Malunion: The Principles

and Management

PRESENTER : Dr CHINTAN N
PATEL

CHAIR PERSON : Dr S.T.

SANIKOP
Dept of Orthopaedics , J.N. Medical College and
Dr. Prabhakar Kore Hospital and MRC, Belgaum
 Objectives
To understand:
• the definition of malunion
• the natural history of malunions
• the indications for treatment
• the surgical alternatives
 Definition of Malunion
Malunion is defined as a healing of the bones in an
abnormal position
• Site
– upper vs lower extremity
– spine / pelvis
• Location
– intra-articular
– extra-articular
» metaphyseal
» diaphyseal
– combined
 Definition of Malunion
• Types
– simple -
» skeletal malalignment
– complex -
» skeletal malalignment with,
» soft-tissue &/or articular abnormality
 Definition of Malunion
• Direction
– angular
– rotational
– translation
– length
 Malunion

Etiology:
• Failure of nonoperative treatment
• Failure of operative treatment
– incomplete surgical correction
– inadequate stability of fixation
– noncompliance of the patient
Importance of Limb Alignment
Detrimental effects of malalignment
Immediate
Functional limitations
Pain
Chronic
Joint related ( arthritis)
 Management Overview
• Anatomical assessment
– Limb
» assessment of deformity
» status of surrounding joints

• Patient expectations

• Available Literature on expected outcome

• Surgeon experience
Management - History and Physical
Examination
• Injury • Soft-tissues status
– mechanism – incisions
– energy – Defects

• Fracture • Previous treatment

– location – type
– pattern – stability
– bone loss – complication(s)
– ROM of
surrounding joints
 Management: Investigations
Plain Radiographs

CT - scanogram
– rotational / length deformities
MRI
– intraarticular pathology
Assessment of Limb Alignment

Comparison with contralateral limb important

 Assessment of Joint
Arthroscopy MRI
Alternates for Nonsalvagble Joint
• Debridement
• Arthrodiesis
• Arthroplasty
 Biomechanical Principles
Effect of Surgery on:

• joint function
• alignment
• soft tissues
• limb length
 Deformity Correction
General Considerations:
• Functional assessment – disability
• GOAL: Anatomical correction of deformity
• UL - upto 3 to 4 cm shortening well
tolerated.
• LL – upto 2 cm shortening treated with
Shoe Raise.
 Timing for Deformity
Correction

• Extra-articular - controversial

• Intra-articular - ASAP
 Surgical Overview
Preoperative Plan: selection of ,
• surgical approach / exposure
• osteotomy - location / type
• fixation technique(s)
• intraoperative use of,
– femoral distractor
– bone graft / substitute
 Surgical Overview
Osteotomy
• site of deformity
• closed vs open
• simple vs multi planar
• technique -
– Predrill / osteotome
– Saw (irrigate)
 Osteotomy
Type of deformity Type of osteotomy
 length  Transverse
 rotational  Transverse
 angular  Oblique
Wedge(opening/closing)
 complex  Bi- / Tri- planar
Crescentic (Dome)
 Intraoperative Fixation

• Open fixation:
– If stable - IM nail vs plate vs circular
fixation
– lag screw with plate
• Closed fixation:
– IM nail
– percutaneous plate
– circular fixation
 Examples
 Proximal humerus
 Distal radius
 Proximal femur
 Femoral shaft
 Tibia
 Ankle
 Distal Humerus
 Clavicle
 1. Proximal Humerus

Deformity:
– varus
– extension
Problem:
– reduced ROM
– impingement
Treatment:
– Osteotomy:
» Biplanar
Fixation:
– Blade plate
 2. Distal radius

