Non union is a delayed complication of fracture. Literally it means absence of union. But by definition a bone can be labeled as in non union only when the union has not occured in the bone even after passage of sufficient time [in which the bone normally would have united]. Fractures of shaft of long bone should not be considered nonunion until at least 6 months post injury but in contrast, a central fracture of the femoral neck can sometimes be defined as a non union after only 3 months
Causes of Non Union
There is a long list of causes of non union. These are patient related like age, injury related like open fractures and treatment related. Few of them are modifiable and others are not.
Patient Related Factors
- Older age
- Poor nutrition
- Steroid therapy
- Radiation therapy
- Anticoagulant therapy
- Smoking
- High alcohol intake
Injury Related Factors
- Open injuries
- Soft tissue interposition
- Bone loss resulting in gap
- Compromised blood supply following injury to nutrient artery
- Stripping injury to muscle and periosteum
- Severe comminution
- Infection
Treatment Related Factors
- Inadeuqate immobilisation
- Distraction of fragments from traction or internal fixation
- Malposition of fragments
- Implant failure
Types
Hypertrophic non-union
Callus is formed, but the bone fractures have not joined. This can be due to inadequate fixation of the fracture or inadequate mobilisation. Fracture is capable of a healing response to injury.There is increased uptake on radionuclide scans.
Oligotrophic non unions
The callus is absent and occur after major displacement of fractures, distraction of fragments, or internal fixation without accurate apposition of fragments. Blood supply is usually good. They demonstrates uptake on radionuclide scans but the healing response is inadequate.
Atrophic non-union
No callus is formed. This is often doe to impaired bony healing due to decreases blood supply. They show radionuclide uptake failure.
Gap non union
There is a loss of a fragment of the diaphysis of a bone. The ends of the fragments are viable but as time passes the ends of the fragments become atrophic. Occur after open fractures, sequestration in osteomyelitis, and resection of tumors;
Diagnosis
Diagnosis is made on clinical examination and xrays. On clinical examination, the fracture fragments would show relative mobilitya and there would be absence of tenderness on the fracture site. Absense of tenderness differentiates non union from delayed union and denotes absence of any biological activity.
Xrays would show
- Absence of bone crossing the fracture site (bridging trabeculae)
- Sclerotic fracture edges
- Persistent fracture lines
- No changes toward union on serial xray
Presence or absence of callus is not a very reliable finding especially in cases of rigid fixation.
Treatment
Nonunion is a failure of healing process. The treatment principle is to augment the healing process by freshening the ends of bone and one grafting and provide adequate immobilisation.
Typical treatment of non union is surgical. Following are the essential steps
- Exposure of fracture site
- Freshening of sclerotic edges to get a bleeding surface.
- Opening of intramedullary cavities of fragments to facilitate flow of blood circulation
- Rigid fixation
- Bone grafting to augment bone healing
- External splinatge if required.
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I have a non union fracture of the humerus. The fracture has not healed. The bone has deteriated to the point that the metal in my arm is causing infections and needs to be removed. Is there anything that can be put in my arm to stabilize the arm?
Dr Arun Pal Singh Reply:
July 5th, 2010 at 12:45 pm
@Anne,
I have already answered that.
I have a fractured arm. The bone has deteriated to the point that the metal inside is causing infections and needs to be removed. Is there anything that can be put in my arm to stabilize the arm
Dr Arun Pal Singh Reply:
July 4th, 2010 at 6:43 am
@Anne,
It is difficult to answer your question without looking at xray.
But if your bone is not unnited and metal has failed, it needs to be reoperated.
I am 48 yrs old and have a non-union spiral fracture of my left ulna. The injury occured 11/13/09 and I didn’t know it was broken so I did not go to the doctor.
My question is this, what do you know and think about the autogenous bone marrow injection process vs. traditional plate surgery?
I’d like to avoid the more invasive if possible.
Thank you in advance for your expertise.
Dr Arun Pal Singh Reply:
September 27th, 2010 at 11:01 pm
@Helen,
Both have there own indications and cannot be compared in isolation.
Visit a specialist who would give you right advice after looking at you.
I had a traffic accident in June 09 and fractured my humerus…surgical procedure performed and a plate was put /grafting from the hip region done…whilst on the operating table the radial nerve was severed and nerve grafting done…after six months we realised that the fracture was non union and the plate was bent. The fracture was re operated upon and a new plate was put…now after 9 months after the second surgery that bone is still not healed and is a “non union” case….what could be the possible causes and what can be done now.?
Dr Arun Pal Singh Reply:
September 27th, 2010 at 11:29 pm
@Alok Lall,
Please go through following article
http://boneandspine.com/fractures-dislocations/factors-affecting-fracture-healing/
fracturde femur izquierdo de 4 años de evolucion 3 cirugias previas 1 con kutcher 2 clavo bloqueado el cual se fatigo 3 clavo bloqueado mas injerto oseo,radiologicamente con osteomielitis y no union de fractura. puede ayudarme?? estoy en guatemala centroamerica pero podria viajar a usa. gracias.
