Fracture: Malunion fundamentals

"Malunion" is a clinical term used to indicate that a fracture has healed, but that it has healed in
less than an optimal position. This can happen in almost any bone after fracture and occurs for
several reasons.
Malunion may result in a bone being shorter than normal, twisted or rotated in a bad position, or
bent. Many times all of these deformities are present in the same malunion.
Malunions can also occur in areas where a fracture has displaced the surface of the joint. When
this happens, the cartilage in the joint is no longer smooth. This may cause pain, joint
degeneration, "post-traumatic arthritis" or catching or "giving-way" episodes resulting from
instability or incongruency of the joint.

What are the symptoms?

Swelling
Pain

Tenderness

Deformity

Difficulty bearing weight

What are my treatment options?

In almost all situations, treatment involves cutting the bone, at or near the site of the original
fracture. The cut or osteotomy is done to correct the mal-alignment. In addition, some secure
method of fixation must be used to hold the bones in the desired position. This fixation may
require plates, rods, or an external frame with pins.
Malunions that include shortening of the bone often require some method for bone lengthening.

What are the risks of surgery?

Risks include nerve injury, infection, bleeding, and stiffness.

How do I prepare for surgery?

Complete any pre-operative tests or lab work prescribed by your doctor.

Arrange to have someone drive you home from the hospital.

Refrain from taking aspirin and non-steroidal anti-inflammatory medications (NSAIDs)

one week prior to surgery.

Call the appropriate surgery center to verify your appointment time. If your surgery is
being done at Cleveland Clinic, call 216.444.0281.

Do not eat or drink anything after midnight the night before surgery.

What do I need to do the day of surgery?

If you currently take any medications, take them the day of your surgery with just a sip of
water.
Do not wear any jewelry, body piercing, makeup, nail polish, hairpins or contacts.

Leave valuables and money at home.

Wear loose-fitting, comfortable clothing.

What happens after surgery?

Elevate your upper body while you sleep and take acetaminophen for pain. If wearing a cast,
apply heat to the injured area to improve blood circulation and promote healing. After the cast is
removed, massage the injured area with ice.
Finally, follow a nutritious diet and exercise the non-affected muscle groups to maintain your
overall health during the recovery process. Most importantly, avoid smoking, as nicotine has
been shown to inhibit fracture healing. Additionally, avoid, if possible, radiation therapy,
chemotherapy, NSAIDs and systemic corticosteroids, as all of these treatments are known to
slow the bone-healing process.
Ask your surgeon for complete post-operative instructions.

How long is the recovery period after surgery?

Your doctor will use an X-ray to determine whether the fracture has fully healed. The X-ray will
determine how long the recovery is.

What is the rehab after surgery?

Your doctor will provide instructions regarding weight bearing and physical therapy.

How can I manage at home during recovery from the procedure?

Activity at home will depend upon your doctors instructions.

Tibial Malunion ICD-9

733.81 (Malunion of fracture)

733.82 (Nonunion of fracture, pseudoarthrosis)

Tibial Malunion Etiology / Epidemiology / Natural History

>5 angulation has been shown to cause subjective complaints and functional limitations
(Kyro A, Ann Chir Gynaecol 1991;80:294).
Tibial malunion leads to degenerative changes in the knee and ankle (van der Schoot DK,
JBJS 1996;78Br:722).
Coronal plan angulation alters lower extremity alignment anc can contribute to
ligamentous laxity.

Tibial Malunion Anatomy

Size ranges from 30-47cm in adults, intramedullary diameter =8-15mm

Proximal tibia has average 15 degree apex anterior angulation

Radius of supramalleolar curvature is approximately 20cm, ie medial surface turns

medially @25degrees.

Diaphyseal blood supply is via a single nutrient artery, the proximal branch of the
posterior tibial artery which passes through the most proximal portion of the tibialis
posterior to obliquely enter the tibial shaft on its posterior surface in the proximal portion
of the middle third of the bone. Only peripheral 1/3-1/4 of diaphyseal cortex is supplied
by periosteal vessels.

Fibula bears 6-17% of body weight, fibular head is attachment for LCL and biceps
femoris, common peroneal nerve wraps around fibular neck.

