Delayed union and non union


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  • X ray hip
  • # neck of femur
  • # and dislocation
  • Multple pins
  • Blade plate fixation
  • Dynamic hip screw
  • nonunion
  • Case Example:    - 45 year old female w/ osteomalacia due to Sheenan's syndrome sustained a femoral neck fracture which was treated w/ a compression hip screw;          - once the patient progressed w/ weight bearing, the hardware cut out superiorly and the fracture went on to non union;
  • Bone scan
  • Dual only
  • Sliding graft
  • Delayed union and non union

    1. 1. Delayed Union and Non Union Gopisankar.M.G. 2008 MBBS
    2. 2. Nonunion When a minimum of 9 months has elapsed since the injury & The fracture shows no radiologically visible progressive signs of healing continuously for 3 months
    3. 3. Classification Paley’s Classification Muller and Weber’s Classification
    4. 4. Paley’s Classification Type A  Bone loss <1cm Type B  Bone loss >1cm
    5. 5. Muller & Weber’s classification Amount of callus at the fracture site1. Hypervascular Nonunion2. Avascular Nonunion
    6. 6.  Hypervascular  Avascular1. Hypertrophic/Elephant 1. Torsion Wedge foot 2. Comminuted2. Horse hoof 3. Defect3. Oligotrophic 4. Atrophic
    7. 7. Causes of nonunion Compound fractures Infection Segmental fractures Distraction of fracture fragments Soft tissue interposition Ill devised open reduction Insecure and inadequate fixation
    8. 8. Clinical features History1. Trauma resulting in fractures2. Open fractures3. Improper / delay / inadequate treatment Symptoms1. Minimal / no pain2. Loss of function
    9. 9.  Signs1. Painless abnormal mobility2. Shortening3. Scars4. Sinuses5. Deformity6. Wasting of limb muscles
    10. 10. Investigations X-ray AP and Lateral view1. Gap between fracture fragments2. Fragments are rounded and sclerotic3. Amount of callus formed could be less or more4. Decreased density of bone is due to osteoporosis
    11. 11. Management Surgery 1. Open reduction2. Rigid internal fixation3. Bone grafting Electrical stimulation Ilizarov’s technique
    12. 12. Bone Graft Promotes Osteogenesis ,provide stability Types1. Cancellous Bone Graft2. Cortical Bone Graft3. Phemister Bone Graft
    13. 13. Cancellous bone Graft In defects < 2.5cm Better tolerated Rapidly revascularized
    14. 14. Cortical Bone Graft Fixation + Osteogenesis Stabilizing property For nonunion of shafts of any long bones Single only  when placed on one surface Dual only  when it is placed on both sides Sliding graft  piece is sided from above to the fracture
    15. 15. Phemister bone graft Graft is placed subperiosteally Blood supply is not disturbed Simple Placed posteriorly Useful in tibia
    16. 16. Electrical stimulation in Nonunion 20 mA Fibrous tissue  fibrocartilage  endochondral ossification Types1. Noninvasive2. Semi invasive3. Invasive Pulsed Electromagnetic field after excision of fibrous tissue followed by grafting Immobilization is done to decrease stress Slow not always successful
    17. 17. Ilizarov’s technique Best for infected nonunions Corrects deformity + boneloss In hypertrophic  gradual compression Avascular  corticotomy , Bone transport and compression