex#essie lonitudinal ro)t in te #artilae of

te epipyseal plate of all bones (7y(er;7ndr(la*ia

tat form by endo#ondral ossifi#ation

Ara;7nda;6ily> Apider finersB; ex#essie lent

of te limbs and lesser extent of te trun$

##urs rarely; male O female;

Life treatenin by enerally )ea$ #ondition; )it Doint

laxity; s#oliosis; pe#tus ex#aatum; extremely flexible

flat feet; and #onenital eart disease and #onenital

dislo#ation of te lens

http://hernaturehisnurture.files.wordpress.com/2008/08/phelps13.jpg


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g

#. DISORDERS O$ E%I%H&SIS ANDE%I%H&SEAL GRO'TH %LATE

*pipysis appear to be more resistant to infe#tion andneoplasm; but more ulnerable to aas#ular ne#rosis

/ as#ular ne#rosis of te epipyseal #enter represents>te initial loss of blood supply; te dead of bone; and teradual repla#ement by liin bone.

6ost #ommon from te aes of 3 to 10.

'oys more tan irls Lo)er limb more tan upper limb

'ilateral in 15? of inoled #ildren

redisposin fa#tors> eneti#; trauma and idiopati#

T"E OSTEOC"ONDROSES (disorders of epipysis

Congenital Bone Disease :Disorders o( e)i)h*sis and e)i)h*seal !ro+th )late


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/re self-limitin disorders tat eentually eal spontaneusly/re self-limitin disorders tat eentually eal spontaneusly %e patoloi#al pro#ess%e patoloi#al pro#ess runrunin 4 pasesin 4 pases forfor2 to F years2 to F years

dependin on te ae of onset and te extent of inolementdependin on te ae of onset and te extent of inolement1.1. *arly pase of*arly pase of AAa*;-lari6ya*;-lari6y>> disruption of blood supply;disruption of blood supply;

symptomless and no deformitysymptomless and no deformity2.2. ase ofase of RRea*;-laria6inea*;-laria6in)it bone deposition and resorption>)it bone deposition and resorption>

o##urin a patoloi#al fra#ture in te sub#ondral bone )it paino##urin a patoloi#al fra#ture in te sub#ondral bone )it painand synoial effusion and appearan#e ofand synoial effusion and appearan#e of AAframentationframentation AA)it)it)ea$enin of epipysis #ausin a proressie deformity)ea$enin of epipysis #ausin a proressie deformity

3.3. ase ofase of BBnene ""ealin)ealin)> 'one resorption #eases and bone> 'one resorption #eases and bonedeposition #ontinues )it bioloi#al plasti#itydeposition #ontinues )it bioloi#al plasti#ity

4.4. ase ofase of RRe*id-ale*id-al DDe,ri6ye,ri6y> lead to te radual deelopment of> lead to te radual deelopment oftete deeneratie Doint diseasedeeneratie Doint disease

g ( ) ) * ) ) * ! )


Congenital Bone Disease :Disorders o( e)i)h*sis and e)i)h*seal !ro+th )late


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%H* *E9*L/*>

ub#ondral fra#ture in te epipysis; ubluxation of te Doint;

&eformity of te epipysis and e#ondary deeneratie Doint disease

%H* /6 ! %*/%6*%>

%o preent deformity of te epipysis and to preent se#ondary /

>y (re*erin) ;n)r-i6y , 67e =in6

g ) ) * ) ) * ! )


Congenital Bone Disease :Disorders o( e)i)h*sis ,the osteo-ondroses


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g ) ) * ,

L*88-C/L+P-*%H* &*/*%*CH& ! !*6/L H*/&(/+/C9L/ *C ! *H:*9sually aes 3-11years (mostly @-F

/s early as 2 years; as late as teens'oys>8irls O 5 > 1

'ilateral 15? of te affe#ted #ildren

Caused by poorly understood non

eneti# fa#tors

o eiden#e of ineritan#e 10?



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A1ascular necrosis o$ epiphyses

g ) ) * ,



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Catterall7s ead at ris$ sins

Lateral subluxation of te ead

ole of te ead inoled

Cal#ifi#ation lateral to epipysis 6etapyseal #ysts

8ae7s sin

Hori=ontal pysis


) ) *



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alter-%ompson Classifi#ation

implifi#ation of Catterall

'ased on status of lateral

marin of #apital femoral

epipysis

8roup / (Catterall I

e,uialent> less tan 50?

8roup ' (Catterall I +

e,uialent> more tan 50?

) ) *



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T7e 6rea6en6* (rin;i(leis #ontainment of te

femoral ead; plus a full rane of ip Doint motion andfull )eitbearin so tat te inoled femoral ead

may be prote#ted from be#omin flattened. (/bdu#tion

plaster #ast bra#e for LCT7e *-r)i;al (r;ed-re* are desined to preent

subluxation of te inoled ip; used in #ildren older

tan 5 years )it M 50? ead inolement (arusfemoral osteotomy and innominate osteotomy

T7e (r)n*i* is ood in #ildren )ose onset

o##urs before te ae of 5 years> seldom re,uire any

Congenital Bone Disease :Disorders o( e)i)h*seal !ro+th )late


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L*& 9* !*6/L *H:ADOLESCENT COHA !ARA> te epipysisslips do)n)ard and ba#$)ard in relation to te ne#$

of femur. e#ond ip atta#$ in 30? subse,uently

lder #ild from years old to te end of ro)t.%all tin or obese !roli# type.

