NON UNIONPRESENTER-Dr RAVI VARMA V NMODERATOR-Dr RAVI KIRANJSS MEDICAL COLLEGE

DEFINITIONUS FDA PANEL DEFINED NON UNION AS

“when a minimum of 9 months has elapsed since injury with no visible healing progressive signs for 3 months”.

•On a cellular level, nonunion occurs when there is cessation of a reparative process antecedent to bony union Practically,Nonunion occurs when a fracture has failed to heal in the expected time and is not likely to heal without new intervention Diagnosing involves Both radiological and clinical criteria

Causes

Diabetes53%

Vasculopathy59%

Smoking81%

Host factors

1. Smoking-81%

Directly inhibit osteoblasts early stages of fracturehealing

Inhibits expression of BMP

vasoconstriction

inhibit tissue differentiation

normal angio- genic

responses

1. Diabetes -59% • In early stages-Decreased cellular proliferation • Decreased callus strength at the later phases

• Most importantly diabetes increases the chance of infection as it is a hyperglycemic state

alterations in bone

metabolism

microvascular

disease

neuropathy immunocompetence

Nonsteroidal Anti-Inflammatory Drugs

Prostaglandins are inflammatory mediators present during the initial phases of fracture healing

Selective cox 2 and NSAIDS interfere with PG’s synthesis inhibiting cox

Yet the issue is controversial and better to avoid NSAIDS in fracture management

Other host factors• Age • gender, nutritional status, bone quality, endocrine disorders, fracture

energy, location and pattern, associated injuries, • Bisphosphonates- increased incidence of stress fractures and affect

union of the same• Chronic health conditions• Steroids• Rheumatoid immunosupression• Malignancy

Treatment factors• Mechanical stability – difficult to define and quantify• In nature, fractures can heal without stabilization, but stabilization can

reduce the risk of nonunion • Medical practice has similarly evolved to understand that fractures

heal more reliably when immobilized • Most fractures heal with the relatively limited stability provided by

splint or cast immobilization –[secondary]• Rigid internal fixation, represents the opposite end of the stability

spectrum associated with fracture care – [primary] relatively unnatural, yet successful, strategy.

• Irrespectively -improper technique can lead to an increased risk of nonunion

1. Improperly applied splint or cast, lipomatous extremity2. Rigid fixation without bone to bone contactIt is often difficult to predict the fracture healing response to excessive motion, as either abundant callus or a paucity of callus may result

PARREN ‘S THEORY of interfragmentary strain S M/GS-strainM-motionG-gap

It is defined as “the ratio of relative displacement of fracture ends versus initial fracture gap width”.It relates the tissue response to the local mechanical environmentStrain is the deformation of a material when a given force is applied.

• ε=d/G where ε-the inter-fragmentary strain, d-fracture ends displacement, & G– gap between ends.

• ε=d/G≤2%        >Bone formation• ε=d/G≤10%      >Fibrocartilage• ε=d/G≤100%    >Granulation tissue• ε=d/G>100%    >No tissue formation• Disadvantages of the Theory:

1. Oversimplified theory2. Only Longitudinal Strain is considered3. Multidirectional principal strains are not even considered.

• Strain is the deformation of a material when a given force is applied. • Normal strain is the change in length (Δ l) in comparison to original length

(l)when a given load is applied. • Intact bone has a normal strain tolerance of 2% (before it fractures),

whereas granulation tissue has a strain tolerance of 100%. • Bony bridging between the distal and proximal callus can only occur when

local strain (ie, deformation) is less than the forming woven bone can tolerate. Thus, hard callus will not bridge a fracture gap when the movement between the fracture ends is too great .

• Nature deals with this problem by expanding the volume of soft callus. This results in a decrease in the local tissue strain to a level that allows bony bridging.

• This adaptive mechanism is not effective when the fracture gap has been considerably narrowed so that most of the interfragmentary movement occurs at the gap, producing a high-strain environment. Thus, overloading of the fracture with too much interfragmentary movement later in the healing process is not well tolerated

• Interfragmentary movement stimulates the formation of a callus and accelerates healing . As the callus matures, it becomes stiffer, reducing the interfragmentary movement sufficiently, so that bridging by hard bony callus can occur.

• If the interfragmentary strain is excessive (instability), or the fracture gap is too wide, bony bridging by hard callus is not obtained in spite of good callus formation, and a hypertrophic nonunion develops [25].

