What is the management of a nonunion ulnar fracture?

Management of Nonunion Ulnar Fracture

Surgical intervention with compression plate fixation and autologous bone grafting is the definitive treatment for ulnar shaft nonunion, achieving union rates approaching 100%. 1, 2

Surgical Approach

Primary Surgical Technique

• Remove all previous hardware if present, as retained implants may contribute to persistent nonunion 3
• Resect the nonunion site to create viable bone edges with adequate blood supply 3
• Apply rigid compression plate fixation using locking plates, which provides superior stability compared to standard plating 3, 1
• Add autologous bone grafting in most cases, particularly when bone stock is compromised or the nonunion is atrophic 1, 2
• Consider strut bone grafts for structural support in cases with significant bone loss 3

Technical Considerations

• Plate fixation combined with bone grafting achieved union in 11 of 12 cases (92%) in established nonunions 1
• In a large series of 51 forearm nonunions, compression plating with autologous grafting when needed achieved 100% union rate at median 7 months 2
• Revision osteosynthesis using locking plates with callus resection and bone grafting resulted in union at mean 4.8 months postoperatively 3

Special Considerations

Bisphosphonate-Associated Fractures

• Suspect atypical fracture patterns in elderly women on long-term bisphosphonate therapy (>5 years) 3
• Standard ORIF will fail in these cases due to compromised bone metabolism affecting resorption, remodeling, and healing 3
• Screen for bilateral involvement and contralateral incomplete fractures, as these patients have systemic bone pathology 3
• Consider discontinuing bisphosphonates in consultation with the prescribing physician 3

Infection Exclusion

• Rule out fracture-related infection (FRI) before proceeding with nonunion surgery 4
• Obtain deep tissue biopsies during surgery for microbiology and histopathology 4
• Presence of >5 polymorphonuclear leukocytes per high-power field confirms infection (100% specificity) 4
• If infection is present, perform thorough debridement with antimicrobial therapy before definitive fixation 4

Adjunctive Therapies to Avoid

Low-Intensity Pulsed Ultrasound (LIPUS)

• Do not use LIPUS for nonunion treatment, as high-quality evidence shows no benefit on patient-important outcomes 4
• The BMJ guideline panel found no compelling anatomical or physiological reasons why LIPUS would benefit nonunions, despite manufacturer claims 4
• LIPUS does not represent efficient use of healthcare resources given lack of efficacy 4

Expected Outcomes

Union Rates

• Compression plating with bone grafting achieves union in >90% of ulnar nonunions 1, 2
• Expected time to union: 4-7 months postoperatively 3, 2

Functional Results

• Despite high union rates, only 62% achieve excellent functional outcomes and 21% have unsatisfactory results due to stiffness and soft tissue scarring from prolonged nonunion 2
• Early surgical intervention for nonunion is preferable to avoid these complications 2

Common Pitfalls

• Attempting conservative management of established nonunion—this will not succeed and only delays definitive treatment 1
• Using inadequate fixation such as intramedullary nailing, which has higher failure rates than plate osteosynthesis 4
• Failing to address bone grafting needs—most nonunions require biological augmentation for successful healing 1, 2
• Missing occult infection—always obtain tissue cultures during revision surgery 4