CASE PRESENTATION

BATCH B
INTRODUCTION
Patient ZAHIDA, 50 years female, resident of Charsadda, right hand dominant,
presented and admitted via OPD
PRESENTING COMPLAINT
Pain in her left arm…..1.5 years
HISTORY OF PRESENTING COMPLAINT
Patient was in his usual state of health 1.5 years back when he had history of RTA,
while traveling from swat to Charsadha. Car slipped off from cliff and resulted in
open wounds with bleeding from left arm and forearm. Multiple wounds were there.
Rescue team did dressing over wound, but did not wash,neither any antibiotics were
given. After 4 hours, she presented to PIMS , where wounds were washed,
antibiotics were administered , x-rays were done by orthopedic department and ex-
fix was applied. Patient was discharged after 3 days from hospital with advice of
daily dressing.
She went home and did daily dressings, wounds got healed. Ex-fix remain applied
for several months, in between pin sites also got infected. She lost follow-up. After
few months, ex-fix was removed and sent home for pin sites healing.
HISTORY OF PRESENTING COMPLAINT

Patient was told with removal of external fixator that her bones sre not healed and
she will need definitive surgery later on.
This time patient presented with healed pin sites, with complain of pain in her left
arm generalized, dull-aching, persistent pain, non-radiating, aggravated with
movement of limb. Not associated with fever, weight loss, skin disorder,
rheumatology disorder, bleeding disorder.
Patient expectations are moderate as she wants unnecessary movement of left
limb to get fixed and able to carry out house chores and daily life easily and
independently.
PAST MEDICAL HISTORY: non-significant
PAST SURGICAL HISTORY: non-significant
Allergy or drug history:
FAMILY HISTORY: non-significant
PERSONAL HISTORY: no known addictions, normal sleep and appetite, married
since 19 years, 5 children all healthy
SOCIOECONOMIC STATUS: affording, upper middle class, husband is
contractor, own house, ground floor, decreased sun-expousre but adequate
ventilation
EXAMINATION
A Middle aged female, sitting comfortably in bed, well oriented in time, place and
person
Vitally stable
J A C K L E T negative
no devices or prosthesis seen
ABDOEMEN: soft, non-tender, bowel sounds audible
Chest: clear and bilaterally equal air entry
LOCAL EXAMINATION (left upper limb)
Look:
● Multiple scar makrs from previous wound and ex-fix surgery. Healed with no
discharge from those
● Left upper limb appears shortened
● Muscle bulk is reduced
Feel:
● Tenderness on fracture site
● Fractures mobile in all planes
● Temperature is comparable
● Lymph nodes not palpable
● Sensations intact
● Distal pulses intact
● Power ⅘ in forearm flexors and extensors.
Move:
Range of movement (passive): normalin shoulder and mild decrease in elbow
Active: unable to abduct shoulder, flexion at elbow (30 to 100 degrees)
and pronation supination cant be done.
X-RAYS
 Non-Union
Batch B
Orthopaedics
FRACTURE HEALING
Fracture healing involves a complex and sequential set of events to restore injured
bone to pre-fracture condition
● stem cells are crucial to the fracture repair process
● periosteum and endosteum are the two major sources

Fracture stability dictates the type of healing that will occur

● mechanical stability governs the mechanical strain

● when the strain is below 2%, primary bone healing will occur
● when the strain is between 2% and 10%, secondary bone healing will occur
Modes of bone healing
1. primary bone healing (strain is < 2%)
● intramembranous healing
● occurs via Haversian remodeling
● occurs with absolute stability constructs

1. secondary bone healing (strain is between 2%-10%)

● involves responses in the periosteum and external soft tissues.
● endochondral healing
● occurs with non-rigid fixation, as fracture braces, external fixation, bridge
plating, intramedullary nailing, et
EXAMPLES
SECONDARY BONE HEALING
● as early as 24 hours post-injury
● Primary callus forms within two weeks
VARIABLES THAT INFLUENCE FRACTURE HEALING

Internal variables
1. blood supply (most important)
2. head injury may increase osteogenic response
3. mechanical factors
● bony soft tissue attachments
● mechanical stability/strain
● location of injury
● degree of bone loss
● pattern (segmental or fractures with butterfly fragments)
increased risk of nonunion likely secondary to compromise of the blood supply to
the intercalary segement
VARIABLES THAT INFLUENCE FRACTURE HEALING

Blood supply:
● Initially the blood flow decreases with vascular disruption
● After few hours to days, the blood flow increases
● This peaks at 2 weeks and normalizes at 3-5 months

