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Nonunion
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For the meaning in organized labour, see Trade union.

Nonunion is permanent failure of healing following a broken bone unless intervention (such as surgery) is
performed. A fracture with nonunion generally forms a structural resemblance to a fibrous joint, and is
therefore often called a "false joint" or pseudoarthrosis (from Greek pseudo-, meaning false, and
arthrosis, meaning joint). The diagnosis is generally made when there is no healing between two sets of
medical imaging, such as X-ray or CT scan. This is generally after 6–8 months.[1]

Nonunion is a serious complication of a fracture

Nonunion
and may occur when the fracture moves too
much, has a poor blood supply or gets infected.
Patients who smoke have a higher incidence of
nonunion. The normal process of bone healing is
interrupted or stalled.[citation needed]

Since the process of bone healing is quite

variable, a nonunion may go on to heal without
intervention in very few cases. In general, if a
nonunion is still evident at 6 months post-injury it
will remain unhealed without specific treatment,
usually orthopedic surgery. A non-union which
does go on to heal is called a delayed union.[2]

Contents

Signs and symptoms

Causes

Risk factors

Types of nonunion
Hypertrophic nonunion

Atrophic nonunion

Oligotrophic nonunion
Hypertrophic nonunion of the tibia
Diagnosis
Specialty Orthopedics
Treatment
Surgery

Bone stimulation

Prognosis

See also

References

External links

Signs and symptoms

A history of a broken bone is usually apparent. The patient complains of persistent pain at the fracture site
and may also notice abnormal movement or clicking at the level of the fracture. An X-ray plate of the
fractured bone shows a persistent radiolucent line at the fracture. Callus formation may be evident but
callus does not bridge across the fracture. If there is doubt about the interpretation of the x-ray, stress x-
rays, tomograms or CT scan may be used for confirmation.[citation needed]

Causes

The reasons for non-union are:[citation needed]

avascular necrosis (the blood supply was interrupted by the fracture)[3]

the two ends are not apposed (that is, they are not next to each other)

infection (particularly osteomyelitis)[4]

the fracture is not fixed (that is, the two ends are still mobile)

soft-tissue imposition (there is muscle or ligament covering the broken ends and preventing them from
touching each other)

Risk factors

1. Related to the person:

1. Old age.

2. Poor nutritional status.

3. Habitual nicotine and alcohol consumption.

4. Metabolic disturbances such as hyperparathyroidism.

5. Can be found in those with NF1.

6. Genetic predisposition.[5]

2. Related to the fracture site:

1. Soft tissue interposition.

2. Bone loss at the fracture.

3. Infection.

4. Loss of blood supply.

5. Damage of surrounding muscles.

3. Related to the treatment:

1. Inadequate reduction.

2. Insufficient immobilization.

3. Improperly applied fixation devices.

Types of nonunion

There are typically three types of nonunion described.

Hypertrophic nonunion

In a hypertrophic nonunion, the fracture site contains adequate blood supply but the fracture ends fail to
heal together.[6] X-rays show abundant callus formation. This type of nonunion is thought to occur when the
body has adequate biology, such as stem cells and blood supply, but inadequate stability, meaning the bone
ends are moving too much. Typically, the treatment consists of increasing stability of the fracture site with
surgical implants.[7]

Atrophic nonunion

In an atrophic nonunion, x-rays show little to no callus formation. This is usually due to impaired bony
healing, for example due to vascular causes (e.g. impaired blood supply to the bone fragments) or
metabolic causes (e.g. diabetes or smoking). Failure of initial union, as when bone fragments are separated
by soft tissue, may also lead to an atrophic non-union. Atrophic non-unions can be treated by stimulating
blood flow and encouraging healing. This is often done surgically by removing the end layer of bone to
provide raw ends for healing and the use of bone grafts.[8]

Oligotrophic nonunion

As the name implies, an oligotrophic nonunion demonstrates some attempt by the body to heal the fracture.
These are thought to arise from adequate biology but displacement at the fracture site.[7]

Diagnosis

A diagnosis of nonunion is made when the clinician feels there will be no further bone healing without
intervention. The FDA defines it as a fracture at least 9 months old that has not shown any signs of
radiographic healing within the last 3 months.[9] CT scans offer a closer look at the fracture and may also
be used to evaluate how much of the fracture has healed. Blood tests can evaluate if the patient has
adequate levels of nutrients such as calcium and vitamin D. Blood tests can also look for markers of
infection such as ESR and CRP.[7]

Treatment

Surgery

Currently, there are different strategies to augment the

bone-regeneration process, however, there is no
standardised clinical treatment guideline yet.[9] Surgical
treatment options include:[citation needed]

Debridement: radical surgical removal of necrotic or

infected soft tissue and bone tissue is deemed
essential for the healing process.[10]

Immobilization of the fracture with internal or external Scaphoid pseudarthrosis before and after surgical
fixation. Metal plates, pins, screws, and rods, that are fixation
screwed or driven into a bone, are used to stabilize
the broken bone fragments.

