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Clinical Features of Mal-union and Non-union. Reza Sh. Kamrani M.D. TUMS POTA refreshment symposium 20/1/88. Clinical Features of Non-union. Pain Motion Function impairment. Clinical importance of Clinical findings Definition Diagnosis Classification Treatment. Introduction.

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clinical features of mal union and non union

Clinical Features of Mal-union and Non-union

Reza Sh. Kamrani M.D.

TUMS

POTA refreshment symposium

20/1/88

clinical features of non union
Clinical Features of Non-union
  • Pain
  • Motion
  • Function impairment
slide4

Clinical importance of Clinical findings

  • Definition
  • Diagnosis
  • Classification
  • Treatment
introduction
Introduction

Bone has a remarkable capacity of healing

(regeneration)

introduction1
Introduction

UNION

Monitoring

Radiologically and Clinically

Biology and Biomechanics of healing and fixation is very important to monitor healing

introduction biology1
Introduction (Biology)
  • Bone healing process;
    • Enchondral ossification, Callus formation
    • Direct osteonal healing. Non-callus
      • Contact healing
      • Gap healing
introduction2
Introduction
  • Stages of healing
    • 1- hematoma formation
    • 2- inflammatory response
    • 3- reparative phase
    • 4- remodeling
    • Fx. Healing is said to be complete when repopulation of the marrow space occure (months to years )
introduction biomechanics1
Introduction (Biomechanics)

There is always a race between healing and implant failure

Implant failure;

rarely; catastrophic overload

usually; a fatigue failure between bone implant /

implant itself

introduction3
Introduction
  • Endurance limit;

A stress more than one can be borne with infinite number of cycle

introduction4
Introduction
  • Implant construction
    • Load bearing

More stress on the implant and bone-implant

    • Load sharing
slide17

In complex reconstructions with load sharing in spite of incomplete healing progressive failure occures quite late

definition1
Definition
  • Delayed union;
    • A Fx. That has not healed within its expected healing time
    • Can go on

to heal

to non-union

    • Histological
      • Callus formation prominent
      • Interfragmenting tissue consist of fibrous tissue
definition2
Definition
  • Non-union;
    • A Fx. That has not healed without an intrvention
    • Failure to show any progressive changes in radiographic appearance for at least 3 months after expected union period time
    • Repair is not completed in expected period and the cellular activity for healing is ceased
    • Union is not achieved in 6-8 months
classification
Classification
  • Weber and Czech
    • Hypertrophic, viable
      • Elephant foot
      • Horse hoof
      • oligotrophic
    • Atrophic, non viable
      • Torsion wedge
      • Comminuted
      • Defect
    • Pseudoarthrosis
classification1
Classification
  • Weber and Czech
    • Hypertrophic, viable
      • Elephant foot
      • Horse hoof
      • oligotrophic
    • Atrophic, non viable
      • Torsion wedge
      • Comminuted
      • Defect
    • Pseudoarthrosis
classification2
Classification
  • Weber and Czech
    • Hypertrophic, viable
      • Elephant foot
      • Horse hoof
      • oligotrophic
    • Atrophic, non viable
      • Torsion wedge
      • Comminuted
      • Defect
    • Pseudoarthrosis
classification3
Classification
  • Weber and Czech
    • Hypertrophic, viable
      • Elephant foot
      • Horse hoof
      • oligotrophic
    • Atrophic, non viable
      • Torsion wedge
      • Comminuted
      • Defect
    • Pseudoarthrosis
classification4
Classification
  • Paley and Herzenberg
    • Stiff (<5 degrees mobility)
    • Partially mobile (5-20 degrees)
    • flail (>20 degrees)
classification5
Classification
  • Paley and Herzenberg
    • Stiff (<5 degrees mobility)
    • Partially mobile (5-20 degrees)
    • flail (>20 degrees)
classification6
Classification
  • Kamrani, himself
    • Clinically silent, Natural history silent
    • Clinically silent, Natural history progressive
    • Clinically obvious, treatment is curative
    • Clinically obvious, treatment is more hazardous
classification7
Classification
  • Kamrani, himself
    • Clinically silent, Natural history silent
    • Clinically silent, Natural history progressive
    • Clinically obvious, treatment is curative
    • Clinically obvious, treatment is more hazardous
classification8
Classification
  • Kamrani, himself
    • Clinically silent, Natural history silent
    • Clinically silent, Natural history progressive
    • Clinically obvious, treatment is curative
    • Clinically obvious, treatment is more hazardous
classification9
Classification
  • Kamrani, himself
    • Clinically silent, Natural history silent
    • Clinically silent, Natural history progressive
    • Clinically obvious, treatment is curative
    • Clinically obvious, treatment is more hazardous
classification10
Classification
  • Kamrani, himself
    • Clinically silent, Natural history silent
    • Clinically silent, Natural history progressive
    • Clinically obvious, treatment is curative
    • Clinically obvious, treatment is more hazardous
risk factors
Risk factors

???

