Malunion and Non-union – Mr.

Kamarul

Long Case: mostly lower limb

Difference between Malunion and Non-union?

Malunion Non-union
- Fracture united - Fracture no united
- Weight bearing, can walk - Non weight bearing, cannot walk
- No Pain - No pain

Most exam case are Malunion because patient can walk EXCEPT case of fracture of the upper limb
(humerus), can be both malunion or non-union.

Malunion Types
1. Shortening
2. Angulation
3. Malrotation

Aim:

1. Identify Malunion or Non-union.

2. If patient can walk (Malunion)
– Identify Malunion types (angulation, shortening or malrotation)
3. If limb is Malunited – Identify the level (Femur or Tibia)

History:

Chief Complaint: Deformity of lower limb (80% of case)

Analysis of Chief Complaint:

Malunion or Non-union? What types of Malunion?

How to know whether is Malunion or Non-union?
- Can patient use his limb to walk?
- Can patient weight bear on it?
Malunion:
- Can use his limb to walk.
- Can weight bear on it.
Non-union:
- Cannot weight bear (because fracture is not united, limb is soft)

1. Translation: swelling of one side of leg

2. Bowing of the limb?/ angulation
- Inward bowing (varus deformity) – “kaki bengkok ke dalam”
- Outward bowing (valgus deformity) – “kaki bengkok ke luar”

3. Shortening of the limb?

- Shortening on right side – “kaki pendek kanan”
- Shortening on left side – “kaki pendek kiri”

4. Malrotation?
 - Is foot in same position or not when walking?
- If patient complaint of one side of the foot is externally rotated or internally rotated, then
must problem with malrotation.
- Ask patient about the position of foot when walking, is it “pusing keluar” or “pusing ke
dalam”

Malunion do not have pain at leg but usually pain occurred due to complication of malunion.

Common site of complication pain in malunion?

1. Low back pain (but no need to list out all the causative factor of low back pain in history
because the problems is not at the lower back. It is due to alignment of the knee)
2. Secondary Osteoarthritis in knee

Rest of the history just add on:

- Is there history of fracture (open fracture)?
- Is there history of trauma?
- Long antibiotic treatment
- History of infection
- Recurrent admission to hospital

Examination:
Inspection, palpation, movement, special test & measurement.

Exposure:
- Malunion in Lower Limb: umbilicus and below
- Malunion in humerus: umbilicus and above

Inspection:
Walking
Aim: identify shortening, angulation or malrotation?
• Shortening:
- Shoulder: Shoulder is tilted to one side & short limb gait.
• Malrotation: foot is externally or internally rotated?
- Position of foot: Foot progression angle opened out gradually during walking
(initially 10°, then 20°, 30°, 40°) because as you walk along, the angle of rotation of foot is
around 30° – 40°) usually will be same on both side
If patient having malrotation: initially will be normal but as patient walk, the abnormal site
will be externally rotated.
• Angulation:
- Ask patient to stand
- Bring the foot together
- See for any gaps
Gap at knee: Varus deformity of lower limb
Gap at foot: Valgus deformity of lower limb
- Measure in both standing and supine like for Osteoarthritis
• Translation: Swelling: thigh or leg
Squat:
- not required in malunion & sport injury case
- required in low back pain (lower limb muscle power) & osteoarthritis (look for stiffness)

Supine Position:
General Inspection (head to toe)
Specific Inspection: cannot detect rotation
1. Shortening of Lower Limb + Varus or Valgus deformity
Go to the foot, bring the foot together, dorsiflex (4 fingers at the dorsum of the foot and
thumb is at the plantar of the foot. Then, push the foot with thumb), look at any shortening
at heel region from top, any gapping between two knees (Varus deformity), any gapping
between two ankles (Valgus deformity). If Varus or Valgus deformity is present, measure the
gapping.
Comment:
- If there is shortening around 2cm on right or left side (no need to measure, just estimate),
you just tell the examiner there is a shortening around 2cm on the right side or left side.
- Then, comment on varus or valgus deformity on the lower limb.
- If Varus deformity, u tell the examiner because there is a gap in between the two knees
measuring about 6 cm or 8 cm (roughly)
- If Valgus deformity, u tell the examiner because there is a gap in between two ankles
measuring about 3 cm or 4 cm (roughly)

