Raiyyan Tahsan

Raiyyan Tahsan
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TC(968).(05).Orthopedics Case No 46. Malunion

Malunion — সংজ্ঞা

Malunion হলো: fracture/broken bone heal করেছে, কিন্তু ভুল position/alignment-এ heal করেছে—যেমন bone বাঁকা, ছোট, rotate/twist, angulated বা joint surface uneven হয়ে গেছে। এতে pain, deformity, limp, movement limitation ও early arthritis হতে পারে।

Core meaning: হাড় জোড়া লেগেছে, কিন্তু সোজা/সঠিক anatomical position-এ লাগে নাই।

Cause / Risk Factor — কারণগুলো

  1. Improper reduction
    Fracture হওয়ার পর bone fragment ঠিকভাবে সেট না হলে ভুল alignment-এ heal করে।
  2. Inadequate immobilization
    Cast/splint/plate/nail যথেষ্ট stable না হলে fracture fragment healing চলাকালে সরে যায়।
  3. Cast early removal / early weight bearing
    সময়ের আগে cast খুলে ফেলা বা fracture fully heal হওয়ার আগে weight-bearing করলে deformity develop করতে পারে।
  4. Delayed treatment / neglected fracture
    fracture হওয়ার পর দেরিতে চিকিৎসা নিলে bone already displaced position-এ heal শুরু করে।
  5. Comminuted fracture
    হাড় অনেক টুকরা হলে anatomical alignment ধরে রাখা কঠিন হয়; AAOS অনুযায়ী comminuted fracture malunion-এর risk বাড়ায়।
  6. Poor surgical fixation
    ভুল plate/nail position, inadequate screw purchase, short fixation, loss of reduction।
  7. Biological factors
    diabetes, smoking/nicotine, malnutrition, vitamin D deficiency, thyroid disease, old age—healing quality খারাপ করে।
  8. Infection / osteomyelitis
    infection থাকলে bone healing ও alignment দুটোই disturb হতে পারে।

Symptoms — লক্ষণগুলো

  1. Visible deformity
    হাড়/হাত/পা বাঁকা দেখা যায়—bowing, angulation, crooked limb।
  2. Shortening / limb length discrepancy
    এক পা অন্য পায়ের চেয়ে ছোট বা বড় মনে হতে পারে; হাঁটায় imbalance হয়।
  3. Rotational deformity
    পা ভিতরের দিকে/বাইরের দিকে ঘুরে থাকে; হাতের ক্ষেত্রে wrist/forearm rotation limitation হতে পারে।
  4. Pain on use
    rest-এ কম, কিন্তু হাঁটা/ওজন নেওয়া/হাত ব্যবহার করলে pain বাড়ে। Cleveland Clinic malunion-এ bone pain, swelling ও limping উল্লেখ করেছে।
  5. Swelling / tenderness
    local swelling থাকতে পারে, বিশেষ করে overuse বা joint involvement থাকলে।
  6. Limping / abnormal gait
    lower limb malunion-এ patient খুঁড়িয়ে হাঁটে; gait analysis diagnosis-এ গুরুত্বপূর্ণ।
  7. Reduced range of motion
    adjacent joint stiff হয়ে যায়—ankle, knee, elbow, wrist।
  8. Neurological symptom
    nerve stretch/entrapment হলে numbness, tingling, weakness, neuropathic pain হতে পারে।

Clinical Diagnosis — clinically কীভাবে ধরবেন

  1. History
    • fracture date, mechanism of injury
    • treatment delay ছিল কি না
    • cast কতদিন ছিল
    • operation হয়েছিল কি না
    • pain, deformity, limp, functional limitation
    • smoking, diabetes, steroid use, malnutrition
  2. Inspection
    • angulation, shortening, rotation
    • surgical scar, sinus, swelling
    • limb axis: varus/valgus/recurvatum/procurvatum
  3. Palpation
    • tenderness
    • bony prominence
    • temperature rise → infection suspicion
  4. Range of Motion
    • nearby joint: knee/ankle/wrist/elbow
    • contracture আছে কি না
  5. Gait analysis
    • limp
    • foot progression angle
    • toe-in/toe-out gait
  6. Limb length measurement
    • true length: ASIS to medial malleolus
    • apparent length: umbilicus to medial malleolus
    • block test for lower-limb discrepancy
  7. Neurovascular examination
    • pulse, capillary refill
    • sensory/motor nerve function
    • compartment sequelae

