The document discusses delayed union and nonunion of fractures. It defines nonunion as a fracture that shows no signs of healing after 9 months. It classifies nonunions based on bone loss and callus formation. The causes, clinical features, investigations, and management of nonunions are described. Management options include open reduction, rigid fixation, bone grafting, electrical stimulation, and the Ilizarov technique. Types of bone grafts like cancellous, cortical, and Phemister grafts are also outlined.

1. Delayed Union and Non Union
Gopisankar.M.G.
2008 MBBS

3. 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

4. Classification
 Paley’s Classification
 Muller and Weber’s Classification

5. Paley’s Classification
 Type A  Bone loss <1cm
 Type B  Bone loss >1cm

6. Muller & Weber’s classification
 Amount of callus at the fracture site
1. Hypervascular Nonunion
2. Avascular Nonunion

8.  Hypervascular  Avascular
1. Hypertrophic/Elephant 1. Torsion Wedge
foot 2. Comminuted
2. Horse hoof 3. Defect
3. Oligotrophic 4. Atrophic

12. Causes of nonunion
 Compound fractures
 Infection
 Segmental fractures
 Distraction of fracture fragments
 Soft tissue interposition
 Ill devised open reduction
 Insecure and inadequate fixation

13. Clinical features
 History
1. Trauma resulting in fractures
2. Open fractures
3. Improper / delay / inadequate treatment
 Symptoms
1. Minimal / no pain
2. Loss of function

14.  Signs
1. Painless abnormal mobility
2. Shortening
3. Scars
4. Sinuses
5. Deformity
6. Wasting of limb muscles

15. Investigations
 X-ray AP and Lateral view
1. Gap between fracture fragments
2. Fragments are rounded and sclerotic
3. Amount of callus formed could be less or more
4. Decreased density of bone is due to osteoporosis

25. Management
 Surgery 
1. Open reduction
2. Rigid internal fixation
3. Bone grafting
 Electrical stimulation
 Ilizarov’s technique

26. Bone Graft
 Promotes Osteogenesis ,provide stability
 Types
1. Cancellous Bone Graft
2. Cortical Bone Graft
3. Phemister Bone Graft

27. Cancellous bone Graft
 In defects < 2.5cm
 Better tolerated
 Rapidly revascularized

28. 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

31. Phemister bone graft
 Graft is placed subperiosteally
 Blood supply is not disturbed
 Simple
 Placed posteriorly
 Useful in tibia

32. Electrical stimulation in Nonunion
 20 mA
 Fibrous tissue  fibrocartilage  endochondral
ossification
 Types
1. Noninvasive
2. Semi invasive
3. Invasive
 Pulsed Electromagnetic field after excision of fibrous
tissue followed by grafting
 Immobilization is done to decrease stress
 Slow not always successful

33. Ilizarov’s technique
 Best for infected nonunions
 Corrects deformity + boneloss
 In hypertrophic  gradual compression
 Avascular  corticotomy , Bone transport and
compression