• Callus formation requires some mechanical stimulation and will not take place when the strain is too low. A low-strain environment will be produced if the fixation device is too stiff, or if the fracture gap is too wide [22]. Delayed healing and nonunion will result.

• The same deforming force produces more strain at the site of a simple fracture than at that of a multifragmentary fracture.

Biological environment• The damaged bone has a reduced inherent capacity to form new bone

and the damaged soft tissues have a reduced ability to stimulate the reparative process

• Whereas modern surgical techniques emphasize biologically friendly tissue handling,

Biological failure -The main causes arei.Distraction at the fracture siteii.Soft - tissue interpositioniii.Bone loss at the time of fractureiv.Infection from an open fracturev.Damage to blood supply of fracture fragments

vi.Pathological fracture

INFECTION• The inflammatory process in response to infection may inhibit fracture

healing by causing excessive remodeling and osteolysis • Loose nonvital bone fragments - sequestra• Infection not only predisposes to nonunion, but makes nonunion repair

substantially more complex

Summary • The involved bone and the specific location of the fracture within any

given bone influence the innate ability for fracture healing. • The characteristics of the original injury, • The patient’s ability (or inability) to generate a normal healing response

to the particular injury, • The mechanical and biologic environment created by the chosen

treatment method, • The presence or absence of associated infection • Are among the factors that can influence the rate and the likelihood of

uncomplicated and timely fracture healing.

Classification of Non-union:Judet Muller Weber, Cech Classification:1. Hypertrophic

Hypertrophic

2. Atrophic

Elephant foot Non-

union

Horse Hoof Non-union

Oligotrophic Non-union

• Atrophic:

Torsion Wedge

Non-union

Comminuted

Non-unionGap

Non-union

Atrophic Non-union

Dror Paley et at Classification:A- Bone loss < 1cm B- Bone loss > 1cm

A1 A2.1 A2.2 B1 B2 B3A1 - LaxA2. - StiffA2.1 - No DeformityA2.2 - With fixed deformity

B1- Bone gap without shorteningB2- No Bone gap with shorteningB3- Bone gap with shortening

PSEUDOARTHROSIS• Sub-classification of nonunion .• Because of excessive and chronic motion, an actual synovial

pseudocapsule is formed, containing fluid much like an actual synovial joint .

DIAGNOSIS• the diagnosis of a nonunion may be one of inclusion or exclusion • In usual clinical practice, the information gathered from many

modalities, such as history, physical examination, radiographs, and other special tests is used in concert to determine the presence or absence of fracture union

RADIOGRAPHY• Plain radiographs are used ubiquitously in the evaluation • circumferential bridging, as evidenced by bridging across four cortices

on orthogonal x-rays• radiograph and fracture are coplanar. • Serial Radiological Assessment is necessary.

• Stress radiograph gives the status of stability of the fixation.

• Scoring systems - Radiographic Union Score for Tibia Fractures (RUST)

• lack of union may be directly or indirectly evident.• Direct- Direct evidence is a fracture gap seen on a radiograph taken coplanar with the fracture • Indirect- Progressively loosened or broken implants indicate persistent motion at the fracture

• Ct scan- can be reformatted in high quality in any plane -to evaluate potential absence of bridging bone

• Highly sensitive but less specific

• Nuclear imaging-(Tc-99m) bone scintigraphy can be used to help diagnose nonunion yet non specific

• psseudoarthrosis where a cleft between two intense areas• SPECT is used in evaluating vital and avital even infected nonunions

Non operative treatment

LIPUS

TREATMENTOBJECTIVES1. Healing of fracture2. Correction of deformity3. Mobilization of adjacent stiff joints4. Complete eradication of infection

The common requirements to all successful techniques are reduction and firm stabilization with or without bone grafting

Timing of operative treatment• Difficulty in establishing the optimal time to intervene surgically in the

treatment of a nonunion parallels the difficulty in the diagnosis of a nonunion

• Once diagnosed can be interevened• however, if a future nonunion can be accurately predicted at an early

stage then interevened early

Treatment of uninfected non union1. First step to classify and decide on type2. Soft tissue consideration-look for skin condition,neurovascular injuryGoals• Good reduction• Stable fixation• Stimulation of bone healing

• The methodology-1.Clinical examination to check for stiffness/ mobility.

2.Radiograph of the affected part to check for the following:• Bone gap• Shortening• Nature of fragments whether transverse or oblique• To locate the nonunion site whether it is near to joint or

away from the joint.

