principles of management of malunion Malunion of fractures

1. Discuss the principles and
management of Malunion
Dr P Shindang
Orthopedic department
NHA

2. Outline
• Introduction
• Etiology
• Types of deformity
• Classification
• Management
• Complications
• Current trend
• Local experience
• Conclusion.

3. Introduction
• Any bone that does not heal in an anatomic position is
a malunion.
• It is consolidation of a fracture with shortening,
malrotation or angulation producing unacceptable
cosmetic deformity or significant functional deficit.
• Bone alignment must be evaluated in terms of bone
length, axial rotation and angulation in both the
frontal and coronal planes

4. Etiology
• Inaccurate fracture reduction
• Insufficient fracture immobilization
• Inadequate fracture fixation
• Ill advised weight bearing
• Injudicious intervention by traditional bone
setters
• Neglected fractures

5. Types of deformities
• Angulation
• Rotation
• Translation
• Leg length discrepancy

6. Classification
• Based on the Location
• Intraarticular
• Extra-articular
– Metaphyseal
– Diaphyseal
• Combined
• Plane malalignment
– Simple – one plane
– Complex - several plane and translation

7. Indications for Operative management
• Malunion with functional disability
• Intra-articular malunion with joint instability
• Mechanical overload
• Capsulo-ligamentous strain
• Cosmesis.

8. Management
• Preoperative
• History
– Deformity
– Pain
– Mechanism of injury of initial fracture
– History of previous intervention or no intervention
– Functional limitations
– Associated comorbidities

9. • Examination
– Presence of incisions, active drainage or sinus formation
• Leg length discrepancy, evaluated
• Rotational alignment should be determined compared
with the normal side.
– Malunion site
• Stress to rule out motion
• Stress to rule out pain
– Range of motion of joints proximal and distal to malunion.
– Neurovascular status of the limb

10. Investigation
• Plain radiographs
– AP, LAT, oblique
• CT Scan with 3D recon
– Evaluating rotational deformities
• MRI
– Intraarticular malalignment
– Associated ligamentous injury
• Laboratory investigations
– FBC
– CRP, ESR
– HBA1c

11. Radiographic assessment
• Objectives
– Is there a deformity
– Where is the deformity
– What are the characteristics of the dformity

12. X-ray: bilateral full length standing AP
and LAT views
• Anatomical axis:
– The anatomic axes are defined as the line that
passes through the center of the diaphysis along
the length of the bone.
• Joint orientation lines:
– describes the relation of a joint to the respective
anatomic and mechanical axes of a long bone

13. • The mechanical axis:
Defined as the line that
passes through the joint
centers of the proximal
and distal joints.

15. • Center of rotation of
angulation(CORA)
– The point about which a
deformity may be
rotated to achieve
correction.
– It is used to plan the
operative correction of
angular deformities.

16. Operative Treatment
• AIM:
– To correct translational, rotational and angular
deformity
– To achieve a functionally acceptable limb

17. Pre-Operative plan
• Planned Surgical approach/exposure
• Osteotomy – location/type
• Fixation techniques
• Intraoperative adjuncts
– use of bone graft/ bone substitute.
– Image intensifiers

18. Intra op
• Osteotomy
– Site of deformity
– Simple or multiplanar
– Type of osteotomy

19. Osteotomy
• Type of deformity
• Length
• Rotational
• Angular
• Complex
• Type of osteotomy
• Transverse
• Transverse
i. Oblique
ii. Wedge(opening/closing)
• Dome

20. Malunion: treatment by deformity
type
• Length Discrepancy
o Acute or gradual correction possible
1. Acute correction
– Bone ends acutely distracted or
compressed to desired length
– Osteotomy stabilized with intramedullary nail
or plate
– Bone graft utilized in acute distraction
2. Gradual correction
– Distraction thru corticotomy. Bone formed by distraction
osteogenesis
– Ex fix can correct all deformites simulatneously

21. • Angulation
• Acute or gradual correction possible
– Acute correction
• Dome osteotomies well suited for juxta-articular deformities
• Wedge osteotomies work well in diaphyseal region
• Osteotomy typically stabilized with intramedullary nail, plate
or lag screws
• Gradual correction
– using external fixation to both restore alignment and
provide stabilization during healing.

23. • Translation
– A single transverse osteotomy may be made to restore
alignment through pure translation
– A single oblique osteotomy may be made at the level of
the deformity to restore alignment and gain length.
– Two wedge osteotomies at the level of the respective
CORAs and angular corrections of equal magnitudes in
opposite directions may be used to correct a translational
deformity
• Gradual correction may be carried out using external
fixation.

25. • Combined deformities
– often require gradual correction to allow
adaptation of the bone,surrounding soft tissues
and neurovascular structures.
– The external fixator(Ilizarov) can be used to
achieve correction of multiple deformity types in a
single bone.
– Taylor Spatial Frame which uses six telescopic
struts, can be used to correct complex combined
deformities.

27. Treatment by deformity location
• Intraarticular malunion
• Intraarticular osteotomies are salvage procedures
that should be considered in symptomatic
patients.
• correction osteotomy
• Arthrodesis
• Arthroplasty

28. Complications
• Under- and overcorrection
• Nonunion
• Neurovascular compromise
• Delayed union
• Failure of fixation
• Infection
• Thromboembolism
• Joint stiffness

29. FOLLOW UP
Aims:
-Early detections of complications and treatment
-Documentation of outcome
-To fine tune management and skills
• Duration, frequency and prognosis depend on:
-Types of surgery
-Stabilization device
• History, examination and investigation at each follow up
visit

30. case
• A 35yr old female
• Had closed distal tibia
fracture
• Managed
nonoperatively
• c/o toe turned out
• Deformity
– 20deg ext rotation
– 10deg procurvartum
– 5 deg varus

31. • Osteotomy of tibia
• Closing anterior and
lateral wedge and
derotation osteotomy
• Oblique osteotomy of
fibula
• Fixation
– Distal medial tibial
locking plate

32. Future trend
• 3D imaging – patient specific to guide
osteotomy.
• Arthroscopy-Assisted Corrective Osteotomy

33. LOCAL PERSPECTIVE
• Facilities
• Culture and beliefs
• Quackery and TBS issues
• Late presentation
• Cost/insurance
• Poor follow up

34. Conclusion
• Management of malunions requires a sound
understanding of the principles and biomechanics
of internal fixation, the biology of fracture union,
and the limits of the specific implants employed.
• Due to the unique nature of each patient’s
problem, patients with malunion require an
individualized treatment plan with specific goals,
being also be aware of potential complications.

35. References
• Animesh A. Malunions, diagnosis evaluation and
management. Springer, (2021) ch 1: introduction; p. 1-12
• Brinker MR, Oconnor DP. Basic sciences. In: Miller MD, ed.
Review of orthopedics. Philadelphia, PA: WB Saunders; 2004
• Chapman, Michael W. Chapman's Orthopedic Surgery, 3rd Ed:
Lippincott Williams & Wilkins 2001; p 848-888
• Richard E., Christopher G, Theerachai A, AO Principles of
Fracture Management. Thieme; 2018; p 493-512
• Google images.