2. Muscle Atrophy + Scars + Effusion (knee)

Go to the knee, see the Vastus Medialis Obliquus for any muscle atrophy, scars, Medial
parapatellar gutter, see Gastronemius (medial) & Peroneus muscle (lateral) atrophy.
Scar:
- Surgical scar (Linear + Stitch line)
- Open wound scar (Irregular + sign of contracture)

***If you are fast enough, when you see Vastus Medialis Obliquus atrophy.
You can measure the thigh circumference. If not atrophy, no need to measure.
Thigh circumference: 15cm proximal to the superior pole of the patella
Calf muscle circumference: 10cm distal to tibial tuberosity

Palpation:
Superficial Palpation
• Temperature (should not have raised T)
Palpate temperature on the both sides using dorsum aspect of hand for thigh, knee & leg.
(all together 6 regions)
• Soft Tissue
Palpate for Vastus Medialis Obliquus, Gastronemius & Peroneus muscle. (Grip the muscles
and see if got any soft muscle)
Deep Palpation
Aim:
• Aim of Deep palpation in Scoliosis case, is to determine the Direction of Convexity.
• Aim of Deep palpation in Malunion case, is to determine the Direction of Angulation (varus
or valgus), (Mal-Union) & Gapping (Non-Union)
How to palpate the tibia?
• Tibia
- Deep palpation of Tibia is similar like the deep palpation of the knee,
- Flex patient’s knee, sit on patient’s foots, make sure patient is relax and start palpating
using your thumb along the shin of the tibia.
- Palpate the whole length pf tibia from proximal to distal

Identify the direction of Angulation (Mal-Union)

- When palpating the shin of the tibia (mark it with a pen and draw an imaginary line).
- So that, you know in which direction the angulation is.
- Is the angulation in the Femur or in the tibia?
- If in the tibia, is it Varus or Valgus deformity?

Identify any gapping at the site of Angulation (Non-Union)

- When palpating the tibia, identify is there any gapping or not when palpate toward the site
of angulation.
- If gapping present (because of the fracture site is not united yet), diagnosis is non-union
even though patient able to weight bear.
- In most of the case, there will be no gapping but you still need to tell the examiner
“there is no gapping at the site of angulation”.
- So that, examiner know that the student trying to rule out Non-Union.

How to palpate the femur?

• Femur
- Where is most subcutaneous part of the femur? Lateral or Medial? (Lateral)
- Lateral one is the one you need to palpate to look for angulation of the femur.
- Then, you need to locate 2 points in the Femur (1 point is at the greater trochanter &
another one is at the lateral condyle of the femur)

How to locate the greater trochanter?

- patient in supine position, then internally rotate the knee, then palpate from distal to
proximal femur. You will feel soft when palpate from distal to proximal femur until you feel
the hard consistency or the 1st bony prominent which is the greater trochanter. Then, you
need to mark it with your pen.

How to locate the lateral condyle?

- you used your four finger and put it at the lateral border of the patella. The fifth finger is
where the lateral condyle is. Little finger is at the lateral border of the patella.
Alternatively,
- you can use the similar method where you use to locate the lateral collateral ligament. (ask
patient flex the knee and palpate laterally from patella tendon until you feel the hard
consistency which is the lateral collateral ligament also the where the lateral condyle is.)

Now, you have two bony point at the femur which the greater trochanter (proximal point)
and lateral condyle (distal point).
- Then, internally rotate the lower limb and palpate along the two bony point from distal to
proximal along the femur bone.
 - Then, you mark it with pen and draw an imaginary line. So that, you will know whether
there is angulation or not.
- Once, you reach at the site of angulation, you must look for gap. If there is a gap at the site
of angulation, the diagnosis is Non-Union. If only got angulation but no gap, the diagnosis is
Malunion.

Movement
Flex the knee, extend the knee actively and passively
Hip movement different?

Special Test:
Aim:
- To determine is it valgus, varus, shortening or malrotation?
- To determine is it femur affected or tibia affected?

Special Test
Shortening
a. Galleazi’s Test
- bring the both feet together in extended position, dorsiflex both feet, you will see
shortening. However, that shortening, you don’t know is tibia or femur.
- Then, you flex the knee to 90°, then put a ruler or card at femur or at tibia.
▪ If you want to identify Tibial Shortening,
- put a ruler or card perpendicular to femur at supra-patella region and then look
downward at -30° to -45° below horizontal line.
- see whether the ruler or card tilted to the left femur or the right femur.
- if tilted to the left femur, mean left tibial shortening.
- if tilted to the right femur, mean right tibial shortening.
- IF shortening at Tibial mean Malunion at the tibia.

