Nonunion is a 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 (the Greek stem “pseudo-” means false and “arthrosis” means joint). The diagnosis is generally made when there is no healing between two sets of medical imaging such as an X-ray or CT scan. This is generally after 6–8 months.
Types of Nonunion
Types of Nonunion
Judet and Judet, Muller, Weber and Cech, and others classified nonunions into two types according to the viability of the ends of the fragments: Hypervascular nonunions and avascular nonunions.
Hypervascular nonunions are subdivided as:
- “Elephant foot” nonunions: These are hypertrophic, rich in callus, and are a result of inadequate immobilization, insecure fixation, or premature weight-bearing.
- “Horse hoof” nonunions: Mildly hypertrophic, poor in callus and is due to unstable fixation.
- Oligotrophic nonunions: They are not hypertrophic but vascular, no callus seen, and is due to severely displaced fracture or fixation without accurate apposition of fragments.
Avascular nonunions are subdivided as
- Torsion wedge nonunions have an intermediate fragment with decreased or absent blood supply. This fragment has healed to one main fragment but not to the other.
- Comminuted nonunions have one or more intermediate fragments that are necrotic.
- Defect nonunions have a gap in the diaphysis of bone due to a loss of a fragment.
- Atrophic nonunions usually are the final result when the intermediate fragments are missing and scar tissue that lacks osteogenic potential is left in their place.
Depending on its cause, nonunion classifications are as follows:
- Septic (infected) or aseptic
- Pseudarthrosis
- Hypertrophic – characterized by inadequate immobilization, but adequate blood supply persists
- Atrophic – characterized by inadequate immobilization and inadequate blood supply in the early stages of fracture healing
- Oligotrophic – characterized by inadequate reduction with the persistence of fracture diastasis; no callus can form
- Hypertrophic non-union – Callus is formed, but the bone fractures have not joined. This can be due to inadequate fixation of the fracture and treatment with rigid immobilization.
- Atrophic non-union – No callus is formed. This is often 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. insulin is low or not working well. সহজ বাংলা: রক্তে চিনি বেশি থাকার রোগ।" data-rx-term="diabetes" data-rx-definition="Diabetes is a condition where blood sugar stays too high because insulin is low or not working well. সহজ বাংলা: রক্তে চিনি বেশি থাকার রোগ।">diabetes or smoking). Failure of the initial union, for example, when bone fragments are separated by soft tissue may also lead to atrophic non-union. Atrophic non-union can be treated by improving fixation, removing the end layer of bone to provide raw ends for healing, and the use of bone grafts.
As mentioned, an adequate interplay between host biology and reduction technique is key to achieving fracture healing. The development of a nonunion is multifactorial. Factors that contribute to the development of a nonunion include the following, listed here with known risk factors[rx][rx][rx]
Causes of Nonunion
The reasons for non-union are
- avascular necrosis (the blood supply was interrupted by the fracture)
- the two ends are not opposed (that is, they are not next to each other)
- infection (particularly osteomyelitis)
- 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)
Fracture and Injury-Related Factors
- High-energy fractures with significant comminution
- Type of fracture (closed/open)
- Location and pattern (highly comminuted or butterfly fragments)
- Extent of soft tissue injury
- Bone loss and fracture gaps (greater than 3 mm)
- Lack of cortical continuity
- Infection
Biology and Patient-Related Factors (Local and Systemic)
- Nutritional status
- insulin is low or not working well. সহজ বাংলা: রক্তে চিনি বেশি থাকার রোগ।" data-rx-term="diabetes" data-rx-definition="Diabetes is a condition where blood sugar stays too high because insulin is low or not working well. সহজ বাংলা: রক্তে চিনি বেশি থাকার রোগ।">Diabetes
- Smoking
- Inadequate blood supply
- Vitamin D deficiency
- Renal insufficiency
- Medications (steroids, NSAIDs, opiates, etc.)
