Reza Sh. Kamrani M.D.

TUMS POTA refreshment symposium 20/1/88

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Pain

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Motion

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Function impairment

 Clinical importance of Clinical findings  Definition  Diagnosis  Classification  Treatment

Bone has a remarkable capacity of healing (regeneration)

UNION Monitoring Radiologically and Clinically Biology and Biomechanics of healing and fixation is very important to monitor healing

 Bone healing process;  Enchondral ossification, Callus formation  Direct osteonal healing. Non-callus   Contact healing Gap healing

Callus

 Stages of healing     1- hematoma formation 2- inflammatory response 3- reparative phase 4- remodeling  Fx. Healing is said to be complete when repopulation of the marrow space occure (months to years )

There is always a race between healing and implant failure Implant failure; rarely; catastrophic overload usually; a fatigue failure between bone implant / implant itself

 Endurance limit; A stress more than one can be borne with infinite number of cycle

 Implant construction  Load bearing More stress on the implant and bone-implant  Load sharing

In complex reconstructions with load sharing in spite of incomplete healing progressive failure occures quite late

 Delayed union;  A Fx. That has not healed within its expected healing time  Can go on to heal to non-union  Histological   Callus formation prominent Interfragmenting tissue consist of fibrous tissue

 Non-union;  A Fx. That has not healed without an intrvention  Failure to show any progressive changes in radiographic appearance for at least 3 months after expected union period time  Repair is not completed in expected period and the cellular activity for healing is ceased  Union is not achieved in 6-8 months

 Weber and Czech   Hypertrophic, viable    Elephant foot Horse hoof oligotrophic Atrophic, non viable    Torsion wedge Comminuted Defect  Pseudoarthrosis

 Weber and Czech   Hypertrophic, viable    Elephant foot Horse hoof oligotrophic Atrophic, non viable    Torsion wedge Comminuted Defect  Pseudoarthrosis

 Weber and Czech   Hypertrophic, viable    Elephant foot Horse hoof oligotrophic Atrophic, non viable    Torsion wedge Comminuted Defect  Pseudoarthrosis

 Weber and Czech   Hypertrophic, viable    Elephant foot Horse hoof oligotrophic Atrophic, non viable    Torsion wedge Comminuted Defect  Pseudoarthrosis

 Paley and Herzenberg    Stiff (<5 degrees mobility) Partially mobile (5-20 degrees) flail (>20 degrees)

 Paley and Herzenberg    Stiff (<5 degrees mobility) Partially mobile (5-20 degrees) flail (>20 degrees)

 Kamrani, himself   Clinically silent, Natural history silent Clinically silent, Natural history progressive   Clinically obvious, treatment is curative Clinically obvious, treatment is more hazardous

 Kamrani, himself   Clinically silent, Natural history silent Clinically silent, Natural history progressive   Clinically obvious, treatment is curative Clinically obvious, treatment is more hazardous

 Kamrani, himself   Clinically silent, Natural history silent Clinically silent, Natural history progressive   Clinically obvious, treatment is curative Clinically obvious, treatment is more hazardous

 Kamrani, himself   Clinically silent, Natural history silent Clinically silent, Natural history progressive   Clinically obvious, treatment is curative Clinically obvious, treatment is more hazardous

 Kamrani, himself   Clinically silent, Natural history silent Clinically silent, Natural history progressive   Clinically obvious, treatment is curative Clinically obvious, treatment is more hazardous

    Severity of local injury Type of bone   Cancellous / Cortical Specific bones Radiation Systemic factors     Age Illness Hormons Smoking  NSAIDs

 Diagnostic importance   Radiologic findings equivocal Radiologic finding is misleading  Radiologic drawbacks   Direct healing Clinical union prior to radiologic union

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Pain

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Motion

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Function impairment

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Discomfort

 Pain   Rarely acute failure of implant Usually progressive failure  Sometimes masked with rigid fixation   Pain related to concomitant injury Infected union may be painful

 Motion   Subtle Frank  Sometimes masked with rigid fixation

 Motion   Subtle Frank  Sometimes masked with rigid fixation

 Functional impairment  Discomfort

Still

diagnosis is not simple in all cases

 Hand and Foot  Clinical union before radiologic union   Crush injuries Distal phalanx  5 th metatars and talus and scaphoid are at risk

 Forearm  Non-union rate 2-3%  Non-union of one bone  Styloid ulna non-union  Benefit of non-union

 Humerus

 Femur   Incidence ; 2-17% Risk factors       Infection Vascular insult Insufficient fixation Distraction NSAIDs Open fracture

 Femur  Expected union time  80-200 days in reamed IM nail  Definition  Lack of progression of healing combined with clinical symptoms of discomfort at minimum of 6 months

 Femoral neck  Risk fctor;  Primary displacement  Union without callus formation  Expected union time   3 m for delay union 6 m for nonunion

 Femoral neck  Pain after 3 months of fracture   AVN Non-union    MRI CT Scan Bone scan with pin colometer (85-90% for AVN)

 Tibia  The definition of what constitutes a tibial non-union is surprisingly difficult  Expected time for closed fractures; 16-19 m  Failed to union within 9 months with no progressive changes in radiography for at least 3 months 

 Tibia  Clinical finding   Continuing pain at the Fx. Site Associated with motion and local swelling  Confused clinical findings in large reamed IM nail  Infected union is symptomatic

 Classification; Kamrani himself   Clinically silent, Natural history silent Clinically silent, Natural history progressive   Clinically obvious, Natural history progressive Clinically obvious, Natural history silent

 Classification; Kamrani himself   Clinically silent, Natural history silent Clinically silent, Natural history progressive   Clinically obvious, Natural history progressive Clinically obvious, Natural history silent

 Classification; Kamrani himself   Clinically silent, Natural history silent Clinically silent, Natural history progressive   Clinically obvious, Natural history progressive Clinically obvious, Natural history silent Humerus

 Classification; Kamrani himself   Clinically silent, Natural history silent Clinically silent, Natural history progressive   Clinically obvious, Natural history progressive Clinically obvious, Natural history silent Scaphoid

 Classification; Kamrani himself   Clinically silent, Natural history silent Clinically silent, Natural history progressive   Clinically obvious, Natural history progressive Clinically obvious, Natural history silent Superamalleolar

 Classification; Kamrani himself   Clinically silent, Natural history silent Clinically silent, Natural history progressive   Clinically obvious, Natural history progressive Clinically obvious, Natural history silent Cubitus varus