  • Severity of local injury
  • Type of bone
    • Cancellous / Cortical
    • Specific bones
  • Radiation
  • Systemic factors
    • Age
    • Illness
    • Hormons
    • Smoking
    • NSAIDs
clinical features of non union diagnosis
Clinical features of non-union (diagnosis)
  • Diagnostic importance
    • Radiologic findings equivocal
    • Radiologic finding is misleading
    • Radiologic drawbacks
      • Direct healing
      • Clinical union prior to radiologic union
clinical features of non union1
Clinical Features of Non-union
  • Pain
  • Motion
  • Function impairment
  • Discomfort
slide42

Pain

    • Rarely acute failure of implant
    • Usually progressive failure
    • Sometimes masked with rigid fixation
    • Pain related to concomitant injury
    • Infected union may be painful
slide44

Motion

    • Subtle
    • Frank
    • Sometimes masked with rigid fixation
slide46

Motion

    • Subtle
    • Frank
    • Sometimes masked with rigid fixation
slide50

Still

diagnosis is not simple in all cases

slide54

Hand and Foot

    • Clinical union before radiologic union
      • Crush injuries
      • Distal phalanx
    • 5th metatars and talus and scaphoid are at risk
slide56

Forearm

    • Non-union rate 2-3%
    • Non-union of one bone
      • Styloid ulna non-union
    • Benefit of non-union
slide65

Femur

    • Incidence ; 2-17%
    • Risk factors
      • Infection
      • Vascular insult
      • Insufficient fixation
      • Distraction
      • NSAIDs
      • Open fracture
slide66

Femur

    • Expected union time
      • 80-200 days in reamed IM nail
    • Definition
      • Lack of progression of healing combined with clinical symptoms of discomfort at minimum of 6 months
slide68

Femoral neck

    • Risk fctor;
      • Primary displacement
    • Union without callus formation
    • Expected union time
      • 3 m for delay union
      • 6 m for nonunion
slide71

Femoral neck

    • Pain after 3 months of fracture
      • AVN
      • Non-union
      • MRI
      • CT Scan
      • Bone scan with pin colometer (85-90% for AVN)
slide72

Tibia

    • The definition of what constitutes a tibial non-union is surprisingly difficult
    • Expected time for closed fractures; 16-19 m
    • Failed to union within 9 months with no progressive changes in radiography for at least 3 months
slide73

Tibia

    • Clinical finding
      • Continuing pain at the Fx. Site
      • Associated with motion and local swelling
      • Confused clinical findings in large reamed IM nail
      • Infected union is symptomatic
mal union
Mal-union
  • Classification; Kamrani himself
    • Clinically silent, Natural history silent
    • Clinically silent, Natural history progressive
    • Clinically obvious, Natural history progressive
    • Clinically obvious, Natural history silent
mal union1
Mal-union
  • Classification; Kamrani himself
    • Clinically silent, Natural history silent
    • Clinically silent, Natural history progressive
    • Clinically obvious, Natural history progressive
    • Clinically obvious, Natural history silent
mal union2
Mal-union
  • Classification; Kamrani himself
    • Clinically silent, Natural history silent
    • Clinically silent, Natural history progressive
    • Clinically obvious, Natural history progressive
    • Clinically obvious, Natural history silent

Humerus

mal union3
Mal-union
  • Classification; Kamrani himself
    • Clinically silent, Natural history silent
    • Clinically silent, Natural history progressive
    • Clinically obvious, Natural history progressive
    • Clinically obvious, Natural history silent

Scaphoid

mal union4
Mal-union
  • Classification; Kamrani himself
    • Clinically silent, Natural history silent
    • Clinically silent, Natural history progressive
    • Clinically obvious, Natural history progressive
    • Clinically obvious, Natural history silent

Superamalleolar

mal union5
Mal-union
  • Classification; Kamrani himself
    • Clinically silent, Natural history silent
    • Clinically silent, Natural history progressive
    • Clinically obvious, Natural history progressive
    • Clinically obvious, Natural history silent

Cubitus varus