Bone grafting. Filling of the bone defect resulting from debridement must be performed. Autologous bone
graft is the "gold standard" treatment and possesses osteogenic, osteoinductive, and osteoconductive
properties, although only a limited sample can be taken and there is a high risk of side effects.[11]

Bone graft substitutes. Inorganic bone substitutes may be used to complement or replace autologous
bone grafting. The advantage is that there is no morbidity on sampling and their availability is not
restricted. S53P4 bioactive glass has shown good results as a promising bone graft substitute in
treatment of nonunions, due to its osteostimulative, osteoconductive and antimicrobial properties.[12]

In simple cases, healing may be evident within 3 months. Gavriil Ilizarov revolutionized the treatment of
recalcitrant nonunions demonstrating that the affected area of the bone could be removed, the fresh ends
"docked" and the remaining bone lengthened using an external fixator device.[13] The time course of
healing after such treatment is longer than normal bone healing. Usually, there are signs of union within 3
months, but the treatment may continue for many months beyond that.

Bone stimulation

Bone stimulation with either electromagnetic or ultrasound waves has been suggested to reduce the healing
time for non-union fractures.[14] The proposed mechanism of action is by stimulating osteoblasts and other
proteins that form bones using these modalities. The evidence supporting the use of ultrasound and
shockwave therapy for improving unions is very weak[15] and it is likely that these approaches do not make a
clinically significant difference for a delayed union or non-union.[16]

Prognosis

By definition, a nonunion will not heal if left alone. Therefore, the patient's symptoms will not be improved
and the function of the limb will remain impaired. It will be painful to bear weight on it and it may be
deformed or unstable. The prognosis of nonunion if treated depends on many factors including the age and
general health of the patient, the time since the original injury, the number of previous surgeries, smoking
history, the patient's ability to cooperate with the treatment. In the region of 80% of nonunions heal after
the first operation. The success rate with subsequent surgeries is less.[citation needed]

See also

Distraction osteogenesis

References

1. ^ Page 542 in: Rigmor Texhammar, Christopher 10. ^ Simpson, A. H. R. W.; Deakin, M.; Latham, J. M.
Colton (2013). AO/ASIF Instruments and Implants: A (April 2001). "Chronic osteomyelitis: THE EFFECT
Technical Manual (2 ed.). Springer Science & OF THE EXTENT OF SURGICAL RESECTION ON
Business Media. ISBN 9783662030325. INFECTION-FREE SURVIVAL" . The Journal of
Bone and Joint Surgery. British Volume. 83-B (3):
2. ^ "Nonunions - OrthoInfo - AAOS" . Retrieved
403–407. doi:10.1302/0301-
2018-09-02.
620X.83B3.0830403 . ISSN 0301-620X .
3. ^ "Questions and Answers about Osteonecrosis
11. ^ Sen, M.K.; Miclau, T. (March 2007). "Autologous
(Avascular Necrosis)" . NIAMS. October 2015.
iliac crest bone graft: Should it still be the gold
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4. ^ "Osteomyelitis" . The Lecturio Medical Concept
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Janosch; Hax, Peter-Michael; Steinhausen, Eva
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Kamber L.; Pellegrini, Amelia M.; Raskin, Kevin A.; Bone Graft Substitute in the Treatment of Chronic
Perlis, Roy H. (January 2019). "Genomewide Osteomyelitis and Infected Non-Unions – a
Association Study of Fracture Nonunion Using Retrospective Study of 50 Patients" . Zeitschrift
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6. ^ RHINELANDER, FREDERIC W. (June 1968). "The 13. ^ Niedzielski K, Synder M (2000). "The treatment
Normal Microcirculation of Diaphyseal Cortex and of pseudarthrosis using the Ilizarov method". Ortop
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"Nonunions" , Skeletal Trauma, Elsevier, pp. 615– 5413.50844 . ISSN 0019-5413 .
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External links

AAOS Wikimedia Commons has

media related to
Pseudarthrosis.

Last edited on 14 December 2023, at 18:56

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