'oysMirls

mbalan#e bet)een ro)t ormone and sexormones )ea$ens te epipyseal plate; ulnerable

to te searin for#es of )eit bearin and inDury.

(disorders of epipyseal ro)t plate

Congenital Bone Disease :Disorders o( e)i)h*seal !ro+th )late


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6ost #ommon in obese boys in adoles#en#e6ost #ommon in obese boys in adoles#en#e Classified as a#ute; #roni#; and a#ute-on-#roni#Classified as a#ute; #roni#; and a#ute-on-#roni# lit limp; trendelenbur type ait; externallylit limp; trendelenbur type ait; externally

rotated lo)er limb.rotated lo)er limb. radual or sudden #auses painradual or sudden #auses pain abdu#tion I internal rotation are limitedabdu#tion I internal rotation are limited

"lein7s line on xray"lein7s line on xray Trea6en6Trea6en6> innin in situ to preent furter> innin in situ to preent furter

slippin (for#efull manipulation must be aoidedslippin (for#efull manipulation must be aoided

)lippe. $emoral epiphysis


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!ra#ture Healin

Fra;6-re "ealin)Fra;6-re "ealin)


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))

Fra;6-re "ealin): T"E REACTI!E P"ASEFra;6-re "ealin): T"E REACTI!E P"ASE


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"ea6a Fra6in 21"ea6a Fra6in 21*6*633

&ead bone and tissue Oinflammatory rea#tion in#ludin

asodilation; plasma exudate; andinflammatory #ells

Cell-lar Fra6in 2#Cell-lar Fra6in 2#ndnd33

/#idi# enironment but turnin neutral nflux of endosteal #ells from #ambium

layer to produ#e a ,i>r-* ;all-*(enironment as i oxyen tensionten ;ar6ila)e (as a lo) oxyen tensionenironment

Fra;6-re "ealin): T"E REACTI!E P"ASEFra;6-re "ealin): T"E REACTI!E P"ASE

Fra;6-re "ealin): T"E REPARATI!E P"ASEFra;6-re "ealin): T"E REPARATI!E P"ASE


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Call-* Fra6in 2$Call-* Fra6in 2$rdrd33

nternal #allus (ro)s ,ui#$ly to #reatenternal #allus (ro)s ,ui#$ly to #reateriid immobili=ationriid immobili=ation

!ibroblast deposit #ollaen in te!ibroblast deposit #ollaen in teranulation tissueranulation tissue

S,6 Call-*S,6 Call-*is formed (9norani=edis formed (9norani=ednet)or$ of )oen bonenet)or$ of )oen bone

"ard ;all-*"ard ;all-*G a radual #onne#tion ofG a radual #onne#tion ofbone filament to te )oen bone (/#tsbone filament to te )oen bone (/#tsli$e a temporary splintli$e a temporary splint>> 3-4 monts.3-4 monts.

'one is beinnin to strenten and'one is beinnin to strenten andimmobili=eimmobili=e

f proper immobili=ation does not o##urQf proper immobili=ation does not o##urQ

#artilae )ill form instead of bone#artilae )ill form instead of bone

O**i,i;a6in 2?O**i,i;a6in 2?676733

!ra#ture is brided and united ill o##ur )it ade,uate

immobili=ation 'one ends be#ome #rossed )it a

ne) Haersian system tat )ill

eentually lead to te layin do)nof primary bone

Fra;6-re "ealin): T"E REPARATI!E P"ASEFra;6-re "ealin): T"E REPARATI!E P"ASE

Fra;6-re "ealin): T"E REODELING P"ASEFra;6-re "ealin): T"E REODELING P"ASE


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Redelin) P7a*e 2Redelin) P7a*e 2676733

emodelin ard #allus to #ompa#t boneemodelin ard #allus to #ompa#t bone 6ay ta$e a fe) years6ay ta$e a fe) years Completed )en te fra#tured bone as beenCompleted )en te fra#tured bone as been

restored to its oriinal form or sape or )en itrestored to its oriinal form or sape or )en it#an )itstand te imposed stresses pla#ed on it#an )itstand te imposed stresses pla#ed on it

Fra;6-re "ealin): T"E REODELING P"ASEFra;6-re "ealin): T"E REODELING P"ASE



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Conditions tat interfere )it fra#ture

ealin oor blood supply to te fra#tured areaQoor blood supply to te fra#tured areaQ

#ould lead to aas#ular or asepti# ne#rosis#ould lead to aas#ular or asepti# ne#rosis

oor immobili=ation of fra#ture site mayoor immobili=ation of fra#ture site may#ause misalinment or deformity#ause misalinment or deformity

nfe#tion G more #ommon )it opennfe#tion G more #ommon )it open

fra#turesfra#tures

))



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*&9C%&ire#t I ndire#t/natomi#al I !un#tional

%/'LR/%

/bsolute s elatie

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Documents

(Drfranky) Disboncongenietalease - 10 Agustus 2012