NONUNION OF NONUNION OF FRACTURESFRACTURES

Presented by:Presented by:

Dr. AbdulRahman Al-GarniDr. AbdulRahman Al-Garni

Introduction::

5% of long bone fractures will 5% of long bone fractures will result in nonunion and even more result in nonunion and even more in in delayed union.delayed union.

Nonunion is considered when Nonunion is considered when healing healing has not advanced at the has not advanced at the average rateaverage rate for the location and for the location and type of fracture type of fracture (usually more (usually more than 6 months).than 6 months).

Nonunion is difficult to define Nonunion is difficult to define because of the many different because of the many different factors that must be considered. factors that must be considered. In general, the absence of any In general, the absence of any clinical or radiographic evidence clinical or radiographic evidence of progression of fracture healing of progression of fracture healing for 2-3 months after the for 2-3 months after the expected time period for healing expected time period for healing constitutes a nonunion. constitutes a nonunion.

Causes:: Although the exact causes of non-Although the exact causes of non-

union are unknown, both union are unknown, both systemic systemic and local factors are and local factors are thought to thought to contribute to the contribute to the development.development.

Systemic factors include the Systemic factors include the patients metabolic and nutritional patients metabolic and nutritional status, general health and activity status, general health and activity level. Smoking and the use of level. Smoking and the use of alcohol has been implicated.alcohol has been implicated.

Local factorsLocal factors:: Nonunion is more common Nonunion is more common

when the fracture of long bone is when the fracture of long bone is open, infected, segmental with open, infected, segmental with impaired blood supply usually to impaired blood supply usually to the middle fragment, immobilised the middle fragment, immobilised for an insufficient time, distracted for an insufficient time, distracted (either by traction or plating) or (either by traction or plating) or fracture of irradiated bone).fracture of irradiated bone).

The incidence of nonunion in the The incidence of nonunion in the long bones varies with each bone long bones varies with each bone and and with the methods of treating with the methods of treating acute fractures.acute fractures.

Tibia probably is the most frequent Tibia probably is the most frequent site of nonunion with the increasing site of nonunion with the increasing frequency of severe frequency of severe open tibial open tibial fractures, however, fractures, however, with the more with the more frequent use of frequent use of interlocking interlocking femoral nails, nonunion after femoral femoral nails, nonunion after femoral fractures have become rare.fractures have become rare.

In a non union, the normal In a non union, the normal fracture fracture repair process occurs repair process occurs only only minimally, is interrupted, or minimally, is interrupted, or does not result in the formation does not result in the formation of bridging bone.of bridging bone.

The most common cause of non The most common cause of non union in humans despite modern union in humans despite modern treatment, is excessive motion treatment, is excessive motion at the fracture site.at the fracture site.

It results in cell and matrix It results in cell and matrix disruption that prevents bridging disruption that prevents bridging of the fracture site by of the fracture site by calcified or calcified or ossified tissue.ossified tissue.

Loss of blood supply to the Loss of blood supply to the bone bone ends at the fracture site or ends at the fracture site or in in the surrounding soft-tissue the surrounding soft-tissue envelope.envelope.

Certain fractures have a higher Certain fractures have a higher incidence of non union due to incidence of non union due to anatomic factors in the anatomic factors in the

vascular vascular supply to one or more supply to one or more of the of the major bone fragments. major bone fragments.

Typical examples are displaced Typical examples are displaced subcapital fractures of the femoral subcapital fractures of the femoral neck, which result in avascular neck, which result in avascular necrosis of the femoral head and necrosis of the femoral head and non non union of the femoral neck; union of the femoral neck; fractures at the waist of the fractures at the waist of the carpal scaphoid, which result in carpal scaphoid, which result in avascularity of the proximal avascularity of the proximal pole pole and nonunion; and fractures and nonunion; and fractures of the of the neck of the talus, which neck of the talus, which can result can result in loss of blood supply in loss of blood supply to the to the body of the talus, body of the talus, particularly if particularly if associated with a associated with a subtalar or subtalar or ankle dislocation. ankle dislocation.

