very good basic

1. Dr (Major) Parthasarathy S
Pg Resident,MS Orthopaedics
Stanley Medical College,Chennai
Ref:Rockwood and Wilkin’s fractures in children 8th
edition
Chapman’s orthopaedic surgery 3rd
edition
Campbell’s operative orthopaedics 12th
edition
Pics courtesy : internet

3.  Rare 1 in 250,000 live births
 Cause is unknown
 Specific type of nonunion
 At birth is either present or incipient
 May be related to fibrous dysplasia
 Neurofibromatosis closely related
 Distal half of the tibia
 Anterolateral bowing common
 L>R

5.  Boyd classification:
 Type1:
 Ant. Bowing and defect in tibia present at birth
 Other congenital deformities also present which
affect the ultimate management of the
pseudoarthorosis

6.  Type2:
 Most common
 Often associated with NF
 Worst prognosis
 Ant bowing and hourglass constriction of tibia
present at birth
 Spontaneous fracture or fracture following minor
trauma commonly occurs before 2 yr of age
 ‘’HIGH RISK TIBIA’’
 Tibia is tapered and sclerotic and the medullary
canal is obliterated

7.  Type3:
 Develops in congenital cyst usually near the
junction of the middle and distal third of the
tibia
 Ant bowing may precede or follow the
development of fracture
 Recurrence of the fracture after Rx is less
common than type 2
 excellent results after only one operation noted

8.  Type 4:
 Originates in the sclerotic segments of the bone
in classic location without narrowing of tibia
 Medullary canal is partially or completely
obliterated
 Insufficiency or stress fracture develops in the
cortex of the tibia and gradually extends through
the sclerotic bone
 With completion of the fracture, healing fails to
occur and fracture widens and pseudoarthosis
occur
 Prognosis: good to better

9.  Type5:
 Pseudoarthosis of tibia with dysplastic fibula
 May be both bone involved
 Prognosis: good if lesion confined to fibula
 If progresses to tibia mostly prognosis and progression
resembles type 2

10.  Type6:
 Occurs in interaosseous neaurofibroma or
schwanoma that results in pseudoarthosis
 rarest

11.  Type 1 :
 ANTEROLATERAL BOWING OF TIBIA=best prognosis
 Type 2:
 anterolateral bowing
 increased cortical thickness
 narrow medullary canal
 tubular defect
 Type 3:
 cystic lesion
 Type 4:
 presence of fracture, a cyst or frank
pseudoarthosis=worst prognosis

17.  Refracture
 Length discrepancy
 Stiffness –ankle & subtalar jt
 Progressive angulation of tibia
 Ankle valgus

18.  Resection of the pseudarthrosis
 Correction of length discrepancy and axial
deformity
 Achievement of fusion
 Correction of additional problems around
the main deformity
 Alignment
 leg-length discrepancy
 ankle valgus

19.  Bone grafting alone
 Prophylactic before a # occurs in bowed tibia
 Mc Farland technique
 Long corticocancellous graft from opposite tibia
placed posteriorely
 Spanning the normal biomechanical axis
 Concomitant curretage for cystic lesion

20.  Excision of pseudoarthrosis
 Deformity correction
 Rigid internal fixation + bone grafting
 Transfix ankle & subtalar jt to stabilise distal
tibial fragment
 These jts progressively freed with growth &
prox migration of rod
 Absence of significant stiffness
 Extentable rods + bone graft
 Not removed till skeletal maturity

22.  Implanted direct current bone growth
stimulator/external device with pulsating
EMF
 Increases success rate of bone graft +
internal fixation

23.  Free vascularised bone graft=rib,iliac
crest,fibula
 Fibula = best

25.  Advantages
 Provides excellent stability
 Allows complete resection of the
pseudarthrotic
 Enables weight bearing during the whole time
of treatment
 Transport the fibula distally
 Does not prohibit other treatment methods if
this method fails

26.  Disadvantages
 Time-consuming
 Not easy to perform
 complications
 pin track infections
 Fracture
Ankle valgus
Ankle stiffness.

29.  Anticipated shortening of more than 2 or 3
inches (5 to 7.5 cm)
 Multiple failed surgical procedures
 Stiffness and decreased function of a limb
that would be more useful after an
amputation and fitting with a prosthesis

30.  Boyd/Symes amputation
 Preserves heel pad
 Preserves distal tibial epiphysis
 Amputaion through pseudoarthrosis
 Poor end bearing stump
 Previous scars poor skin cover
 Overgrowth
 Amputation above pseudoarthrosis
 Better skin cover
 Bony overgrowth problem

32.  Most established pseudarthroses
 Initial treatment should be INTRAMEDULLARY
RODDING AND BONE GRAFTING+- ELECTRCAL
STIMULATION
 Vascularized fibular grafts/Ilizarov
With gaps of more than 3 cm
Multiple surgical procedures have failed

34.  Rare
 Precedes or accompanies the same
condition in the ipsilateral tibia
 Several grades of severity
 Bowing of the fibula without pseudarthrosis
 Without ankle deformity
 With ankle deformity
 With latent pseudarthrosis of the tibia
 It even develops between the time of
successful bone grafting of a pseudarthrosis of
the tibia and skeletal maturity=the lateral
malleolus becomes displaced proximally, a
progressive valgus deformity of the ankle
develops

35.  Until skeletal maturity is reached=ankle-
foot orthosis
 At maturity= supramalleolar osteotomy

36.  For children to prevent valgus deformity or
progression = Langenskiöld operation
 Synostosis between the distal tibial and
fibular metaphyses
 An operation that prevents the ankle
deformity without grafting in fibular
pseudarthrosis is useful

38.  Rare
 Failure of normal ossification
 Unknown etiology
 B/L rare
 Right > Left
 Not associated with neurofibromatosis
 Autosomal recessive inheritance

39.  Subclavian artery compress the developing Rt
clavicle
Explains the Rt predominance
Dextrocardia Lt lesion
 Failure of 2 ossification centers to fuse

40.  Prominent middle third clavicle
 Increase with age
 Not painful
 Shoulder ROM normal
 Radiograph : osseous seperation with
enlarged rounded bone ends and absence of
callus
 No classification

41.  Prominent/painful
 Pseudoarthrosis resection and bone
grafting/plating –simple resection causes
shoulder to droop
 Arm sling 6 weeks
 Complications
 Hypertrophic scar
 Infection
 Non union
 Neurovascular injury
 Bone graft donor site morbidity

44.  Rare
 Associated with neurofibromatosis
 Etiology unknown
 Progressive forearm deformity
 Forearm short bowedradial head dislocates
 Motion usually not affected
 No classification

45.  Pain and progressive deformity
 Resection of pseudoarthrosis and free
vascularised fibular graft +- bone graft
 Complications
 Recurrence
 Difficult union
 If recurs & regraft fails = one bone forearm