Investigations — specific test

  1. X-ray: AP + lateral view
    • affected bone-এর full length
    • proximal ও distal joint include করতে হবে
    • angulation, shortening, translation, rotational clue দেখা যায়
  2. Comparison X-ray
    • opposite normal limb-এর সাথে compare করলে deformity planning সহজ হয়।
  3. Long-leg standing alignment X-ray
    • femur/tibia malunion-এ mechanical axis deviation দেখতে।
  4. Scanogram / EOS / CT scanogram
    • limb length discrepancy measure করতে; AAOS scanogram mention করেছে।
  5. CT scan with 3D reconstruction
    • rotational malunion
    • intra-articular malunion
    • complex deformity planning
    • pre-operative osteotomy planning
  6. MRI
    • AVN suspicion
    • cartilage/ligament/soft tissue problem
    • occult infection/osteomyelitis suspicion
  7. Blood tests — malunion confirm করার জন্য নয়; cause/complication খুঁজতে
    • CBC
    • ESR, CRP → infection suspicion
    • Serum calcium, phosphate, ALP
    • 25-OH Vitamin D
    • HbA1c / fasting glucose
    • TSH
    • Renal function, liver function
    • Albumin/protein status
    • PTH if metabolic bone disease suspected
  8. Culture / biopsy
    • sinus, discharge, osteomyelitis, infected implant থাকলে culture sensitivity।

Complications — রোগের জটিলতা

  1. Permanent deformity
    হাড় ভুলভাবে জোড়া লাগলে limb cosmetically ও functionally abnormal থাকে।
  2. Limb length discrepancy
    পা ছোট হলে back pain, hip/knee overload, limping হয়।
  3. Early osteoarthritis
    joint surface uneven হলে joint cartilage-এর ওপর abnormal pressure পড়ে—ankle/knee/hip arthritis early হতে পারে।
  4. Chronic pain
    malalignment-এর কারণে muscle, tendon, ligament ও joint-এর ওপর abnormal stress পড়ে।
  5. Joint stiffness / contracture
    দীর্ঘদিন immobilization বা wrong alignment-এর কারণে joint movement কমে যায়।
  6. Muscle wasting / weakness
    disuse ও pain-এর কারণে muscle atrophy হয়।
  7. Nerve compression / neuropathic pain
    deformity nerve stretch/entrapment করলে burning pain, tingling, numbness হতে পারে।
  8. Reduced functional capacity
    হাঁটা, দৌড়ানো, সিঁড়ি ওঠা, হাত দিয়ে কাজ করা—সব কমে যায়।
  9. Psychological impact
    visible deformity ও chronic pain থেকে anxiety/depression হতে পারে।

Treatment / Management

A. Non-pharmacological treatment

  1. Observation
    • deformity mild হলে, pain/function problem না থাকলে follow-up।
  2. Brace / orthosis
    • unstable feeling বা mild deformity compensation।
  3. Shoe raise
    • lower limb shortening থাকলে।
  4. Physiotherapy
    • ROM exercise
    • strengthening
    • gait training
    • balance training
    • post-operative rehabilitation
  5. Correct underlying factor
    • diabetes control
    • smoking stop
    • vitamin D/calcium deficiency correct
    • nutrition improvement

