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CHAPTER38
DELAYEDUNION,NONUNION,AND
MALUNION
DAVIDM.NUNAMAKER,FREDERICW.RHINELANDER,ANDR.BRUCE
HEPPENSTALL

DelayedUnion
Nonunion
Malunion
Inadequateresponsetothefractureinjurysometimesoccurs,resultingindelayedunionor
nonunion.Mostfractures,ifleftcompletelyalone,wouldprobablyhealbutwithsuch
malunionthatfunctionmightbelost.Theroleoftheclinicianistopromotefunctional
fracturehealing.Thischapterisdesignedtodiscusstheproblemsthatsometimesoccurwith
fracturetreatment,thereasonsfortheseproblems,andsomemethodstoovercomethem.
SincethetimeofHippocratesithasbeenadvocatedthatimmobilizationoffracturestosome
degreeoranotherisadvantageoustotheireventualunion.Thetypeandextentofimmobility
varywiththeformoftreatmentandmayplayanimportantpartintheoverallresult.Ithas
beenestimatedthatofthenearly2millionfracturesthatoccuryearlyinhumans,nearly5%
becomenonunions.(23)Inthedog,nosuchstatisticsareavailable.Clinicalpractice,however,
showsthatdelayedunionandnonunionarenotuncommonproblems.(39)
DELAYEDUNION
Innormalfractures,acertainamountoftimeisrequiredbeforebonehealingcanbeexpected
tooccur.Thisnormaltimemayvaryaccordingtoage,species,breed,boneinvolved,levelof
thefracture,andassociatedsofttissueinjury.Delayedunion,bydefinition,ispresentwhenan
adequateperiodoftimehaselapsedsincetheinitialinjurywithoutachievingboneunion,
takingintoaccounttheabovevariables(Fig.381).Thefactthataboneisdelayedinitsunion
doesnotmeanthatitwillbecomeanonunion.Nonunionisoneendresultofadelayedunion,
andthedifferentiationbetweenthetwoissometimesdifficulttomake.Classicallythestated
reasonsfordelayedunionareproblemssuchasinadequatereduction,inadequate
immobilization,distraction,lossofbloodsupply,andinfection.
Inadequatereductionofafracture,regardlessofitscause,maybeaprimereasonfordelayed
unionornonunion.Itusuallyleadstoinstabilityorpoorimmobilization.Inaddition,
inadequatereductionmaybecausedbysuperimpositionofsofttissuesthroughthefracture
area,whichmaydelayhealing.Softtissuedisruptionusuallyleadstolossofvascularsupply
atthefracturesite.Inwellmuscledareas,thisvascularsupplymayreturnquickly.Inother
areas,suchasthedistalthirdoftheradiusandulnainthedog,inwhichlittlemuscleis
present,thisvascularsupplymaynotreturn.
