Clinical Features of Mal-union and Non-union

2. Clinical Features of Mal-union and Non-union Reza Sh. Kamrani M.D. TUMS POTA refreshment symposium 20/1/88

3. Clinical Features of Non-union • Pain • Motion • Function impairment

4. Clinical importance of Clinical findings • Definition • Diagnosis • Classification • Treatment

5. Introduction Bone has a remarkable capacity of healing (regeneration)

6. Introduction UNION Monitoring Radiologically and Clinically Biology and Biomechanics of healing and fixation is very important to monitor healing

7. Introduction (Biology)

8. Introduction (Biology) • Bone healing process; • Enchondral ossification, Callus formation • Direct osteonal healing. Non-callus • Contact healing • Gap healing

10. Callus

11. 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 )

12. Introduction (Biomechanics)

13. 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

14. Introduction • Endurance limit; A stress more than one can be borne with infinite number of cycle

15. Introduction • Implant construction • Load bearing More stress on the implant and bone-implant • Load sharing

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

19. Definition

20. 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

26. 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

27. Classification • Weber and Czech • Hypertrophic, viable • Elephant foot • Horse hoof • oligotrophic • Atrophic, non viable • Torsion wedge • Comminuted • Defect • Pseudoarthrosis

28. Classification • Weber and Czech • Hypertrophic, viable • Elephant foot • Horse hoof • oligotrophic • Atrophic, non viable • Torsion wedge • Comminuted • Defect • Pseudoarthrosis

29. Classification • Weber and Czech • Hypertrophic, viable • Elephant foot • Horse hoof • oligotrophic • Atrophic, non viable • Torsion wedge • Comminuted • Defect • Pseudoarthrosis

30. Classification • Weber and Czech • Hypertrophic, viable • Elephant foot • Horse hoof • oligotrophic • Atrophic, non viable • Torsion wedge • Comminuted • Defect • Pseudoarthrosis

32. Classification • Paley and Herzenberg • Stiff (<5 degrees mobility) • Partially mobile (5-20 degrees) • flail (>20 degrees)

33. Classification • Paley and Herzenberg • Stiff (<5 degrees mobility) • Partially mobile (5-20 degrees) • flail (>20 degrees)

34. Classification • Kamrani, himself • Clinically silent, Natural history silent • Clinically silent, Natural history progressive • Clinically obvious, treatment is curative • Clinically obvious, treatment is more hazardous

35. Classification • Kamrani, himself • Clinically silent, Natural history silent • Clinically silent, Natural history progressive • Clinically obvious, treatment is curative • Clinically obvious, treatment is more hazardous

36. Classification • Kamrani, himself • Clinically silent, Natural history silent • Clinically silent, Natural history progressive • Clinically obvious, treatment is curative • Clinically obvious, treatment is more hazardous

37. Classification • Kamrani, himself • Clinically silent, Natural history silent • Clinically silent, Natural history progressive • Clinically obvious, treatment is curative • Clinically obvious, treatment is more hazardous

38. Classification • Kamrani, himself • Clinically silent, Natural history silent • Clinically silent, Natural history progressive • Clinically obvious, treatment is curative • Clinically obvious, treatment is more hazardous

39. Risk factors ??? • Severity of local injury • Type of bone • Cancellous / Cortical • Specific bones • Radiation • Systemic factors • Age • Illness • Hormons • Smoking • NSAIDs

40. 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

41. Clinical Features of Non-union • Pain • Motion • Function impairment • Discomfort

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

44. Motion • Subtle • Frank • Sometimes masked with rigid fixation

46. Motion • Subtle • Frank • Sometimes masked with rigid fixation

47. Functional impairment • Discomfort

50. Still diagnosis is not simple in all cases