Classification::

Nonunion can be classified Nonunion can be classified according to the status of bone according to the status of bone ends into:ends into:

A. Hypertrophic (Hypervascular):A. Hypertrophic (Hypervascular): Sclerotic and flared out.Sclerotic and flared out.

B. Atrophic (Avascular):B. Atrophic (Avascular): Osteoporotic, narrowed and Osteoporotic, narrowed and

rounded. rounded.

Hypervascular nonunion can beHypervascular nonunion can besubdivided into:subdivided into:

1. Elephant’s foot: 1. Elephant’s foot: Hypertrophic and rich in callus.Hypertrophic and rich in callus.

2. Horse hoof: 2. Horse hoof: Mildly hypertrophic and poor in Mildly hypertrophic and poor in callus.callus.

3. Oligotrophic: 3. Oligotrophic: Not hypertrophic but are vascular.Not hypertrophic but are vascular.

Avascular Non-union::

1.1. Torsion wedgeTorsion wedge : An intermediate : An intermediate fragment has healed to one main fragment has healed to one main fragment.fragment.

2.2. Comminuted: One or more necrotic Comminuted: One or more necrotic intermediate fragments.intermediate fragments.

3.3. Defect: Loss of fragment of a Defect: Loss of fragment of a diaphysis of a long bone.diaphysis of a long bone.

4.4. Atrophic: Final result Atrophic: Final result

Infected non unions must be Infected non unions must be recognized. A history of prior recognized. A history of prior infection is important, but if the infection is important, but if the nonunion site shows no local nonunion site shows no local signs signs of infection and of infection and there has there has been been no active drainage for 6 no active drainage for 6 mos. or mos. or more (particularly if the more (particularly if the previous previous infection was caused by infection was caused by an an antibiotic-sensitive organism antibiotic-sensitive organism that that was successfully eradicated), was successfully eradicated), then then operative intervention can operative intervention can usually proceed.usually proceed.

Nonunion with active signs of Nonunion with active signs of infection ,however usually require infection ,however usually require eradication of the infection first,with eradication of the infection first,with thorough irrigation and thorough irrigation and debridement,removal of all debridement,removal of all devitalised bone ,good devitalised bone ,good stability(usually with external stability(usually with external fixator),and achievement of good fixator),and achievement of good quality,soft tissue coverage.quality,soft tissue coverage.

It is possible to achieve union in the It is possible to achieve union in the presence of active infection,but presence of active infection,but usually it must be eradicated before usually it must be eradicated before proceeding with treatment .proceeding with treatment .

PRINCIPLES OF TREATMENTPRINCIPLES OF TREATMENT

The primary objective is to achieve The primary objective is to achieve solid union of the fracture site,good solid union of the fracture site,good level of function,little or no level of function,little or no shortening or malalignment and good shortening or malalignment and good range of motion,musle strength and range of motion,musle strength and neurovascular function.neurovascular function.

DIAGNOSISDIAGNOSIS

History : original injury and the History : original injury and the initial treatment,infection at any initial treatment,infection at any time,systemic illness and habits.time,systemic illness and habits.

DIAGNOSISDIAGNOSIS

The most typical complaint is pain at The most typical complaint is pain at fracture site often severe and fracture site often severe and aggravated by motion and weight aggravated by motion and weight bearing.bearing.

DIAGNOSISDIAGNOSIS

In the physical examination,theIn the physical examination,the

pathognomonic sign is motion in the pathognomonic sign is motion in the fracture site,occasionally with fracture site,occasionally with crepitus.Limb alignment,joint and NV crepitus.Limb alignment,joint and NV status.status.