Inadequateimmobilizationmayresultinbiomechanicalaswellasphysiologicproblems
associatedwithfracturehealing(Fig.382).Perren,inarecentpublication,stateshis
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hypothesisregardingtheproblemsassociatedwithrelativemotionatthefracturesite.(30)His
concernaboutthetoleranceofrepairtissuetomotion,especiallyelongation(strain),fitsinto
whatweknowaboutthenormalcourseofclassicfracturehealing.Theinterfragmentary
strainlevelsinthetissuesofthehealingfractureshowthatsmallgapsrequireverylittle
motiontodisruptthetissue,whereaslargergapsmayallowforlargeramountsofmotion
beforetissuedisruptionoccurs.Thistheoryaccommodatesthetwotypesoffracturehealing
thatoccursocommonlyinveterinaryorthopaedics:castimmobilizationwithrelativemotion
(classicfracturehealing)andplatefixationwithstableinternalfixation(primaryfracture
healing).Inclassicfracturehealing,thefractureendsareusuallyimmobilizedfirstwitha
hematoma,whichuntilitisorganizediscapableofaninfiniteamountofelongation.Asthis
hematomaorganizesintoafibrinclot,granulationtissueappearsinthearea.Granulation
tissuecanelongateapproximately100%beforerupture,therebyallowingearlyrelative
immobilizationofthesefracturefragmentends.Asthegranulationtissueisreplacedby
cartilage,whichhasanelongationpropertyofapproximately10%torupture,itcanbeseen
thatthefracturemustbecomerelativelymorestable.Finally,bone,withitselongationof
approximately2%torupture,fillsinthefracturegap,completingboneunion.Thusitcanbe
seenthatifthereisarelativelylargegapofmanymillimeters,thisgapcanchangeits
dimensioninitiallyuptolOO%withoutdisruptingtheearlygranulationtissue.If,infact,the
boneisheldtogetherwithamorerigidplate,thegapwouldbeconsiderablyless.Hence,the
motiontoleratedatthesiteofthefracturetoprovideingrowthofthisgranulationwouldbe
evenmorerestricted.Therefore,withthesmallgapsallowedbyrigidfixation,smallamounts
ofmotionhaveamuchmoresignificant(harmful)effectthanthesameamountofmotion
withlargegaps.Sincethephysiologyoffracturehealingfollowsthiscourse,whichisrelated
tothemechanicsofthetissueinvolved,itisimportantwhendealingwithadelayedunionor
nonuniontoascertainwhichproblemsareinvolvedtotrytoinstitutechangesinthetreatment.
Thesechangescanbeveryslight,suchasinmodificationofcastsorsplintsorimmobilization
ofthepatient,ortheycanbetheextremesofchangingthetypeoffracturetreatmententirely.
Thefactthatfracturehealingisdelayedandmayeventuallygoontounionisoftennot
sufficientreasontoallowtreatmenttocontinueaswasoriginallyinstituted.Manytimesit
willbebeneficialtothepatienttochangetheformoftreatmentsothatfunctionalhealingcan
occurmorerapidly,therebyreturningtheanimaltoafunctionallife,whileatthesametime
negatingsomeoftheproblemsofprolongedtreatment.
FIG.381Maturecanineradiusandulna6weeksafter
displacedfractureandapplicationofplastercast.(A)Final
roentgenogramsshowexternalcallustraversedbyazoneof
radiolucency,atypicalpictureoffibrocartilaginousdelayed
union.(B)MicroangiogramoftheradialfractureshowninA
revealstheavascularzonecorrespondingtothezoneof
radiolucency.Thisrepresentsaplateoffibrocartilage.(original
magnificationx4)(C)Photomicrographofhistologicsection
fromasimilarareainanotherexperimentshowstheveryactive
vascularInvasionofthefibrocartilageandthereplacementby
newboneintheexternalcallus(H&E,x125).(A,B.Yasudal:
Fundamentalaspectsoffracturetreatment.JKyotoMedSoc
4:395,l953G.RhinelanderFW,SarogryRA:
Microangiographyinbonehealing:Undisplacedclosed
fractures.JBoneJointSurg44A:l273,1962)
FIG.382Maturecanineradius6weeksafterosteotomy
andfixationwithastandardfourholeplateandscrews.(A)
Standardroentgenogramshowsextrusionofthetwo
proximalscrewswithelevationoftheplate.Theosteotomy
siteisradiolucentandisborderedbysmallmoundsof
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externalcallusinthecranialcaudalprojection.(B)
Microangiogramshowslooseningandelevationoftheplate
ontheleft,withanexcellentcorticalbloodsupply,while
thevesselsintheosteotomysiteareacongestedmass.The
cortexbeneaththetightportionoftheplate,ontheright,
containsafewsmallvesselscomingfromthemedulla.
(originalmagnificationx53(C)Photomicrographic
enlargementattheosteotomysiteshowsdebrisandfibrous
tissueadjacenttothemassofdisorganizedbloodvesselson
theright.(H&E,x52.5)(A,RhinelanderFW,Wilson
JW:Bloodsupplytodevelopingmatureandhealingbone.
