BONE-FRACTURES-Nonunion-Diagnosis-And-Management-At-Shaheed-Suhrawardy-Medical-College-Hospital-Dhaka-Bangladesh.

1. 1

2. • Definition
• Types
• Causes of non-union
• Diagnosis of non-union
• Management/Treatment.
2

3. Definition-1
3

4. Definition-2
4

5. Definition-3
5

6. Definition-4
(Current)
6

7. (Based on blood supply)
7

8. Hypertrophic
(elephant foot)
Hypertrophic
(horse hoof)
Oligotrophic
or atrophic
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9. 9

10. 10

11. 11

12. Causes of Non unions
12

13. Etiology of Nonunion:
13

14. Etiology of Nonunion
Etiology of
Nonunion:
(Systemic)
14

15. Etiology of Nonunion
Etiology of
Nonunion
(Local Factors)
15

16. Etiology of Nonunion
Local Risk Factors-
Etiology of
Nonunion
(Local Factors)
16

17. Etiology of Nonunion
Etiology of Nonunion
(Local Factors)
17

18. Etiology of Nonunion
Traumatic Soft Tissue Disruption
1. During initial trauma
2. Iatrogenic
Etiology of Nonunion
(Local Factors)
18

19. Etiology of Nonunion
Etiology of
Nonunion
(Local Factors)
2 3
1
4 5
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20. Etiology of Nonunion
Etiology of
Nonunion
(Local Factors)
20

21. Etiology of Nonunion
Etiology of
Nonunion
(Local Factors)
21

22. 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.
22

23. Examination
Diagnosis of
• Abnormal movements
Nonunion-
• Deformity
• Evidence of infection
• Soft tissue abnormality? (scar,
atrophied skin, pigmentation etc)
23

24. Investigations-
General:
 Blood count
 Biopsy
Diagnosis of
Nonunion-
Investigations:
 FNAC
 Wound swab/ pus C/S
Specific:
• Radiologic Evaluation
• Radionuclide Scanning
• CT scan
• MRI
24

25. Investigations-
Radiologic Evaluation
Diagnosis of
Nonunion-
• Standard radiographs are often diagnostic
Investigations: Specific-
• 45 degree oblique films can increase
diagnostic accuracy
• Despite additional projections, the
potential for false-positive results for
fracture healing remains
25

26. X-Ray and Imaging
Diagnosis of • Usually a plain X-Rays is adequate for
Nonunion-
Investigations: Specific-
diagnosis of Non Union.
• But rarely stress X-ray, CT scans and MRI
is required.
26

27. Valgus
Diagnosis of
Nonunion- Varus
Investigations: Specific-
Clinical diagnosis can be confirmed and
information about stability obtained with
stress radiographs.
27

28. Radionuclide Scanning
• Technetium - 99 diphosphonate
• Detects repairable process in bone ( not
Diagnosis of specific)
Nonunion-
Investigations: • Gallium - 67 citrate
Specific-
• Accumulate at site of inflammation (not
specific)
• Sequential technetium or gallium
scintigraphy
• Only 50-60% accuracy in subclinical
ostoemyelitis
28

29. CT scan
Diagnosis of
Nonunion-
Investigations:
Specific-
29

30. CT scan
Diagnosis of
Nonunion-
Investigations:
Specific-
30

31. Diagnosis of
Nonunion-
Investigations:
Specific-
MRI
31

32. Management/ Treatment-
•Non-
operative
•Operative 32

33. Non-operative-
BMP (Bone morphogenic protein
Treatment injection)
Bone marrow injection
Ultrasound
Electric stimulation
Low Level Laser Therapy.
But in established non union, non operative
method rarely helpful. 33

34. Surgical Treatment-
A. Hypertrophied non inions unite with
Treatment 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. 34

35. Infected Non-unions
• Contaminated implants and devitalized
implants must be removed
Treatment • Infection treated:
Infected • Temporary stabilization (external
nonunion
fixation)
• Culture specific antibiotics
• +/- local antibiotic delivery (antibiotic
beads)
• Secondary stabilization with augmentation
of osteogenesis (cancellous grafting)
35

36. Bone Grafting-
Treatment
Atrophied • Osteoinductive - contain proteins or
non union 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
36

37. Treatment Bone Grafting-
Atrophied
non union
• 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 37

38. Autogenous Cancellous Bone
• Sites
Posterior Iliac Crest (20 cc)
Anterior Iliac Crest (10cc)
Treatment
Atrophied Proximal Tibia (7cc)
non union 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

39. Treatment
Hypertrophied Locking Plate
non inions
Technology
• Will give better fixation in
pathologic bone
• Most likely will prevent early
failure
(Occasionally seen with traditional
compression plating techniques )39

40. Treatment
Hypertrophied
non inions
Traumatic Bone Loss-
• Reconstructive planning and
intervention should begin prior to
meeting the time requirements for
nonunion
• Options
Distraction osteogenesis
Vascularized bone graft
with Iliac crest bone grafting
40

41. Intra-medullary Nailing-
• Mechanically stabilizes long bone nonunion as a load
sharing implant
• Corrects mal-alignment
Treatment
• Reaming is initially detrimental to intra-medullary
Hypertrophied
blood supply, but it does recover and is believed to
non inions
stimulate biologic healing at fracture
• Allow patient to mobilize surrounding joints and
dynamize fracture environment.
41

42. Intra-medullary Nailing
Treatment
Hypertrophied
• Can be performed without direct
non inions exposure or dissection of the
fracture soft tissue envelope
• Non-applicable in articular
fractures.
42