nonunion and malunion causes and management for undergraduates

1. DELAYED UNION
NONUNION
DR KISHORE VEMULA
ASSISTANT PROFESSOR OF ORTHOPAEDICS
KIMS-RF, AMALAPURAM

2. DEFINITIONS AND OBJECTIONS…………
• WHEN A FRACTURE TAKES MORE THAN USUAL TIME OF UNION , IT IS CALLED AS DELAYED UNION.
• NONUNION: FAILURE OF A FRACTURE TO UNITE THAT HAS NO POTENTIAL TO HEAL
WITHOUT FURTHER INTERVENTION
• TIME BASIS??
• FDA- 9 MONTHS TIME TO DECLARE IT
• BUT WHAT ABOUT FRACTURES IN CHILDREN ?
• IS TIME SAME FOR ALL BONES TO DECLARE?
• FOR OPEN # AND COMPLEX PATTERNS?
Perkin laws:( rule of three)
• No bone unite before 3 weeks
• # union time in children takes twice as
infants
• # union time in adults takes twice as
children
• # union time for lowerlimbs takes twice as
upperlimbs
• Transverse # takes longer time
• Open # takes longer time

3. “FAIURE OF UNION OF FRACTURE WITHIN PERIOD OF 9 MONTHS SINCE INJURY AND
FRACTURE SHOWS NO PROGRESSIVE SIGNS OF UNION BOTH CLINICALLY AND
RADIOLOGICALLY FOR 3 MONTHS FOLLOWUP”

4. NON UNION : BIOLOGICAL OR MECHANICAL FAILURE ?
√√

5. CLASSIFICATION OF NONUNION
HYPERTROPHIC OR HYPERVASCULAR
• VIABLE FRACTURE ENDS
• CALLUS PRESENT BUT FAILS TO FORM BRIDGING CALLUS
• MECHANICAL FAILURE– INADEQUATE STABILISATION OF FRACTURE
ATROPHIC OR AVASCULAR
• NON VIABLE FRACTURE ENDS
• ENDS ARE SCLEROSED AND ATROPHIC AND FIBROSIS
OF FRACTURE SITE TO FORM PSEUDOARTHROSIS
• CALLUS ABSENT
• BIOLOGICAL FAILURE– INABILITY TO FORM CALLUS

6. ATROPHIC NONUNION HYPERTROPHIC NONUNION

9. CAUSES OF NONUNION ;INCIDENCE –( 5-10%)
PATIENT FACTORS
• SMOKING
• ALCOHOL
• DIABETES, HTN
• MALNUTRITION
• OSTEOPOROSIS
• HYPOPITUTARISM,
HYPOTHYROIDISM
• CHRONIC SYSTEMIC ILLNESS
• MALIGNANCY
• NSAIDS, STEROIDS
INJURY FACTORS
• OPEN #
• COMMUNITED#
• SEGMENTAL#
• BONE LOSS AT INJURY
• EXTENSIVE SOFT TISSUE
DISRUPTION
Treatment variables
(5 “I”)
Inaccurate reduction
Inaadequte stabilisation
Ischemia
Infection
Interposition of soft tissues

10. CLINICAL FEATURES AND IMAGING IN NONUNION
• ABNORMAL MOBILITY AT FRACTURE SITE IS CHARACTERISTIC
• USUALLY PAINLESS
• PAIN MAY BE AT FRACTURE SITE DUE TO DELAY UNION OR SOFT TISSUE STRETCH
• X RAYS – AP, LATERAL, OBLIQUE VIEWS
• CT & MRI
• LINEAR TOMOGRAPHY – USEFUL IN PRESENCE OF HARDWARE
• RADIONUCLEOTIDE SCAN – SEPTIC NONUNIONS

11. BIOLOGICAL AUGMENTATION METHODS FOR
DELAYED OR IMPENDING NONUNIONS
• EARLY WEIGHT BEARING AND MOBILISATION OF JOINTS
• DYNAMISATION- ALLOWS AXIAL MICROMOTION AT FRACTURE SITE
• LOW INTENSITY PULSE ULTRASOUND THERAPY ( LIPUS)
• ELECTRICAL STIMULATION
• LOCAL INJECTION OF PLATELET RICH PLASMA(PRP)
• LOCAL INJECTION OF BONE MARROW (B-MAC)
• ORAL CISSUS QUADRANGULARIS
• SUBCUTANEOUS LOW DOSE PARATHORMONE INJECTION( R PTH)

12. DYNAMISATION: ALLOWS AXIAL MICROMOVEMENTS AT
FRACTURE SITE.

13. BIOLOGICAL AUGMENTATION IN ESTABLISHED
NONUNIONS BY BONE GRAFTING
• AUTOLOGOUS BONE GRAFTING IS GOLD STANDARD
• CANCELLOUS OR CORTICAL
• VASCULARISED OR NON VASCULARISED

14. MECHANICAL AUGMENTATION OF NONUNION
• NAILING- EXCHANGE NAILING
• PLATING
• EXTERNAL FIXATORS- ILLIZAROV RING FIXATOR/LRS

15. MANAGEMENT OF GAP NONUNIONS
(BOTH MECHANICAL AND BIOLOGICAL
AUGMENTATION)
• STABILISATION + BONE GRAFTING
• MASQUELET PROCEDURE
• BONE TRANSPORT/ DISTRACTION OSTEOGENESIS

16. DISTRACTION OSTEOGENESIS / BONE TRANSPORT

18. OTHER METHODS OF AUGMENTATIONS
• FIBULAR OSTEOTOMY FOR TIBIAL SHAFT FRACTURES
• FEMORAL NECK OSTEOTOMIES FOR NONUNION NECK OF FEMUR

19. HOW TO MANAGE SEPTIC NONUNION
• CONVERT SEPTIC NONUNION TO ASEPTIC NONUNION
DEBRIDEMENT AND BONE EXCISION, ANTIBIOTICS
• COVER THE DEFECT
BONE GRAFT/ BONE TRANSPORT
STABILISATION WITH ILLIZAROV / LRS

20. THANK YOU………