Delayed Union and Non Union

Gopisankar.M.G.

2008 MBBS

Nonunion

When a minimum of 9 months has elapsed since the injury

&

The fracture shows no radiologically visible progressive

signs of healing continuously for 3 months

Classification

Paley’s Classification

Muller and Weber’s Classification

Paley’s Classification

Type A Bone loss <1cm

Type B Bone loss >1cm

Muller & Weber’s classification

Amount of callus at the fracture site

1. Hypervascular Nonunion

2. Avascular Nonunion

Hypervascular

1. Hypertrophic/Elephant foot

2. Horse hoof

3. Oligotrophic

Avascular

1. Torsion Wedge

2. Comminuted

3. Defect

4. Atrophic

Causes of nonunion

Compound fractures

Infection

Segmental fractures

Distraction of fracture fragments

Soft tissue interposition

Ill devised open reduction

Insecure and inadequate fixation

Clinical features

History

1. Trauma resulting in fractures

2. Open fractures

3. Improper / delay / inadequate treatment

Symptoms

1. Minimal / no pain

2. Loss of function

Signs

1. Painless abnormal mobility

2. Shortening

3. Scars

4. Sinuses

5. Deformity

6. Wasting of limb muscles

Investigations

X-ray AP and Lateral view

1. Gap between fracture fragments

2. Fragments are rounded and sclerotic

3. Amount of callus formed could be less or more

4. Decreased density of bone is due to osteoporosis

Management

Surgery

1. Open reduction

2. Rigid internal fixation

3. Bone grafting

Electrical stimulation

Ilizarov’s technique

Bone Graft

Promotes Osteogenesis ,provide stability

Types

1. Cancellous Bone Graft

2. Cortical Bone Graft

3. Phemister Bone Graft

Cancellous bone Graft

In defects < 2.5cm

Better tolerated

Rapidly revascularized

Cortical Bone Graft

Fixation + Osteogenesis

Stabilizing property

For nonunion of shafts of any long bones

Single only when placed on one surface

Dual only when it is placed on both sides

Sliding graft piece is sided from above to the fracture

Phemister bone graft

Graft is placed subperiosteally

Blood supply is not disturbed

Simple

Placed posteriorly

Useful in tibia

Electrical stimulation in Nonunion

20 mA

Fibrous tissue fibrocartilage endochondral ossification

Types

1. Noninvasive

2. Semi invasive

3. Invasive

Pulsed Electromagnetic field after excision of fibrous tissue followed by grafting

Immobilization is done to decrease stress

Slow not always successful

Ilizarov’s technique

Best for infected nonunions

Corrects deformity + boneloss

In hypertrophic gradual compression

Avascular corticotomy , Bone transport and compression