1 / 111

MALUNITED FRACTURES

jela
Download Presentation

MALUNITED FRACTURES

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

    2. MALUNITED FRACTURES DR.FAAIZ ALI SHAH

    3. PATTERN OF PRESENTATION 1.Malunion - general 2.Malunion - specific

    4. DEFINITION A malunited fracture is one that has healed with the fragments in a nonanatomical position. Commonly are the rule in the closed treatment of fractures.

    5. CAUSES 1.Inaccurate reduction 2. Ineffective immobilization during healing. 3. Patients with multiple injuries---02 factors

    6. CLASSIFICATION A.LOCATION 1.Intra-articular 2.Metaphyseal 3.Diaphyseal B. SIMPLE: One plane C. COMPLEX: Several planes/translation

    7. SIGNIFIGANCE Impair function in several ways: 1.Irregular weight transfer-- arthritis of the joint. 2.Rotation or angulations—balance/gait. 3.Shortening. 4.Neighboring joints movements blocked  

    8. INVESTIGATIONS X-ray AP/lateral view, joint above & below full limb x-ray/axis 2. CT/3D for intra-articular malunion

    9. GENERAL PRINCIPLES Acceptability of fracture reduction: 1.Alignment 2.Rotation 3.Restoration of normal length 4.Actual position of the fragments  KEY: Skilful treatment of fresh fractures

    10. OBJECTIVES OF SURGERY 1.Restore function 2.Relieve pain 3.Cosmetic Surgery 6 to 12 months after the fracture Early surgery in intraarticular fractures  

    11. CHOICE OF IMPLANT DCP ILN ANGLED BLADE PLATE BUTTRESS PLATE EX FIX/ILIZAROVE

    12. MALUNION IN CHILDREN Axial alignment deformity in less than 9 years old   Near a joint and in the plane of its motion.  

    13. SURGICAL OPTIONS 1.Corrective surgery at the site of malunion. 2. Compensatory procedure. Degree of osteoporosis Soft-tissue atrophy Ilizarov ring Ex Fix—ORIF inappropriate due to previous Infection/multiplane deformity

    14. Phalanges of the Toes A deformity that causes pain Osteotomy and alignment of the fragments/wide resection    

    15. Metatarsals Malunion of the neck or shaft of a metatarsal. Correct angulations so that weight bearing does not cause painful pressure on the sole of the foot.

    16. Tarsals Violent trauma/several bones may be involved /comminuted/dislocated The distal fragment a prominence on the dorsum of the foot. Proximal fragment forms a mass on the sole. Partial or total resection and arthrodesis of one or more of the tarsal joints

    17. Malunion of the Neck of Talus Usually the deformity is one of valgus, with the head deviated medially and dorsally. Talar neck osteotomy with bone graft. Triple arthrodesis/ankle arthrodesis for traumatic arthritis.  

    18. Malunion of the Body of Talus If superior and inferior articular surfaces of the talus are irregular, posterior arthrodesis of the ankle, including the subtalar joint. If body is nonviable, calcaneotibial arthrodesis. Traumatic arthritis--ankle fusion / subtalar fusion.    

    19. Calcaneus Stephens and Sanders Classification: Type I: large lateral wall exostosis, no subtalar arthritis Type II: large lateral wall exostosis, significant subtalar arthritis Type III: lateral exostosis, significant subtalar arthritis, calcaneal body malalignment of more than 10 degrees hindfoot varus.  

    21. Stephens and Sanders Treatment Guidelines: TYPE I= Lateral exostectomy through extensile L shaped lateral Incision. TYPE II= Lateral exostectomy plus subtalar arthrodesis using resected exostosis as graft. TYPE III= Lateral exostectomy plus subtalar arthrodesis plus calcaneal osteotomy.

    22. Clare, Lee, and Sanders Study 45 calcaneal malunions, with an average follow-up of 5.3 years Type I=5, Type II=30, Type III=10 93% of the arthrodeses united 24% had delayed healing One deep infection Mild residual pain was present in 64% of patients        

    23. ANKLE Even a minor varus or valgus deformity of the joint produces an abnormal weight bearing alignment/ posttraumatic arthritis. Objectives are to restore alignment (Osteotomy) for recent fracture or to relieve symptoms of arthritis (Ankle fusion) if more than 3 months.  

