reza sh. kamrani m.d. tums pota refreshment symposium 20/1/88
TRANSCRIPT
Reza Sh. Kamrani M.D.
TUMS
POTA refreshment symposium
20/1/88
Pain Motion
Function impairment
Clinical importance of Clinical findings
DefinitionDiagnosis
Classification Treatment
Bone has a remarkable capacity of healing(regeneration)
UNIONMonitoring
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 healingGap healing
Callus
Stages of healing
1- hematoma formation2- inflammatory response 3- reparative phase4- 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 overloadusually; 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 bearingMore 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 onto healto 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 CzechHypertrophic, viable
Elephant footHorse hoofoligotrophic
Atrophic, non viableTorsion wedgeComminutedDefect
Pseudoarthrosis
Weber and CzechHypertrophic, viable
Elephant footHorse hoofoligotrophic
Atrophic, non viableTorsion wedgeComminutedDefect
Pseudoarthrosis
Weber and CzechHypertrophic, viable
Elephant footHorse hoofoligotrophic
Atrophic, non viableTorsion wedgeComminutedDefect
Pseudoarthrosis
Weber and CzechHypertrophic, viable
Elephant footHorse hoofoligotrophic
Atrophic, non viableTorsion wedgeComminutedDefect
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 silentClinically silent, Natural history progressive
Clinically obvious, treatment is curativeClinically obvious, treatment is more hazardous
Kamrani, himself
Clinically silent, Natural history silentClinically silent, Natural history progressive
Clinically obvious, treatment is curativeClinically obvious, treatment is more hazardous
Kamrani, himself
Clinically silent, Natural history silentClinically silent, Natural history progressive
Clinically obvious, treatment is curativeClinically obvious, treatment is more hazardous
Kamrani, himself
Clinically silent, Natural history silentClinically silent, Natural history progressive
Clinically obvious, treatment is curativeClinically obvious, treatment is more hazardous
Kamrani, himself
Clinically silent, Natural history silentClinically silent, Natural history progressive
Clinically obvious, treatment is curativeClinically obvious, treatment is more hazardous
Severity of local injuryType of bone
Cancellous / CorticalSpecific bones
RadiationSystemic factors
Age IllnessHormonsSmokingNSAIDs
???
Diagnostic importance
Radiologic findings equivocalRadiologic finding is misleading
Radiologic drawbacksDirect healingClinical union prior to radiologic union
Pain Motion
Function impairment
Discomfort
Pain
Rarely acute failure of implantUsually progressive failure
Sometimes masked with rigid fixation
Pain related to concomitant injuryInfected union may be painful
Motion
SubtleFrank
Sometimes masked with rigid fixation
Motion
SubtleFrank
Sometimes masked with rigid fixation
Functional impairment
Discomfort
Still
diagnosis is not simple in all cases
Hand and Foot
Clinical union before radiologic unionCrush injuriesDistal phalanx
5th metatars and talus and scaphoid are at risk
Forearm
Non-union rate 2-3%
Non-union of one boneStyloid ulna non-union
Benefit of non-union
Humerus
Femur
Incidence ; 2-17%Risk factors
InfectionVascular insultInsufficient fixationDistraction NSAIDsOpen fracture
Femur
Expected union time80-200 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 time3 m for delay union6 m for nonunion
Femoral neck
Pain after 3 months of fracture
AVNNon-union
MRICT ScanBone 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 findingContinuing pain at the Fx. SiteAssociated with motion and local swelling
Confused clinical findings in large reamed IM nail
Infected union is symptomatic
Classification; Kamrani himself
Clinically silent, Natural history silentClinically silent, Natural history progressive
Clinically obvious, Natural history progressiveClinically obvious, Natural history silent
Classification; Kamrani himself
Clinically silent, Natural history silentClinically silent, Natural history progressive
Clinically obvious, Natural history progressiveClinically obvious, Natural history silent
Classification; Kamrani himself
Clinically silent, Natural history silentClinically silent, Natural history progressive
Clinically obvious, Natural history progressiveClinically obvious, Natural history silent
Humerus
Classification; Kamrani himself
Clinically silent, Natural history silentClinically silent, Natural history progressive
Clinically obvious, Natural history progressiveClinically obvious, Natural history silent
Scaphoid
Classification; Kamrani himself
Clinically silent, Natural history silentClinically silent, Natural history progressive
Clinically obvious, Natural history progressiveClinically obvious, Natural history silent
Superamalleolar
Classification; Kamrani himself
Clinically silent, Natural history silentClinically silent, Natural history progressive
Clinically obvious, Natural history progressiveClinically obvious, Natural history silent
Cubitus varus