General Principles in the Assessment

and Treatment of Nonunions

Fracture
Andriessanto Lengkong

Previous Definitions of Nonunion
Nonunion: A fracture that is a minimum of 9
months post occurrence and is not healed and
has not shown radiographic progression for 3
months






Orthopaedic Advisory Panel: Food & Drug Administration, 1986
Waiting 9 months or more is often
inappropriate:
Prolonged morbidity
Inability to return to work
Narcotic dependence
Emotional impairment

Definitions
Nonunion: A fracture that has not and is not
going to heal
Delayed union: A fracture that requires more
time than is usual and ordinary to heal
Classification of Nonunions
Two important factors for consideration :
(1) Presence or absence of infection
(2) Vascularity of fracture site
Classification
(1) Hypertrophic
(2) Oligotrophic
(3) Avascular


Weber and Cech, 1976


Hypertrophic
Vascularized
Callus formation present on x-ray
Elephant foot - abundant callus
Horse hoof - less abundant callus
Oligotrophic
No callus on x-ray
Vascularity is present on bone scan
Avascular
Atrophic or similar to oligotrophic on x-ray
Ischemic or cold on bone scan
Hypertrophic
(elephant foot)
Hypertrophic
(horse hoof)
Oligotrophic
or atrophic
Incidence of Nonunion
Boyd et.al Connolly
No. 842(1965) No.602 (1981)
Tibia 35 % 62%
Femur 19% 23%
Humerus 17.5% 7%
Forearm 15.5% 7%
Clavicle 2% 1%

*Increasing frequency of tibial nonunion over time
Etiology of Nonunion:
Systemic

Malnutrition
Smoking
Malnutrition
Adequate protein and energy is required
for wound healing
Screening test:
serum albumin
total lymphocyte count
Albumin less than 3.5 and lymphocytes less
than 1,500 cells/ml is significant

Seltzer et.al. JPEN 1981
Smoking
Decreases peripheral oxygen tension
Dampens peripheral blood flow
Well documented difficulties in wound healing
in patients who smoke

Schmite, M.A. e.t. al. Corr 1999
Jensen J.A. e.t. al. Arch Surg 1991
Etiology of Nonunion
(Local Factors)
Infection
Energy of fracture mechanism
Mechanical factors of fracture configuration
Increased motion between fracture fragments
Inadequate fixation
Wolfs Law - lack of physiologic stresses to bone
Anatomic location

INFECTION

The inflammatory response to bacteria at
the site of the fracture disrupts callus,
increases gap between fragments, and
increases motion between fragments.
Energy of Fracture Mechanism
Initial fracture displacement
Fracture pattern i.e:
comminution
bone loss
segmental patterns
Soft tissue disruption (vascularity and oxygen
delivery)
Fracture Pattern
Fracture patterns in higher energy injuries
(i.e.: comminution, bone loss, or segmental
patterns) have a higher degree of soft tissue
and bone ischemia
Soft Tissue Disruption
1. Iatrogenic
Excessive soft tissue dissection and periosteal
stripping at time of previous fixation
2. Traumatic
Mechanical Factors
Excessive motion at fracture secondary to
poor fixation, failed fixation, or inadequate
immobilization
Lack of physiologic mechanical stimulation to
fracture area (i.e. nonweight bearing, fracture
fixed in distraction, adynamic environment
with external fixation)
Diagnosis of Nonunion- History
Nature of original injury (high or low energy)
Previous open wounds of injury site
Pain present at fracture site
Symptoms of infection
History of any drainage or wound healing
difficulties


Examination
Alignment
Deformity
Soft tissue integrity
Erythema, warm, drainage
Vascularity of limb
Pulses, transcutaneous oximetry
Stability at fracture site
Treatment
Nonoperative
Operative
Nonoperative
Ultrasound
Electric stimulator
Bone marrow injection
Ultrasound
Ultrasound fracture stimulation devices
have shown ability to increase callus
response in fresh fractures (shortens time
for visible callus on x-ray)
Prospective randomized trial in nonunion
population has not been done
Use in nonunions remains theoretical
Goodship & Kenwright JBJS 1985
Electric Stimulation
Piezoelectric nature of bone - stress generated
electric potentials exist in bone and are related
to callus formation
Fukada & Yasuda,J Phys Soc Jpn 1957
Busse H CAL e.t. al. Science 1962
Electromagnetic fields influence vascularization
of fibrocartilage, cell proliferation & matrix
production
Monograph Series,AAOS
Bone Marrow Injection
Percutaneous bone marrow injected to level of
fracture
9 of 10 delayed tibia fractures united
80% of 100 tibial fracture patients united when
in conjunction with adequate fixation
*Nonradomized and anecdotal studies

Connolly J., CORR. 1995

Surgical Treatment
Fibular osteotomy
Bone graft
Plate osteosynthesis
Intramedullary nailing
External fixation
Fibular Osteotomy
Fibula can distract or unweight physiologic
forces seen in the tibia Teitz, C.C. e.t.al.JBJS 1980
Often used as adjunctive procedure to assist
with deformity correction and surgical
stabilization of tibia
Dynamizes tibial to augment healing
environment
Bone Grafting
Osteoinductive - contain proteins or
chemotactic factors that attract vascular
ingrowth and healing
i.e.. demineralized bone matrix & BMPs
Osteoconductive - contains a scaffolding for
which new bone growth can occur
i.e. allograft bone, calcium hydroxyappatite
Plate Osteosynthesis
Corrects malalignment
Restores function & stabilizes fracture fragments
directly
Compresses fragments in some circumstances to
augment healing
Allows patients to mobilize surrounding joints
and dynamize fracture environment
Requires adequate skin and soft tissue coverage
Often used with adjunctive bone graft

Intramedullary Nailing
Mechanically stabilizes long bone nonunions as a
load sharing implant
Corrects malalignment
Reaming is initially detrimental to intramedullary
blood supply, but it does recover and is believed
to stimulate biologic healing at fracture
Allow patient to mobilize surrounding joints and
dynamize fracture environment
External Fixation
Correct malalignment
Used primarily in management of infected nonunions
Allows for repeated debridements, soft tissue
reconstructive procedures, and adjunctive bone-
grafting
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