Reducing the fragments• Fibrous tissue between the fragments- If in good allignment-retain periosteum, callus and fibrous tissue stabilize and graftIf displaced –using external fixator correct deformity, secondary plating or nailing may be plannedAlso ilozarov frame is used –to restore length,appose fragments and stabilize till unionPlating if planned – scar tissue excisedmeduallry canal opened Nailing is preferred for diaphyseal nonunionBut mataphyseal region plating will be the best option

Treatment of hypertrophic non union• As its vital non union –increasing stability alone will achieve union1. Intramedullary nailing> plating2. Ilizarov-distraction alone gives result and deformities also can be

corrected

Treatment of atrophic non union• Avital ,hence the intervening fibrous tissue with avascular bony ends

are resected to get punctuate bleeding, bone grafting might me useful

• plate with compression and bone graft • Nailing-reaming will additionally add bone graft at fracture site• If ilizarov –Initial compression and ditractioncorticotomy and bone transport are usually necessary

• Articular nonunions are relatively uncommon.• A potential causative factor is inadequate compression of the articular fracture

gap leading to prolonged exposure of the fracture surfaces to synovial fluid.• These nonunions are therefore commonly oligotrophic and amenable to

compression techniques.• As with any articular fracture, the goals of articular nonunion treatment include • restoration of articular congruity,• recreation of proper limb alignment,• maximization of joint function,• minimization of pain.• When these goals cannot be accomplished with non- union repair, joint

arthroplasty becomes a relatively attractive option, resection arthroplasty or arthrodesis become considerations.

Metaphyseal articular non union

Metaphyseal articular non union• Most difficult• The small articular fragment are porotic and displaced• The joint is stiff secondary to adhesions ,muscle contracture and

malalignment• Pseudoarthrosis as the neighbouring joint is stiff• Treatment- stiff joint to be mobilized in OT joint is opened and capsulectomy arthrolysis-releasing adhesons and synovium loose fragments and bodies removed adjacent muscles are also released

• Treatment of synovial pseudoarthrosis-follows methodology of atrophic non union,

debridement of the pseudoarthrosis, opening of the medullary canal, and enhancement of stability, typically with compression at the nonunion site

• Treatment of oligotrophic non union- where its intermediate vascularityusually manifest minimal radiographic healing reac- tion (callus),

combination of biologic and mechanical method

Soft tissue management with non unions• The soft tissues about nonunions are compromised by the original

injury or subsequent surgeries • If operative treatment is planned, it may be necessary to acquire soft

tissue coverage with local, rotational, or free tissue flaps prior to successful nonunion repair

• Most important with infected non union after 3 to 4 debridements and infection controlled flaps planned

• Another successful strategy is primary shortening during nonunion repair, followed by secondary lengthening after union

• ilizarov is used extensively in the management

Operative techniques• Exchange nailing, • Nail dynamization, • Plate osteosynthesis, • Ilizarov circular external fixation, and external bone stimulation for a

mid-diaphyseal tibial nonunion Planned with consideration of the integrity of the soft tissue envelope, the degree of bone loss, and coexisting conditions Nonunion in the face of associated infection makes repair with plates less, and external fixation more attractive

Plates and screws• Nonunion repair with plate and screw constructs is applicable to most

anatomic locations ,repair of diaphyseal as well as end segment nonunions Advantages• Ability to address angular, rotational, and translational deformities, • With minor technical modifications the ability to manage periprosthetic

nonunions • Powerful method that can be used successfully for any class of nonunion

(i.e., atrophic or hypertrophic)

• DisadvantagesCannot be used with soft tissue compromiseInfectionAs it’s a load bearing device cannot weight bear early

I M NAILING• Three forms: primary nailing of a nonunion in the absence of a pre-

existing nail, exchange nailing, and dynamization. • Most applicable to diaphyseal nonunions Primary nailing.

EXCHANGE NAILING• Where deficiencies of the pre-existing nail can be overcome with a

new, larger reamed nail • Deficiencies include lack of rotational and stability with undersized

nail• The reaming associated with an exchange nailing procedure can

deposit small amounts of local bone graft and can stimulate an inflammatory response

• When considering exchange nailing for the tibia, an associated fibular osteotomy to allow fracture compression during repair has been considered an integral part of the procedure

• Cannot be used in bone loss and angular deformities

Dynamization.

