reza sh. kamrani m.d. tums pota refreshment symposium 20/1/88

Reza Sh. Kamrani M.D.

TUMS

POTA refreshment symposium

20/1/88

Pain Motion

Function impairment

Clinical importance of Clinical findings

DefinitionDiagnosis

Classification Treatment

Bone has a remarkable capacity of healing(regeneration)

UNIONMonitoring

Radiologically and Clinically

Biology and Biomechanics of healing and fixation is very important to monitor healing

Bone healing process;

Enchondral ossification, Callus formation

Direct osteonal healing. Non-callus

Contact healingGap healing

Callus

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 )

There is always a race between healing and implant failure

Implant failure;rarely; catastrophic overloadusually; a fatigue failure between bone implant /

implant itself

Endurance limit;

A stress more than one can be borne with infinite number of cycle

Implant construction

Load bearingMore stress on the implant and bone-implant

Load sharing

In complex reconstructions with load sharing in spite of incomplete healing progressive

failure occures quite late

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

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

Weber and CzechHypertrophic, viable

Elephant footHorse hoofoligotrophic

Atrophic, non viableTorsion wedgeComminutedDefect

Pseudoarthrosis

Weber and CzechHypertrophic, viable

Elephant footHorse hoofoligotrophic

Atrophic, non viableTorsion wedgeComminutedDefect

Pseudoarthrosis

Weber and CzechHypertrophic, viable

Elephant footHorse hoofoligotrophic

Atrophic, non viableTorsion wedgeComminutedDefect

Pseudoarthrosis

Weber and CzechHypertrophic, viable

Elephant footHorse hoofoligotrophic

Atrophic, non viableTorsion wedgeComminutedDefect

Pseudoarthrosis

Paley and Herzenberg

Stiff (<5 degrees mobility)Partially mobile (5-20 degrees)flail (>20 degrees)

Paley and Herzenberg

Stiff (<5 degrees mobility)Partially mobile (5-20 degrees)flail (>20 degrees)

Kamrani, himself

Clinically silent, Natural history silentClinically silent, Natural history progressive

Clinically obvious, treatment is curativeClinically obvious, treatment is more hazardous

Kamrani, himself

Clinically silent, Natural history silentClinically silent, Natural history progressive

Clinically obvious, treatment is curativeClinically obvious, treatment is more hazardous

Kamrani, himself

Clinically silent, Natural history silentClinically silent, Natural history progressive

Clinically obvious, treatment is curativeClinically obvious, treatment is more hazardous

Kamrani, himself

Clinically silent, Natural history silentClinically silent, Natural history progressive

Clinically obvious, treatment is curativeClinically obvious, treatment is more hazardous

Kamrani, himself

Clinically silent, Natural history silentClinically silent, Natural history progressive

Clinically obvious, treatment is curativeClinically obvious, treatment is more hazardous

Severity of local injuryType of bone

Cancellous / CorticalSpecific bones

RadiationSystemic factors

Age IllnessHormonsSmokingNSAIDs

???

Diagnostic importance

Radiologic findings equivocalRadiologic finding is misleading

Radiologic drawbacksDirect healingClinical union prior to radiologic union

Pain Motion

Function impairment

Discomfort

Pain

Rarely acute failure of implantUsually progressive failure

Sometimes masked with rigid fixation

Pain related to concomitant injuryInfected union may be painful

Motion

SubtleFrank

Sometimes masked with rigid fixation

Motion

SubtleFrank

Sometimes masked with rigid fixation

Functional impairment

Discomfort

Still

diagnosis is not simple in all cases

Hand and Foot

Clinical union before radiologic unionCrush injuriesDistal phalanx

5th metatars and talus and scaphoid are at risk

Forearm

Non-union rate 2-3%

Non-union of one boneStyloid ulna non-union

Benefit of non-union

Humerus

Femur

Incidence ; 2-17%Risk factors

InfectionVascular insultInsufficient fixationDistraction NSAIDsOpen fracture

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

Femoral neck

Risk fctor;Primary displacement

Union without callus formation

Expected union time3 m for delay union6 m for nonunion

Femoral neck

Pain after 3 months of fracture

AVNNon-union

MRICT ScanBone scan with pin colometer (85-90% for AVN)

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

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

Classification; Kamrani himself

Clinically silent, Natural history silentClinically silent, Natural history progressive

Clinically obvious, Natural history progressiveClinically obvious, Natural history silent

Classification; Kamrani himself

Clinically silent, Natural history silentClinically silent, Natural history progressive

Clinically obvious, Natural history progressiveClinically obvious, Natural history silent

Classification; Kamrani himself

Clinically silent, Natural history silentClinically silent, Natural history progressive

Clinically obvious, Natural history progressiveClinically obvious, Natural history silent

Humerus

Classification; Kamrani himself

Clinically silent, Natural history silentClinically silent, Natural history progressive

Clinically obvious, Natural history progressiveClinically obvious, Natural history silent

Scaphoid

Classification; Kamrani himself

Clinically silent, Natural history silentClinically silent, Natural history progressive

Clinically obvious, Natural history progressiveClinically obvious, Natural history silent

Superamalleolar

Classification; Kamrani himself

Clinically silent, Natural history silentClinically silent, Natural history progressive

Clinically obvious, Natural history progressiveClinically obvious, Natural history silent

Cubitus varus