InSumnerSmith(ed):BoneinClinicalOrthopaedics,Chap
2.Philadelphia,WBSaunders,1982B.C,Rhinelander
FW:Circulationinbone.InBoume(ed)TheBiochemistry
andPhysiologyofBone,2nded,vol2.chap1.NewYork,
AcademicPress,1972)
NONUNION
Asstatedabove,thedifferentiationbetweendelayedunionandnonunionissometimes
difficult.Nonunionisdefinedasthecessationofallreparativeprocessesofhealingwithout
bonyunion.Sinceallofthefactorsdiscussedunderdelayedunionusuallyoccurtoamore
severedegreeinnonunion,thedifferentiationbetweendelayedandnonunionisoftenbased
onradiographiccriteriaandtime.Inhumans,failuretoshowanyprogressivechangeinthe
radiographicappearanceforatleast3monthsaftertheperiodoftimeduringwhichnormal
fractureunionwouldbethoughttohaveoccurred,isevidenceofnonunion.(23)Thechanges
inradiographicappearancemaybeslight,andthereforeradiographsshouldbescrutinized
monthlytoseeif,infact,changeshaveoccurred.Personalexperienceswithanexperimental
modelofdelayedunionintheadultbeagleradiushaveshownunionoccurringinallanimals
between37and52weeks.Nounionsoccurredbefore37weeks,althoughradiographic
appearanceofnonunionwaspresentasdescribedbelow.Carefulradiographicevaluationdid
showchangesovera3monthperiod,however.Thus,itisdifficulttoimagineatwhatpoint
fracturehealingmayceasecompletely.
Theclinicaldiagnosisofnonunionisusuallybasedonthehistoryandphysicalfindings.The
animalmayhavesomepain,whichisusuallymild.Themostcommonsignisnonuseofthe
extremity,whichmayalsoleadtomuscleatrophy,jointstiffness,progressiveangulation,and
malalignmentofthebone.Physicalexaminationrevealsmotionatthefracturesite.
Sometimesthismotionisdifficulttoappreciate,sincethefracturemaybeincloseproximity
tothejointandthemotionmaybethoughttobewithinthejoint.Usuallywhenthereisa
nonunionclosetoajoint,thejointmotionislimited.Deeppalpationoverthefracturesite
mayyieldanexpressionofpaininthepatient,butthisisnotaconstantfinding.
Radiographicallythediagnosisofnonunionismadebythefollowingfindings:aradiolucent
linethroughthefracturesite,sealingoffofthemedullarycavitywithsclerosisattheedgeof
thefracturedbone,andbonyresorptionorregionalosteoporosisaboveandbelowthefracture
site.Theboneendsmaybesomewhatrounded,andalargehypertrophiccallusmaybe
present.This"elephantfoot"appearanceofthecallushasbeenthoughtofasoneofthe
hallmarksofnonunion.Rarely,anatrophicnonunionisseenwithoutanycallusatthe
fracturedboneends.Sometimesalargegapexistsbetweentheendsoftheboneswhilethe
bonesthemselvesmayappeartohavelittlecallusformation.Thisisusuallymorecommon
whenassociatedwithseveresofttissueinjuryoralossofvascularityinthearea.Itmaybe
morecommonwhenviewingnonunionafterinternalfixationandopenreduction.Whenin
doubtastothestructuralrigidityofthefracture,stressfilmsmaybetakentoshowangular
deformitiesthatmayoccuratthefracturesite.Onceadiagnosisiscomplete,treatmentmust
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beinitiated.Beforethisisdone,however,itisimportanttodoathoroughphysical
examinationoftheanimalandtheinjuredparttoascertainanyassociatednervedamageor
limitationsofjointsandsofttissues.Itisoftenpossiblethroughsurgicaltreatmenttoturna
nonunionintoastrongunionthatstillleavestheanimalwithafunctionlessextremity.The
purposeofcreatingaunionisforadequatefunction.Ifadequatefunctionisnottobe
expected,thetreatmentshouldnotbecarriedout.Functionalrequirementsmaydictatethe
needforothermeasuressuchasamputation.
