Dr. D.

Tejaswi MS (ORTHO)
ASST.PROFESSOR
DEPARTMENT OF ORTHOPEDICS
NIMS, NIMRA HOSPITAL
 MAL UNION
 • Definition :
when fracture heals in an
abnormal position,

CAUSES:
1. Inaccurate Reduction
2. Ineffective
Immobilization
•Causes
- Closed Reduction
- Treatment By Quacks
- Improper Immobilisation Techniques
- Multiple And Multisystem Injuries
M.C Sites Of Malunion
 Displaced fractures often malunite when treated
conservatively
 Every bone with inaccurate reduction if
unitesmalunites

 colles fracture
 supracondylar humerus
 clavicle
 M.c Sites Deformities
 Distal radius -  Dinner Fork Deformity
 Distal Humerus   Gunstock Deformity
Cubitus Varus
 Proximal femur   Coxa Vara
 Clavicle
 Proximal humerus
 Femoral shaft
 Tibia
 Ankle
Alignment And Architecture
Neck shaft angle
Mechanical Axis
MidDiaphyseal Axis
 Classification
1. Length malunion
2. Rotatory malunion
3. Angulatory malunion
LOCATION
 1. Intra-articular
 2. Extra-articular -
-Metaphyseal
-Diaphyseal
 3.Combined
Clinical features
 Deformity
 Shortening
 Muscle wasting
 Loss of function  IMPAIRED FUCNTION by
 Abnormal joint surface
 Rotation or Angulation
 Overriding malunion
 Movement of neighbouring
joint may be blocked
 Shortening of limb
Investigations
 Plain Radiographs
- lower extremity - weight bearing/ long cassette
 Normal Side CT - Scanogram –
 MRI – Intraarticular pathology
Indications For Surgery
 Cosmotic
 Progressive deformity
 Gross Deformitiy
 Shortening
 Functional (ROM) limilations
 Arthritis
 Synostosis
 TREATMENT
1. Observation
2. Excision / Debridement

3. Corrective Osteotomy-

4. TSF-Taylors spatial frame

6.Alternates for Non
5. Bone Legthening salvageable Joint
-Ilizarov Ext.Fixator -Arthrodesis
-Orthofix -Arthroplasty
 1.OBSERVATION
 Observation is recommended in children
 Most of deformity upto 5-10 deg corrected by
remodeling exept mal rotation

 Shortening >2cm is compensated

>2m limb legth discrepancy in young needs surgery
 Rotational deformity - usually not acceptable when
functional limitation occurs
3.Corrective Osteotomy-
 Recommended Atleast 1 year following fracture.
(Bone remodeling and tissue equilibrium)

Type Of Deformity Type of osteotomy

 Length -----------  Transverse
 Rotational -----------  Transverse
 Angular ----------  Oblique
 Complex ------------  Wedge(opening/closing)
- Bi / Tri planar
- Crescent (Dome)
 Wedge Osteotomy
1.Lateral closing wedge osteotomy
-Most stable inherently
2.Medial open wedge osteotomy with bone graft
3.Oblique osteotomy with derotation
Intraoperative Fixation
Open Fixation: (ORIF)
1. K- wire fixation
2. PLATE FIXATION
3. Intra Medullary nail
4. Lag screw with plate
FRENCH OSTEOTOMY
Cross union
Fernandez osteotomy
TSF -Taylors spatial frame
Malunited BB # Leg1/3
4.Limb Lengthening
Replacement for Non Salvageable
Wrist Arthrodesis
NONUNION
 Definition
 Failure of fracture to unite by bony continuity.

 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
 DELAYED UNION
 When fracture takes more than the usual time to unite

 Every fracture has its own timetable

- long bone shaft fracture 6 months,
- femoral neck fracture 3 months

 Most of fractures in delayedunion unite eventually

Pseudoarthrosis
 Non union may be
painless if psuedo joint is
formed between fracture
ends
 Active movements are
possible
 No synovial capsule
 CAUSES
 Open Fractures
 Wound Infection
 Segmental Fractures
 Bone Loss
 Distraction Of Fracture Fragments (Fracture Gap )
 Soft Tissue Interposition
 Insecure And Inadequate Fixation (Unstable Fixation)

