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Transcript of bone-fractures-nonunion-diagnosis-and-management-at-shaheed-suhrawardy-medical-college-hospital-dhaka-bangladesh...
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Dr. Md Nazrul IslamMBBS, M.sc (BME)
Department of Orthopedics & TraumatologyShaheed Suhrawardy Medical College HospitalDhaka-1207, Bangladesh
BONE-FractureNon-union
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CONTENTS:• Definition• Types• Causes of non-union• Diagnosis of non-
union•
Management/Treatment.
Non union of Fractures
Definition-1
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Nonunion: When A Fracture Fails To Unite (Permanent Failure). And Shows No Evidence Of Further Union.
Delayed Union: A Fracture That Requires MoreTime Than Is Usual.
Non union of Fractures
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Definition-2
Non union of Fractures
Previous Definitions of Nonunion
A fracture that is a minimum of 9 months post occurrence and is not healed and has not shown radiographic progression for 3 months.
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Definition-3
Non union of Fractures
Different bone different healing time.
some shows potential of healing but some does not.
9 month waiting for every bone before starting treatment as nonunion is impractical.
This old definition has been criticized because-
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Definition-4(Current)
Non union of Fractures
“The designation of a delayed union or nonunion is currently made when the surgeon believes the fracture has little or no potential to heal”.
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Non union of Fractures
Types of Non-union
(Based on blood supply)
HYPERTROPHIC
OLIGOTROPHIC
AVASCULAR
Hypertrophic (horse hoof)
Oligotrophic or atrophic
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Hypertrophic (elephant foot)
Non union of Fractures
Types of Non-union
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Non union of Fractures
Types of Non-union
Hypertrophic-
VascularizedCallus formation present on x-ray
Elephant foot - abundant callus
Horse hoof - less abundant callus
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Non union of Fractures
Types of Non-union
Oligotrophic-
No callus on x-rayVascularity is present on bone scan
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Non union of Fractures
Types of Non-union
Avuncular/Atrophic-
Atrophic or similar to Oligotrophic on x-ray Ischemic or cold on bone scan.
Causes of Non unions
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Non union of Fractures
• Inadequate
immobilization
• Poor blood supply
• Infection
Etiology of Nonunion:
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Non union of Fractures
Systemic factors- 1. Smoking, 2. Diabetes, 3. Endocrine
disorder, 4. NSAIDS
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Etiology of Nonunion: (Systemic)
Non union of Fractures
Etiology of Nonunion
Smoking-Decreases peripheral oxygen
tensionDampens peripheral blood flow(vaso- constriction)
Well documented difficulties in wound healing in patients who smoke
Etiology of Nonunion
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Etiology of Nonunion(Local
Factors)
Non union of Fractures
Local Factors-
1. Infection2. Energy of fracture
mechanism (extend of soft tissue injury)
3. Mechanical factors of fracture configuration
o Increased motion between fracture fragments
o Inadequate fixationo Wolf’s Law - lack of
physiologic stresses to bone
4. Anatomic location
Local Risk Factors-
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Etiology of Nonunion(Local Factors)
Non union of Fractures
Open FracturesHigh energy fractures with bone devitalization
Severe associated soft tissue injury
Bone lossInfection.
Etiology of Nonunion
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Etiology of Nonunion(Local Factors)
Non union of Fractures
Energy of Fracture Mechanism
Fracture pattern i.e.ocombinationobone lossosegmental patterns
Soft tissue disruption (vascularity and oxygen delivery)
Initial fracture displacement
Etiology of Nonunion
Traumatic Soft Tissue Disruption
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Etiology of Nonunion(Local Factors)
1. During initial trauma2. Iatrogenic
Non union of Fractures
Etiology of Nonunion
• Incidence of nonunion is increased with open fractures• More severe open fracture (i.e. Gustillo III B vs. Grade I) have higher incidence of nonunion.
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1
2 3
4 5
Etiology of Nonunion(Local Factors)
Non union of Fractures
Etiology of Nonunion
Iatrogenic Stripping
Indiscriminate devitalization (1) Leads to limited healing potential and implant failure (2,3) Occasionally requiring resection and reconstruction prior to healing (4,5) Excessive soft tissue dissection and periosteal stripping at time of previous fixation.
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Etiology of Nonunion(Local Factors)
Non union of Fractures
Revascularization of ischemic bone fragments in fractures is derived from the soft tissue.
If the soft tissue (skin, muscle, adipose) is ischemic, it must first recover prior to revascularizing the bone.
Etiology of Nonunion
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Etiology of Nonunion(Local Factors)
Non union of Fractures
Etiology of NonunionAnatomic Location of Fractures-
Some areas of skeleton are at risk for nonunion due to anatomic vascular considerations i.e. -Neck of tallus, femoral neck, carpal scaphoid.
Diagnosis of Nonunion- History
• Painless abnormal movement
at fracture site• Pain present at fracture site,
but in established non union it is pain free.
• Symptoms of infection • In ability to bear weight.
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Non union of Fractures
Examination
• Abnormal movements• Deformity• Evidence of infection• Soft tissue abnormality?