Surgical-Related Factors
- Inadequate stabilization
Related to the person
- Age: Common in old age
- Nutritional status: poor
- Habits : Nicotine and alcohol consumption
- Metabolic disturbance: Hyperparathyroidism
- can be found in those with NF1
- Genetic predisposition
Causes related to fracture
- Related to the fracture site
- Soft tissue interposition
- Bone loss at the fracture
- Infection
- Loss of blood supply
- Damage of surrounding muscles
Related to treatment
- Inadequate reduction
- Insufficient immobilization
- Improperly applied fixation devices.
Symptoms of Nonunion
- 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.
Diagnosis
History
Your doctor in the emergency department may ask the following questions
- How – How was the fracture created, and, if chronic, why is it still open? (underlying etiology)
- When – How long has this fracture been present? (e.g., chronic less than 1 month or acute, more than 6 months)
- Where – Where on the body parts is it located? Is it in an area that is difficult to offload, complicated, or keep clean? Is it in an area of high skin tension? Is it near any vital organ and structures such as a major artery?
- What is your Past – Has your previous medical history of fracture? Are you suffering from any chronic disease, such as hypertension, blood pressure, diabetes mellitus, previous major surgery? What kind of medicine did you take? What is your food habits, geographic location, Alcohol, tea, coffee consumption habit, anabolic steroid uses for athletes, etc?
Physical
Physical examination is done by your doctor, consisting of palpation of the fracture site, eliciting boney tenderness, edema, swelling. If the fracture is in the dept of a joint, the joint motion, normal movement will aggravate the pain.
- Inspection – Your doctor also check superficial tissue, skin color, involving or not only the epidermal layer or Partial-thickness affects the epidermis and extend into the dermis, but full-thickness also extends through the dermis and into the adipose tissues or full-thickness extends through the dermis, and adipose exposes muscle, bone, evaluate and measure the depth, length, and width of the fracture. Access surrounding skin tissue, fracture margins for tunneling, rolled, undermining fibrotic changes, and if unattached and evaluate for signs and symptoms of infect warm, pain, delayed healing.
- Palpation – Physical examination may reveal tenderness to palpation, swelling, edema, tenderness, worm, temperature, open fracture, closed fracture, microtrauma, and ecchymosis at the site of fracture.
- Motor function – Your doctor may ask the patient to move the injured area to assist in assessing muscle, ligament, and tendon function. The ability to move the joint means only that the muscles and tendons work properly, and does not guarantee bone integrity or stability. The concept that “it can’t be fractured because you can move it” is not correct. The jerk test and manual test are also performed to investigate the motor function.
- Sensory examination – assesses sensations such as light touch, worm, paresthesia, itching, numbness, and pinprick sensations, in its fracture side.
- Range of motion – A range of motion examination of the fracture associate joint and it’s surrounding joint may be helpful in assessing the muscle, tendon, ligament, cartilage stability. Active assisted, actively resisted exercises are performed around the injured area joint.
- Blood pressure and pulse check – Blood pressure is the term used to describe the strength of blood with which your blood pushes on the sides of your arteries as it’s pumped around your body. An examination of the circulatory system, feeling for pulses, blood pressure, and assessing how quickly blood returns to the tip of a toe to heart and it is pressed the toe turns white (capillary refill).
Lab Test
Laboratory tests should be done as an adjunct in overall medical status for surgical treatment.
- CBC, ESR test
- Random blood sugar, glucose, and routine diabetes test if the patient has diabetes mellitus.
- Microscopic urine examination test, and stool test.
- ECG, EKG test for heart abnormality is present
- Ultrasonography test in some cases.
- Normalized hemoglobin, hematocrit test
- Coagulation profile with bleeding time and coagulation time test, prothrombin time (PT) test for surgery if needed,
- Partial thromboplastin time (PTT), and platelet counts will be needed for operative intervention.
