Delayed Union & Nonunion of Fractures

1. Dr. Armaan Singh

2. Delayed Union
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)

3. Nonunion
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)

4. Delayed/Nonunion
Factors contributing :
Systemic
Local

5. Systemic factors
Nutritional status- Malnutrition
Metabolic - Diabetes (neurovascular)
Smoking Tobacco and alcohol use
General health
Activity level
Use 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

6. Local factorsFracture characteristics-
Open
Infected
segmental
Comminuted by severe trauma
Anatomic Location of Fractures

7. Soft tissue injury
Traumatic
Iatrogenic
Treatment related
Insecure fixation
Insufficient immobilization
Fixation in distraction
Irradiated bone

8. Classification
Based on viability of the bone
ends
1. Hypervascular non-unions
2. Avascular nonunion

9. Hypervascular or Hypertrophic:
1. Elephant foot
(hypertrophic, rich in
callus)
2. Horse foot (mildly
hypertrophic, poor in
callus)
3. Oligotrophic (not
hypertrophic, no
callus)

10. Avascular or Atrophic
Torsion wedge
(intermediate fragment)
Comminuted (necrotic
intermediate fragment)
Defect (loss of
fragment)
Atrophic (scar tissue
with no osteogenic
potential)

11. Treatment
1. Electrical
2. Electro-magnetic
3. Ultrasound
4. Surgical
PREVENTION IS ALWAYS BETTER THAN
CURE

12. 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

13. Bone Grafting
 Autogenous cancellous bone remains the “gold
standard” in grafting material
 Other options
 allograft bone
 synthetic bone substitute
 Vascularised bone grafting

14. Low intensty ultrasound
 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

15. Electrical and electromagnetic
stimulation.
Bone growth stimulators - used in
conjunction.
External electrical stimulation
-advantageous in infected nonunion.
EXTERNAL ELECTRICAL STIMULATION IS
ESPECIALLY ADVANTAGEOUS IN INFECTED
NONUNION MANAGEMENT OR WHEN
SURGICAL INTERVENTION IS
CONTRAINDICATED

16. Considerations before Surgery
Status of Soft Tissues and
Neurovascular Structures –
Unyielding scar tissues,
Deep scarring may prevent bone
transport or grafting.
Soft-tissue contractures must be
considered

17. Status of Bones
Hypertrophic (hypervascular) non-unions
stable fixation.
Atrophic (avascular) non-unions
decortication and bone grafting
Consideration to the factors responsible for
non or delayed union is desired before
proceeding to further treatment

18. Reduction of Fragments
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

19. Stabilization of fragments.
Adequate stabilization obtained by -
Plates and screws.
Intra-medullary nails.
External fixation.
Provide sufficient stability – without excessive
rigidity.

20. External Fixation
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.

22. Surgical guidelines
Good reduction
Bone grafting
Firm stabilization
biomechanical
stability and
biological vitality of
the bone.