Dr Samir D Bhirud,Dept of Orthopedics

ESIPGIMSR MGM HOSPITAL

Delayed Union and Nonunion of

Fractures

Approximately 5% of all long bone fractures will result in non-unions and

even more in delayed unions

The exact time when a given fracture should be united cannot be defined

Union is delayed when healing has not advanced at the average rate for the location and type of fracture(Between 3-6 months)

Delayed Union

FDA defined nonunion as “established when a minimum of 9 months has elapsed since fracture with no visible progressive signs of healing for 3 months”

Every fracture has its own timetable (long bone shaft fracture 6 months, femoral neck fracture 3 months)

Nonunion

Factors contributing :

Systemic

Local

Delayed/Nonunion

Nutritional status- MalnutritionMetabolic - Diabetes (neurovascular)Smoking Tobacco and alcohol useGeneral healthActivity levelUse of NSAIDs (have been found to decrease

fracture healing in multiple animal studies)

THE LITERATURE IS STILL CONFLICTING CONCERNING THE INFLUENCE OF NSAIDS ON FRACTURE HEALING

Systemic factors

Fracture characteristics-OpenInfectedsegmentalComminuted by severe trauma

Anatomic Location of Fractures

Local factors

Soft tissue injuryTraumaticIatrogenic

Treatment relatedInsecure fixationInsufficient immobilizationFixation in distraction

Irradiated bone

Based on viability of the bone ends

1. Hypervascular non-unions

2. Avascular nonunion

Classification

Hypervascular or Hypertrophic:

1. Elephant foot (hypertrophic, rich in callus)

2. Horse foot (mildly hypertrophic, poor in callus)

3. Oligotrophic (not hypertrophic, no callus)

Avascular or Atrophic

Torsion wedge (intermediate fragment)

Comminuted (necrotic intermediate fragment)

Defect (loss of fragment)

Atrophic (scar tissue with no osteogenic potential)

1. Electrical2. Electro-magnetic3. Ultrasound4. Surgical

Treatment

PREVENTION IS ALWAYS BETTER THAN CURE

General Treatment principals

Vast number of surgical and nonsurgical methods available but….

Rarely - one method successful .Simplest, most easily tolerated.Should allow potential use of

other methods

Autogenous cancellous bone remains the

“gold standard” in grafting material

Other options

allograft bone

synthetic bone substitute

Vascularised bone grafting

Bone Grafting

Theories stimulates the genes involved in inflammation

and bone regeneration. increases blood flow through dilation of

capillaries and enhancement of angiogenesis, increasing the flow of nutrients to the fracture site.

chondrocyte stimulation is enhanced, which leads to an increase in enchondral bone formation.

PROTOCOL IS TO USE THE ULTRASOUND EQUIPMENT FOR 20 MINUTES ONCE A DAY

Low intensty ultrasound

Bone growth stimulators - used in conjunction.

External electrical stimulation -advantageous in infected nonunion.

Electrical and electromagnetic stimulation.

EXTERNAL ELECTRICAL STIMULATION IS ESPECIALLY ADVANTAGEOUS IN INFECTED NONUNION MANAGEMENT OR WHEN SURGICAL INTERVENTION IS CONTRAINDICATED

Status of Soft Tissues and Neurovascular Structures –Unyielding scar tissues, Deep scarring may prevent bone

transport or grafting.Soft-tissue contractures must be

considered

Considerations before Surgery

Hypertrophic (hypervascular) non-unionsstable fixation.

Atrophic (avascular) non-unions decortication and bone grafting

Status of Bones

Consideration to the factors responsible for non or

delayed union is desired before proceeding to further

treatment

The fragments are mobilized, preserving their normal soft-tissue attachments as much as possible.

Extensive dissection is avoided, resecting only the scar tissue and the rounded ends of the bones so that contact is maximal

Medullary canals are cleared of fibrous tissue to aid in medullary osteogenesis and they are apposed

Reduction of Fragments

Adequate stabilization obtained by -

Plates and screws.

Intra-medullary nails.

External fixation.

Provide sufficient stability – without

excessive rigidity.

Stabilization of fragments.

Advantage–relatively noninvasive and does not

disturb soft tissues surrounding the nonunion.

ability to correct deformity and provide stable fixation.

The Ilizarov external fixator is very effective, tool in the treatment of non-unions.

External Fixation

Good reductionBone graftingFirm stabilization

biomechanical stability and

biological vitality of the bone.

Surgical guidelines

THANK YOU