Theincidenceofnonunioninthedogisunknown.Itiswellknown,however,thattheratesof
nonunionseemtobehigherinsmallbreedratherthanlargebreeddogsandthatcertainbones
predominate.(39)SumnerSmithandVaughanintwoseparatestudiesshowedthat
approximately60%ofallnonunionsinthedogoccurintheradiusandulna.Twentyfive
percentoccurinthetibia,and15%areinthefemur.(33,39)Therewerenohumeralnonunions
inthisstudy,buttheyarenotrareinourexperience.Nonunioncanoccuratanylevelinany
bone.
TREATMENT
Treatmentofnonunionisdirectedtowardimprovingthelocalphysiologicalandmechanical
environmenttoallowfracturehealingtoproceed.Thisisdoneinpartbyaddressingallofthe
problemsthatcausedelayedunionandnonunionasdescribedabove.Althoughmanyforms
oftreatmentfornonunionhavebeenadvocatedinthepast,weusetwomethodsthatcan
accommodatemostifnotallnonunions.
TRADITIONAL
Thefirsttechniqueisthatofcompressionplatinginwhichanopensurgicalreductionismade
ofthenonunionsite.Ifadequatereductionandalignmentofthefracturewereachieved
initiallyandsomecallusisevidentatthefracturesite,theplatemaybeappliedwithout
disturbingthenonunionsite.Compressionisappliedtotheboneendsastheplateisapplied.
Thiscompressionofsofttissueslastsonlyforashorttime,butstabilityatthefracturesiteis
obtained.Noadditionalbonegraftisneededandhealingisusuallyseenwithin6to12weeks.
Whenthebonealignmentatthetimeofoperationwasinadequate,thenonunionsiteis
disturbedandthefibrousconnectivetissueandcartilagearedebridedandthebonesrealigned
beforeplateapplication.Theuseofacancerousbonegraftforthesecaseshelpsensurebone
healing.Whenanatrophicnonunionoccurs,mostcommonlyinradialandulnarfracturesof
thetoybreeddogs,itisimportanttousecancellousbonegraftstohelpconsolidateaunion.
Weightbearingseemstoplayanimportantroleinbonehealing.Thefactthatbonesmay
growintissueculturebutfracturesdonothealinthisenvironmentleadsonetosuggest
partialthenfullweightbearingwhentreatingfracturesandespeciallynonunions.Many
clinicianshaveseenthegradualosteoporosisandresorptionofboneintheulnaandradiusof
smallbreeddogssubjectedtoprolongedcastimmobilizationandnonweightbearing.This
problem,oncebegun,maybeverydifficulttoreverse,especiallyinananimalthatisquite
contenttowalkonlyonitsotherthreelegs.Allattemptsatfracturetreatmentandespecially
nonuniontreatmentshouldhaveasagoalpartialthenfullweightbearingduringthetreatment
period.Thisdictummandatessomeformofstableinternalfixationorfunctionalcast
treatmentofthefracture
Occasionally,nonunionsoccuraftertheuseofroundintramedullarypins.Insuchcasesthe
pinmaintainsreduction,butrotatingmotionatthelevelofthefracturesitepreventsunion.
Oftenitmaynotbenecessarytochangefixationmethodsbutratheraddadditional
stabilizationwithabonegraft.Theuseofanonedgehalfthicknessiliacbonegrafthasbeen
almostuniversallysuccessfulinthesecases.Nospecialinstrumentationisnecessary,and
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resolutionofthefractureusuallyoccurswithin12weeks.Thetechniqueisdescribedin
Chapter39,BoneGrafting.
Oftenwithloosefitting,roundintramedullarypinsitisnotnecessaryordesirabletochange
fromanintramedullarydevicetoaperiostealdevice(plate),sincefurtherdisruptionofthe
vascularsupplytothebonemayoccur.Inthesecasesthereplacementwithatightfitting
intramedullarydeviceplusabonegraft(cancerousorhalfthicknessonedgeiliacgraft)may
resolvetheproblemadequately.
