1. Dr (Major) Parthasarathy S
Pg Resident,MS Orthopaedics
Stanley Medical College,Chennai
Ref:Rockwood and Wilkin’s fractures in children 8th
edition
Chapman’s orthopaedic surgery 3rd
edition
Campbell’s operative orthopaedics 12th
edition
Pics courtesy : internet
2.
3. Rare 1 in 250,000 live births
Cause is unknown
Specific type of nonunion
At birth is either present or incipient
May be related to fibrous dysplasia
Neurofibromatosis closely related
Distal half of the tibia
Anterolateral bowing common
L>R
4.
5. Boyd classification:
Type1:
Ant. Bowing and defect in tibia present at birth
Other congenital deformities also present which
affect the ultimate management of the
pseudoarthorosis
6. Type2:
Most common
Often associated with NF
Worst prognosis
Ant bowing and hourglass constriction of tibia
present at birth
Spontaneous fracture or fracture following minor
trauma commonly occurs before 2 yr of age
‘’HIGH RISK TIBIA’’
Tibia is tapered and sclerotic and the medullary
canal is obliterated
7. Type3:
Develops in congenital cyst usually near the
junction of the middle and distal third of the
tibia
Ant bowing may precede or follow the
development of fracture
Recurrence of the fracture after Rx is less
common than type 2
excellent results after only one operation noted
8. Type 4:
Originates in the sclerotic segments of the bone
in classic location without narrowing of tibia
Medullary canal is partially or completely
obliterated
Insufficiency or stress fracture develops in the
cortex of the tibia and gradually extends through
the sclerotic bone
With completion of the fracture, healing fails to
occur and fracture widens and pseudoarthosis
occur
Prognosis: good to better
9. Type5:
Pseudoarthosis of tibia with dysplastic fibula
May be both bone involved
Prognosis: good if lesion confined to fibula
If progresses to tibia mostly prognosis and progression
resembles type 2
10. Type6:
Occurs in interaosseous neaurofibroma or
schwanoma that results in pseudoarthosis
rarest
11. Type 1 :
ANTEROLATERAL BOWING OF TIBIA=best prognosis
Type 2:
anterolateral bowing
increased cortical thickness
narrow medullary canal
tubular defect
Type 3:
cystic lesion
Type 4:
presence of fracture, a cyst or frank
pseudoarthosis=worst prognosis
12.
13.
14.
15.
16.
17. Refracture
Length discrepancy
Stiffness –ankle & subtalar jt
Progressive angulation of tibia
Ankle valgus
18. Resection of the pseudarthrosis
Correction of length discrepancy and axial
deformity
Achievement of fusion
Correction of additional problems around
the main deformity
Alignment
leg-length discrepancy
ankle valgus
19. Bone grafting alone
Prophylactic before a # occurs in bowed tibia
Mc Farland technique
Long corticocancellous graft from opposite tibia
placed posteriorely
Spanning the normal biomechanical axis
Concomitant curretage for cystic lesion
20. Excision of pseudoarthrosis
Deformity correction
Rigid internal fixation + bone grafting
Transfix ankle & subtalar jt to stabilise distal
tibial fragment
These jts progressively freed with growth &
prox migration of rod
Absence of significant stiffness
Extentable rods + bone graft
Not removed till skeletal maturity
21.
22. Implanted direct current bone growth
stimulator/external device with pulsating
EMF
Increases success rate of bone graft +
internal fixation
25. Advantages
Provides excellent stability
Allows complete resection of the
pseudarthrotic
Enables weight bearing during the whole time
of treatment
Transport the fibula distally
Does not prohibit other treatment methods if
this method fails
26. Disadvantages
Time-consuming
Not easy to perform
complications
pin track infections
Fracture
Ankle valgus
Ankle stiffness.
27.
28.
29. Anticipated shortening of more than 2 or 3
inches (5 to 7.5 cm)
Multiple failed surgical procedures
Stiffness and decreased function of a limb
that would be more useful after an
amputation and fitting with a prosthesis
32. Most established pseudarthroses
Initial treatment should be INTRAMEDULLARY
RODDING AND BONE GRAFTING+- ELECTRCAL
STIMULATION
Vascularized fibular grafts/Ilizarov
With gaps of more than 3 cm
Multiple surgical procedures have failed
33.
34. Rare
Precedes or accompanies the same
condition in the ipsilateral tibia
Several grades of severity
Bowing of the fibula without pseudarthrosis
Without ankle deformity
With ankle deformity
With latent pseudarthrosis of the tibia
It even develops between the time of
successful bone grafting of a pseudarthrosis of
the tibia and skeletal maturity=the lateral
malleolus becomes displaced proximally, a
progressive valgus deformity of the ankle
develops
35. Until skeletal maturity is reached=ankle-
foot orthosis
At maturity= supramalleolar osteotomy
36. For children to prevent valgus deformity or
progression = Langenskiöld operation
Synostosis between the distal tibial and
fibular metaphyses
An operation that prevents the ankle
deformity without grafting in fibular
pseudarthrosis is useful
37.
38. Rare
Failure of normal ossification
Unknown etiology
B/L rare
Right > Left
Not associated with neurofibromatosis
Autosomal recessive inheritance
39. Subclavian artery compress the developing Rt
clavicle
Explains the Rt predominance
Dextrocardia Lt lesion
Failure of 2 ossification centers to fuse
40. Prominent middle third clavicle
Increase with age
Not painful
Shoulder ROM normal
Radiograph : osseous seperation with
enlarged rounded bone ends and absence of
callus
No classification
41. Prominent/painful
Pseudoarthrosis resection and bone
grafting/plating –simple resection causes
shoulder to droop
Arm sling 6 weeks
Complications
Hypertrophic scar
Infection
Non union
Neurovascular injury
Bone graft donor site morbidity
42.
43.
44. Rare
Associated with neurofibromatosis
Etiology unknown
Progressive forearm deformity
Forearm short bowedradial head dislocates
Motion usually not affected
No classification
45. Pain and progressive deformity
Resection of pseudoarthrosis and free
vascularised fibular graft +- bone graft
Complications
Recurrence
Difficult union
If recurs & regraft fails = one bone forearm