nonunion

Distal Tibial Fractures

Definition

Metaphyseal

Extra-articular

Intra-articular Extension

Indications

< 60 with good bone stock and preserved joint space

Reduction

Union rates increased with anatomical reduction

Options

- closed reduction

- open reduction / if closed reduction fails

Accept

- no varus

- < 15^o valgus

- < 10^o AP plane

Definition

Non-union

- arrest of progression to union at fracture site 

- > 6-9 /12

- no visible progressive signs of healing for at least three consecutive months

- individualise for each fracture

- when the surgeon believes the fracture has little or no chance to heal

Delayed union

- failure of fracture to unite within expected time

- still may spontaneously unite

Mechanism

Direct blow

- most common

Indirect

- forced knee flexion with foot fixed / maximally contracted quadriceps

Types

1.  Vertical

2.  Transverse

Epidemiology

Usually young patients

- 15 - 40

15% compound

Aetiology

High velocity injury

- MBA

- MVA

- pedestrian v car

- fall from height

Emergency Managment

EMST principles

- need for transfusion not uncommon

Acute management

Resuscitation

EMST

Neurovascular assessment

Investigations - exclude Pipkin, NOF

Emergent reduction / skeletal stabilisation

Assess stability

Re-evaluate sciatic nerve

Insertion Femoral Steinman Pin

Indications

- displaced acetabular fracture

Epidemiology

Most common long bone fracture

Aetiology

Young patients / sports

Elderly / simple falls

MVA - often compound

Tscherne Soft Tissue Classification

Grade 0

- nil ST injury

Grade 1

Definition

Fracture which extends between the trochanters of the proximal femur

- lower limit is inferior border of lesser tuberosity

Anatomy

Extra capsular / well vascularized

The key to stability is the posteromedial cortex

AVN  

Largely related to degree of displacement

Incidence

Hawkins Type I

- 0% to 13% 

Hawkins Type II 

- 20% to 50% 

- usually only patchy and not a problem (rarely collapses)

Biomechanics

Able to achieve relatively high level of function after STJ fusion

- previously believed that isolated STJ fusion should not be performed

- believed that triple arthrodesis was operation of choice for hindfoot

- STJ fusion has superior result with less stress on AJ

Average loss of DF 30% / PF 10%

Position of hindfoot determines flexibility of transverse tarsal (CCJ & TNJ) joints

- imperative that fusion be positioned in ~ 5^o valgus