Case Presentation 1 - Non Union Shaft of Femur Fracture

Case Presentation

Prabin Maharjan 20 years / male  Sindhuli

C/C –Pain on thigh left side for 18 months

HOPI – He was apparently well until 18 months back when he was involved in a RTA while riding a truck which collided with another truck and his knee struck against the dashboard.

Following that he had pain in mid thigh and hip joint on left side , Bone was punctured out through a wound on mid thigh .Thigh was deformed .

There was a cut injury on chin and eye . He has transient Loss of Consciouness.

He was transported on a police vehicle and taken to BPKIHS,Emergency Department .He was lifted by 4 people on extremities and put on ampulance.

At BPKIHS ,

IV Cannula opened ,CBC ,Blood grouping , RFT sent

X-ray

            Chest AP

            C-spine Lateral

            Pelvis – AP – Hip dislocation rt side

            Rt Femur – AP/Lat – Rt SOF fracture

Immediate Hip Relocation 4 hours after dislocation

Rt Long leg posterior Slab Applied

Inj. TT 1 ampoule im

Inj .Taxim 1 gm IV stat

Inj. Genta 1 Ampoule IV stat

Admitted in Orthopaedic ward for 4 weeks .

IV antibiotics continued

Blood transfusion was done , 4 Pints given.

Closed reduction for hip dislocation was done.

IMIL done for SOF Lt side. Wounds on chin healed spontaneously.

After 2 months , implant failure

At 2 ½ months he underwent refixation with IMIL .

Touch Weight bearing was given at 5 months and walked on crutches. He had persistent pain on mid thigh.

At 18 months ,He was diagnosed as Non union and comes to our centre for further management.

Functionally ,

Walks on crutches with touch weight bearing

Lying on same side painful

Able to Sit , use commod for toilet and dressing.

Past history – No known drug allergy and other medical and surgical illnesses. Not under NSAIDS.

Family and Socioeconomic Status – He lives in a joint family. 5 Members in family- Two brothers and his parents. Good exposure of Sun light. He lives in first floor.

Personally – He does not have habit of drinking alcohol and smoking .

On Examination

G.C. –Fair , apparently healthy looking

Conscious well oriented to time place and person

Co-operative during examination

Average build up

Vitals stable

Pallor Icteric Lymph nodes ,

Systemically well

Chest

CVS

P/A

MSK

Walks on crutches

Able to squat

LE Rt Side

Normal Alignment

No particular Attitude

Inspection

            Scars

             Lt Gluteal region – scar from GT to proximally oriented around 4 cm long healed scar

            Mid Thigh – healed scar of lateral approach surgical approach

            No LLD

            Quadriceps Wasting

Palpation

            Temperature – normal

            Scar are non –tender , mobile and non adherent to underlying structures , tinel’s sign negative          over scar

            Tenderness on mid thigh

            No abnormal mobility of AP and lateral plane

            Draining lymph nodes not palpable

Movement                                           Rt Hip

Flexion / Extension                              90/0

IR/ER                                                   20/20

Abduction/adduction                           30/10

                                                            Rt Knee

Flexion /Extension                               110/0

Measurements

0.5 cm longer on affected side

3 cm quadriceps wasting

Special tests

Trendelenburg test – positive

Telescopic test – negative

Tripod side –   Negative

SLRT – Negative

Impression – Non union shaft of Femur Lt side

What might be causes of non union

Multiple time intervention – devascularization of bone

Investigations

CBC, ESR

X-Rays – Pelvis AP , with B/L hips already done

Xray Femur Rt Side  - AP , Lat

X-ray Rt knee AP , Lat

Traction X-rays – To see length of proximal fragment for fixation not done in painful .

