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.


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Definition-2


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


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)


“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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Types of Non-union

(Based on blood supply)

HYPERTROPHIC

OLIGOTROPHIC

AVASCULAR

Hypertrophic (horse hoof)

Oligotrophic or atrophic

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Hypertrophic (elephant foot)


Types of Non-union

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Types of Non-union

Hypertrophic-

VascularizedCallus formation present on x-ray

Elephant foot - abundant callus

Horse hoof - less abundant callus

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Types of Non-union

Oligotrophic-

No callus on x-rayVascularity is present on bone scan

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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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• Inadequate

immobilization

• Poor blood supply

• Infection

Etiology of Nonunion:

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Systemic factors- 1. Smoking, 2. Diabetes, 3. Endocrine

disorder, 4. NSAIDS

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Etiology of Nonunion: (Systemic)


Etiology of Nonunion

Smoking-Decreases peripheral oxygen

tensionDampens peripheral blood flow(vaso- constriction)

Well documented difficulties in wound healing in patients who smoke


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Etiology of Nonunion(Local

Factors)


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)


Open FracturesHigh energy fractures with bone devitalization

Severe associated soft tissue injury

Bone lossInfection.


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Energy of Fracture Mechanism

Fracture pattern i.e.ocombinationobone lossosegmental patterns

Soft tissue disruption (vascularity and oxygen delivery)

Initial fracture displacement


Traumatic Soft Tissue Disruption

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1. During initial trauma2. Iatrogenic



• 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




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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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.


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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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Examination

• Abnormal movements• Deformity• Evidence of infection• Soft tissue abnormality?

(scar, atrophied skin, pigmentation etc)

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Diagnosis of Nonunion-


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-


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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Varus

Valgus

Clinical diagnosis can be confirmed and information about stability obtained with stress radiographs.



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:


Specific-

CT scan

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Diagnosis of Nonunion-Investigations: Specific-


CT scan

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Diagnosis of Nonunion-Investigations:Specific-


MRI

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Diagnosis of Nonunion- Investigations:Specific-


Management/ Treatment-

•Non- operative•Operative

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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


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


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


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


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


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


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


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


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



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



bone-fractures-nonunion-diagnosis-and-management-at-shaheed-suhrawardy-medical-college-hospital-dhaka-bangladesh...

Health & Medicine

allograft bone

long bone nonunion

diagnosis of nonunion

specificclinical diagnosis

specific sequential

definition types

ct scans

ccanterior iliac crest