B. Surgical treatment — definitive correction

  1. Corrective osteotomy
    • malunited bone আবার planned way-তে cut করে correct alignment করা।
    • Malunion correction-এর common definitive procedure হলো osteotomy।
  2. Open reduction and internal fixation
    • plate, screw, intramedullary nail দিয়ে fixation।
  3. External fixator / Ilizarov
    • complex deformity, shortening, infected case, limb lengthening।
  4. Bone graft
    • biological deficiency বা nonunion component থাকলে।
  5. Limb lengthening
    • significant shortening থাকলে।
  6. Arthrodesis / arthroplasty
    • severe joint arthritis হলে selected case-এ।

Bangladesh Prescription-use Drug List

Important: Malunion-এর “হাড় সোজা করার” কোনো tablet নেই। Drug used হয় pain control, post-operative pain, infection prophylaxis, DVT prophylaxis, nerve pain, vitamin/mineral deficiency correction-এর জন্য। নিচের dose adult typical dose; renal disease, liver disease, pregnancy, peptic ulcer, cardiac disease, anticoagulant use থাকলে dose/choice বদলাতে হবে।

1. Paracetamol

  1. Generic name: Paracetamol / Acetaminophen
  2. Therapeutic category: Analgesic, antipyretic
  3. Pharmacological class: Para-aminophenol derivative; non-opioid analgesic
  4. Bangladesh available brand name: Napa 500 mg, Napa One 1000 mg, Napa Extend 665 mg, Ace 500 mg
  5. Typical adult dose: 500 mg–1 g every 6–8 hourly PRN; maximum usually 3–4 g/day depending on liver status
  6. Duration: 3–7 days for pain; chronic use doctor supervision
  7. কেন used হয়: mild to moderate bone/joint pain control
  8. Side effect: nausea, rash, liver toxicity in overdose
  9. Interaction: alcohol, warfarin, liver enzyme inducer
  10. Purpose: safest first-line analgesic when inflammation কম কিন্তু pain আছে। MedEx paracetamol-কে mild to moderate pain-এর miscellaneous analgesic হিসেবে উল্লেখ করে।

2. Ibuprofen

  1. Generic name: Ibuprofen
  2. Therapeutic category: Pain and inflammation control
  3. Pharmacological class: NSAID; non-selective COX inhibitor
  4. Bangladesh available brand name: Flamex 400 mg, Profen 400 mg, Reumafen 400 mg, Intaflam 400 mg, Inflam 400 mg
  5. Typical adult dose: 200–400 mg 6–8 hourly after meal; max OTC-type dose often 1200 mg/day
  6. Duration: 3–5 days; prolonged use avoid without doctor
  7. কেন used হয়: pain + swelling/inflammation থাকলে
  8. Side effect: gastritis, peptic ulcer bleeding, renal impairment, BP rise, edema
  9. Interaction: anticoagulant/warfarin, aspirin, steroid, ACE inhibitor/ARB + diuretic, other NSAIDs
  10. Purpose: prostaglandin synthesis কমিয়ে pain/inflammation কমায়; MedEx ibuprofen-এর analgesic, anti-inflammatory, antipyretic activity ও COX inhibition উল্লেখ করেছে।

3. Diclofenac Sodium

  1. Generic name: Diclofenac Sodium
  2. Therapeutic category: NSAID analgesic
  3. Pharmacological class: Non-selective NSAID
  4. Bangladesh available brand name: Diclofen 50 mg, Diclofen SR 100 mg, Diclofast SR 100 mg, DicloGel 1%, Diclomol SR 100 mg
  5. Typical adult dose: 50 mg 2–3 times daily after meal OR SR 100 mg once daily
  6. Duration: 3–5 days; chronic use avoid
  7. কেন used হয়: stronger musculoskeletal pain/inflammation
  8. Side effect: gastritis, GI bleeding, renal injury, edema, hypertension, cardiovascular risk
  9. Interaction: anticoagulant, antiplatelet, steroid, SSRI, ACEi/ARB, diuretic, lithium, methotrexate
  10. Purpose: post-traumatic inflammatory pain; MedEx diclofenac sodium-কে NSAID therapeutic class-এ দেখিয়েছে।