(scar, atrophied skin, pigmentation etc)
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Diagnosis of Nonunion-
Non union of Fractures
General: Blood count Biopsy FNAC Wound swab/ pus C/SSpecific:• Radiologic Evaluation• Radionuclide Scanning• CT scan• MRI
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Diagnosis of Nonunion- Investigations:
Investigations-Non union of Fractures
Radiologic Evaluation
• Standard radiographs are often diagnostic
• 45 degree oblique films can increase diagnostic accuracy
• Despite additional projections, the potential for false-positive results for fracture healing remains
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Diagnosis of Nonunion- Investigations: Specific-
Investigations-
Non union of Fractures
X-Ray and Imaging
• Usually a plain X-Rays is adequate for diagnosis of Non Union.
• But rarely stress X-ray, CT scans and MRI is required.
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Diagnosis of Nonunion- Investigations: Specific-
Non union of Fractures
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Varus
Valgus
Clinical diagnosis can be confirmed and information about stability obtained with stress radiographs.
Diagnosis of Nonunion- Investigations: Specific-
Non union of Fractures
Radionuclide Scanning
• Technetium - 99 diphosphonate• Detects repairable process in
bone ( not specific)• Gallium - 67 citrate
• Accumulate at site of inflammation (not specific)
• Sequential technetium or gallium scintigraphy• Only 50-60% accuracy in
subclinical ostoemyelitis
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Diagnosis of Nonunion- Investigations:
Non union of Fractures
Specific-
CT scan
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Diagnosis of Nonunion-Investigations: Specific-
Non union of Fractures
CT scan
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Diagnosis of Nonunion-Investigations:Specific-
Non union of Fractures
MRI
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Diagnosis of Nonunion- Investigations:Specific-
Non union of Fractures
Management/ Treatment-
•Non- operative•Operative
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Non union of Fractures
Non-operative-
BMP (Bone morphogenic protein injection)
Bone marrow injectionUltrasoundElectric stimulationLow Level Laser Therapy. But in established non union,
non operative method rarely helpful.
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Treatment
Non union of Fractures
Surgical Treatment-
A. Hypertrophied non inions unite with good adequate fixation (intramedulary nails, Locking plates or DCP and different types of wiring), may not require bone graft.
B. Atrophied non union always needs bone graft with adequate fixation.
C. Gap non union needs vascularised fibula graft or bone transportation / lengthening.
D. Infected nonunion needs special combined effort.
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Treatment
Non union of Fractures
Infected Non-unions• Contaminated implants and
devitalized implants must be removed
• Infection treated:• Temporary stabilization
(external fixation)• Culture specific antibiotics• +/- local antibiotic delivery
(antibiotic beads)• Secondary stabilization with
augmentation of osteogenesis (cancellous grafting)
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Treatment
Non union of Fractures
Infected nonunion
Bone Grafting-• Osteoinductive - contain
proteins or chemotactic factors that attract vascular ingrowths and healing i.e.. dematerialized bone matrix & BMP’s
• Osteoconductive - contains a scaffolding for which new bone growth can occur
i.e. allograft bone, calcium hydroxyapatite
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Treatment
Non union of Fractures
Atrophied non union
Bone Grafting-• Used to stimulate
biologic response of healing in nonunion (usually atrophic nonunion)
• Also used to fill defects in fracture zone i.e. up to 6 cm intercalary
defects of long bones)
Bosse, MJ e.t.al. JBJS 1989
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Treatment
Non union of Fractures
Atrophied non union
Autogenous Cancellous Bone
• SitesPosterior Iliac Crest (20 cc)Anterior Iliac Crest (10cc)Proximal Tibia (7cc)Distal Radius, Calcaneus, Olecronon (?).
• All series suggest some incidence of donor morbidity dependent upon harvest site and
volume required.• Still considered by many to be the most
osteogenic graft material.38
Treatment
Non union of Fractures
Atrophied non union
Locking Plate Technology
• Will give better fixation in pathologic bone
• Most likely will prevent early failure
(Occasionally seen with traditional compression plating techniques )
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Treatment
Non union of Fractures
Hypertrophiednon inions
Traumatic Bone Loss-
• Reconstructive planning and intervention should begin prior to meeting the time requirements for nonunion
• OptionsDistraction osteogenesisVascularized bone graft with Iliac crest bone grafting
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Treatment
Non union of Fractures
Hypertrophied non inions
Intra-medullary Nailing-• Mechanically stabilizes long bone nonunion
as a load sharing implant• Corrects mal-alignment• Reaming is initially detrimental to intra-
medullary blood supply, but it does recover and is believed to stimulate biologic healing at fracture
• Allow patient to mobilize surrounding joints and dynamize fracture environment.
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Treatment
Non union of Fractures
Hypertrophiednon inions
Intra-medullary Nailing
• Can be performed without direct exposure or dissection of the fracture soft tissue envelope
• Non-applicable in articular fractures.
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Treatment
Non union of Fractures
Hypertrophiednon inions