delayed non and malunions Flashcards
4 tenets of bone healing
mechanics, scaffold, growth factors and cells
In a fracture gap model in which compression is applied after 4 weeks of healing describe the different forces felt by the cells of the callous in different locations of the callous and what effect that has on these cells
Cells in the middle of the callous feel the compression while cells on the periphery experience tension
Stemcells under tension tend toward osteoblastic lineage and bone is formed (think distraction osteogenesis)
Stemcells under compression tend toward chondroblastic lineage and cartilage is formed
Describe stress protection and how to avoid it
Inadequate amounts of stress is imparted to the fracture site so cell aren’t stimulated to propagate and differentiate (healing is retarded)
Avoid limiting strain to less than 1-2%
Rule of thumb - simple fracture with a few to several millimeters of gap or comminution can tolerate 5-10% strain
Using axial strain as an example define strain
Strain is a measure of the amount of motion relative to the span over which the motion occurs.
Axial strain is the degree of compression across a gap
The decrease in the width of the gap divided by the total width of the gap
Describe the ideal relationship of stiffness to load ( aka activity level)
Linear
At low load (activity) levels stiffness should also be low (i.e. some movement at fracture site)
As load level increases stiffness should increase
According to Tobias the two predominant forces of the skeleton
Compressive and tensile (bending is a combo of both - compression on the concave aspect and tensile on the convex aspect)
Which force acting on a fracture is least tolerated
How is this force generated with oblique vs transverse fractures?
Shear
Oblique in axial load
Transverse in rotation load
What is the clinical enigma of the term delayed union
It assumes eventual healing - which can’t be guaranteed until it has or has not healed
Negative intrinsic factors associated with bone healing
Diaphyseal cortical bone, decreased/compromised vascularity of the periosteum, sparse soft tissue attachments, aged and or ill patient
Negative extrinsic factors associated with bone healing
ORIF (approach, lavage, removal of hematoma etc.. all clear out the cellular and humoral components of early healing)
Armament - some less biologic than others (plate luting for e.g.)
Reaming
What is the principle cell type of early bone healing and what is an important source of this cell type
Mesenchymal stem cell and the cambium layer of the periosteum is an important source. They are richest in areas of thick and vascular periosteum
What is a delayed union?
A prolongation in time for fracture healing. This time will vary depending on intrinsic and extrinsic factors.
Whats the most common cause of delayed union
Intrinsic factors of the patient and or fracture. Regardless of root cause results in inadequate cellular activity
Two broad categories of Non-unions and broad characteristics of each
Viable - biologic environment is adequate (which may or may not be noted via evidence of healing on x-rays) so healing can occur with improved fixation
Non-viable - Biologically inactive so that osteosynthesis cannot occur even with adequate fixation.
Types of viable non-unions
Hypertrophic (elephants foot/horses foot) and Oligotrophic
Hypertrophic non-union - appearance, most likely cause and treatments
Considerable callous on either side of the fracture line.
Typically due to excessive motion at fracture site
Debride fibrous tissues at fracture site, re-establish communication with medullary canal of bones.
Consider bone graft
Rigid fixation with dynamic compression is recommended to ensure an axial load is preferred (not shear)
Oligotrophic non-union
Hard to diff from non-viable on rads because its defined as viable non-union without radiographic evidence of biologic activity.
Problem here is both instability and disrupted cellular activity. Loose cerclage is common culprit
Gotta improve stability, remove loose shit and give cellular activity a boost - graft
Types of non-viable non-unions
dystrophic, necrotic, defect, atrophic
Dystrophic non-union
Non-viable bone on one or both sides of fracture. Compromise to the blood supply has occurred so there is no living bone tissue on the ends.
Necrotic non-viable non-union
Implies a sequestrum
Defect non-viable non-union
Gap too big. Gets filled with with tissue other than living bone. Typically fibrous tissue or muscle
Atrophic non-viable non-union
Usually a result of a defect non-viable non-union. Body resorbs dead bone without a healing or restorative process.
Components of a necrotic non-viable non-union
Sequestrum - the dead non-viable piece of bone inhibiting complete healing
Involucrum - the new bone grown surrounding the sequestrum
Treatment recommendations for Atrophic non-viable non-union
Remove all non-viable bone and regenerate new bone -
Rigid fixation and stimulation of regeneration via autologous cancellous graft, commercially available growth factors (rhBMP-2 or -7) with suitable matrix material, or distraction osteogenesis.
Challenging, guarded prognosis and relatively higher complication rate so amputation often chose
Additional ways to stimulate bone regeneration/growth
Extracorporeal shock wave, pulsed magnetic field, low-intensity ultrasonongraphy
Tissues within a callous from most to least tolerant to strain
fibrous tissue, cartilage and lastly bone
T or F
Small strains encourage healing in small fracture gaps?
False
30% strain was better than 7% for 1mm gap