4. Naproxen Sodium

  1. Generic name: Naproxen Sodium
  2. Therapeutic category: Analgesic, anti-inflammatory
  3. Pharmacological class: NSAID
  4. Bangladesh available brand name: Napro-A 500 mg, Napryn 500 mg, Naxin 500 mg, DP-Naproxen 500 mg
  5. Typical adult dose: 250–500 mg twice daily after meal
  6. Duration: 3–7 days
  7. কেন used হয়: persistent inflammatory musculoskeletal pain
  8. Side effect: dyspepsia, GI bleeding, renal dysfunction, fluid retention
  9. Interaction: anticoagulant, aspirin, steroid, SSRI, ACEi/ARB, diuretic
  10. Purpose: longer duration NSAID pain relief; MedEx naproxen-এর adult daily dose 500–1000 mg divided dose হিসেবে উল্লেখ করে।

5. Etoricoxib

  1. Generic name: Etoricoxib
  2. Therapeutic category: Pain and inflammation
  3. Pharmacological class: Selective COX-2 inhibitor NSAID
  4. Bangladesh available brand name: Setorib 60/90/120 mg, Etoxib 60/90 mg, Cox-E 90 mg
  5. Typical adult dose: 60–90 mg once daily; acute severe painে 120 mg once daily short course only
  6. Duration: 3–7 days; lowest dose shortest duration
  7. কেন used হয়: GI risk relatively বেশি হলে nonselective NSAID-এর alternative, কিন্তু cardiac risk assess করতে হবে
  8. Side effect: hypertension, edema, renal impairment, dyspepsia, cardiovascular risk
  9. Interaction: warfarin, ACEi/ARB, diuretic, lithium, methotrexate
  10. Purpose: once-daily inflammatory pain control; MedEx etoricoxib 60/90/120 mg brands list করে।

6. Ketorolac

  1. Generic name: Ketorolac Tromethamine
  2. Therapeutic category: Post-operative analgesic
  3. Pharmacological class: NSAID
  4. Bangladesh available brand name: Maxdol 10 mg tablet, Maxdol 30 mg/ml injection, Minolac 10 mg tablet, Minolac 30 mg/ml injection, Lupelac 10 mg
  5. Typical adult dose: 10 mg oral 6 hourly PRN OR 30 mg IM/IV 6 hourly in hospital setting
  6. Duration: maximum 5 days
  7. কেন used হয়: moderate to severe acute post-operative pain
  8. Side effect: GI bleeding, renal injury, bleeding tendency, bronchospasm
  9. Interaction: anticoagulant, antiplatelet, steroid, other NSAIDs, SSRI
  10. Purpose: short-term strong NSAID pain relief; MedEx ketorolac post-operative pain indication দেখায় এবং MedlinePlus 5 দিনের বেশি ব্যবহার না করার কথা বলে।

7. Tramadol

  1. Generic name: Tramadol Hydrochloride
  2. Therapeutic category: Moderate–severe pain analgesic
  3. Pharmacological class: Centrally acting opioid analgesic; weak μ-opioid agonist + serotonin/noradrenaline reuptake inhibition
  4. Bangladesh available brand name: Tramal 50 mg, DP-Tramadol 50 mg, Anadol 50 mg, Ultram 50 mg
  5. Typical adult dose: 50–100 mg every 6–8 hourly PRN; max usually 400 mg/day
  6. Duration: 2–5 days; long-term avoid unless specialist supervised
  7. কেন used হয়: severe pain/post-operative pain যখন paracetamol/NSAID enough নয়
  8. Side effect: nausea, vomiting, dizziness, sedation, constipation, dependence, respiratory depression, seizure risk
  9. Interaction: MAOI, SSRI/SNRI/TCA, alcohol, benzodiazepine, carbamazepine
  10. Purpose: central pain pathway suppress করে; MedEx tramadol pharmacology ও MAOI interaction উল্লেখ করেছে।