    24. SURGICAL OPTIONS 1.Osteotomy of the fractured fibula or medial malleolus or both with restoration of fibular length and internal fixation of the osteotomies. 2.Supramalleolar osteotomy when only realignment of the lower extremity is required. 3.Arthrodesis of the ankle with or without supramalleolar osteotomy

    27. Supramalleolar Osteotomy If ankle is in valgus or varus & normal tibiotalar relationship 1.Dome osteotomy= not sacrifice length, correcting deformity in the frontal (varus-valgus) plane than in the sagittal (flexion-extension) plane. 2. Wedge osteotomy can be used to correct multiplanar deformities. -Closing wedge provide broad bony surfaces for healing, but cause some shortening of the extremity. -Opening wedge maintain length, but bone grafting is required to fill the gap created.      

    29. Arthrodesis for Malunited Fractures of the Ankle 1.Malunited bimalleolar fractures/deformity/arthritis/pain. 2.Malunited trimalleolar fractures/dislocated talus. 3.Deformity not completely corrected by conservative reconstruction/extensive surgery will cause arthritic changes in the ankle.

    30. Shafts of the Tibia and Fibula Angular deformities = osteoarthritis Surgery is indicated for: 1.valgus deformity of more than 12 degrees. 2.varus deformity of more than 6 degrees. 3.external rotation deformity of more than 15 degrees. 4. internal rotation deformity of more than 10 degrees.  

    36. TREATMENT Limb must be evaluated for infection, soft tissue coverage, neurovascular, contractures. Osteotomy= Dome, closing or opening wedge, Oblique-multiplaner/lengthening. At the site of the old fracture or supramalleolar osteotomy. Fixation of osteotomy with a compression plate or intramedullary nail or The Ilizarove Fixator (infected/soft tissues)

    41. Condyles of the Tibia If instability=repair the ligament. If axial malalignment after depression of a condyle= transverse subcondylar osteotomy combined with the insertion of a graft and internal fixation. An oblique osteotomy through the old fracture; the depressed condyle is elevated and fixed with a buttress plate and screws, and the defect is filled with bone graft. If reconstruction is impractical= an arthrodesis or arthroplasty.        

    42. Condyles of the Femur Malunion of the lateral femoral condyle can produce external rotation, flexion, and valgus deformities of the knee. Malunion of the medial condyle produces internal rotation, flexion, and varus deformities. ORIF with AO Cancellaus screws/buttress plate. For Both Femoral Condyles fractures, realignment osteotomy for varus or valgus through metaphysis /Arthrodesis/Arthroplasty

    44. Femoral Shaft Malunions after closed treatment Cause disturbances in gait and posture, stress on knee and spine. Significant only if they result in shortening of more than 2.5 cm, are angulated more than 10 degrees. Evaluate the limb.        

    45. In children 13 years age,25 degrees of malunion femur in any plane remodels. If sever, proximal or distal metaphyseal osteotomy is preferred.

    47. Surgical options Osteotomy, fixation with an ILN, and BG/ ORIF with broad DCP with BG or Ex Fix / Ilizarov technique. Kempf one-stage femoral lengthening with Z-step osteotomy stabilized with an intramedullary nail. Ferguson, Thompson, and King two-stage osteotomy(old technique)

    51. Trochanteric Region of the Femur Varus malunion is the most common deformity after intertrochanteric fracture and leads to limb shortening; abductor muscle imbalance; limp; and hip, back, and knee pain. Malunions with internal or external rotation, coxa vara, and shortening treated with subtrochanteric osteotomy.

    53. PELVIS Usually, malunions of the pelvis in which correction is justified are those involving the acetabulum. Indications for surgery are pain, instability, sitting imbalance, limb shortening, and vaginal wall impingement and Cosmetic. Each pelvic malunion is unique and requires individualized plans and techniques for operative reduction and stabilization.        

    54. SURGICAL OPTIONS A .Three stage reconstruction: 1.The deformed anterior pelvic structures are osteotomized. 2. Posterior pelvic deformities are osteotomized or mobilized, the pelvis is reduced, and posterior structures are internally fixed. Wounds are closed between each stage. 3. The initial wound is reopened, the anterior reduction is completed, and internal fixation is applied. B. Arhrodesis C. Arthroplasty

    55. CLAVICLE Symptoms include rapid fatigability, thoracic outlet syndrome, and difficulty wearing over-the-shoulder straps, weakness, pain, and cosmetic deformity. The malunions that usually are disabling are malunions of the medial or lateral third of the bone.

    57. TREATMENT Osteotomy and plating for symptomatic clavicular malunions include malunions with substantial shortening (usually 2 to 3 cm), angular deformity greater than 30 degrees, or translation greater than 1 cm.