Interosseous membrane fibers run downward and laterally

Tibial Malunion Clinical Evaluation

Evaluate limb alignment and knee /ankle ligamentous exam

Document NVexam

Tibial Malunion Xray / Diagnositc Tests

Full-length standing xrays with beam centered at the knee (beam directed at the patella
from @10ft away) indicated to determine mechanical axis and joint orientation.
A/P and lateral views of the tibia.

Tibial Malunion Classification / Treatment

Nonsurgical: unloading knee braces, shoe orthoses, shoe lifts, NSAIDs.

Surgical correction is indicated for: ligamentous instability on the convex side of the
deformity, leg-length discrepancy >2cm, inability to place the foot in a plantigrade
position, unicondylar knee arthritis, >10 varus deformity at knee or ankle, >15 valgus
deformity at knee or ankle, or 20mm medial shift in the mechanical axis.

Closing wedge osteotomy

Opening wedge osteotomy

Dome osteotomy

Oblique cut osteotomy: (Rab GT, JPO 1988;8:715), (Sanders R, JBJS 1995;77A:240),
(Sangeorzan BJ, JOT 1989;3:267), (Sanders R, JBJS 1996;78:151).

Distraction Ostogenesis: (Tetsworth KD, CORR 1994;301:102).

Talor Spatial frame (Feldman DS, JOT 2003;17:549).

Clamshell Osteotomy: (Russell GV, JBJS 2009;91A:314).

Tibial Malunion Associated Injuries / Differential Diagnosis

Knee arthritis
Ankle arthritis

Tibial Malunion Complications

Nonuion
Malunion

Wound dehiscence

Hardware failure

Peroneal Nerve palsy

Compartment Syndrome

Tibial Malunion Follow-up Care

Post-op: Apply bulky Jones dressing with posterior mold to avoid equinus contracture.
Elevate. Consider DVT prophyaxis.

7-10 Days: Remove splint, wound check. WBAT, PT, knee, ankle mobilization based on
fracture stability / soft tissues.

6 Weeks: Xrays. Advance PT

3 Months: Xrays. Consider bone stimulator/nail dynamization if union is not evident.

Sport specific PT.

6 Months: Return to full activities

1Yr: follow-up xrays, asssess outcomes.

Tibial Malunion Review References

Malunion Fractures
After a bone is broken (fractured), the body will start the healing process. If the two ends of the
broken bone are not lined up properly, the bone can heal with a deformity called a malunion. A
malunion fracture occurs when a large space between the displaced ends of the bone have been
filled in by new bone.
With fractures in the hand, wrist and forearm, a certain amount of angulation, or bend, occurs
when the bone heals. Doctors determine if the position of a fracture will allow for functional use
of the hand or arm after it heals. In many cases, when a fracture heals in a position that interferes
with the use of the involved limb, surgery can be performed to correct it.
Some examples of common upper extremity fractures that may result in malunion include
fractures of the wrists (distal radius), hand bones (metacarpals), and fingers or thumbs
(phalanges).
If you fractured a finger, hand, wrist or elbow, and it has healed but no longer functions well, you
should seek an opinion from a doctor who knows the upper extremity of the body well.
For decades the University of Michigan Department of Orthopaedic Surgery -- one of the oldest
and most well-regarded orthopaedic units in the nation -- has provided excellent treatment for
malunion fractures.

Our goal is to restore you to pre-fracture function as much as possible, as well as improve your
long-term bone health. We are also part of the American Orthopaedic Association's Own the
Bone Program to improve the care of fracture patients age 50 and up.
In addition, the University of Michigan is a Level 1 Trauma Center, which means you
will receive the highest level of care by experts who regularly treat patients with complex
fractures and multiple bone breaks.

Symptoms
These symptoms usually occur after the healing of the initial fracture/break:

Angulation (bend) and/or rotation of the fractured bone.

A wrist that does not flex or extend to allow normal use.

A finger that scissors onto or away from an adjacent finger.

Altered use or function of the involved limb.

Stiffness in finger, hand, wrist or elbow.

