Reza Sh. Kamrani M.D. TUMS POTA refreshment symposium 20/1/88.
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Transcript of Reza Sh. Kamrani M.D. TUMS POTA refreshment symposium 20/1/88.
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Reza Sh. Kamrani M.D.
TUMS
POTA refreshment symposium
20/1/88
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Pain Motion
Function impairment
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Clinical importance of Clinical findings
DefinitionDiagnosis
Classification Treatment
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Bone has a remarkable capacity of healing(regeneration)
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UNIONMonitoring
Radiologically and Clinically
Biology and Biomechanics of healing and fixation is very important to monitor healing
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Bone healing process;
Enchondral ossification, Callus formation
Direct osteonal healing. Non-callus
Contact healingGap healing
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Callus
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Stages of healing
1- hematoma formation2- inflammatory response 3- reparative phase4- remodeling
Fx. Healing is said to be complete when repopulation of the marrow space occure (months to years )
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There is always a race between healing and implant failure
Implant failure;rarely; catastrophic overloadusually; a fatigue failure between bone implant /
implant itself
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Endurance limit;
A stress more than one can be borne with infinite number of cycle
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Implant construction
Load bearingMore stress on the implant and bone-implant
Load sharing
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In complex reconstructions with load sharing in spite of incomplete healing progressive
failure occures quite late
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Delayed union;A Fx. That has not healed within its expected
healing time
Can go onto healto non-union
Histological Callus formation prominent Interfragmenting tissue consist of fibrous tissue
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Non-union;A Fx. That has not healed without an
intrvention
Failure to show any progressive changes in radiographic appearance for at least 3 months after expected union period time
Repair is not completed in expected period and the cellular activity for healing is ceased
Union is not achieved in 6-8 months
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Weber and CzechHypertrophic, viable
Elephant footHorse hoofoligotrophic
Atrophic, non viableTorsion wedgeComminutedDefect
Pseudoarthrosis
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Weber and CzechHypertrophic, viable
Elephant footHorse hoofoligotrophic
Atrophic, non viableTorsion wedgeComminutedDefect
Pseudoarthrosis
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Weber and CzechHypertrophic, viable
Elephant footHorse hoofoligotrophic
Atrophic, non viableTorsion wedgeComminutedDefect
Pseudoarthrosis
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Weber and CzechHypertrophic, viable
Elephant footHorse hoofoligotrophic
Atrophic, non viableTorsion wedgeComminutedDefect
Pseudoarthrosis
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Paley and Herzenberg
Stiff (<5 degrees mobility)Partially mobile (5-20 degrees)flail (>20 degrees)
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Paley and Herzenberg
Stiff (<5 degrees mobility)Partially mobile (5-20 degrees)flail (>20 degrees)
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Kamrani, himself
Clinically silent, Natural history silentClinically silent, Natural history progressive
Clinically obvious, treatment is curativeClinically obvious, treatment is more hazardous
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Kamrani, himself
Clinically silent, Natural history silentClinically silent, Natural history progressive
Clinically obvious, treatment is curativeClinically obvious, treatment is more hazardous
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Kamrani, himself
Clinically silent, Natural history silentClinically silent, Natural history progressive
Clinically obvious, treatment is curativeClinically obvious, treatment is more hazardous
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Kamrani, himself
Clinically silent, Natural history silentClinically silent, Natural history progressive
Clinically obvious, treatment is curativeClinically obvious, treatment is more hazardous
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Kamrani, himself
Clinically silent, Natural history silentClinically silent, Natural history progressive
Clinically obvious, treatment is curativeClinically obvious, treatment is more hazardous
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Severity of local injuryType of bone
Cancellous / CorticalSpecific bones
RadiationSystemic factors
Age IllnessHormonsSmokingNSAIDs
???
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Diagnostic importance
Radiologic findings equivocalRadiologic finding is misleading
Radiologic drawbacksDirect healingClinical union prior to radiologic union
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Pain Motion
Function impairment
Discomfort
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Pain
Rarely acute failure of implantUsually progressive failure
Sometimes masked with rigid fixation
Pain related to concomitant injuryInfected union may be painful
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Motion
SubtleFrank
Sometimes masked with rigid fixation
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Motion
SubtleFrank
Sometimes masked with rigid fixation
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Functional impairment
Discomfort
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Still
diagnosis is not simple in all cases
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Hand and Foot
Clinical union before radiologic unionCrush injuriesDistal phalanx
5th metatars and talus and scaphoid are at risk
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Forearm
Non-union rate 2-3%
Non-union of one boneStyloid ulna non-union
Benefit of non-union
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Humerus
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Femur
Incidence ; 2-17%Risk factors
InfectionVascular insultInsufficient fixationDistraction NSAIDsOpen fracture
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Femur
Expected union time80-200 days in reamed IM nail
Definition Lack of progression of healing combined with
clinical symptoms of discomfort at minimum of 6 months
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Femoral neck
Risk fctor;Primary displacement
Union without callus formation
Expected union time3 m for delay union6 m for nonunion
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Femoral neck
Pain after 3 months of fracture
AVNNon-union
MRICT ScanBone scan with pin colometer (85-90% for AVN)
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Tibia
The definition of what constitutes a tibial non-union is surprisingly difficult
Expected time for closed fractures; 16-19 m
Failed to union within 9 months with no progressive changes in radiography for at least 3 months
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Tibia
Clinical findingContinuing pain at the Fx. SiteAssociated with motion and local swelling
Confused clinical findings in large reamed IM nail
Infected union is symptomatic
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Classification; Kamrani himself
Clinically silent, Natural history silentClinically silent, Natural history progressive
Clinically obvious, Natural history progressiveClinically obvious, Natural history silent
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Classification; Kamrani himself
Clinically silent, Natural history silentClinically silent, Natural history progressive
Clinically obvious, Natural history progressiveClinically obvious, Natural history silent
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Classification; Kamrani himself
Clinically silent, Natural history silentClinically silent, Natural history progressive
Clinically obvious, Natural history progressiveClinically obvious, Natural history silent
Humerus
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Classification; Kamrani himself
Clinically silent, Natural history silentClinically silent, Natural history progressive
Clinically obvious, Natural history progressiveClinically obvious, Natural history silent
Scaphoid
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Classification; Kamrani himself
Clinically silent, Natural history silentClinically silent, Natural history progressive
Clinically obvious, Natural history progressiveClinically obvious, Natural history silent
Superamalleolar
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Classification; Kamrani himself
Clinically silent, Natural history silentClinically silent, Natural history progressive
Clinically obvious, Natural history progressiveClinically obvious, Natural history silent
Cubitus varus
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