2. US FOOD & DRUG ADMINISTRATION PANEL
Established “when a minimum of 9 months has elapsed since
injury and the # shows no visible progressive signs of healing for
3 months”
3. • This criterion cannot be accepted for every # .
• A shaft of long bone # should not be considered as
Non union (NU) until atleast 6 mts after injury
because often union requires more time, esp. if it is
asso. with some local complication such as infection.
• In contrast , NOF# sometimes can be defined NU
after only 3 weeks
4. Host factors
Smoking ( Decreased O2 in cutaneous & subcutaneous tissue)
Tobacco use ( Nicotine – decrease vascularization at # site)
Diabetes ( decreased cellular proliferation in early stage & decrease callus
strength in later stage)
NSAIDS
Vitamin D deficiency ( Brinker et al)
6. Non union of long bones common
when fracture are-
Open fractures
Infected
Segmental with impaired blood supply usually to middle fragment
Comminuted by severe trauma
Insecurely fixed
Immobilized for an insufficient time
Treated by ill advised open reduction
Distracted either by traction or by plate & screws
Irradiated bone
7.
8. According to viability of ends of
fragments
Hypervascular /
Hypertrophic –
Viable & capable of
biological reaction
Avascular / Atrophic – inert
& not capable of uniting
without intervention
Shows rich blood supply
in ends of fragments
(EOF)
Strontium
85 - uptake
Poor blood supply in EOF
9. Hypertrophic Non Union
Hypertrophic
Rich in callus
Result from
- insecure fixation
- Inadequate mobilisation
- Premature wt bearing in a reduced
# with viable fragments
10. Mildy Hypertrophic
Poor in callus
Result from
- moderately unstable
fixation with plate & screws
Ends of fragment – some
callus , insufficient for
union , little sclerosis
11. Not Hypertrophic
Vascular
Absent callus
Typically occurs after major
displacement of a #
Distraction of fragments or
internal fixation without
adequate apposition of
fragments
12. Avascular / Atrophic Non union
Intermediate fragment +
( blood supply – decreased
or absent)
IF – healed to one main
fragment but not to the
other
Eg – Tibial # Rx by plate &
screws
13. IF – one or more & are
necrotic
Xray – no callus
Eg- Breakage of plate
used in stabilising acute
#s
14. Loss of fragment of
diaphysis of bone
EOF – viable but union
across defect is impossible
As time passes, EOF –
Atrophic
Eg – OPEN # ,
Sequestrectomy in
osteomyelitis, resection of
tumors
15. IF – missing
Scar tissue that lacks
osteogenic potential is
left in place
EOF - Osteoporotic &
atrophic
16. • Dror Paley described
classification of non union
of tibia that can be applied
to non union of other bones
• Clinically & radiographically
into two types
17.
18. TREATMENT
• Hypertrophic NU – Stable fixation of
fragments alone
• Atrophic NU – Decortication + bone grafting
for healing
19. Type A Paley – Restoration of alignment followed by
compression
Type B Paley – Additional cortical osteotomy +
Internal bone transport or overall lengthening to
obtain original bone length
21. Low intensity pulsed ultrasound
(LIPUS)
• Xavier & Duarte in Brzail 1st reported Low
intensity ultrasound ( 30 milliwatts/cm2) to
heal Union in humans in 1983
• Theory –
• US stimulation stimulates genes involved in
inflammation & bone regeneration
promotes bone healing
22. • Increases blood flow through dilation of
capillaries & enchancement of angiogenesis,
increasing flow of nutrients to # site
• Enchanced chondrocyte stimulation
increase in enchondral bone formation
23.
24.
25. External electrical & electromagnetic
stimulation
• External electrical stimulation in esp.
advantageous in infected NU Management or
when surgical intervention is contraindicated
