A concise overview of the management of fracture nonunions

1. Management of
Nonunion
Presenter – Dr. Bassey, A E
Supervisor – Dr. Songden, Z D

2. Outline
• Introduction
• Aetiopathogenetic factors
• Classification
• Differential diagnosis
• Management
• Current trends
• Conclusion
• References

3. Introduction
• Nonunion is said to occur when a fracture fails to heal at the expected
time for that bone, and is unlikely to heal without new intervention.
• Current definitions are arbitrary. None has been standardized.
• The prolonged pain and disability, psychological and socioeconomic
toll on the patient and health system make it all important for
fracture surgeons to eunderstand and be able to treat this condition

4. • Data on general nonunion rates in Nigeria are hard to find. A report
from a European journal puts it at 5-10%.
• Nigerian data
• Average age - 39.7-42.5yrs
• M:F – 1.6:1 – 1.9:1
• 65.4 – 77% had TBS initial intervention
• Atrophic > Hypertrophic (69% v 21%)
• Bone involvement – Femur>Humerus>Tibia>Radius/Ulna

5. Aetiopathogenetic factors
• Host factors
• Fracture factors
• Treatment factors
• Infection

6. • Host factors
• Smoking – anti-angiogenesis, vasoconstriction, BMP-2 gene suppression
• Diabetes – microangiopathy
• Vascular disease
• Malnutrition
• Medication – NSAIDs, corticosteroids, chemotherapy
• Rheumatoid disease
• Malignancy
• Fracture factors
• Affected bone
• Anatomical site of bone
• Open vs Closed fractures
• Degree of bone and soft tissue injury

7. • Treatment factors
• Stability of fixation
• Soft tissue stripping
• Infection – inflammationosteolysis, tissue necrosis

8. Classification
• Based on biologic activity
• Atrophic
• Oligotrophic
• Hypertrophic
• Based on infection
• Aseptic
• Septic

9. Atrophic nonunion

10. Hypertrophic nonunion

11. Oligotrophic nonunion

12. Differential diagnosis
• Congenital Pseudarthrosis

13. Management
• Diagnosis
• History
 Activity-related Pain at fracture site, persistent if septic (no pain if pseudoarthrotic)
 New onset pain if fixed
 If LL – inability to bear weight
 Mobility
 Energy/mechanism of initial injury
 Past treatments
 Hx of aetiologic factors
• Examination
 Tenderness at fracture site
 Deformable

14. • Investigations
• Radiology
• Xrays – may mask nonunion if it is not coplanar with xray beam
• CT – better bone anatomy, when in doubt CT better for fracture healing than xrays. quite
useful in planning periarticular nonunions
• Nuclear imaging
• Labs
• TWBC + diff, inflammatory markers
• Ancillary
• DM screen
• Malnutrition

15. Principles of treatment of nonunion
• Proper diagnosis and classification
• Patient optimization
• Stop smoking
• Control DM
• Optimize nutrition
• Stop or reduce offending medication

16. Nonoperative treatment
• Merit Criteria: good alignment, no infection, method has good
potential for success, patient acceptance.
• Methods
• Weightbearing
• Electrical stimulation
• LIPUS
• ESWT
• Gene therapy

17. Operative treatment
• Fixation techniques & devices
• Plate and screws
• Versatile for diaphyseal and metaphyseal fractures, useful for atrophic, oligo- and
hypertrophic, useful in periprosthetic nonunions and for deformity correction
• Problems are soft tissue invasion, limited post op weightbearing, cannot correct limb
shortening, avoid in infection
• Intramedullary nailing
• Allows early WB, can be used even in infected cases, less invasive
• Limited use in metaphyseal nonunions
• External fixators
• Ring fixators are the mainstay of external fixation for nonunions
• Useful for end-segment and diaphyseal nonunions. Management of bone defects, moreso, in
the setting of infection. Correction of deformities.
• Arthroplasty
• Arthrodesis
• Fragment resection
• Osteotomy
• Synostosis
• Amputation

18. • Atrophic nonunion
• Lacks biologic activity and vascularity
• Treatment principles are:
• Debride ends
• Correct deformity if present
• Fracture stabilization and compression
• Bone graft – Autologous graft
• Reconstruct soft tissue if compromised

20. • Hypertrophic nonunion
• Results from poor fracture stability
• Treatment principles
• Fracture debridement not required, not desired
• Stabilize fracture by primary or exchange nailing, or plate
• Bone graft not required – added morbidity
• If pseudoarthrotic, excise, compress and graft

22. • Oligotrophic nonunion
• May be difficult to determine if mechanical or biological
derangements or both are responsible
• It is prudent to employ restorative techniques from both angles

23. • Infected nonunion
• Best treated by staged protocols via a multidisciplinary approach.
• Priority is given to controlling, and if possible, eradicating infection
before achieving union

24. • Principles
• Debridement
• Fracture stabilization by external fixation or antibiotic nail
• Local antibiotic therapy
• Sensitivity-guided parenteral antibiotic therapy
• Management of bone defects
• Soft tissue management
• With infection controlled treat as aseptic nonunion

25. Current trends
• Prediction of nonunion using analysis of telemetric data (avoids
ionizing radiation)

26. Conclusion
• Nonunion diagnosis and treatment have come a long way, but there is
still so much to know regarding them, e.g., are there biomarkers that
can accurately predict/diagnose nonunions?
• We do not know our current nonunion rates in Nigeria. Experts from
Enugu say that from their experience, the rates over there are much
higher than in the developed world
• For as long as TBSs continue to practice in Nigeria we will always have
nonunions, therefore, we who practice here must be ahead of the
curve in knowledge, expertise and research of fracture nonunions and
their treatment.

27. THANK YOU

28. References
• Schmal H, Brix M, Bue M, et al. Nonunion - consensus from the 4th
annual meeting of the Danish Orthopaedic Trauma Society. EFORT
Open Rev. 2020;5(1):46-57.
• Madu KA, Nnyagu H, Ede O. Non-union treatment outcomes in South-
East Nigeria. Niger J Orthop Trauma 2018;17:77-80.
• Ogunlade SO, Omololu AB, Alonge TO, Diete ST, Obawonyi JE.
Predisposing factors and outcome of treatment of non-union of long-
bone fractures in Ibadan, Nigeria. Niger Postgrad Med J.
2011;18(1):56-60.
• Court-Brown CM, Heckman JD, McQueen MM, Ricci WM, Tornetta P.
Rockwood and Green’s Fractures in Adults. 8th Ed. Philadelphia:
Wolters Kluwer Health, 2015. Chapter 27: Principles of Nonunion
Treatment; p. 827-860.