42 year male
Swollen arm: x-rays
taken, conservatively
treated with cast
Healed at 8 weeks: Complaints of
wrist and DRUJ pain, decreased motion
Correction of post-traumatic wrist deformity in adults
by osteotomy, bone-grafting, and internal fixation.
Fernandez DL, JBJS 64(8), 1982
Osteotomy, bone graft and
fixation
 3. Proximal Femur
• Following femoral
neck fracture:
– Varus Malunion
– AVN
• Treatment:
– valgus intertrochanteric
osteotomy
• Fixation:
– blade plate
 Femoral Diaphysis Malunion
• Most common
– rotation and/or
– length
• Preop CT
– Determines rotational
malalignment
• Osteotomy with
IM saw
• Stabilization
– IM nail/plate
 4. Tibial Diaphysis Malunion
Definition:
Controversial!!
• Shortening > 1cm
• Varus > 5º
• Valgus > 5 - 10º
• Internal / External rotation > 5 - 10º
• Recurvatum / Procurvatum > 10º
 Tibial Diaphysis Malunion
Options for Fixation:
• IM Nail
• Plate
• Circular Fixator
 Case Example
35 year female
•closed tibia fracture
•Cast immobilization
•healed
•complains of “toe
turned out”
 Case Example
•Deformity:
– 20º external
rotation
– 10 º procurvatum
– 5º varus
•Confirmed:
– clinical exam &
CT scanogram
 Case Example

•Osteotomy of tibia:
– biplanar transverse:
» closing anterior
& lateral wedge
and derotation
» oblique
osteotomy of
fibula
•Fixation:
– periarticular plate
5. Malunion of Ankle Fractures
Radiographic exam
Malunion Ankle Fractures
STEPS:
» fibular osteotomy - assess length
» osteotomy medial malleollus and/or
post malleollus if necessary
» reduce syndesmosis / joint
» temporary fixation
» stabilize fibula
6. Malunited Humerus
CUBITUS VARUS
“Gun-stock
Deformity” –
Looks like a
loading stock of
old long barrel
guns
 TREATMENT
 Lateral closing wedge osteotomy
Easiest
Safest
Most stable inherently
 Medial open wedge osteotomy with
bone graft
 Oblique osteotomy with derotation
 CUBITUS VARUS
Modified French
French Osteotomy Osteotomy
(Bellemore)
 Post. Longitudinal approach  Posterolateral approach
 Detach whole of triceps  Lateral half of triceps
 Ulnar nerve explored detached
 Medial cortex broken  Ulnar nerve Not explored
 Medial cortex intact so
more stability
 7. MALUNITED CLAVICLE
Double- osteotomy planned and practiced on solid
Real Bone models

 Target normal clavicle

 Planned correction

 Abnormal clavicle
Treatment Plan

 Closing wedge osteotomy peformed

at mid-clavicle, bone wedge removed

 Opening wedge osteotomy

performed in lateral third, grafted with
bone wedge
 BONE REMODELING in
CHILDREN
 Fractures close to ends of long bones
remodel much faster than fractures in
mid-shaft. Hence remodeling is faster
in PHYSEAL > METAPHYSEAL
>DIAPHYSEAL INJURIES.
 UL- most active growth plate is at
PROXIMAL HUMERUS AND
DISTAL RADIUS AND ULNA, hence
injuries of Proximal Humerus and
Wrist remodel faster than injuries of
elbow and proximal forearm.
 Inverse for the LL- remodeling is faster
at the Knee- Distal Femur and
Proximal Tibia than in Proximal
Femur and Distal Tibia.
 ACCEPTABLE DEFORMITY
Distal Radius Metaphyseal # – 15 degrees of primary
angulation and 1cm of shortening in boys upto 14 years
and girls upto 12 years.
Radius-Ulna shaft # -upto 10 degrees of plastic
deformation acceptable.
Radius neck # -upto 30 degrees angulation, 2mm
translocation remodel.
Supracondylar Humerus # - upto 20 degrees angulation
in sagital plane remodel but no angular remodeling in
coronal plane
Humerus shaft # - 20 degrees angulation and upto 2 cm
bayonet shortening acceptable.
 ACCEPTABLE DEFORMITY
• Femur
shaft # -

• Tibia
shaft # -
 Malunion Treatment
• Goals
– Improve function
– Decrease pain
– Prevent arthrosis
• Conclusion:
Corrective osteotomy has a definite role in the
treatment of malunited fractures.
THANK YOU !