8. Pregabalin

  1. Generic name: Pregabalin
  2. Therapeutic category: Neuropathic pain medicine
  3. Pharmacological class: Gabapentinoid / anticonvulsant
  4. Bangladesh available brand name: Nervalin 50/75 mg, Pregaba 50/75/150 mg, Pregaben 50/75/150 mg, Nervaid 50/75 mg
  5. Typical adult dose: 50–75 mg at night or BD; titrate according to response; renal dose adjustment needed
  6. Duration: usually 2–6 weeks then reassess
  7. কেন used হয়: nerve compression/tingling/burning neuropathic pain থাকলে
  8. Side effect: dizziness, sleepiness, edema, weight gain, blurred vision
  9. Interaction: alcohol, benzodiazepine, opioid/tramadol—sedation/respiratory depression risk বাড়ে
  10. Purpose: nerve hyperexcitability কমায়; MedEx pregabalin neuropathic pain-first line হিসেবে উল্লেখ করে।

9. Omeprazole / Esomeprazole

  1. Generic name: Omeprazole / Esomeprazole
  2. Therapeutic category: Gastroprotection / acid suppression
  3. Pharmacological class: Proton Pump Inhibitor
  4. Bangladesh available brand name:
    • Omeprazole: Losectil 20 mg, Seclo 20 mg, PPI 20 mg, Omecap 20 mg
    • Esomeprazole: Nexum 20/40 mg, DP-Esomeprazole 20/40 mg, Eso 20/40 mg
  5. Typical adult dose: Omeprazole 20 mg OD before breakfast OR Esomeprazole 20–40 mg OD
  6. Duration: NSAID চলাকালে 5–14 days; ulcer risk থাকলে longer
  7. কেন used হয়: NSAID-induced gastritis/ulcer prevention
  8. Side effect: headache, diarrhea/constipation, abdominal pain; long-termে B12/Mg deficiency, fracture risk concern
  9. Interaction: clopidogrel বিশেষ করে omeprazole, warfarin monitoring, antifungal absorption কমতে পারে
  10. Purpose: stomach acid কমিয়ে NSAID gastritis risk কমায়; MedEx omeprazole gastric acid secretion inhibitor হিসেবে উল্লেখ করে।

10. Calcium + Vitamin D3

  1. Generic name: Calcium Carbonate + Cholecalciferol
  2. Therapeutic category: Bone health supplement
  3. Pharmacological class: Mineral + vitamin supplement
  4. Bangladesh available brand name: A-Cal D, Calci-D Plus 500 mg+200 IU, Calcibo D 500 mg+200 IU, Oscal-D Forte 600 mg+400 IU, Orthocal-D 500 mg+200 IU
  5. Typical adult dose: Calcium 500–600 mg + Vitamin D3 200–400 IU 1 tablet BD after meal
  6. Duration: 1–3 months or deficiency/osteoporosis অনুযায়ী
  7. কেন used হয়: vitamin D/calcium deficiency, osteoporosis, fragility fracture risk থাকলে
  8. Side effect: constipation, bloating, hypercalcemia, kidney stone risk
  9. Interaction: tetracycline/doxycycline, quinolone, levothyroxine, iron—2–4 hour gap দরকার; digoxin caution
  10. Purpose: bone formation/maintenance support; MedEx calcium + vitamin D3 bone formation ও fracture prevention support উল্লেখ করে।

11. Cholecalciferol / Vitamin D3

  1. Generic name: Cholecalciferol
  2. Therapeutic category: Vitamin D supplement
  3. Pharmacological class: Fat-soluble vitamin
  4. Bangladesh available brand name: Ditarol 1000 IU, Hi-D 20000/40000 IU, DP-Vitamin D3 20000 IU, D-Cap 20000/40000 IU
  5. Typical adult dose: deficiency হলে 20,000–40,000 IU weekly for 6–8 weeks, then maintenance 1000–2000 IU/day; lab অনুযায়ী
  6. Duration: deficiency correction 6–8 weeks, then maintenance
  7. কেন used হয়: vitamin D deficiency থাকলে bone healing environment improve করতে
  8. Side effect: hypercalcemia, nausea, polyuria, kidney stone
  9. Interaction: thiazide diuretic, digoxin, calcium supplement
  10. Purpose: calcium absorption ও bone mineralization; MedEx cholecalciferol calcium/phosphate absorption ও healthy bone-এর জন্য দরকার বলে উল্লেখ করে।