Rectifyingthecausesofdelayedunionandnonunioncanallowfunctionalfracturehealing.
Providingstabilitywithweightbearingandtheuseofbonegraftswhennecessarywillsolve
mostcasesofnonunion.Othermodesoftreatmentarebecomingmorepopularinthe
treatmentofnonunionsinhumansandhavebeenusedinanimals.Directelectrical
stimulationwithanelectrodeplacedintothenonunionsiteaswellasnoninvasivetechniques
usingelectromagneticfieldsandcapacitivecouplingmaychangethewaywetreatnonunions
inthefuture.Theclinicianshouldbeawareofnewmethodsbutmusttrytokeepthemin
perspective,sincegoodresultsaretheobjective.
ELECTRICALSTIMULATION
Modernuseofelectricalenergyforthetreatmentofnonunionshaditsstartin1953when
YasudafromJapandemonstratednewboneformationaroundanegativeelectrode(cathode)
followingapplicationofasmallcurrentinthemicroamperagerange,appliedcontinuouslyfor
3weeksinarabbitfemur.(37)Healsodescribedstressgeneratedpotentialsinbone.(22)Inthe
late1950sBassettandBeckerintheUnitedStatesreportedonsimilarindependentstudies
withthesameresult.(2)Intheearly1960sShamosandLavine,alsoworkinginan
independentlaboratory,reportedsimilarfindings.(36)Intheearly1960sFriedenbergand
Brightontookadifferentapproachtotheproblemanddocumentedthebioelectricalsignalsin
bone.(16)Theseweresignalsfromviable,nonstressedboneandrepresentedadifferent
electricalpotentialthatwaspresentinbone.Therefore,twoseparatetypesofelectricalsignals
orpotentialsweredescribedinbone:stressgeneratedorstrainrelatedpotentialsand
bioelectricalorstandingpotentials(2,10,16,18,22,36)
Ifboneisstressed,anegativepotentialmaybemeasuredfromtheconcavesideor
compressionsideoftheboneandapositivepotentialfromtheconvexsideortensionsideof
thebone.Itisimportanttorealizethatthesepotentialsarenotdependentoncellviabilityand
areproducedwhenevertheboneisstressed.Thesepotentialsarestillpresentevenifthebone
hasbeendecalcified.Therefore,ithasbeendemonstratedthatthepotentialitselforiginates
fromtheorganicandnotthemineralcomponentofbone.(10)
Bioelectricalpotentialsaremeasuredfromviable,nonstressedbone.Theyareabsentindead
bone.Inatypicallongbone,thediaphysealregionexhibitsanelectropositivecharge,while
thegrowthplatemetaphysealregionexhibitsanelectronegativecharge.Ifafractureiscreated
inthediaphysealregion,thenormalelectropositivechargerevertstoanegativechargeand
remainselectronegativeuntilthefractureheals,whenitagainbecomeselectropositive.(18)
Anotherimportantdiscoverywasmadeintheoppositegrowthplatemetaphysealarea,witha
fractureinthediaphysis.Undertheseconditions,thenormalelectronegativepotentialis
intensifiedandremainsthatwayuntilthefracturehashealed.Itisknownclinicallythatbone
overgrowthhasbeenassociatedwithlongbonefracturesinchildrenwhenthefracture
surfacesareproperlyrealigned.Itisprobablethattheincreasedelectronegativechargeatthe
growthplatemayaccountforthisfinding,sinceitisabsentinadultbone.