Diagnosis/Treatment

History and physical exam: Your doctor or mid-level health care provider
will obtain a history of your problem and perform an appropriate physical
exam to find the exact area of concern.
Imaging: Usually, imaging of the site in question begins with X-rays. If more
information is needed, your doctor or mid-level provider may order a CT Scan
or an MRI.
Surgery: The goal of treatment is to realign your bone in a position that
improves the function of the upper extremity. While you are under anesthesia
in the operating room, your surgeon will re-break the bone to realign the
fracture. Depending on the type of malunion, some of the bone may need to
be trimmed to allow for proper orientation of the fractured ends. To keep the
straightened bone in proper alignment, your surgeon may insert screws,
plates, and/or pins. Additionally, the surgeon may perform a bone graft to aid
in fracture healing.

Pre-operative Care
If a decision for surgery is made after seeing one of our Orthopaedic Hand Surgeons, you may
require pre-operative medical clearance by our Anesthesia department or your Primary Care
Provider. This depends on your other chronic medical conditions. Your surgeon will let you know
if this clearance is necessary.

Post-operative Care
Your physician will give you specific instructions. In general:

After surgery, you will be placed in a post-operative dressing/splint which you

must wear until your first post-operative visit with one of our providers. You
must keep the dressing CLEAN and DRY to avoid risk of infection and other
wound healing complications.
Someone should be with you for the first 24 hours after surgery.

You will be given a prescription for post-operative pain medicine. Do not take
it with other pain medicines unless directed by your doctor. Do not drive,
drink alcohol or make important decisions while taking the pain medicine.

Do not smoke, use smokeless tobacco, nicotine gum or nicotine patches.

Nicotine is a vasoconstrictor, and can impede healing by limiting blood flow
to the surgical site(s).

You must remain non-weight bearing (no use) with the surgical hand and arm
until cleared by one of our health care providers. This may be several weeks,
depending on your healing.

At the first post-operative visit, your stitches will be removed. You will be
placed in either a cast or a splint, depending on your surgeons preference. If
your cast becomes wet or soiled, you should come into the office for a new
cast as soon as possible.

To evaluate the healing of the fracture at your follow-up appointments, your

doctor will order imaging such as X-rays or a CT scan.

After several weeks of immobilization, you will probably be stiff and weak in
your hand / wrist. We often send patients to an Occupational Therapist with
the goal of regaining functional use of the operative hand. Remember: You
are an active participant in your care, and part of your recovery depends on
your desire to participate in occupational therapy.

Mal union
Malunion adalah keadaan dimana fraktur menyembuh pada saatnya, tetapi terdapat
deformitas yang berbentuk angulasi, varus/valgus, rotasi, kependekan atau union secara
menyilang misalnya pada fraktur radius dan ulna.
Etiologi :
Fraktur tanpa pengobatan, pengobatan yang tidak adekuat, reduksi dan imobilisasi yang
tidak baik, pengambilan keputusan serta teknik yang salah pada awal pengobatan, osifikasi
premature pada lempeng epifisis karena adanya trauma.
Gambaran Klinis :
Deformitas dengan bentuk yang bervariasi, gangguan fungsi anggota gerak, nyeri dan
keterbatasan pergerakan sendi, ditemukan komplikasi seperti paralysis tardi nervus ulnaris,

Osteoartritis apabila terjadi pada daerah sendi, bursitis atau nekrosis kulit pada tulang yang
mengalami deformitas.
Radiologis :
Pada foto roentgen terdapat penyambungan fraktur tetapi dalam posisi yang tidak sesuai
dengan keadaan yang normal.
Pengobatan :
Konservatif dilakukan refrakturisasi dengan pembiusan umum dan diimobilisasi sesuai
dengan fraktur yang baru,pada pasien malunion yang masih terbentuk fase subkalus. Apabila
ada kependekan anggota gerak dapat dipergunakan sepatu ortopedi. Operatif dilakukan
osteotomi koreksi (osteotomi Z) dan bone graft disertai dengan fiksasi interna, atau dengan
osteotomi dengan pemanjangan bertahap misalnya pada anak-anak, atau dengan osteotomi
yang bersifat baji.