Dr Arun Pal Singh Reply:
October 3rd, 2010 at 7:17 am
@francisco figueroa,
I am sorry but I cannot understand the language.
Here is Google translation of what you wrote
left femur fracture 4 years of previous surgeries evolution 3 2 1 with locked nail kutcher which locked nail fatigue 3 bone graft and radiologically with osteomyelitis and non union of fracture. can you help? I am in Guatemala but may travel to Central America uses. thanks.
What I can make out from this is that you have a non union of femur with osteomylitis.
Xrays and examination can reveal how severe your condition is.
You should see a specialist. You need to see the choices available depending upon the health care system you are in.
You would definitely need a surgical procedure, may be more than one, depending on your situation as there is infected non union.
All the best.
Just to add little help from Google
Lo que puedo hacer a partir de esto es que usted tiene una unión no de fémur con osteomylitis.
francisco figueroa,
Radiografías y el examen puede revelar la gravedad de su condición.
Usted debe consultar a un especialista. Tienes que ver las opciones disponibles dependiendo del sistema de atención de salud que se in
Usted definitivamente necesita un procedimiento quirúrgico, puede haber más de una, dependiendo de su situación ya que está infectado unión no.
Todo lo mejor.
I shattered my skull resulting in an epidural hematoma and emergency craniotomy in 2006. Since the feeling in my head came back in 2008 I have suffered from chronic pain and severe tenderness at the site of injury. A recent CT shows that the skull is still fractured along the cut line. If it is tender does that mean it may still heal? It has been a long time, but the nerves and blood vessels were all severed (I think some of my pain is these reconnecting) which could have caused a lack of blood flow and a non – or delayed union?
Dr Arun Pal Singh Reply:
December 14th, 2010 at 3:07 pm
@Judi,
Please take an opinion from a concerned specialist, namely neurosurgeon.
He/she would explain it better.
My son 17 years old suffered a motocross accident 5/10… The original surgeon inserted flexible rods. A month later the rods had to be ‘shaved’ down due to them being too long and causing extreme pain. In 9/10 he was hospitalized for 3 days with a staph infection and was sent home with oral antibiotics. THEN 12 days later he had to have his 3rd surgery where the rods were removed, a plate with 9 screws inserted and over 200cc of fluid/pus removed. He was sent home with a PICC line and had a reaction to the antibiotics. He was hospitalized then for 3 days where the PICC line was removed and since we refused another PICC line was sent home with a peripheral line and had ANOTHER reaction to a different antibiotic.
Now 12/10, he has a non-union (callus’ is being formed on the outside of the break) and the surgeon wants to perform a 4th surgery and insert antibiiotic beads with graphs… Long story short..
Do you think this is the best thing for my son now? Should I look for another surgeon? I can’t believe all the problems he has gone through..
Dr Arun Pal Singh Reply:
December 15th, 2010 at 5:41 am
@Tammy,
Does he still has infection. There is no harm in seeking another opinion if you are doubtful or unconvinced.
I had a slip last Dec. 2010. The xray showed a complete, impacted transverse fracture of the distal radius with posterior displacement of the distal fragment (COLLES FRACTURE)and a complete fracture at the base of the ulnar styloid. After 7 weeks of wearing a cast ( no operation performed), The fracture still didn’t heal yet.Can it be considered a non union? If so, what would be my best option? Should I wait for 1 more month to see if the fracture would heal or would I undergo an operation?
Dr Arun Pal Singh Reply:
February 22nd, 2011 at 7:26 am
@lili,
I think it is better to give it some more time. Colles fractures usually do not have problems in union.
My dad was involved in a lawnmower accident and broke his neck in several places as well as a broken back back. He had a 7 hour surgery where a rod was placed to stablize his neck and back. He was discharged to go home five days after surgery. During his stay at the hospital and while sent home he was never treated for blood clots. He died three days later at home from a pulmonary embolism. Is it normal care not to treat a back/neck surgery patients for blood clots? Also the autopsy also showed a large collection of blood in the right chest cavity which could of been secondary to his death. Is bleeding internally a big risk of these types of surgeries and fractures?
Dr Arun Pal Singh Reply:
May 28th, 2011 at 1:47 pm
@Brenda,
I am sorry to know about your father. Your questions are specific while the answers to them would depend on a lot of factors/variables specific to your father.
His overall condition at the time of injury, his extent of injuries other than cervical injuries, his clotting profile etc.
As for as your question is concerned, there is not enough evidence to give anticoagulant therapy in back surgeries.
But that applies to population in general, not to a specific patient.