▪ If you want to identify Femur Shortening,

- put a ruler or card perpendicular to tibia and look downward directly from top.
- see whether the ruler or card tilted to the left tibial or the right tibial.
 - if tilted to the left tibia, mean left femur shortening.
- if tilted to the right tibia, mean right femur shortening.
- IF shortening at the Femur, the shortening can be at the femur shaft (infra-
trochanteric) or at the hip region (supra-trochanteric).

b. Bryant’s Triangle
- To differentiate whether the shortening is supratrochanteric or infratrochanteric.
- What are the points, you have to mark for Bryant’s Triangle?
➢ Anterior Superior Iliac Spine
- use 4 fingers of both hands to press from Umbilicus downward until you feel the
first bony prominent which is the pubic tubercles.

- Then, marked the pubic tubercles with pen.

- Then, you flex the hip. 45 deg. As you flex the hip, there will be a flexion crease.
- Then, you palpate from pubic tubercle along the flexion crease until you feel the
first bony prominent which is the Anterior Superior Iliac Spine (ASIS)
➢ Greater Trochanter
- Internal rotate the leg.
- Palpate along the lateral side of the thigh from distal to proximal until you feel the
first bony prominent which is the greater trochanter.
- Then, marked the greater trochanter with pen.

- After you located both bony prominent which is ASIS & Greater Trochanter.
- Then, you start to draw line.
- Line A: Anterior Superior Iliac Spine (ASIS) connect to Greater Trochanter.
 - Line B: Draw a straight line perpendicular to the table from ASIS.
- Line C: Then, draw a straight line parallel to the table from Greater Trochanter until
intersect with the Line B.
- After connect all the 3 line, a Triangle is form which is called as Bryant Triangle.
- Measure the line C (Greater Trochanter to the intersected point between line B & C)
- Then, compare length of line C on left and right side.
- In Normal person, length of line C will be equal on both sides.
- In person with Fracture of the neck of femur, there will be shortening in length of line C.
- If

Angulation
- Bring the both feet together in extended position.
- Then, you see gap in between two knees or in between two ankles.
- If there is a gap in between two ankle, Varus deformity.
- It there is a gap in between two knee, Valgus deformity.
- If there is a gap (either Varus or Valgus deformity) mean there is Angulation,
but you don’t know the Angulation is at the Tibia or Femur.
- Now, you go beside the bed & fully flex the knee.
- Then, you see at foot end of the bed. Is there any varus or valgus deformity or not?
Is the deformity persisted or not?
- If the deformity persisted (you still can see the varus or valgus deformity at the foot end of
the bed). Then, the angulation is from the tibia.
- Because if the angulation is from the femur, after you fully flex, you don’t see the deformity
anymore.

Malrotation
Method 1: See the direction of patella in sitting position
- Aim: Measure the Malrotation of the Femur.
- Ask patient to sit and hang the legs at the side of bed and the patella must be on the bed.
- Then, see the position of the patella from directly from above.
 - Normally, the direction of patella is the same in both knees.
- If one of the directions of patella pointing sideway mean there is a malrotation in the femur.
- However, this examination is not accurate & unable to estimate the amount of angulation.

Method 2: Thigh Foot Angle- 0-20 deg is normal

- Aim: Measure the Malrotation of the Tibia.
- Ask patient to lye prone.
- You stand at the side of the bed.
- Hold patient both ankle and flex 90°
- Then, see the both sole on top and compare with the thigh. Are they equal?
- Then, use a pen to mark it on 2nd toe & center of the heel. Then, draw an imaginary line.
- Then, compared the imaginary line at the sole with the line at the middle of the thigh.
- In normal person, the imaginary line at the sole and the line at the middle of the thigh are
the same.
- In case of malrotation, there will be an angulation.
- If the angulation < 20°, mean the malrotation are minimal (Normal).
- If the angulation > 20° (30°, 45°, 90°), mean this is malrotation.