Factors contributing
1.Systemic
2.Local
 Systemic
1. Nutritional status - Malnutrition
2. Metabolic - Diabetes (neurovascular)
3. Smoking Tobacco and alcohol use
4. General health
5. Activity level
6. Use of NSAIDs (have been found to decrease
fracture healing in multiple animal studies)
 Local
Fracture characteristics- 6.Soft tissue injury
1. Open # -Traumatic
2. Infected # -Iatrogenic
3. segmental # 7.Treatment related
4. Comminuted by severe -Insecure fixation
trauma -Insufficient immobilization
-Fixation in distraction
5. Anatomic Location of
8. Irradiated bone
Fractures
M.C Sites
 Neck of femur
 Scaphoid
 lower third tibia
 Lower 1/3 ulna
 Lat. condyle humerus
Symptoms & Signs
1. Minimal / No Pain
2. Loss Of Function
3. Painless Abnormal Mobility (pseudoArthrosis)
4. Shortening
5. Scars
6. Sinuses
7. Deformity
7. Wasting Of Limb Muscles
MULLER AND WEBER CLASSIFICATION
1.HYPERVASCULAR NON UNION –
 Fracture ends are viable and show biological reaction,

 stable internal fixation is enough no bone grafting required

2.AVASCULAR NON UNION –

 the fracture ends are not viable due to poor blood supply.

 Needs rigid internal fixation with bone grafting after

decortication of non viable ends

1.HYPERVASCULAR NONUNION
 1.Elephant foot
(hypertrophic, rich in callus)
 2. Horse foot
(mildly hypertrophic,
poor in callus)
 3. Oligotrophic
(not hypertrophic)
Hypervascular Nonunion- Elephant foot
Hypervascular Nonunion- Horse Foot
2. AVASCULAR NONUNION
1.Torsion wedge nonunion– intermediate fragment
has healed at one end and not at the other end
2. Comminuted nonunion – in comminuted #
3. Defect / Gap nonunion -In open fracture s,
- Infected fractures,
- Fracture with bone loss
4. Atrophic nonunion- ends are thin and
sclerotic with excessive scar tissue in b/w
Comminuted Nonunion
Gap Nonunion
Atropic Nonunion
•Infected nonunion
Investigations
 Serial X-ray to detect progress /
non progression of callus
 CBP
 ESR / CRP
 Plain Radiographs –stress x rays
-weight bearing X ray
 CT – scan
 MRI scan
TREATMENT
1. ICB MARROW INJECTION
2. Bone grafting -cancellous bonegraft
-cortico-cancellous
-cortical (fibular graft)
3. Open reduction-Rigid internal fixation
4. Bone transport -Ilizarov’s technique
-ORTHOFIX

5. Ultrasound
6. Electrical stimulation
7 .Antibiotics and+ Sx
 Hypertrophic Atrophic
(Hypervascular) (Avascular)
Nonunions Non-unions

 Adequate stabilization  Decortication And Bone

obtained by - Grafting
-Plates and screws.  ICBone Marrow Injection
-Intra-medullary nails.  Open reduction-Rigid
-External fixation. internal fixation
 Bone transport
-ILIZAROV’S TECHNIQUE
-ORTHOFIX
-TAYLORS FRAME -TSF
2.Bone Grafting
 Autogenous cancellous bone remains the “gold
standard” in grafting material
 Other options -Allograft Bone
- Synthetic Bone Substitute
- Vascularised Bone Grafting
 Bone Graft Promotes Osteogenesis, provide stability
 Types
1. Cancellous Bone Graft
2. Cortical Bone Graft
3. Phemister Bone Graft
CANCELLOUS BONE GRAFTING

Comminuted Nonunion
3. Intramedullary Nailing
 Hypertropic nonuinion
 Reaming of medullary
canal and snugfit intra
medullary nailing.
Fibular Grafting And Locking Plating
Fibular Grafting And Orthofix
 In Gap nonunion fractures
 Excision of fracture ends
 Fibular graft from same
side
 Transfixing distal tibia and
fibula
 Orthofix application
4 .ILIZAROV’S TECHNIQUE- Bone Transport
NonUnion IC # Neck Femur

-Hemiarthroplasty
-THR
5. Ultrasound
 Stimulates The Genes involved in inflammation and

bone regeneration.

 Increases Blood Flow through dilation of capillaries

and enhancement of angiogenesis

 Chondrocyte Stimulation is enhanced, which leads

to an increase in enchondral bone formation