Atthetimeofpreparationofthischapter,therewerethreemajordevicesonthemarketfor
electricalstimulationofnonunionasapprovedbytheFoodandDrugAdministration(FDA)
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foruseinhumans.ThefirstisthedirectcurrentstimulatorsuppliedbyZimmer(Warsaw,
Indiana).ItwasdevelopedbyBrighton,Friedenberg,andBlackandtheresearchgroupatthe
UniversityofPennsylvaniaSchoolofMedicine.(7,8,12,13,24)Thesecondisinductive
couplingsuppliedbyElectroBiology,Inc.(Fairfield,NewJersey).Thiswasdevelopedby
BassettofColumbiaUniversityinNewYork.(3,5,6)Thethirdisdirectcurrentstimulationby
acompletelyimplantablesystemsuppliedbyTelectronicsProprietaryLtd.(Milwaukee,
Wisconsin).ItwasdevelopedbyDwyerandWickhamofAustralia.(14)
Thesemiinvasivedirectcurrentstimulatorhasdemonstratedthefollowingresultsinthe
laboratory:(1)Newboneformationoccursatthenegativeelectrode(cathode).(2)Bone
resorptionoccursatthepositiveelectrode(anode)ifitisimplantedinbone.Theanodeis,
therefore,situatedexternallytotheboneontheskinanddoesnotinterferewithosseous
metabolism.(3)Ifaconstantdirectcurrentisappliedtobone,atypicaldoseresponsecurveis
demonstrated.Currentlevelsoflessthan5uAfailtoproducenewbone.Atcurrentlevelsof
5uAto20uA,progressivelyincreasingamountsofboneareformed.However,ifcurrent
levelsofgreaterthan20uAareinduced,cellularnecrosisresultsatthecathode.(4)Iftwo
electrodesareimplantedintissues,aresistancequicklydevelopsbetweentheelectrodes,
resultinginadecreaseincurrent.Therefore,atransistorized,controlledpowerpackmustbe
usedifaconstantcurrentistobemaintainedbetweentheelectrodesastheresistance
fluctuates.(5)Variousmetalsexhibitdifferentdoseresponsecurvesatthenegativepole.
Stainlesssteelisoptimalat20uA,platinumisoptimalat5uAto20uA,silverisoptimalat
0.1uAtol.luA.(6)Iftheanodeisimplantedinbone,resorptionoccursaroundtheelectrode.
If,however,theanodeispositionedontheskintocompletethecircuit,aminimalskin
reactionmayresult.Thisisdecreasedorpreventedbymovingtheelectrodepadtoadifferent
location.Thesystemrequirespatientcooperation,sincethedeviceistranscutaneous,withthe
electrodeimplantedatthenonunionsiteandthepowersupplyandsignalgeneratorremaining
external.
Anelectricalsignalmayalsobeinducedinbonebyanelectricalfieldthatisappliedexternal
totheaffectedlimb.Theelectricalfieldiscreatedbymeansofinductivecoupling.This
methodinvolvesapplicationofexternalcoilsatthelevelofthefracturesite.Acurrent
varyingwithtimeisapplied,whichresultsinatimevaryingmagneticfieldinducingatime
varyingelectricalfield.Thebasicresearchbehindthismethodinvolvedapplyingapairof
Helmholtzcoilsbothmediallyandlaterallytothedoghindlimbtostimulatehealingofan
osteotomyofthefibulabetweenthecoils.(4)Atimevaryingelectricalfieldwasinitiatedin
thebonebyanalternatingcurrentappliedtothecoils,whichresultedinatimevarying
magneticfield.Specificsofthecircuitinvolvedapulsedurationof150us,repeatedat6Hzto
5Hz,resultinginapeakof20mV/cmofbone.Theosteotomizedfibulasubjectedtothis
treatmentfor28dayswasmechanicallystifferthanthecontrolosteotomizedfibula.(5)This
methodwasthenappliedclinicallytopatientswithnonunion.