I have read a lot of complications on this site for others and because my son has gone through sooo many complications as well I want to say this: SEEK and SEARCH to find the right doctor. Find out all your options especially if you are looking at infections and non-unions. We found Dr. Brinker in Houston, TX to be the BEST thing that ever happened for us. Not only did he answer all of our questions but he gave us all the options that would be best for my sons femur (non-union and osteomyelitis). Our surgeon in Las Vegas performed 3 surgeries on my son (where he came down with infections) and after 7 months there was NO healing at all…. The surgeon here in Vegas wanted then to perform a 4th surgery to insert ‘antibiotic beads’. I researched and found Dr. Brinker. After a couple of tests it was discovered my son NO longer had an infection (so why did the surgeon in Vegas want to use antibiotic beads???) Now after 3 months…. my son is now showing great signs of union and light at the end of the tunnel…
Please… take the time to find the best doctor/surgeon for your condition… it will pay off in the end!!
Hi, I fell down a hill and fractured my ankle in fall of 2009. It literally looked like a boomerang. Surgery and hardware inserted. Hardware was driving me crazy and surgeon removed in Sept of 2010. Ankle collapsed in November of 2010. Surgeon would not take any pics and insisted I was healed and told me to get on with my life and ordered MORE PT. Could not even work part time without extreme swelling and severe pain. Went to surgeon again with symptoms. She blew up and said I was healed and suggested I might have nerve damage. Sent me to a neurologist. Nero ordered a 3 phase bone scan which was indicative of osteomylitis . So a MRI was ordered. Nerve damage confirmed and considered severe. MRI showed an infarction of bone and non union of fracture. Since this is a workmans comp issue, I have requested another surgeon at Vanderbilt in Nashville to get another opinion. Surgeon here has no interest nor knowledge of how to treat infarcts nor has offered to help with non union. My foot is blue cold and numb still. I think going to another surgeon that is more knowledgeable will help me understand more,,,,but can he still do anything since the DOI was in November of 2009?
Thank you for any suggestion, help, advice you may offer. I have already had to apply for disability since the pain is so bad. This has changed my life 180. 51 years old. Surgeon said my bones were great, but even I can feel the “confusion” in the lower leg bones next to the ankle.
Dr Arun Pal Singh Reply:
July 9th, 2011 at 1:49 pm
@Susan,
You need to tell me names of injured bones. Which bone had osteomyelitis?
What nerve was damaged?
Which bone is infarcted.
If you could send me an image, I would understand things better.
Hi Dr Arun my name is carrowmore I fell and fractured my neck of femur Dec. 09 Introchanteric fracture during this operation my femur fractured followed by operation 2nd.Jan. Having spent 8 weeks non weight bearing my frractures are healed now. However I have a 4cm leg length discrepancy operated leg longer than the other. An abductor contracture and a tilted pelvis. A large screw and plate followed by two overlaping plates at neck of femur and shaft with approx 16 screws. Life is unbareable with pain and I am unable to walk with the weight of both legs. My knee is also affected turning inwards with pressure, I am 66 and my surgeon says there is nothing he can do. Can you please give me some advice.
Dr Arun Pal Singh Reply:
August 13th, 2011 at 11:46 am
@carrowmore,
You need to be more detailed. I am getting too little information. Be as specific as possible and do not worry bout the length of the comment.
You can also send me an xray at contact [at] boneandspine [dot] com
My wife (39) sustained comminuted fracture of humerus distal 1/3 rd in june ’11 which was surgically treated (orif with ss wire). It failed and she was again operated in sep’11 (orif with locking plate with cancellous bone graft).
During review in dec’11, the surgeon said there is radiological union and gave consent for regular activities along with shoulder exercises, Asked to report after three wks. Reported to the surgeon today and he has said there is progressive union, He has given fitness certificate for resuming school duties( my wife is a kindergarten teacher). Called for next review after two months.
My query is what is the difference between radiological union and progrssive union? Iam apprehensive whether the fracture has united or not?
Dr Arun Pal Singh Reply:
January 11th, 2012 at 4:47 pm
@Sankar Mukherjee,
I am not sure whether these terms were actually used or is a translation of translation.
After the surgery, we follow up with xrays to look for signs of union.
Xray signs are most definitive way of telling union in routine practice. That is how we look for union.
Before I go further, I must explain that there exist two terms.
Uniting and United
A united fracture is where the enough radiological signs are present to say that the fracture has healed [Basically we look for bone bridge formation across the fracture]
A uniting fracture when mentioned means that there are enough signs to point that process of union is active and fracture may be called united at some later point of time.
So when you say there is radiological union what I presume that doctor has tried to tell you that radiological signs of union are present.
It is hard to decipher if he mentioned uniting or united.
Same is for other term ‘Progressive union”.
These terms does not impart any meaning until the context is known.
For example second time he might have meant that union has progressed from previous point.
Go back to your doctor and get your query cleared.
Ask the same question as you have asked here in the last sentence.
I hope that helps.