CASE REPORT

MAY 2014

NON UNION FRACTURE

LEFT RADIUS ULNA

By:
Izzad bin Azlan C 111 08 793
Advisors:
dr. Arnold Darmawan
dr. Aries Freddy Hutabarat
Supervisor:
dr. M Petrus Johan, SpOT

Orthopedic and Traumatology Department

Hasanuddin University
Makassar
2014
1

PATIENTS IDENTITY

I.

NAME

: Mrs. A

AGE

: 51 years old

GENDER

: Female

MR

: 392356

DATE OF ADMISSION

: 28th April 2014

HISTORY TAKING
CHIEF COMPLAINT: Cannot move her left forearm normally.
Suffered since 1 year ago. The patient has a history of fallen from a motorcycle. During
that, the patient has no visible wound on her forearm. The patient has a history of going
to bone setter to alleviate the symptoms but to no avail.
The patient went to the hospital for further treatment and her forearm is applied with a
cast splint. After 3 months, the cast splint was removed and the patient still cannot move
her forearm normally.

II.

PHYSICAL EXAMINATION
A. GENERAL STATUS
Conscious/ Over-nourished, height = 153cm, weight = 63kg (BMI = 26.9kg/m)
Vital Signs
Blood Pressure

: 120/80 mmHg

Pulse Rate

: 88 bpm

Respiratory Rate

: 20 bpm (thoracoabdominal)

Temperature

: 36.8 C (Axillary)

B. LOCAL STATUS (Left Forearm Region)

Inspection:
Deformity (+), angulation at the left antebrachii. Swelling (+) False joint (+)
Palpation:
Pain (-) Sensibility is normal. Pulsation of a. radialis is palpable. CRT < 2
ROM
Active and passive movement of the elbow joint and the wrist joint is in normal
range
C. CLINICAL PRESENTATION

III.

LABORATORY FINDINGS
22/04/2014

IV.

WBC

8 x 10/uL

RBG

78 mg/dL

RBC

4.1 x 10/uL

GOT

20 U/L

HB

11.9 g/dL

GPT

15 U/L

HCT

37.2 %

Albumin

4.8 gr/dL

PLT

340 x 10/uL

HbsAg

Negative

Ur

36 mg/dL

CT

830

Cr

0.7 mg/dL

BT

200

RADIOLOGICAL FINDINGS
Conclusion: Old fracture at the
1/3 media of left radius and
ulna

V.

RESUME
4

 Female, 51 years old came to the hospital with cannot move her left forearm normally
since 1 year ago. The patient has a history of fallen from a motorcycle. During that, the
patient has no visible wound on her forearm. Her forearm is applied with a cast splint.
After 3 months, the cast splint was removed and the patient still cannot move her forearm
normally.
From physical examination, deformity (+), angulation at the left forearm, swelling (+)
false joint (+). Pain (-) Sensibility is normal. Pulsation of a. radialis is palpable. CRT <
2. Active and passive movement of the elbow joint and the wrist joint is in normal range.
Normal laboratory findings.
Radiological findings shows old fracture at the 1/3 media of left radius and ulna.
VI.

DIAGNOSIS
Non-union fracture left radius ulna.

VII.

THERAPY

Planning for ORIF

NON-UNION FRACTURE

I.

INTRODUCTION
The FDA defines non-union as established when a minimum of nine months has
elapsed since fracture with no visible progressive signs of healing for three months.

II.

ETIOLOGY
Causes of non-union are: (1) distraction and separation of the fragments,
sometimes the result of interposition of soft tissues between the fragments; (2) excessive
movement at the fracture line; (3) a severe injury that renders the local tissues nonviable
or nearly so; (4) a poor local blood supply and (5) infection.
Perkins timetable is used to predict how long the fracture to consolidate and to
unite. A spiral fracture in the upper limb unites in 3 weeks; for consolidation multiply by
2; for the lower limb multiply by 2 again; for transverse fractures multiply again by 2.
There are, of course, also biological and patient-related reasons that may lead to
non-union:
Smoking
Older age
Severe anemia
Diabetes
Infection
Hypothyroidism
Poor nutrition
Associated drug abuse, anti-inflammatory or cytotoxic immunosuppressant
medication

III.

CLASSIFICATION

Non-unions are septic or aseptic. In the latter group, they can be either stiff or
mobile as judged by clinical examination. The mobile ones can be as free and painless as
to give the impression of a pseudoarthrosis. On x-ray, non-unions are typified by a lucent
line still present between the bone fragments; sometimes there is thick callus trying but
failing to bridge the gap between fracture (hypertrophic non-union) or at times none at all
(atrophic non-union) with a sorry, withered appearance to the fracture ends. They are
usually arises from impaired repair process, classified into necrotic, gap and atrophic on
X-ray.

A
A.
B.
C.
D.

IV.

Hypertrophic (elephant foot)

Necrotic
Gap
Atrophic

TREATMENT

Non-union is occasionally symptomless, needing no treatment or, at most, a

removable splint. Even if symptoms are present, operation is not the only answer; with
hypertrophic non-union, functional bracing may be sufficient to induce union, but
splintage often needs to be prolonged. Pulsed electromagnetic fields and low-frequency,
pulsed ultrasound can also be used to stimulate union.
With hypertrophic non-union and in the absence of deformity, very rigid fixation
alone (internal or external) may lead to union. With atrophic non-union, fixation alone is
not enough. Fibrous tissue in the fracture gap, as well as the hard, sclerotic bone ends is
excised and bone grafts are packed around the fracture. If there is significant die-back,
this will require more extensive excision and the gap is then dealt with by bone
advancement using the Ilizarov technique.