ThecompletelyinvasivedirectcurrentstimulatorwasoriginallydevelopedbyDwyerin
Australiaforthemanagementofspinalfusions.Itinvolvescompletesurgicalimplantationof
thecathodeatthenonunionsite,aswellasimplantationofthepowerpackandanodeinsoft
tissueincloseproximitytothenonunionsite.Thepowerpackitselfisencapsulatedinapure
titaniumshellandthecathodeismadeoftitanium,whiletheanodeismadeofplatinum
(TelectronicsProprietary,Ltd.).Intheusualmanagementofnonunion,a20uAdirectcurrent
isdeliveredtoasinglecathode,whichiswrappedinahelicalconfigurationtospanthe
nonunionsite.Theadvantageofthissystemisthatitdoesnotrequirecooperationonthepart
ofthepatient.Alltheinstrumentationisburiedundertheskinandthereforedoesnotrequire
anytypeofmanipulationbythesurgeonorthepatient.(l4)
Itappearsfromareviewoftheliteraturethatallofthethreesystemsdescribedaboveprovide
asimilaroverallsuccessrateofapproximately80%to87%forthetreatmentofestablished
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nonunionsinman.Thesemiinvasivedirectcurrentsystemandtheinductivecouplingcoil
systembothrequirecooperationonthepartofthepatientandthetreatingphysician.The
completelyinvasivedirectcurrentstimulatordoesnotrequirecooperationandhasbeen
recommendedinhumansforpatientsthatmaybeuncooperative.Infectionisa
contraindicationtotheuseofthesemiinvasivedirectcurrentstimulatorandthecompletely
invasivestimulator.However,theinductivecouplingcoilshavebeenusedinthepresenceof
infectionandhavebeenreportedtogivegoodresultstodate.(37)
Anotherapplicationofanelectricalfieldiscapacitivecoupling.Inthistypeofelectrical
stimulation,anelectricalfieldisinducedinbonebyanexternalcapacitor.Thisrequirestwo
chargedmetalplatesthatarepositionedoneithersideoftheanimal'slimbandareattachedto
anappropriatevoltagesource.Aconstantcapacitivecoupledfieldmaythenbeinduced,ora
pulsedcapacitivecoupledfieldmaybeused.Earlystudiestodatehavedemonstratedthat
boththeconstantandpulsedcapacitivecoupledelectricalfieldshavealteredfracturerepair
andepiphysealplategrowthinrabbits.Thismethodispresentlybeingevaluatedandmay
wellrepresentamodeofelectricalstimulationinthefuture.
Theexactmechanismofactionofelectricalstimulationatthecellularlevelisunknownatthe
presenttime.Severaltheorieshavebeenadvocatedinthisregard.Ithasbeendemonstrated
previouslythatcollagenfiberswillrealignundertheinfluenceofelectricalfields.Itis
possiblethatthecathodealtersthelocaloxygenmicroenvironmentbyconsumingoxygenat
itstip.Ifthismethodisoperational,thelocalenvironmentduringbonedepositionisoneof
relativehypoxia.Ithasbeendemonstratedthatboneformsunderconditionsofrelative
hypoxiaandthatbonefollowspredominantlyananaerobicpathwayformetabolism.9
Activationofthecyclicadenosinemonophosphate(cAMP)systemhasalsobeensuggestedas
amechanismofactionforelectricity.Itisprobablethattheeffectofelectricityonthecellular
environmentismultifactorial,andfurtherstudiesatabasiclevelwillhelptooutlinethe
exactmechanismsofaction.
MALUNION
MalunionisdefinedasahealingofthebonesinanabnormalpositionMalunionscanbe
classifiedasfunctionalornonfunctional.Functionalmalunionsareusuallythosethathave
smalldeviationsfromnormalaxesthatdonotincapacitatethepatient.Someofthese
functionalmalunionsmaybeunacceptableindogs,especiallyiftheanimalisashow
specimen.Nonfunctionalmalunionswillbediscussedinthissection.Malunionscanoccur
withbothaxialdeviationsandrotationaldeformities.Axialdeformitiessuchasthevalgusor
lateraldeviationoftheforepawthatoccurswithapoorlysetfracturemaycausesecondary
degenerativejointdiseaseofthecarpusbecauseofcontinuedweightbearinginanabnormal
position.Veryoftentheseaxialdeviationmalunionswilldevelopassociatedjointproblems.