12. Cefazolin — surgery prophylaxis

  1. Generic name: Cefazolin Sodium
  2. Therapeutic category: Antibiotic; perioperative prophylaxis
  3. Pharmacological class: 1st generation cephalosporin
  4. Bangladesh available brand name: Cefazol 500 mg/1 g vial, Zolibac 1 g vial, Cefazoline Panpharma 1 g
  5. Typical adult dose: 1–2 g IV within 60 minutes before incision; long surgery হলে repeat dose; hospital protocol অনুসারে
  6. Duration: usually single perioperative dose or <24 hours prophylaxis; infection থাকলে culture অনুযায়ী longer
  7. কেন used হয়: corrective osteotomy/ORIF surgery-তে surgical site infection prevention
  8. Side effect: allergy, diarrhea, rash, rare anaphylaxis
  9. Interaction: anticoagulant monitoring, nephrotoxic drug caution
  10. Purpose: skin flora coverage; MedEx cefazolin perioperative prophylaxis ও bone/joint infection indication উল্লেখ করে।

13. Cefuroxime Axetil — selected infection case

  1. Generic name: Cefuroxime Axetil
  2. Therapeutic category: Antibiotic
  3. Pharmacological class: 2nd generation cephalosporin
  4. Bangladesh available brand name: Turbocef 250/500 mg, Cefuxet 500 mg, Famicef 250/500 mg, Furex 250/500 mg, Ximetil 250/500 mg
  5. Typical adult dose: 250–500 mg twice daily
  6. Duration: 5–7 days or infection severity/culture অনুযায়ী
  7. কেন used হয়: malunion-এর জন্য routine নয়; wound/soft tissue infection suspicion থাকলে doctor prescribe করতে পারেন
  8. Side effect: diarrhea, nausea, rash, allergy
  9. Interaction: antacid/PPI absorption কমাতে পারে; warfarin effect monitoring
  10. Purpose: bacterial infection control; MedEx cefuroxime sensitive bacterial infection treatment হিসেবে উল্লেখ করে।

14. Enoxaparin

  1. Generic name: Enoxaparin Sodium
  2. Therapeutic category: Anticoagulant
  3. Pharmacological class: Low Molecular Weight Heparin
  4. Bangladesh available brand name: Noxarin 2000/4000/6000/8000 Anti-Xa IU, Neoparin 4000 Anti-Xa IU, Ovenox 2000/6000 Anti-Xa IU
  5. Typical adult prophylaxis dose: 40 mg SC once daily; renal impairmentে adjust
  6. Duration: lower limb surgery/immobilization risk অনুযায়ী 7–14 days বা longer
  7. কেন used হয়: lower limb surgery/immobilization-এর পর DVT/PE prevention
  8. Side effect: bleeding, bruising, thrombocytopenia, hyperkalemia
  9. Interaction: aspirin, NSAID, clopidogrel, warfarin, DOAC—bleeding risk বাড়ে
  10. Purpose: clot prevention; MedEx orthopedic/general surgery-associated venous thromboembolism prophylaxis indication উল্লেখ করে।

Bangladesh doctors commonly prescription-এ যা ব্যবহার করেন — practical list

  1. Pain mild/moderate:
    Paracetamol 500 mg / 1 g
  2. Pain + inflammation:
    Ibuprofen 400 mg OR Diclofenac 50 mg OR Naproxen 500 mg OR Etoricoxib 60/90 mg
    একসাথে একাধিক NSAID নয়।
  3. NSAID দিলে gastric protection:
    Omeprazole 20 mg OR Esomeprazole 20/40 mg
  4. Severe pain / post-op pain:
    Tramadol 50 mg short course
    Ketorolac 10 mg or injection hospital setting, maximum 5 days
  5. Nerve pain:
    Pregabalin 50/75 mg
  6. Bone health deficiency:
    Calcium + Vitamin D3
    Cholecalciferol weekly dose if deficiency documented
  7. Operation prophylaxis:
    Cefazolin IV pre-op
  8. Lower limb surgery/immobilization VTE prevention:
    Enoxaparin SC if risk present

