Netter’s Sports Medicine PDF
Netter’s Sports Medicine is Netter’s Sports Medicine is a that is designed to help you with the challenges that presented by patients in this growing field.
Treatment of the nonunion is dependent on the etiology. Hypertrophic nonunions as a result of inadequate stability can be treated with revision surgery with a stiffer construct to reduce the strain and motion at the fracture site. Patients with metabolic or endocrinologic issues should be identified by laboratory values including serum calcium, phosphorus,
alkaline phosphatase, 25-hydroxy-vitamin D, and thyroid-stimulating hormone levels.
Patients with abnormalities should be referred to an endocrinologist for further workup and treatment. An infection workup should be performed to rule out indolent infection. This includes a blood count with differential, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP). An aspiration or open biopsy should also be considered.
Management of an infected nonunion is often complex but includes debridement and antibiotics. Certain atrophic nonunions can be supplemented with various types of bone graft, including autograft, allograft, demineralized bone matrix (DBM), bone morphogenic protein (BMP), synthetic bone graft, and stem cells.
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Patients with a hypertrophic nonunion have adequate blood supply to the fracture site, but may have too much motion at the fracture site. Atrophic nonunion is frequently caused by other factors including insufficient vascular supply to the fracture site or host factors leading to poor healing. Oligotrophic nonunions have adequate vasculature and biologic capacity to heal, but callus formation does not occur due to displaced or distracted fracture fragments and inadequate apposition.
Nonunions can occur for a number of reasons. First, if there is inadequate stability of the fracture site, excessive motion leads to connective tissue deposition rather than fracture healing. Second, host or patient-dependent factors, such as poor nutrition, smoking, low vitamin D levels, hypothyroidism, and hypogonadism, can lead to inadequate healing capability. Third, inadequate vascular supply to the fracture fragments and surrounding soft tissue envelope is necessary for healing. Lastly, infection at the fracture site will prevent
Articular or hyaline cartilage is found on joint surfaces and functions to decrease friction and dissipate axial forces. Fibrocartilage is found at tendon and ligament insertions to bone and is also formed in response to articular cartilage injury. Elastic (trachea) and fibroelastic (the meniscus) are the other two types of cartilage.