IMAGINGIMAGING

Plain radiograph:AP,lateral and or Plain radiograph:AP,lateral and or oblique.The key to dignosis on plain oblique.The key to dignosis on plain films is placing the nonunion in line films is placing the nonunion in line with the cetral beam of the with the cetral beam of the radiograph.radiograph.

IMAGINGIMAGING

CT with reconstruction particularly CT with reconstruction particularly for metaphyseal and juxaarticular for metaphyseal and juxaarticular fractures.fractures.

IMAGINGIMAGING

Use technetium bone scans to rule Use technetium bone scans to rule out synovial pseudarthrosis in out synovial pseudarthrosis in hypertrophic non unions of which hypertrophic non unions of which you are contemplating treatment you are contemplating treatment with either electrical stimulation or with either electrical stimulation or closed intramedullary nailing.closed intramedullary nailing.

NONOPERATIVE TREATMENTNONOPERATIVE TREATMENT

Cast and brace immobilisation:little Cast and brace immobilisation:little role.role.

ELECTRICAL STIMULATIONELECTRICAL STIMULATION

In tissue and bone cells, the intial In tissue and bone cells, the intial response to electricity is increased response to electricity is increased bone cell proliferation and no change bone cell proliferation and no change in or decreased matrix production in or decreased matrix production and alkaline phosphatase activity. and alkaline phosphatase activity. Later, matrix production Later, matrix production increases increases and matrix calcification is stimulated and matrix calcification is stimulated or increased.or increased.

ELECTRICAL STIMULATIONELECTRICAL STIMULATION

The most common indication is delayed The most common indication is delayed union in good position particularly of the union in good position particularly of the diaphysis of the tibia or femur.Other diaphysis of the tibia or femur.Other indications include fractures in acceptable indications include fractures in acceptable alignment,which can be immobilised in alignment,which can be immobilised in functional casts or brace in patients who functional casts or brace in patients who significants contraindications to surgery significants contraindications to surgery such as systemic illness,poor quality soft such as systemic illness,poor quality soft tissue and infection.tissue and infection.

ELETRICAL STIMULATIONELETRICAL STIMULATION

Contraindications to non invasive Contraindications to non invasive electrical stimulation for treating electrical stimulation for treating nonunion include a large gap at the nonunion include a large gap at the fracture site and synovial fracture site and synovial pseudarthrosis. pseudarthrosis.

Success rate is 74% to 79%.Success rate is 74% to 79%.

Ultrasound and Bone Marrow Ultrasound and Bone Marrow Injection: may have a role however Injection: may have a role however not proven.not proven.

SURGICAL TREATMENTSURGICAL TREATMENT

Proper preoperative planning.Proper preoperative planning.

PLATE FIXATIONPLATE FIXATION

Plate fixation without bone graft is Plate fixation without bone graft is applicable to hypertrophic and well applicable to hypertrophic and well vascularized nonunions where vascularized nonunions where increasing the stability of the fracture increasing the stability of the fracture site alone will result in union. site alone will result in union. Oligotrophic nonunions and all of the Oligotrophic nonunions and all of the avascular nonunions require bone avascular nonunions require bone grafting.grafting.

IM NAILINGIM NAILING

Locked IM nailing is most useful for Locked IM nailing is most useful for nonunions in the diaphysis of tibia or nonunions in the diaphysis of tibia or femur.femur.

The best indication for The best indication for dynamization is a nonunion of dynamization is a nonunion of the the femur or tibia that already femur or tibia that already has has a large reamed nail in place a large reamed nail in place and and where the fracture is oblique where the fracture is oblique so so that weight bearing will cause that weight bearing will cause increasing stability, particularly increasing stability, particularly in rotation. in rotation.

Exchange nailingExchange nailing

Ilizarov techniqueIlizarov technique

Severe shortening,major bone Severe shortening,major bone deficiency,deformity and soft tissue deficiency,deformity and soft tissue contractures.contractures.

THANK YOUTHANK YOU