• Practice of removing interlocking screws at one end of a nail to allow axial shortening with weight bearing

• Usually just a few millimeters

External Fixation for Nonunion Treatment

• Relative paucity of soft tissue trauma• Correction of deformities• In failed plate fixation• Fine tune correction and the potential for early weight bearing.• Oppurtunity to address soft tissue coverage • Computer-guided treatment with the Taylor Spatial Frame is a recent

advance , six axes of deformity can simultaneously and accurately be corrected

Ilizarov • Stiff nonunions have inherent biologic activity and therefore usually

do not require a bone graft and respond favorably to closed external fixation methods that utilize compression, distraction, or a combination of both

• Before distraction, a short period of compression, typically 7 to 14 days, may be helpful to “prime” the site for the osteogenic process

• Treatment of mobile nonunions with ring fixators usually requires opening the nonunion site to surgically convert the nonviable atrophic nonunion to fresh viable bone ends,

• Perform a corticotomy of the involved bone at a site surrounded by healthy soft tissues followed by transport of the intercalary segment to eventually achieve healing by compression at the nonunion and regenerate formation at the corticotomy site

problems• Pin site infection• Costly • Cumbersome

Arthroplasty for Nonunion Treatment

• There are limited circumstances that make total joint arthroplasty or hemiarthroplasty a viable option.

• Minimum requirement is nonunion in a periarticular location , that can accommodate the bone resection.

• In the elderly, especially with associated joint arthrosis, which may be in the form of pre-existing arthritis, post-traumatic arthritis, joint destruction from prior implants, or osteonecrosis, arthroplasty is preferred.

• Physiologically younger patients, arthroplasty becomes less advantageous because of limited longevity of the implants.

• Active infection at the site of nonunion is a contraindication to arthroplasty.

Amputation for Nonunion Treatment

• Amputation as definitive treatment for nonunions is often dictated by associated comorbid conditions and by patient preference rather than a technical inability to eventually achieve union.

• Psychological and psychosocial factors specific to each individual patient are important to recognize, discuss, and consider before pursuing shared decision making for amputation

Arthrodesis for Nonunion Treatment

• Arthrodesis is sometimes indicated for the management of peri- articular nonunions.

• The choice of arthrodesis is typically one of last resort • Nonreconstructable periarticular nonunions without good arthroplasty

options that can accommodate bone defects (e.g., ankle),• Young patients who are likely to have poor long term success with

arthroplasty, and infected periarticular nonunions, are typical indications for arthrodesis

Fragment Excision and Resection Arthroplasty for Nonunion Treatment • Avulsion fractures of the base of the fifth metatarsal, fractures of the

medial malleolus, the inferior pole of the patella, the greater trochanter of the femur, the ulnar styloid, the olecranon,and the greater tuberosity of the humerus

Osteotomy for Nonunion Treatment

• Osteotomy related to the treatment of nonunions usually serves the purpose to realign the nonunion directly or to allow secondary axial shortening of an adjacent bone

• The ultimate goal of osteotomy is to allow compression at the nonunion site to promote healing

• Prototypical reallignment osteotomy is the Pauwels osteotomy for a femoral neck nonunion

• Fibular osteotomy or partial excision is performed • The level of fibular excision has been suggested to be at a site other

than that of the nonunion

synostosis for Nonunion Treatment • The lower leg > forearm, by virtue of having paired bones, are

amenable to synostosis techniques

ADJUNCTS TO OPERATIVE NONUNION REPAIR

• Autologous > allografts• Properties• Osteogenic a source of vital bone cells

• Osteoinductive recruitment of local mesenchymal cells

• Osteoconductive scaffold for ingrowth of new bone

• The ideal graft substitute for nonunion treatment would be inexpensive, of unlimited supply, easy to prepare and handle, easy to implant, without adverse reactions, and 100% efficacious.

• But none have all

Autogenous graft• Standard graft substance used in the repair of atrophic nonunions,

some oligotrophic nonunions, and some pseudoarthroses .• Cancellous autogenous bone graft supplies osteogenic and

osteoconductive materials .• Recent data also indicate that various growth factors and BMPs are

present in autologous bone graft .• It has been estimated that the limit of defect length that can be filled

using iliac crest bone graft (ICBG) is 5 to 7 cm .• Limiations-limited quantities that can be harvested, variable quality,

and donor site morbidity.

ICBG-iliac crest bone graft• The anterior iliac crest is the most common site .• A number of techniques are available. • Trap door in the crest , from the inner table , or from the outer table. • Structural graft is available in the form of a tricortical wedge from the

crest. • Most commom complications are pain,infection,lateral femoral

cutaneous nerve symptoms ,abdominal herniation etc.

