What are the management steps for a non-union fracture at 2 months?

Management of Non-Union Fractures at 2 Months

For a 2-month-old non-union fracture, percutaneous vertebral augmentation (VA) through vertebroplasty (VP) or balloon kyphoplasty (BK) is indicated if the patient has failed conservative therapy with persistent pain. 1

Diagnostic Evaluation

1. Imaging Assessment:

   • MRI: First-line imaging for suspected non-union at 2 months to assess:
     • Fracture line visibility
     • Bone marrow edema (typically resolves within 1-3 months in healing fractures) 1
     • Fracture clefts that may indicate non-union
   • CT scan: To evaluate bone structure and fracture morphology
   • SPECT/CT: May be helpful to precisely localize abnormalities, with 63-80% agreement with MRI in detecting acute vertebral compression fractures 1

2. Risk Assessment:

   • Evaluate for factors contributing to non-union:
     • Osteoporosis status
     • Medication use (especially bisphosphonates)
     • Fracture location (high-risk locations include anterior tibial diaphysis, lateral femoral neck, navicular) 1
     • Systemic factors (diabetes, smoking, nutritional status)

Treatment Algorithm

Step 1: Confirm Failed Conservative Management

• Determine if patient has failed 6-8 weeks of conservative therapy 1
• Failure defined as:
  • Pain refractory to oral medications (NSAIDs or narcotics)
  • Contraindication to such medications
  • Requirement for parenteral narcotics or hospital admission 1

Step 2: Interventional Management

For vertebral compression fractures:

• Percutaneous Vertebral Augmentation (VA) is indicated for patients who have failed conservative therapy for 2-3 months 1
  • Options include:
    • Vertebroplasty (VP): Injection of bone cement
    • Balloon Kyphoplasty (BK): Creation of cavity with balloon before cement injection

For non-vertebral fractures:

• Surgical Intervention based on fracture location:
  • High-risk fractures (lateral femoral neck, navicular, fifth metatarsal base): Consider early surgical fixation 1
  • Low-risk fractures: May attempt extended conservative management with close monitoring

Step 3: Adjunctive Therapies

• Bone Stimulation:
  • Electrical stimulation
  • Ultrasound therapy
• Biological Augmentation:
  • Bone grafting for established non-unions
  • Consider autologous bone marrow aspirate

Special Considerations

Vertebral Compression Fractures

• Multiple studies have shown benefit of vertebral augmentation over conservative treatment in acute osteoporotic vertebral compression fractures 1
• Benefits include improvements in:
  • Pain intensity
  • Vertebral height
  • Sagittal alignment
  • Functional capacity
  • Quality of life 1

Medication Management

• Calcitonin: Consider for acute vertebral compression fractures (0-5 days after injury) for 4 weeks 1
• Bisphosphonates: Ibandronate may help prevent additional fractures 1
• Pain Management: Use NSAIDs and limited opioids with caution due to sedation risks and fall potential 1

Pitfalls and Caveats

1. Delayed Diagnosis: Non-union may be missed if appropriate imaging is not obtained at the 2-month mark
2. Misattribution of Pain: Ensure pain is from the fracture and not another source
3. Overtreatment: Not all non-unions require surgical intervention; decision should be based on:
   • Fracture location
   • Patient symptoms
   • Functional limitations
   • Risk of progression
4. Vertebral Augmentation Risks: Be aware of potential cement leakage and adjacent level fractures 2

Follow-up Recommendations

• Regular radiographic assessment to monitor healing progress
• Pain and functional status evaluation using standardized scales
• Secondary fracture prevention through systematic risk evaluation 1
• Consider Fracture Liaison Service (FLS) involvement for comprehensive care 1

By following this structured approach to managing 2-month-old non-union fractures, clinicians can optimize outcomes and minimize complications while addressing both the mechanical and biological aspects of fracture healing.