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•   Definition•   Types•   Causes of non-union•   Diagnosis of non-union•   Management/Treatment.                         ...
Definition-1               3
Definition-2               4
Definition-3               5
Definition-4(Current)               6
(Based on blood supply)                          7
Hypertrophic(elephant foot)                  Hypertrophic                  (horse hoof)                                 Ol...
9
10
11
Causes of Non unions                       12
Etiology of Nonunion:                        13
Etiology of NonunionEtiology ofNonunion:(Systemic)                                     14
Etiology of NonunionEtiology ofNonunion(Local Factors)                                         15
Etiology of Nonunion                  Local Risk Factors-Etiology ofNonunion(Local Factors)                               ...
Etiology of NonunionEtiology of Nonunion(Local Factors)                                              17
Etiology of Nonunion                       Traumatic Soft Tissue Disruption                       1. During initial trauma...
Etiology of NonunionEtiology ofNonunion(Local Factors)      2        3 1           4       5                              ...
Etiology of NonunionEtiology ofNonunion(Local Factors)                                         20
Etiology of NonunionEtiology ofNonunion(Local Factors)                                         21
Diagnosis of Nonunion-History• Painless abnormal movement at fracture  site• Pain present at fracture site, but in  establ...
ExaminationDiagnosis of               •   Abnormal movementsNonunion-               •   Deformity               •   Eviden...
Investigations-                  General:                   Blood count                   BiopsyDiagnosis ofNonunion-Inv...
Investigations-                               Radiologic EvaluationDiagnosis ofNonunion-                            • Stan...
X-Ray and ImagingDiagnosis of                • Usually a plain X-Rays is adequate forNonunion-Investigations: Specific-   ...
ValgusDiagnosis ofNonunion-                              VarusInvestigations: Specific-                Clinical diagnosis ...
Radionuclide Scanning                  • Technetium - 99 diphosphonate                     • Detects repairable process in...
CT scanDiagnosis ofNonunion-Investigations:Specific-                            29
CT scanDiagnosis ofNonunion-Investigations:Specific-                            30
Diagnosis ofNonunion-Investigations:Specific-                  MRI                        31
Management/ Treatment-•Non-operative•Operative               32
Non-operative-            BMP (Bone morphogenic proteinTreatment    injection)            Bone marrow injection         ...
Surgical Treatment-            A. Hypertrophied non inions unite withTreatment      good adequate fixation (intramedulary ...
Infected Non-unions            • Contaminated implants and devitalized              implants must be removedTreatment   • ...
Bone Grafting-TreatmentAtrophied   • Osteoinductive - contain proteins ornon union     chemotactic factors that attract   ...
Treatment     Bone Grafting-Atrophiednon union            • Used to stimulate biologic              response of healing in...
Autogenous Cancellous Bone             • Sites                Posterior Iliac Crest (20 cc)                Anterior Iliac ...
TreatmentHypertrophied     Locking Platenon inions                  Technology                • Will give better fixation ...
TreatmentHypertrophiednon inions                  Traumatic Bone Loss-                • Reconstructive     planning    and...
Intra-medullary Nailing-              • Mechanically stabilizes long bone nonunion as a load                sharing implan...
Intra-medullary NailingTreatmentHypertrophied                • Can be performed without directnon inions        exposure o...
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bone-fractures-nonunion-diagnosis-and-management-at-shaheed-suhrawardy-medical-college-hospital-dhaka-bangladesh

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

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Transcript of "bone-fractures-nonunion-diagnosis-and-management-at-shaheed-suhrawardy-medical-college-hospital-dhaka-bangladesh"