Management of Hip dislocation

Histroy and physical examination

Pain management

Emergency Relocation of Hip

Assessment – Stability

                        DNVS

Investigation

X-ray Pelvis to – B/L Hip joints AP to see concentric reduction

CT Hip if not concentric

Complications

AVN of femoral head

Degenerative arthritis (cartilage loss during trauma )

Difference of Delayed Union vs . Non union

Delayed Union	Non union
Painless	Painful
No mobility	Mobile
No tenderness	Tender
Some continuity at fracture site	No continuity at fracture site

Delayed Union – healing not advanced at average rate for location and type of fracture .

Treatment

1)      Cast

            UE – Allow  exercise of shoulder and fingers

            LE – weight bearing cast for 4-12/52

2)      Ext Ultrasound

3)      Electrical Stimuli

        

Non union- US FDA panel defined Non union is established when minimum of 9 months have elapsed since injury and fracture shows no visible progressive signs of healing for 3 months.

Consider Non –union

            For Long Bone – 6 months

            For NOF – 3 months

Non union common in following circumstances

1)      Local Factors

            Open fracture

            Infected Cases

            Segmental Fracture

            Communited Fracture

2)      Host Factors

Immunocompromised –DM ,Anaemic

Smoker

Drugs – NSAIDs

3)      Surgeon’s Factor

Insecurely Fixed

Immobilization for insuffient time

Treated by ill advised open reduction

Distracted mode

Irradiated bone

Management

Manage metabolic and nutrional factors

Stop tobacco , NSAIDs

Non surgery

1)      Electrical and electromagnetic stimulation

2)      Ultrasound

3)      Bone grafting

4)      Rigid Fixation –Dynamization , removal of static screws

5)      Ilizarov

Bone grafting Tecniques

Onlay bone grafting

Dual onlay Bone grafting

Cancellous bone grafting

Free vascularized bone grafting

Massive sliding graft

Intramedullary sliding graft

Intramedullary fibular grafting

BMPs

Bone graft properties

Osteoconduction

Provides passive porous scaffold to support direct bone formation

Calcium Sulfate , Cermics , Clacium Phosphates cements , collagen , bioactive glass , synthetic polymers

Osteoinduction

Induces differentiation of stem cells into osteogenic cells

Demineralized bone matrix ,BMPs , growth factors , gene therapy

Osteogenesis

Provides stems cells with osteogenic potentiality while directly lays down new bone.

Bone marrow aspirate

Combines

Provides more than above mentioned properties combined.

Structural integrity

Fibular strut grafting .

Low Intensity Ultrasound (30 MW/CM² )

Stimulates gene involved in inflammation and bone regeneration

Chondrocyte stimulation and increase blood flow

            Successful in 70 -73 percent cases.

            20 minutes once a day

ESWT

Electric and electromagnetic stimulation /TENS

            Implantation of electrode

            Inductive coupling

            Recreate Helmholtz configuration

Management of Infected Non-union

1)      Convetional /Classic

2)      Active Method

3)      Pulsed Electromagnetic Field

4)      Ilizarov

5)      Medical management

            Vitk , Matriheal

6)      Semi Invasive – PRP / Stem Cells

Conventional Method

Aim- to convert infected and draining non-uinion to a one that has not drained for several months Skin made as near normal as possivle.

3 operations carried out

            1 Wound debridement

            2 Fixing fracture laterally

            3 Split thickness skin graft  / rotational flap

Active Treatment

Aim is to obtain union early , shorter period of convalescence and preserve motion inadjacent joints.

Restore bony continuity

Ex. Fixator /Int. Fixator application

Suction drain

STSG

Success – 83 – 98 %

PMMA Antibiotics bead

Tobramycin and gentamycin mixed with bone cement.

Voriconazole added for yeast infection .

Not to add quinolones , delay bone healing. Cancellous bone grafting with antibiotics are described but graft in infection is questionable.

Ilizarov

Monofocal

compression

Sequential distraction and compression

Dsitraction

Sequential compression and distraction .

Bifocal

Compression – distraction lengthening

Distraction –compression transport (bone transoport )

Trifocal

Various combinations

Non union Tibial Shafts