- Serum creatinine test,
- Serum lipid profile
- Serum uric acid test
Treatment of Nonunion
Treatment of nonunions should aim to achieve healing of the fracture while preserving functionality. The following are available options for the treatment of non-unions[rx]:
Nonoperative Treatment
- Removal of all scar tissue – from between the fracture fragment immobilization of the fracture with internal or external fixation. Metal plates, pins, screws, and rods, that are screwed or driven into a bone, are used to stabilize the broken bone fragments.
- Conservative treatment/weight-bearing – In some circumstances and special patient characteristics (e.g., elderly patients not eligible for operative treatments), nonunions can be treated with weight-bearing and watchful waiting. Weight-bearing can be coupled with operative methods such as dynamization or bone excision.
- Electrical stimulator/electromagnetic fields – Growth factors are stimulated in response to the electric and electromagnetic fields.[rx][rx]
- Ultrasound (low-intensity pulsed ultrasound [LIPUS]) – Low sine waves will promote bone healing by increasing the osteoblastic response.[rx]
Do no HARM for 72 hours after injury
- Heat—hot baths, electric heat, saunas, heat packs, etc has the opposite effect on the blood flow. Heat may cause more fluid accumulation in the fracture joints by encouraging blood flow. Heat should be avoided when inflammation is developing in the acute stage. However, after about 72 hours, no further inflammation is likely to develop and heat can be soothing.
- Alcohol stimulates the central nervous system that can increase bleeding and swelling and decrease healing.
- Running, and walking may cause further damage, and causes healing delay.
- Massage also may increase bleeding and swelling. However, after 72 hours of your fracture, you can take a simple message, and applying heat may be soothing the pain.
Medication
The following medications may be considered by your doctor to relieve acute and immediate pain, long term treatment
- Antibiotic – Cefuroxime or Azithromycin, or Flucloxacillin or any other cephalosporin/quinolone, meropenem antibiotic must be used to prevent infection or clotted blood removal to prevent further swelling, inflammation, and edema.
- NSAIDs – Prescription-strength drugs that reduce both pain and inflammation. Pain medicines and anti-inflammatory drugs help to relieve pain and stiffness, allowing for increased mobility and exercise. There are many common over-the-counter medicines called non-steroidal anti-inflammatory drugs (NSAIDs). They include first choice NSAIDs is Ketorolac, then Etoricoxib, then Aceclofenac, naproxen.
- Muscle Relaxants – These medications provide relief from spinal muscle spasms, spasticity. Muscle relaxants, such as baclofen, tolperisone, eperisone, methocarbamol, carisoprodol, and cyclobenzaprine, may be prescribed to control postoperative muscle spasms, spasticity, stiffness, contracture.
- Calcium & vitamin D3 – To improve bone health, blood clotting, helping muscles to contract, regulating heart rhythms, nerve functions, and healing fractures. As a general rule, too absorbed more minerals for men and women age 50 and older should consume 1,200 milligrams of calcium a day, and 600 international units of vitamin D a day to heal back pain, fractures, osteoarthritis.
- Neuropathic Agents – Drugs(pregabalin & gabapentin) that address neuropathic—or nerve-related—pain. This includes burning, numbness, tingling sensation, and paresthesia.
- Glucosamine & Diacerein, Chondroitin sulfate – can be used to tighten the loose tendon, cartilage, ligament, and cartilage, ligament regenerates cartilage or inhabits the further degeneration of cartilage, ligament. The dosage of glucosamine is 15oo mg per day in divided dosage and chondroitin sulfate approximately 500mg per day in different dosages, and diacerein minimum of 50 mg per day may be taken if the patient suffers from osteoarthritis, rheumatoid arthritis, and any degenerative joint disease.[rx]
- Topical Medications and essential oil – These prescription-strength creams, gels, ointments, patches, and sprays help relieve pain and inflammation in acute trauma, pain, swelling, tenderness through the skin. If the fracture is closed and not open fracture then you can use this item.