  1. 1. 1
  2. 2. • Definition• Types• Causes of non-union• Diagnosis of non-union• Management/Treatment. 2
  3. 3. Definition-1 3
  4. 4. Definition-2 4
  5. 5. Definition-3 5
  6. 6. Definition-4(Current) 6
  7. 7. (Based on blood supply) 7
  8. 8. Hypertrophic(elephant foot) Hypertrophic (horse hoof) Oligotrophic or atrophic 8
  9. 9. 9
  10. 10. 10
  11. 11. 11
  12. 12. Causes of Non unions 12
  13. 13. Etiology of Nonunion: 13
  14. 14. Etiology of NonunionEtiology ofNonunion:(Systemic) 14
  15. 15. Etiology of NonunionEtiology ofNonunion(Local Factors) 15
  16. 16. Etiology of Nonunion Local Risk Factors-Etiology ofNonunion(Local Factors) 16
  17. 17. Etiology of NonunionEtiology of Nonunion(Local Factors) 17
  18. 18. Etiology of Nonunion Traumatic Soft Tissue Disruption 1. During initial trauma 2. IatrogenicEtiology of Nonunion(Local Factors) 18
  19. 19. Etiology of NonunionEtiology ofNonunion(Local Factors) 2 3 1 4 5 19
  20. 20. Etiology of NonunionEtiology ofNonunion(Local Factors) 20
  21. 21. Etiology of NonunionEtiology ofNonunion(Local Factors) 21
  22. 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. 23. ExaminationDiagnosis of • Abnormal movementsNonunion- • Deformity • Evidence of infection • Soft tissue abnormality? (scar, atrophied skin, pigmentation etc) 23
  24. 24. Investigations- General:  Blood count  BiopsyDiagnosis ofNonunion-Investigations:  FNAC  Wound swab/ pus C/S Specific: • Radiologic Evaluation • Radionuclide Scanning • CT scan • MRI 24
  25. 25. Investigations- Radiologic EvaluationDiagnosis ofNonunion- • Standard radiographs are often diagnosticInvestigations: Specific- • 45 degree oblique films can increase diagnostic accuracy • Despite additional projections, the potential for false-positive results for fracture healing remains 25
  26. 26. X-Ray and ImagingDiagnosis of • Usually a plain X-Rays is adequate forNonunion-Investigations: Specific- diagnosis of Non Union. • But rarely stress X-ray, CT scans and MRI is required. 26
  27. 27. ValgusDiagnosis ofNonunion- VarusInvestigations: Specific- Clinical diagnosis can be confirmed and information about stability obtained with stress radiographs. 27
  28. 28. Radionuclide Scanning • Technetium - 99 diphosphonate • Detects repairable process in bone ( notDiagnosis of specific)Nonunion-Investigations: • Gallium - 67 citrateSpecific- • Accumulate at site of inflammation (not specific) • Sequential technetium or gallium scintigraphy • Only 50-60% accuracy in subclinical ostoemyelitis 28
  29. 29. CT scanDiagnosis ofNonunion-Investigations:Specific- 29
  30. 30. CT scanDiagnosis ofNonunion-Investigations:Specific- 30
  31. 31. Diagnosis ofNonunion-Investigations:Specific- MRI 31
  32. 32. Management/ Treatment-•Non-operative•Operative 32
  33. 33. Non-operative- BMP (Bone morphogenic proteinTreatment injection) Bone marrow injection Ultrasound Electric stimulation Low Level Laser Therapy. But in established non union, non operative method rarely helpful. 33
  34. 34. Surgical Treatment- A. Hypertrophied non inions unite withTreatment 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. 35. Infected Non-unions • Contaminated implants and devitalized implants must be removedTreatment • Infection treated:Infected • Temporary stabilization (externalnonunion fixation) • Culture specific antibiotics • +/- local antibiotic delivery (antibiotic beads) • Secondary stabilization with augmentation of osteogenesis (cancellous grafting) 35
  36. 36. Bone Grafting-TreatmentAtrophied • Osteoinductive - contain proteins ornon 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. 37. Treatment Bone Grafting-Atrophiednon 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. 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. 39. TreatmentHypertrophied Locking Platenon inions Technology • Will give better fixation in pathologic bone • Most likely will prevent early failure (Occasionally seen with traditional compression plating techniques )39
  40. 40. TreatmentHypertrophiednon 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. 41. Intra-medullary Nailing- • Mechanically stabilizes long bone nonunion as a load sharing implant • Corrects mal-alignmentTreatment • Reaming is initially detrimental to intra-medullaryHypertrophied blood supply, but it does recover and is believed tonon inions stimulate biologic healing at fracture • Allow patient to mobilize surrounding joints and dynamize fracture environment. 41
  42. 42. Intra-medullary NailingTreatmentHypertrophied • Can be performed without directnon inions exposure or dissection of the fracture soft tissue envelope • Non-applicable in articular fractures. 42
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