    59. Contraindications include inadequate soft-tissue coverage, active infection, asymptomatic malunion, noncompliant patient, or severely osteopenic or pathological bone.

    60. HUMERUS Beredjiklian et al. classification proximal humeral malunions Type I= malposition of the greater or lesser tuberosity of more than 1 cm. Type II=intraarticular incongruity or step-off of the articular surface of more than 5 mm. Type III=rotational malalignment of the articular segment by more than 45 degrees in the coronal, sagittal, or axial plane. Soft-tissue abnormalities were categorized as soft-tissue contracture, rotator cuff tear, and impingement.      

    62. TREATMENT Severe pain or loss of function or both. Malunion of a two-part surgical neck fracture, with resultant varus deformity treated with a valgus wedge osteotomy and fixed with a T-shaped AO plate. Two-part greater tuberosity fractures-ORIF/release of soft-tissue contractures / removal of prominent bone for less severe deformities. Some three-part and most four-part and head-splitting malunions are treated best by arthroplasty.    

    64. Arthrodesis is recommended for patients with infection or severe neurological deficit. Malunion of the Anatomical neck with severe, painful traumatic arthritis should be treated by shoulder fusion by prosthetic humeral head replacement or total shoulder arthroplasty or by acromioplasty. Shaft of Humerus=ORIF/BG

    66. Distal Humerus (1) Supracondylar fractures /children (2) T-fractures of the condyles, (3) Fractures of the distal condylar articular surface, (4) Fractures of the condyles -Cubitus Varus/elbow instability  

    68. TREATMENT For a severe deformity (>15 degrees) and high functional demands, O'Driscoll et al. recommended osteotomy combined with ligament reconstruction.  

    69. Proximal Third of the Radius and Ulna (1) Radial head. (2) Radial neck. (3) Olecranon. (4) Monteggia fracture. (5) Malunions with synostosis between the radius and ulna.

    70. Radial Head 1.Resect the prominence. 2. Excise the radial head. complications of radial excision include loss of grip strength, wrist pain, distal radial ulnar joint instability, and valgus instability of the elbow. Prosthetic radial head replacement should be considered for patients with radial head malunions associated with distal radioulnar joint pain or instability or laxity of the MCL.      

    71. Radial Neck A malunited radial neck fracture can cause pain, crepitance, elbow laxity, limitation of elbow flexion and extension, and limitation of forearm pronation and supination. Corrective osteotomy of the radial neck should be considered for symptomatic malunions

    72. Olecranon Osteotomy and realignment of the fragments almost always increases the disability. Excise the deformed part. Method of excision

    73. Malunited Monteggia Fracture Joint is damaged & impossible to restore elbow function to near-normal/No reconstruction. Radial head excision + Ulnar osteotomy +fixation +BG.

    75. Synostosis between the Radius and the Ulna Jupiter and Ring classified proximal radioulnar synostosis into three types: A= synostosis at or distal to the bicipital tuberosity. B= synostosis involving the radial head and the proximal radioulnar joint. C= synostosis contiguous with bone extending across the elbow to the distal aspect of the humerus.  

    76. TREATMENT Delay in operative treatment for 6 to 12 months after injury. Jupiter and Ring suggested that early resection is preferable because of its potential ability to limit the degree of soft-tissue contracture and the overall period of severe disability. Resection/Fat graft /anconeus muscle as a vascularized pedicle graft. Resection of a 1-cm thick section of the proximal part of the radial shaft.  

    77. Shafts of the Radius and Ulna in Adults Malunion causes disturbances of the distal radioulnar joint, and arthritis of the proximal radioulnar joint. 15 to 20 degrees angular deformity. Indications for surgery are loss of motion, distal radioulnar joint instability, and unacceptable cosmetic appearance Best results within 1 year (soft tissue contracture) Osteotomy of both bones +ORIF with plating +BG.        

    79. DISTAL RADIUS Fracture characteristics and initial treatment contribute to the development of a malunion   Radial shortening of <5 mm at distal radioulnar joint compared with contralateral wrist Inclination on posteroanterior film =15 degrees Sagittal tilt on lateral projection between 15-degree dorsal tilt and 20-degree volar tilt Incongruity of intraarticular fracture =2 mm at radiocarpal joint  

    84. Malunited Colles fractures Pain and functional deficits severe enough to interfere significantly with daily activities. Osteotomy and grafting. Fernandez technique of osteotomy and grafting of distal radius.    