Fracturesassociatedwithphysealinjuriesmayalsoleadtodeformitiesthatareusuallynot
classifiedasmalunions.Thesedeformitiesareassociatedwithprematureclosureofthe
growthplate.Veryoftenthedeformityinthesecasesisthesameasthatofmalunion,butit
occurredafterthetimeofunionbecauseoffurthergrowthofoneormorebonesin
relationshiptoothernongrowingbones.Rotationalmalunionsalsooccurandareusually
thoseofexternalrotation.Thesedeformitiesallowasurprisingdegreeoffunctioninmost
animalspecies.Conversely,internalrotationaldeformitiesmaycausemoreseriousproblems
butareuncommon.Mostexternalrotationaldeformitiesarenotevenappreciatediftheyare
lessthan10.Itmustberememberedwhendealingwithfracturesthatsomeanimalbreeds
(chondrodystrophoid)exhibitskeletalabnormalitiesintheirnormalstate.Therefore,when
reducingfracturesinthesebreedsitisimportanttomatchthe"normal"deformityofthe
oppositeside.

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Mostexternalrotationalandlateralaxisdeformitiesareassociatedwiththeimproper
positioningoftheanimalduringtheapplicationofacastorsplint.Placingtheinjuredlegin
anuppermostpositionwhentheanimalisinlateralrecumbencywilltendtogiveanexternal
rotationalandlateraldeviationdeformitywhenthelimbismanipulated.Thiscaneasilybe
correctedbyplacingcastsandsplintsonanimalswiththeinjuredlimbonthedownside.Here
extensionandmanipulationofthelimbismorelikelytogiveastraightlimbwithoutthis
valgusdeformity.Externalrotationmaystilloccurifspecialattentionisnotpaidwhen
immobilizingradialandulnarfracturesbythismethod.Rotationaldeformitiesarequite
commonwithfemoralfracturesandusuallyrelatetothemusclesthatcontroleachendofthe
fracturefragment.Fracturesofthefemurusuallyallowtheproximalfracturefragmenttobe
heldinexternalrotationbecauseofspasmsandcontractionsoftheiliopsoasmuscle.If,when
usinginternalfixationwithanintramedullarypinorexternalfixationwithacastorsplint,this
externalrotationoftheproximalfemurisnottakenintoaccount,thefemurwillthenheal
withtheproximalfragmentinexternalrotationandthedistalfragmentintheneutralposition.
Followinguniontheanimalcontrolstheproximalfemurthroughitsproperposition,thereby
givinganinternalrotationaldeformitytothedistalfemur,resultinginaknockkneedstance.
Thisissometimesadisconcertingproblemforthedogandmayleadtogaitabnormalitiesor
lameness.If,infact,thefemoralfractureisapproachedwiththeideathatsincetheproximal
fragmentisalreadyinexternalrotation,thedistalfragmentshouldbeimmobilizedinexternal
rotationalso,thisdeformitywillnotoccur.Attimesloosefittingintramedullarypinsallow
thisdeformitytooccur.
Correctionofmalunionsisundertakenwhenthemalunionisafunctionalliabilitytothe
animal.Correctionofmalunionsinvolvesosteotomiesofbone,whichcanhavealltheserious
sequelaofbonefracturessuchasdelayedunion,nonunion,andinfection.Noosteotomies
shouldbeundertakenlightly,althoughinmostanimalsadequatetreatmentofamalunion
wouldgiveaverygoodresult.Thetechniquesusedfortreatmentofmalunionsarediscussed
inChapter40,PrinciplesandTechniquesofOsteotomy.
Mostmalalignmentsshouldbedetectedbeforehealingoccurs.Inthesecasesadequate
treatmentisundertakenbyresolvingtheaxisorrotationaldeformitythatexists,thereby
allowingnormaluniontotakeplace.Itisusuallybettertointerruptthefracturehealingatan
earlystagetocorrectthedeformitythantowaituntilosteotomyisneeded.Properfollowup
ofcasesafterinternalfixationorsplintingshouldmaketheoccurrenceofmalunionvery
infrequent.

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