Un-reamed nails maintain the endosteal blood supply

Reaming compromises of the inner 50-80% of the cortex

Looser fitting nails allow more quick reperfusion of the endosteal blood supply
versus canal filling nails
External variables
Low Intensity Pulsed Ultrasound (LIPUS)
● accelerates fracture healing and increases mechanical strength of callus (including torque and
stiffness)
● the beneficial ultrasound signal is 30 mW/cm2 pulsed-wave
● healing rates for delayed unions/nonunions has been reported to be close to 80%

Bone stimulators
● direct current (decrease osteoclast activity and increase osteoblast activity by reducing oxygen
concentration and increasing local tissue pH)
● Alternating current
● pulsed electromagnetic fields (cause calcification of fibrocartilage)
● combined magnetic fields

COX-2
● promotes fracture healing by causing mesenchymal stem cells to differentiate into osteoblasts
Patient factors

HIV
● higher prevalence of fragility fractures with associated delayed healing

Medications affecting healing

1. Bisphosphonates: bisphosphonates are recognized as a cause of osteoporotic fractures

with long term usage
2. Systemic corticosteroids
3. NSAIDs
● prolonged healing time becaue of COX enzyme inhbition
1. Quinolones
● toxic to chondrocytes and diminishes fracture repair
Patient factors
Diet
● vitamin D and calcium

Diabetes mellitus
● affects the repair and remodeling of bone
● decreased cellularity of the fracture callus, delayed endochondral ossification and diminished
strength of the fracture callus
● fracture healing takes 1.6 times longer in diabetic patients versus non-diabetic patients

Nicotine
● decreases rate of fracture healing
● inhibits growth of new blood vessels as bone is remodeled
● increase risk of nonunion (increases risk of pseudoarthrosis in spine fusion by 500%)
● decreased strength of fracture callus
● smokers can take ~70% longer to heal open tibial shaft fractures versus non-smokers
Definition
A nonunion is an arrest in the fracture repair process

A Fracture of minimum 9 months occurance and is not healed or no signs of

radiographic progression in last 3 months (FDA 1986)

A Fracture that shows no visibly progressive signs of healing (FDA 1998)

A delayed union is generally defined as a failure to reach bony union by 6 months

post-injury, this also includes fractures that are taking longer than expected to heal
Causes of non-union
1. Poor vascularity (biology)
2. Instability
3. Infection
4. Iatrogenic

location
● scaphoid, distal tibia, base of the 5th metatarsal are at higher risk for
nonunion because blood supply in these areas

pattern
● segmental fractures and those with butterfly fragments
Risk factors

LOCAL IATROGENIC SYSTEMIC PATIENT

● Open ● Poor reduction ● Malnutrition ● non-

fractures ● Unstable ● Smoking compliance
● High energy fixation ● NSAIDs
fractures with ● DM
bone ● Chronic
devitilization alcoholism
● severe soft
tissue injury
● Bone loss
● infection
 Types
1- Septic nonunion
● caused by infection
● CRP test as the most accurate predictor of infection
2- Pseudoarthrosis
3- Hypertrophic nonunion
● caused by inadequate stability with adequate blood supply and biology
● abundant callous formation without bridging bone
● typically heal once mechanical stability is improved
4- Atrophic nonunion
● caused by inadequate immobilization and inadequate blood supply
5- Oligotrophic nonunion
● produced by inadequate reduction with fracture fragment displacement
Classification of nonunion
1. Hypervascular (hypertrophic) or viable and is capable of biological reaction
2. Avascular ( atrophic) or inert and are not capable of uniting without
intervention

HYPERVASCULAR AVASCULAR

● Elephant foot non-union ● Torsin wedge

● Horse hoof non-union ● Comminuted

● Oligotrophic ● Defect
● atrophic
hypevascular
avascular
Patey et al classification
Clinical and radiographic classification:
Type A: non-unions with bone loss less than 1cm
Type B: non-unions with bone loss more than 1cm

Type A1: Lax non-union Type B1: With bone defect

Type A2: stiff non-union Type B2: Loss of bone length

Type A2-1: stiff non-union without deformity Type B3: both

Type A2-2: Fixed deformity

Patey et al classification
Diagnostic points
● Peristent pain
● Non-physiologic movements
● Progressive deformity
● No radiographic evidence of healing
● Failing impants
Laboratory evaluation