    85. Contraindications to radial osteotomy include active reflex sympathetic dystrophy, acceptable function despite deformity, poor soft-tissue envelope, severe osteopenia, and advanced radiocarpal or intercarpal arthritis.

    89. MALUNITED SMITH FRACTURE Less common than Colles. Goals of the procedure are to reduce pain, improve motion, and correct deformity. Volar opening wedge osteotomy of the distal radius, bone grafting, and plating for symptomatic malunited Smith fractures.            

    92. Intraarticular Malunions Intraarticular incongruity of 2 mm or more associated with poor results and a likelihood of posttraumatic arthritis. 1.Procedures aimed at preventing posttraumatic arthritis (intraarticular osteotomies) 2. Salvage procedures (limited carpal arthrodesis, total wrist arthrodesis, proximal row carpectomy, and wrist arthroplasty).      

    93. Intraarticular Osteotomy Young, active patients with high functional demands, more than 2 mm of articular step-off, and no evidence of posttraumatic arthritis. Optimally, intraarticular osteotomies are done within 6 weeks after injury, when fracture lines are more easily identified.

    94. Contraindications to intraarticular osteotomy include advanced osteoarthritis, massive articular comminution, poor bone quality, low functional demands, poor soft-tissue coverage, and reflex sympathetic dystrophy.

    95. Salvage Procedures Symptomatic comminuted intraarticular fractures. Distal radial malunions that develop posttraumatic arthritis.    

    96. 1.Total wrist arthrodesis in young with physical demands and advanced osteoarthritis of RC & MC joints/other options failed 2.Partial wrist arhrodesis/radioscapholunate /radiolunate fusion if MC joint is spared. 3.Proximal row carpectomy. 4.Total wrist arthroplasty.    

    98. Distal Radioulnar Joint Incongruity and Arthrosis Positive ulnar variance or protrusion of the ulna distal to its normal articulation. 1.Procedures that preserve the distal radioulnar joint 2. Procedures that ablate it.  

    99. Radial and ulnar osteotomies alone or in combination. If the radial deformity is unacceptable, a distal radial osteotomy alone frequently realigns the distal radioulnar joint, especially if radial shortening is 6 mm or less. If a positive ulnar variance remains after distal radial osteotomy, an ulnar shortening procedure can be done as well.  

    100. ABLATIVE PROCEDURES Indicated if arthritis of the distal radioulnar joint is advanced, or if the joint cannot be reduced by distal radial or ulnar osteotomies. 1.Complete ablation of the distal ulna (Darrach procedure). 2. Partial resection of the distal ulna (Bowers and Watson arthroplasty). 3. Distal radioulnar joint fusion with proximal ulnar pseudarthrosis (Sauvé-Kapandji procedure).    

    101. Darrach procedure   Elderly, debilitated, low functional demands. No more than 2.5 cm of bone should be resected. Loss of the ulnar support of the carpus and alters axial loading characteristics of the wrist.    

    103. The Sauvé-Kapandji Procedure   Distal radioulnar arthrodesis with more proximal ulnar pseudarthrosis allows restoration of forearm rotation, while reducing pain at the distal radioulnar joint. Modiied by Fernandez,flexor carpi ulnaris as a tenodesis through drill holes in the distal end of the proximal ulnar segment.

    104. Bowers technique of hemiresection arthroplasty A DRUJ arthroplasty involving partial ulnar head resection . Because ulna is too long, it impinges on stylocarpal ligament. This problem can be corrected by interposition of palmaris longus, extensor carpi ulnaris, or flexor carpi ulnaris.    

    106. CARPUS Fusion of the wrist   Excision of one or more carpals    

    107. HAND If metacarpals and proximal phalanges are involved weakness of grasp and pinch. Metacarpal neck fractures with flexion deformities of 40 degrees or more can easily be accepted with good function. 5th & 4th metacarpal=motion in the carpometacarpal joints. 3rd & 2nd metacarpals=no motion in the carpometacarpal joints, hyperextension of the MP joint and secondary contracture of the collateral ligaments often occur; a capsulotomy and an osteotomy is needed.    

    108. PHALANGES 1.Volar angulation 2.Lateral angulation 3.Rotation 4.Shortening

    110. Malunion of a metacarpal shaft or of a phalanx are treated with a medullary cortical bone peg/osteotomy and fixation with Kirschner wires.  

    111. CONCLUSION The indication for a post-traumatic corrective osteotomy depends on the associated disability in each individual. The natural history of the deformity should be considered.

    112. THANK YOU

More Related