Other sites• Distal femur • Proximal tibia • Distal tibia• Proximal humerus• Olecranon

Reamer–Irrigator–Aspirator

• Autogenous graft can also be harvested using the reamer– irrigator–aspirator (RIA) (Synthes)

• Typically 60 to 80 cm of graft can be harvested

Vascularized Grafts

• Vascularized grafts are most commonly used to treat segmental defects.

• They are advantageous in this situation as they provide a live bone graft that also has structural properties.

• The fibula is the most commonly harvested bone although other sites such as the iliac crest and rib have been used.

Bone Graft substitutes and Other Modifiers of Bone Healing

1. Recombinant Proteins

2. Demineralized Bone Matrix

3. Bone Marrow Aspirate

4. Platelet-Rich Plasma

5. Allograft and Ceramics

BMP’s• Extremely costly• Recombinant human osteogenic protein-1 (rhOP-1), also known as

BMP-7 shows good results either alone are adjunt to auto graft only approved for special cases in USA

• BMP-2 and freeze dried cancellous allograft in the management of diaphyseal tibial shaft fractures with segmental defects. While approved by the US FDA only for the treatment of acute open tibia fractures, spinal fusions and oral facial bone augmentatio

• Demineralized Bone Matrix -DBM contains type I collagen and noncollagenous proteins including osteoinductive growth factors

• Bone Marrow Aspirate -contain osteoprogenitor cells and has osteogenic and osteoinductive properties

• Platelet-Rich Plasma -promote osteoblast proliferation and differentiation. How- ever, to date no clinical evidence exists

• Allograft and Ceramics -primarily osteoconductive and function best as graft extenders or carriers

Managing segmental Bone Loss

• acute bone loss or be related to established nonunions • very challenging problem • Options available are1. Autogenous bone grafting2. Free vascularized fibular bone grafts, 3. Fibula stud grafts4. Bone transport using ilizarov

Autogenous Bone Grafting Using the Masquelet Technique

• primary shortening followed by lengthening is favored • the area of segmental loss is filled with a PMMA cement.

• At 4 to 6 weeks, when an osteogenic membrane has been formed around the cement, the membrane is surgically reopened, the cement is removed, and generous cancellous grafting is carried out

• Recorticalization generally occurs slowly but usually by 3 to 6 months. conjunction with internal stabilization

• In his original article, Masquelet reported successful use of this two-stage technique in 35 cases with defects ranging from 4 to 25 cm in length

Ilizarov Techniques

• Typically involves simple compression or distraction or some combination of compression and distraction at the nonunion site , This is considered a monofocal Ilizarov technique.

• When bone defects are present, corticotomy at an adjacent site followed by distraction osteogenesis through the corticotomy (bone transport) and eventual compression at the nonunion site is a bifocal (distraction-compression) Ilizarov method for management of bone defects.

• Two-level lengthening with compression at the nonunion site is considered trifocal bone transport.

• In the Ilizarov approach, vascularity is increased by corticotomy and appli- cation of a circular external fixator

• Ilizarov method allows simultaneous treatment of all components, • The sequence of correction of complex deformities, include

shorteningrotationangulationtranslation • Ilizarov frame careful preoperative evaluation of deformities allows

assembly of the proper frame

Lengthening over nail• Limb lengthening using Ilizarov external fixation is safe, but the

consolidation phase tends to take too long. • A method that can safely reduce the time spent in external fixation

would help increase patient tolerance and comfort • And reduce external fixation duration in limb lengthening.

Management of Infected Nonunions • One of the greatest problems in orthopaedics as we are dealing with both 1)non union

and 2) infection • Problems associated with long standing non union(by gustilo)1. Most cases,multiple surgeries result in scarring and cicatrization and environment

around becomes avascular2. Sinus tract indicating sequestrum3. Osteomyelitis established-hence deliniation will be difficult for normal bone-bone scan

an MRI useful4. Joint stiffness5. Drug resistsant organisms6. Limb length discrepency7. Deformities8. Infected gap non union

Classification • Rosen et al in ao manual1. Infected non draining nonunion Quiesent Active 2. Infected draining nonunion

Principles of treatment• Healing occurs when decreased bacterial activty,stable

fixation,surrounding environment1. Eradication of infection by radical debridemrnt and local antibiotic

beads or rods 2. Achievement of a vascular or viable environment around 3. Fracture stability4. Adequate soft tissue coverage5. Early and massive bone grafting and repeated if necessary6. Early joint mobilization7. Correction of deformity