- Antidepressants – A drug that blocks pain messages from your brain and boosts the effects of endorphins in your body’s natural painkillers. It also helps in neuropathic pain, anxiety, tension, and proper sleep.
- Corticosteroids – Also known as oral steroids, these medications reduce inflammation. To heal the nerve inflammation and clotted blood in the joints.
- Dietary supplement – To eradicate the healing process from fracture your body needs a huge amount of vitamin C, and vitamin E. From your dietary supplement, you can get it, and also need to remove general weaknesses & improved health.
- Cough Syrup – If your doctor finds any chest congestion or fracture-related injury in your chest, dyspnoea, post-surgical breathing problem, then advice you to take bronchodilator cough syrup.
What To Eat and What to avoid
Eat Nutritiously During Your Recovery
All bones and tissues in the body need certain micronutrients in order to heal properly and in a timely manner. Eating a nutritious and balanced diet that includes lots of minerals and vitamins is proven to help heal broken bones and all types of fractures. Therefore, focus on eating lots of fresh food produce (fruits and veggies), whole grains, cereal, beans, lean meats, seafood, and fish to give your body the building blocks needed to properly repair your fracture. In addition, drink plenty of purified mineral water, milk, and other dairy-based beverages to augment what you eat.
- Broken bones or fractures bones need ample minerals (calcium, phosphorus, magnesium, boron, selenium, omega-3) and protein to become strong and healthy again.
- Excellent sources of minerals/protein include dairy products, tofu, beans, broccoli, nuts and seeds, sardines, sea fish, and salmon.
- Important vitamins that are needed for bone healing include vitamin C (needed to make collagen that your body essential element), vitamin D (crucial for mineral absorption, or machine for mineral absorber from your food), and vitamin K (binds calcium to bones and triggers more quickly collagen formation).
- Conversely, don’t consume food or drink that is known to impair bone/tissue healing, such as alcoholic beverages, sodas, fried fast food, most fast food items, and foods made with lots of refined sugars and preservatives.
Operative Treatments
When an operative treatment has been considered, intraoperative culture should always be performed to diagnose a subclinical infection. Radiologic findings and patient characteristics should guide the clinician in the decision of what operative treatment should be done. The following are treatment options:
- Bone grafting – Donor bone or autologous bone (harvested from the same person undergoing the surgery) is used as a stimulus to bone healing. The presence of the bone is thought to cause stem cells in the circulation and marrow to form cartilage, which then turns to bone, instead of a fibrous scar that forms to heal all other tissues of the body. Bone is the only tissue that can heal without a fibrous scar. The autologous bone graft is the “gold standard” treatment of the nonunion the bone is obtained from the iliac crest.
- Nail dynamization and nail exchange – Nail Dynamization and exchange have two similar indications; comminuted fractures and absence of cortical contact after IM Nail.[rx]
- Nail dynamization – A relatively low-cost treatment done when axial stability has been achieved and maintained. The dynamization is achieved by removing interlocking bolts distant to the fracture site facilitating compression and loading across the fracture site.[rx][rx][rx]
- Nail exchange – Removal of the prior intramedullary nail, reaming, and use of a nail with a larger diameter. With this, the reaming process will biologically activate the fracture site, and better axial and mechanical stability can be achieved.[rx][rx][rx]
- Partial fistulectomy – This procedure can be done on its own or combined with other procedures. Two important requisites have to be fulfilled, a stable nonunion and the fistulectomy has to be done in another site different.[rx]
- External fixation – Considered in complex nonunions (e.g., when internal fixation is not possible or not recommended due to infection, substantial deformity, and/or bone loss).[rx]
- Bone grafting – Traditionally, iliac crest bone graft has been used when poor vascular supply is present. This treatment option aims to provide an adequate environment for bone formation (biological factors of the diamond concept).
- Cell therapy – The use of mesenchymal cells within the fracture gap creates a healing environment. [rx][rx]
- Amputation – Considered when adequate functional outcomes cannot be achieved.
