Non Union

CY/RR/HC/YD/RG

Definition
Nonunion failure of fracture bone
to unite
Diagnosed can determined clinically /
radiographically that healing has
ceased and union is highly
improbable

Etiology
(1) distraction and separation of the
fragments, sometimes the result of
interposition of soft tissues between the
fragments;
(2) excessive movement at the fracture line
(3) A severe injury that renders the local
tissues nonviable or nearly so
(4) a poor local blood supply
(5) infection

Classification
(1) Hypertrophic
(2) Atrophic
(3) Oligotrophic

Hypertrophic
Hypervascular
Possess bioligic capacity to heal but lack
mechanical stability
Callus formation present on x-ray
Elephant foot - abundant callus
Horse hoof - less abundant callus

atrophic
avascular and lack the bioogic
capacity to heal
similar to oligotrophic on x-ray

Oligotrophic
No callus on x-ray
Vascularity is present on bone scan

Hypertrophic non-unions often have florid streams of callus around the

fracture gap the result of insufficient stability. They are sometimes
given colourful names, such as: (a) elephants foot.
Atrophic non-unions
usually arise from an impaired repair process; they are classified
according to the x-ray appearance as (b) necrotic, (c) gap and (d)
atrophic.

Treatment
Nonoperative
Operative

Nonoperative
Ultrasound
Electric stimulator
Bone marrow injection

Ultrasound
Ultrasound fracture stimulation
devices have shown ability to
increase callus response in fresh
fractures (shortens time for visible
callus on x-ray)
Use in nonunions remains
theoretical

Electric Stimulation
Piezoelectric nature of bone - stress
generated electric potentials exist in
bone and are related to callus formation

Electromagnetic fields influence

vascularization of fibrocartilage, cell
proliferation & matrix production

Bone Marrow Injection

Percutaneous bone marrow injected to
level of fracture

Surgical Treatment

Fibular osteotomy
Bone graft
Plate osteosynthesis
Intramedullary nailing
External fixation

Fibular Osteotomy
Often used as adjunctive procedure
to assist with deformity correction
and surgical stabilization of tibia

Bone Grafting
Osteoinductive - contain proteins or
chemotactic factors that attract
vascular ingrowth and healing
Osteoconductive - contains a
scaffolding for which new bone
growth can occur

Bone Grafting
Used to stimulate biologic response of
healing in nonunions (usually atrophic
nonunions)
Also used to fill defects in fracture zone
i.e. up to 6 cm intercalary defects of long
bones)
Bosse, MJ e.t.al. JBJS 1989

Plate Osteosynthesis
Restores function & stabilizes fracture
fragments directly
Compresses fragments in some
circumstances to augment healing
Often used with adjunctive bone graft

Intramedullary Nailing
Mechanically stabilizes long bone
nonunions as a load sharing implant
Corrects malalignment
Reaming is initially detrimental to
intramedullary blood supply, but it does
recover and is believed to stimulate
biologic healing at fracture

External Fixation
Correct malalignment
Used primarily in management of infected
nonunions

THANK YOU

 45-year old lady has nonunion of closed

fracture lower third shaft of tibia of nine
months duration. The most likely cause
of this nonunion is
A. comminution of the fracture
B. distraction of the fragments
C. interposition of soft tissue
D. absence of muscle origin from it
E. intact fibula

 How to treat atrophic non union ?

(disuse atropic,disuse osteoporosis
and leg length discrepancy 10 cm)
Explain therapy non union fr. with
infection?