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FRACTURES-Nonunion-Diagnosis-And-Management-At-Shaheed-Suhrawardy-Medical-College-Hospital-Dhaka-Bangladesh.ppt

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FRACTURES-Nonunion-Diagnosis-And-Management-At-Shaheed-Suhrawardy-Medical-College-Hospital-Dhaka-Bangladesh.ppt Powered By Docstoc
					From -
o Definition
o Types
o Causes of non-union
o Diagnosis of non-union
o Management/Treatment.

                           3
4
5
6
(Current)




            7
(Based on blood supply)




                          8
Hypertrophic
(elephant foot)




                  Hypertrophic
                  (horse hoof)

                                 Oligotrophic
                                 or atrophic
                                          9
10
11
12
Causes of Non unions




                       13
Etiology of Nonunion:




                        14
              Etiology of Nonunion

Etiology of
Nonunion:
(Systemic)




                                     15
                  Etiology of Nonunion




Etiology of
Nonunion
(Local Factors)




                                         16
                  Etiology of Nonunion

                  Local Risk Factors-
Etiology of
Nonunion
(Local Factors)




                                        17
                  Etiology of Nonunion

Etiology of
Nonunion
(Local Factors)




                                         18
                  Etiology of Nonunion
                  Traumatic Soft Tissue Disruption

                  1. During initial trauma
Etiology of       2. Iatrogenic
Nonunion
(Local Factors)




                                                     19
Etiology of
Nonunion
                   Etiology of Nonunion
(Local Factors)


     2         3

 1



           4       5

                                          20
                  Etiology of Nonunion



Etiology of
Nonunion
(Local Factors)



                                         21
                  Etiology of Nonunion
Etiology of
Nonunion
(Local Factors)




                                         22
 Diagnosis of Nonunion-
 History

• Painless abnormal movement at
  fracture site
• Pain present at fracture site, but in
  established non union it is pain free.
• Symptoms of infection
• In ability to bear weight.



                                       23
                   Examination


Diagnosis of
               •   Abnormal movements
Nonunion-
               •   Deformity
               •   Evidence of infection
               •   Soft tissue abnormality? (scar,
                   atrophied skin, pigmentation etc)
                                                24
                  Investigations-
                  General:
Diagnosis of
                   Blood count
Nonunion-
Investigations:
                   Biopsy
                   FNAC
                   Wound swab/ pus C/S
                  Specific:
                  • Radiologic Evaluation
                  • Radionuclide Scanning
                  • CT scan
                  • MRI
                                            25
                              Investigations-
                              Radiologic Evaluation
Diagnosis of
Nonunion-
                            • Standard radiographs are often
Investigations: Specific-
                              diagnostic
                            • 45 degree oblique films can increase
                              diagnostic accuracy
                            • Despite additional projections, the
                              potential for false-positive results for
                              fracture healing remains

                                                                         26
                              X-Ray and Imaging
Diagnosis of                • Usually a plain X-Rays is adequate for
Nonunion-
Investigations: Specific-
                              diagnosis of Non Union.
                            • But rarely stress X-ray, CT scans and
                              MRI is required.




                                                                27
                                                  Valgus
Diagnosis of
Nonunion-                             Varus
Investigations: Specific-




                Clinical diagnosis can be confirmed
                and information about stability
                obtained with stress radiographs.

                                                      28
                    Radionuclide Scanning
                  • Technetium - 99 diphosphonate
                     • Detects repairable process in bone (
Diagnosis of
Nonunion-
                       not specific)
Investigations:   • Gallium - 67 citrate
                     • Accumulate at site of inflammation
Specific-
                       (not specific)
                  • Sequential technetium or gallium
                    scintigraphy
                     • Only 50-60% accuracy in subclinical
                       ostoemyelitis
                                                          29
                  CT scan
Diagnosis of
Nonunion-
Investigations:
Specific-




                            30
                  CT scan

Diagnosis of
Nonunion-
Investigations:
Specific-




                            31
Diagnosis of
Nonunion-
Investigations:
Specific-



          MRI




                  32
Management/
Treatment-

•Non-
operative
•Operative    33
             Non-operative-
            BMP (Bone morphogenic protein
Treatment    injection)
            Bone marrow injection
            Ultrasound
            Electric stimulation
            Low Level Laser Therapy.
             But in established non union, non operative
             method rarely helpful.                   34
               Surgical Treatment-
            A. Hypertrophied non inions unite with
Treatment      good adequate fixation (intramedulary
               nails, Locking plates or DCP and
               different types of wiring), may not
               require bone graft.
            B. Atrophied non union always needs bone
               graft with adequate fixation.
            C. Gap non union needs vascularised fibula
               graft or bone transportation /
               lengthening.
            D. Infected nonunion needs special
               combined effort.                    35
              Infected Non-unions
            • Contaminated implants and devitalized
              implants must be removed
Treatment   • Infection treated:
Infected       • Temporary stabilization (external
nonunion
                 fixation)
               • Culture specific antibiotics
               • +/- local antibiotic delivery (antibiotic
                 beads)
            • Secondary stabilization with
              augmentation of osteogenesis (cancellous
              grafting)                               36
                        Bone Grafting-
Treatment
Atrophied non union   • Osteoinductive - contain proteins
                        or chemotactic factors that attract
                        vascular ingrowths and healing
                         • i.e.. dematerialized bone matrix
                           & BMP’s
                      • Osteoconductive - contains a
                        scaffolding for which new bone
                        growth can occur
                        • i.e. allograft bone, calcium hydroxyapatite
                                                                37
Treatment     Bone Grafting-
Atrophied
non union
            • Used to stimulate biologic
              response of healing in
              nonunion (usually atrophic
              nonunion)
            • Also used to fill defects in
              fracture zone
              i.e. up to 6 cm intercalary defects of
                 long bones)

              Bosse, MJ e.t.al. JBJS 1989              38
              Autogenous Cancellous Bone
            • Sites
               Posterior Iliac Crest (20 cc)
               Anterior Iliac Crest (10cc)
Treatment
Atrophied      Proximal Tibia (7cc)
non union      Distal Radius, Calcaneus, Olecronon (?).
            • All series suggest some incidence of donor
              morbidity dependent upon harvest site and
              volume required.
            • Still considered by many to be the most
              osteogenic graft material.

                                                           39
Treatment
Hypertrophied     Locking Plate
non inions
                  Technology

                • Will give better fixation in
                  pathologic bone
                • Most likely will prevent early
                  failure
                  (Occasionally seen with traditional
                  compression plating techniques 40 )
Treatment
Hypertrophied     Traumatic Bone Loss-
non inions
                • Reconstructive     planning    and
                  intervention should begin prior to
                  meeting the time requirements for
                  nonunion
                • Options
                  Distraction osteogenesis
                  Vascularized bone graft
                  with Iliac crest bone grafting
                                                   41
                Intra-medullary Nailing-
Treatment • Mechanically stabilizes long bone nonunion as a load
Hypertrophied   sharing implant
non inions
              • Corrects mal-alignment
              • Reaming is initially detrimental to intra-medullary
                blood supply, but it does recover and is believed to
                stimulate biologic healing at fracture
              • Allow patient to mobilize surrounding joints and
                dynamize fracture environment.
                                                                42
                 Intra-medullary Nailing
Treatment
Hypertrophied
                • Can be performed without direct
non inions        exposure or dissection of the
                  fracture soft tissue envelope
                • Non-applicable in articular
                  fractures.

                                              43

				
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