Reza Sh. Kamrani M.D.
TUMS
POTA refreshment symposium
20/1/88
 Pain
 Motion
 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
 Pain
 Motion
 Function impairment
 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
 5th 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
Humerus
 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
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