Prevention — কীভাবে malunion prevent করবেন

  1. Fracture হলে দ্রুত X-ray ও orthopedic assessment।
  2. Proper reduction and immobilization।
  3. Cast/splint loose বা tight হলে immediately review।
  4. Doctor না বলা পর্যন্ত early weight bearing নয়।
  5. Follow-up X-ray miss করবেন না।
  6. Smoking/nicotine বন্ধ।
  7. Diabetes, thyroid, kidney disease control।
  8. Protein, calcium, vitamin D adequate রাখুন।
  9. Post-op infection prevention: wound clean, fever/discharge হলে দ্রুত consult।
  10. Physiotherapy ঠিকভাবে করা।
  11. Children fracture/growth plate injury হলে follow-up বেশি গুরুত্বপূর্ণ।

Overview / Summary

Malunion হলো fracture heal হয়েছে কিন্তু ভুল alignment-এ heal হয়েছে। প্রধান cause হলো improper reduction, inadequate immobilization, early cast removal/early weight bearing, delayed treatment, comminuted fracture, poor fixation এবং biological factors। Diagnosis clinical deformity + functional assessment + X-ray/CT দিয়ে হয়। Definitive treatment হলো corrective osteotomy ± fixation; medicine malunion cure করে না, শুধু pain, inflammation, neuropathic pain, infection/VTE prevention ও bone-health support দেয়।

Actionable Plan / Steps

  1. AP/lateral X-ray with adjacent joints করুন।
  2. Deformity থাকলে long-leg alignment film/scanogram করুন।
  3. Rotational/intra-articular deformity হলে CT 3D করুন।
  4. Infection suspicion হলে CBC, ESR, CRP ± culture করুন।
  5. Bone health risk থাকলে Vitamin D, calcium, HbA1c, TSH, renal function করুন।
  6. Mild deformity + minimal symptom → brace, orthosis, physiotherapy, analgesic।
  7. Painful/functional/cosmetic significant deformity → orthopedic surgeon for corrective osteotomy planning।
  8. NSAID দিলে gastric/renal/cardiac risk assess করুন; opioid/tramadol short course only।

Reference List

  1. Textbook: Rockwood and Green’s Fractures in Adults, 9th ed. Wolters Kluwer; fracture healing complications, malunion/nonunion principles.
  2. Textbook: Campbell’s Operative Orthopaedics, 14th ed. Elsevier; corrective osteotomy, deformity correction, fracture complication chapters.
  3. Guideline: NICE NG38. Fractures (non-complex): assessment and management; pain assessment, imaging, immobilization and orthopedic follow-up recommendations.
  4. Guideline: WHO. Global guidelines for the prevention of surgical site infection, 2nd ed., 2018.
  5. Guideline/Patient Education: AAOS OrthoInfo. Malunion in the Lower Limb, updated 2020.
  6. Journal DOI: Milner SA, Davis TRC, Muir KR, Greenwood DC, Doherty M. Long-term outcome after tibial shaft fracture: is malunion important? J Bone Joint Surg Am. 2002;84(6):971–980. DOI: 10.2106/00004623-200206000-00011.
  7. Journal DOI: Berríos-Torres SI, et al. CDC Guideline for the Prevention of Surgical Site Infection, 2017. JAMA Surgery. 2017;152(8):784–791. DOI: 10.1001/jamasurg.2017.0904

Md.Rafiqul Islam Lipu,Date:-06-06-2026 saturday ,Time:-08-57-49 Pm

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