1- CBC, ESR, CRP

● must rule out infectious etiology

2- total protein and serum albumin

3- vitamin D, TSH, PTH

● Vitamin D deficiency is the most commonly encountered nutritional deficiency
(60-70%)
Radiographs
● Standard X-rays are often diagnostic
● 45 degrees Oblique films can increase accuracy of diagnosis
● Serial radiographs
● Stress radiographs for confirming the diagnosis and check stability

CT
● if the status of union is in question, a CT scan should be obtained; hardware
artifact may limit utility of the CT scan
HYPERTROPHIC
NON-UNION

Biology: good
Stability: lacking
Tx:
● Provide stability
● Correct deformity
● no bone graft
needed
Atrophic non-union

Biology: poor
Stability: lacking
Tx:
● Provide stability
● Bone graft
Avital Non-Union

Biology: none
Stability: lacking
Tx:
● Provide stability
● Bone graft
● Other
reconstruction
Surgical Management
Principles:

Cure infection if there

Correct deformity if significant

Provide stability via implants

Add biological stimulus when necessary according to type

Treatment principles of septic non-union
Contaminated implants and devitalized tissue must be removed

Infection treatment:
● Temporary stabilization ( ex-fix)
● Culture specific antibiotics
● +/- local antibiotic delivery system

Secondary stabilization with augmentation of osteogenesis (cancellous grafting)

Adding stability
1. External fixator
2. Plate
3. IM Devices
External fixator
Largest indication is a temporary stabilization following infection debridement

Also used in correction of stiff deformity and lengthening

Plate stabilization
Powerful reduction tool

Should strive for absolute stability

Locking plates referred for added stability and strength

Other relative indications are:

● Absent medullary canal
● Metaphyseal non-unions
● when reduction or removal of prior implant is needed
Nail stabilization
Primary nailing

Exchange nail
● New larger diameter
● Reamed nails - provide local bone graft, no bone loss should be there
● Correction of angular deformity
● Ass. Fibular osteotomy

Dynamization: removal of static screw, dynamic screw, all screws

Accordion Manoeuvre
● Bloodless stimulation of bone healing
● Alternate compression and distraction at fracture site
● Compression brings the fragments into contact and crushes the scar tissue
between them
● Distractionn creates columnar fibro-vascular tissues
● Repeated distraction stimulates the production of osteoblasts and helps the
collagen bundles consolidate within bony matrix
Adding Biology/ bone grafting

A material with either osteoconductive, osteoinductive, and/or osteogenic

properties

● autografts
● allografts
● demineralized bone matrix (DBM)
● synthetics
● bone morphogenetic protein (BMP)
● stem cells
Osteoconductive

● material acts as a structural framework for bone growth

● demineralized bone matrices (DBMs)
● the various three-dimensional makeups of the material dictate the conductive
propertiesosteoconductive
Osteoinductive
● material contains factors that stimulate bone growth and induction of stem
cells down a bone-forming lineage
● bone morphogenetic protein (BMP) is most common from the transforming
growth factor beta (TGF-B) superfamily
Osteogenic
● material directly provides cells that will produce bone including primitive
mesenchymal stem cells, osteoblasts, and osteocytes
● mesenchymal stem cells can potentially differentiate down any cell line
● osteoprogenitor cells differentiate to osteoblasts and then osteocytes

cancellous bone has a greater ability than cortical bone to form new bone due to
its larger surface area

autologous bone graft (fresh autograft and bone marrow aspirate) is the only bone
graft material that contains live mensenchymal precursor cells
AUTOGRAFT
Bone graft transferred from one body site to another in the same patient
● osteogenic, osteoinductive, and osteoconductive
● least immunogenic
● cortical, cancellous, or corticocancellous
● vascular or nonvascular

Donor sites
● bone marrow aspirate
● iliac crest is the most common site for autograft
● fibula and ribs are most common sources of vascularized autografts
● tibial metaphysis
ALLOGRAFT
Bone graft obtained from a cadaver and inserted after processing
BONE MORPHOGENETIC PROTEINS (BMP)
Osteoinductive properties solely

stimulates undifferentiated perivascular mesenchymal cells to differentiate into

osteoblasts through serine-threonine kinase receptors

Platelet rich plasma (PRP) (like other BMPs) solely osteoinductive

SYNTHETICS
● Alternative to autografts and allografts
● Made in powder, pellet, or putty form
● osteoconductive only
REAMER ASPIRATOR IRRIGATOR
● Provides large volume of bone graft from intramedullary source
● femur (most common)
● tibia
● Union rates comparable to iliac crest autologous bone grafting
TAHNKYOU