From the Guidelines
Nonunion of a fracture should be treated with surgical intervention, including debridement of the nonunion site, stabilization with internal fixation, and bone grafting, as this approach has been shown to be the most effective in promoting bone healing and preventing further complications 1.
Diagnosis of Nonunion
Nonunion is a complication of fracture healing where a broken bone fails to heal properly within the expected timeframe, typically 6-9 months after injury. The diagnosis of nonunion is based on clinical and radiological evaluation, including X-rays, CT scans, and MRI scans.
Treatment of Nonunion
The treatment of nonunion depends on the specific characteristics of the nonunion, including the location, size, and stability of the fracture, as well as the presence of any underlying medical conditions.
- For stable, well-aligned nonunions with adequate blood supply, non-surgical options may include bone stimulation devices (ultrasound or electrical stimulation) used for 20-30 minutes daily for 3-6 months.
- However, most nonunions require surgical intervention, which involves debridement of the nonunion site, stabilization with internal fixation (plates, screws, rods), and bone grafting.
- Autologous bone graft from the iliac crest is the gold standard, though synthetic bone substitutes or bone morphogenetic proteins may be used as alternatives.
- The use of low-intensity pulsed ultrasound (LIPUS) has been approved by the US Food and Drug Administration (FDA) for fracture healing and non-union treatment, but its effectiveness is still a topic of debate 2.
- A clinical practice guideline published in the BMJ in 2017 recommended that LIPUS should not be used as a first-line treatment for nonunion, but rather as an adjunct to surgical treatment 3.
Prevention of Nonunion
Prevention strategies for nonunion include optimizing nutrition (adequate protein, calcium, vitamin D), avoiding tobacco, controlling diabetes, and ensuring proper initial fracture management. Patients should understand that recovery from nonunion treatment can be prolonged, often requiring 3-6 months of protected weight-bearing and rehabilitation to achieve solid bone healing.
- Risk factors for nonunion include smoking, diabetes, advanced age, infection, poor blood supply, and inadequate fracture stabilization.
- Fracture stability is crucial for bone consolidation and eradication of infection, and the presence of a foreign body increases the risk of infection, but the advantage of implants for stabilization outweighs their increased susceptibility to infection 1.
From the Research
Diagnosis of Nonunion
- Nonunion is a major complication following bone fractures, often caused by a combination of biological, mechanical, patient, and injury factors 4
- Diagnosis of nonunion involves assessing the cause of nonunion, which may be multifactorial, and identifying factors such as infection, impaired biology, and metabolic disorders 4
- Clinical evaluation and treatment options for nonunion vary depending on the location and type of fracture, with upper limb nonunions being rare but potentially debilitating 5
Treatment Options for Nonunion
- Treatment of nonunion often requires a comprehensive plan, including revision surgery, to achieve osseous healing 5
- Bone grafting techniques are commonly used to treat nonunion, with autologous cancellous bone graft being the gold standard 6, 7
- Different types of bone grafts, including allografts and autografts, cortical and cancellous bone grafts, may be used depending on the type of nonunion 7
- Surgical techniques, such as debridement, internal fixation, and staged autogenous bone graft, may be used to treat infected nonunions 6
- New and evolving strategies for diagnosing and treating nonunion, including cell-based therapies and biological adjuvants, are being developed 4
Specific Treatment Approaches
- For infected nonunions, a one-stage procedure involving external fixator removal, surgical debridement, reduction and fixation of the fracture with a locked plate, bone graft, and antibiotic cement usage may be effective 6
- For upper limb nonunions, treatment options may include non-operative management in selected cases, but revision surgery is often necessary to achieve osseous healing 5
- For distal humerus nonunions, a combination of standard nonunion techniques with new plate designs and fixation methods may be used to treat the nonunion successfully 8