Question: How do you prove that the malrotation is in the femur or in the tibia?
Answer:
Point of favour for Malrotation in the Femur:
- History of malrotation in the lower limb.
- History of fracture at Femur (Identify by looking at the site of the scars)
- Foot Progression Angle is Abnormal.
- Thigh Foot Angle is Normal.
Point of favour for Malrotation in the Tibia:
- History of malrotation in the lower limb.
- History of facture at Tibia (Identify by looking at the site of the scars)
- Foot Progression Angle is Abnormal.
- Thigh Foot Angle is Abnormal.
Another Special Test to determine Malunion and Non-Union (Less important)
For Tibia,
- Hold the knee & hold the ankle, just move like doing your Varus & Valgus test.
- See whether they are moving or not.
- If moving, Non-Union.
- If not moving, Malunion.
For Femur,
- Hold the knee & hold the proximal thigh, try to move it.
- See whether they are moving or not.
- If moving, Non-Union.
- If not moving, Malunion.
Measurement:
• Apparent Limb Length Measurement
- measured from Xiphisternum or Umbilicus to Medial Malleolus.
- pelvis is not squared.
- the limbs are not brought into identical position.

• True Limb Length Measurement

- measured from ASIS to Medial Malleolus
- pelvis is squared.
- the limbs are brought into identical position.

• Segmental Measurement
- Femur Length (measured from ASIS to Medial Joint Line)
- Tibia Length (measured from Medial Joint Line to Medial Malleolus)

What is the Aim for measured Apparent Limb Length & True Limb Length?
• True shortening/Limb length discrepancy: means the difference between two true length.
• Apparent shortening: signifies the effect of deformity on the true shortening.
True shortening = Apparent shortening No Compensation
True shortening > Apparent shortening Part of shortening has been compensated
True shortening < Apparent shortening Fixed Adduction deformity of the Hip
without any compensation

How to make sure the pelvis is square before measure the true limb length?
- Imaginary horizontal line between both Anterior Superior Iliac Spine (ASIS) must be
perpendicular to the edge of the bed.

How to square the pelvis?

 • If the patient is smaller size,
move both lower limb until the ASIS is perpendicular to the edge of the bed.
• If the patient is bigger size or patient having pain on the hip,
move one of the legs (non-tender one), either in outward or inward (depend on ASIS level)
- If ASIS is higher compared to the opposite site, leg move inward.
So, ASIS move down to the same level as opposite site.
- If ASIS is lower compared to the opposite site, leg move outward.
So, ASIS move up to the same level as opposite site.

How much different only can considered the Limb Length Discrepancy is significant?
- 4 cm (the limb length discrepancy, can be shortening from femur or tibia)

When do you need to do Segmental measurement?

• When you cannot perform Galeazzi’s Test on patient (because patient having hip pain)
Then, you need to do Segmental measurement to determine whether the shortening is at
femur or at tibia.
• When there are significant different in limb length discrepancy after you done with the true
limb length measurement.
Then, you need to do Segmental measurement to determine whether the shortening is at
femur or at tibia.

Investigation:
(same for Elderly & Young)
Laboratory Investigation:
1. ESR, CRP – to rule out infection
Radiological Investigation:
1. X-ray
- Long X-ray of the Lower Limb AP Standing (from ASIS to Toe)

2. CT scannogram
- to look for evidence of malrotation.
Treatment:
a. Non-Operative:
▪ Medication: painkiller, antibiotic, nerve tonic, muscle relaxant (NO NEED)
▪ Immobilization: (NO NEED)
▪ Injection: (NO NEED)
▪ Physiotherapy: (YES)
- Muscle Strengthening Exercise/ Range of motion exercise
- No pain, so NO NEED to do short wave diathermy, heat therapy.
b. Operative:
▪ Angulation problem: Gradual Deformity Correction
- using Ilizarov or Limb Reconstruction System (LRS)

▪ Shortening problem: Gradual Lengthening of Limb

- using Ilizarov or Limb Reconstruction System (LRS)
▪ Malrotation problem: Derotational Osteotomy

▪ Non-Union problem:
- Internal fixation & bone graft

- Bone transport
(Bone transport is a technique that allows the Orthopaedic Surgeon to regenerate bony tissue within the
patient's extremity. This regeneration is typically used to fill a gap of missing bone due to trauma or
infection. The method is particularly useful in cases of: Infected Non-unions.)
- using Ilizarov or Limb Reconstruction System (LRS)

Tips: Undergraduate Student won’t get Non-Union for exam case, because patient cannot walk in exam
room. You will only get Non-Union case in Humerus. Most of the time, exam case is Malunion because
patient able to walk.