Treatment • Radical debridementstabilization skin coverStep 1-radical debridementTo achieve vascular environment around,excision of sinus and dead and infected tissue till active bleeding notedImplant forms a biofilm and becomes difficult to prevent infection,although implant can be retained for stability ,once union is obvious implant removal becomes a must.Bone is resected till punctuate bleeding occurs.Once debridement give stability by external fixator.Reaming can be done to clear intramedullry infectionThorough wash to be given,local antibiotic wash is adviced in some studies Debridement may be repeated

After debridement• Local antibiotic delivery use antibiotic beads or antibiotic coated nail if

necessary• Beads have greater surface area than a spacer • Bioabsorbable bone substitutes that can be impregnated with antibiotics

are osteoconductive, may promote bone healing, and do not necessarily require a second stage procedure for removal.

• Wound is closed or secondary coverage procedures planned• culture-specific parenteral antibiotics to be continued• Continue for 6-8 weeks when infection is minimal and coverage is ideal

go for definitive fixation

Ilizarov • Although infected non- unions

frequently have been successfully treated without debridement, some authors recommend open debridement to remove necrotic and infected segments, followed by bone

• Monofocal compression also is used for infected hypertrophic nonunions with deformity

• For atrophic nonunions with disuse infection or sequestered bone, open resection of the infected segment is performed and bifocal compression is used

• Wu et al reported success with one-stage surgical treatment of infected nonunion of the distal tibia. Twenty- two consecutive patients were successfully managed to union with a protocol of implant removal, intra- and extramedullary debridement, cancellous autograft with antibiotics (vancomycin and gentamycin), and stabilization with an Ilizarov fixator.

• Conclusively every surgeon has a preferred line of management individualizing it to every patient the local environment,the general conditions of the patient,economy and technical expertise

Management of soft Tissue Compromise Associated with Nonunion

• When soft tissues are poor or deficient and free tissue transfer is not possible, primary shortening with an IM rod followed by full weight bearing and an elevated shoe is preferred. Once healing has occurred, the limb can be relengthened if the patient desires with either an internal skeletal distraction nail or the Ilizarov technique

NONUNION OF SPECIFIC BONES

TIBIA • Medial malloelus-closed treatmentnon union1. resection of the distal fragment of the medial malleolus

2. sliding graft

3. bone graft of medial malleolar nonunion

Femoral neck• vascular insuficiency, inaccurate reduction, and loss of fixation • free vascularized fibular bone grafting in nonunions of femoral neck

fractures in patients younger than 50 years old ,highly demanding1. Osteosynthesis 2. Subtrochanteric osteotomy 3. Prosthetic replacement 4. Total hip arthroplasty; 5. Arthrodesis .

osteotomy1. displacement osteotomy (McMurray)-made just proximal to the

lesser tro- chanter2. angulation osteotomy (Schanz)-made through or just distal to the

lesser trochanter • mechanical advantages of an osteotomy are that the line of weight

bearing is shifted medially and that the shearing force at the nonunion is decreased because the fracture surface has become more horizonta 1

Clavicle • Nonunion of clavicular fractures is rare • Despite the lateral clavicular fracture being the most likely to become

a non- union, it is the midshaft clavicular fracture that is the most common fracture site for nonunion secondary to its higher incidence

• most successful is rigid internal fixation, such as plates and screws and bone grafting

Humerus • Proximal humerus-plating or arthroplasty• Humeral shaft-10%-. Gaps may result from distraction, overriding, so

tissue interposition, or loss of bone. Comminuted fractures may have a disrupted blood supply or+if with plates and screws and bone grafting

• Medial epicondyle-goes to fibrous union if conservatively treatedIf ulnar neuritis anterior transposition of ulnar nerve• Lateral epicondyle-Disability from nonunion in the condylar area

usually is caused by nonunion of the lateral condyle cubitus valgus deformity, and instability of the elbow OPEN REDUCTION INTERNAL FIXATION WITH BONE GRAFTING OF THE HUMERAL CONDYLE

Scaphoid non union• Herbert screw with bone grafting•  Four Corner Fusion; • Proximal Row Carpectomy;• vascularized bone-grafting pedicled on 1,2

intercompartmental supraretinacular artery

References

• J. M. Leow et al, The radiographic union scale in tibial (RUST) fractures ,Bone Joint Res 2016;5:116–121.• Paley D, Herzenberg JE, Paremain G, Bhave A. Femoral lengthening

over an intramedullary nail: A matched-case comparison with Ilizarov femoral lengthening. J Bone Joint Surg Am. 1997;79:1464–80.

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