- Definitions of Slow Union, Delayed Union and Nonunion
- Pathophysiology of Fracture Nonunion
- Causes of Nonunion of Fracture
- Types of Nonunions
- Diagnosis of Nonunion
- Treatment of Nonunion
- Fixation Methods of Nonunion
- Bone Grafting in nonunions
- Biophysical Stimulation of Nonunions
- Infected Nonunions
- Brief View of Nonunions of Different Bones
- Malunion of Fractures
Nonunion of fracture is a delayed complication of fracture. Literally, it means the absence of a union. But by definition, a bone can be labeled as in nonunion only when the union has not occurred in the bone even after a passage of sufficient time [in which the bone normally would have united]. Fractures of the 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.
After the fracture has occurred, the body initiates a complex overlapping sequence of events, including inflammation, repair, and remodeling.
This sequence can restore the normal bone structure, biologic function, and mechanical strength in patients of any age.
Despite the potential for a successful hearing through regeneration of normal bone, certain types of bone injury and, in some instances, the treatment of bone or soft tissue injury, lead to complications such as delayed union, nonunion, malunion, or bone necrosis that prevent the rapid restoration of normal structure and function.
These complications of fractures and their treatment are inevitable in some patients, but it is possible to avoid or minimize complications and becomes important to diagnose and treat them.
Definitions of Slow Union, Delayed Union and Nonunion
Time a fracture should take to unite cannot be determined arbitrarily. This is so because various factors play a role in fracture healing, including the severity of the injury, the fracture pattern, the type of bone, and the age and nutritional status of the patient.
[More about fracture healing and factors affecting it]
The concepts of slow union delayed union, and nonunion are based primarily on the state of activity and rate of progression of the repair process.
Slow Union
This term basically implies that fracture union is present but slow. This is a fracture that maintains the appearance of the early stages of healing for more than a few weeks. The fracture line remains clearly visible, but there is no unusual separation of the fragments, and no cavitation of the surfaces, decalcification, or sclerosis.
A slow union does not result necessarily in a delayed union or nonunion. Such fractures often unite if immobilization is maintained long enough.
Delayed Union
The term delayed union refers to a fracture in which repair is not complete within the interval expected for that specific fracture.
Clinical and radiographic evidence of healing is present. The fracture line is evident on radiographs and usually appears woolly and ill-defined. A delayed union, if given proper milieu, has the potential to unite.
Nonunion
A nonunion exists when repair is not complete within the period expected for a specific fracture, and cellular repair activity at the fracture site ceases. Clinically, a nonunion is diagnosed when a repair process has stopped completely and the union will not occur without therapeutic intervention.
This cessation of activity is the most important feature that differentiates between nonunion and slow/delayed union.
In an established nonunion, sclerosis develops around the bone ends and the medullary canals are sealed off. The bone ends are joined by dense fibrous tissue.
For a fracture of the shaft of a long bone in an adult, at least 6 months must elapse after the injury before this diagnosis can be made.
Thus it must be re-emphasized that terms slow union, delayed union, and nonunion all imply a time frame. This time frame depends on the factors that influence the rate of fracture healing, including the location of the fracture and the amount of soft tissue injury.
Once nonunion has occurred, the fracture would not unite without intervention.
Radiological and clinical features of a given injury help to reach the diagnosis.
However, time elapsed since the injury was used in classical definitions and was important for defining surgical indications.
In the past, surgery was done only in cases where all possibility of healing without intervention was nil.
But with changing times, a more aggressive approach to obtaining fracture union often is taken, and the time frames are less important.
For example, surgery may be contemplated after 4 months of conservative treatment, although technically this does not meet the criteria for a nonunion.
The focus is to decrease the morbidity and enable an early return to function. Similarly, fractures that carry a high risk for nonunion may be grafted primarily. This is mainly done in open fractures and comminuted fractures.
Pathophysiology of Fracture Nonunion
There are multiple factors responsible for the development of nonunion and all the factors responsible for the event may not be known.
Biologic factors play a part in the consolidation of a fracture.
Fracture repair requires at least four events that initiate fracture healing. These events include recruitment, induction, modulation, and osteoconduction.
Following adverse mechanical factors influence the development of nonunion
- Excess motion
- Inappropriate stabilization
- Large interfragmentary gap
- dIstraction by internal fixation or traction
- Interposition of soft tissues
- Loss of bone
- Loss of blood supply.
- High-energy trauma causing loss of the bony soft tissue envelope
- Damage to nutrient vessels
- Segmental or comminuted free fragments
- Excessive periosteal stripping during hardware insertion.
Some bones like scaphoid, distal tibia, the base of the 5th metatarsal are at higher risk for nonunion due to the precarious blood supply in these areas. Fracture patterns like segmental fractures segmental fractures and those with butterfly fragments are at increased risk of nonunion as the blood supply is compromised to the broken fragment.
Causes of Nonunion of Fracture
There is a long list of causes of non-union fracture. 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 a gap
- Compromised blood supply following an injury to the nutrient artery
- Stripping injury to muscle and periosteum
- Severe comminution
- Infection
Treatment-Related Factors
- Inadequate immobilization
- The distraction of fragments from traction or internal fixation
- Malposition of fragments
- Implant failure
Types of Nonunions
Hypertrophic nonunion
Callus is formed, but the bone fractures have not joined. This can be due to inadequate fixation of the fracture or inadequate mobilization is capable of a healing response to injury. There is increased uptake on radionuclide scans.
Hypertrophic or elephant foot callus is a sign of motion at a vascular nonunion where the interposed tissue essentially is fibrocartilage. The union will occur rapidly when motion is stopped by stable internal or external fixation devices. A bone graft usually is unnecessary.
Oligotrophic nonunions
The callus is absent. It occurs after major displacement of fractures, a distraction of fragments, or internal fixation without correct apposition of fragments. Blood supply is usually good. They demonstrate uptake on radionuclide scans but the healing response is inadequate.
Atrophic nonunion
No callus is formed. This is often due to impaired bony healing due to decreases blood supply. They show radionuclide uptake failure.
The bone remains avascular or is revascularized very slowly or poorly.
If alignment is good and there is no gap, then stabilization under compression, with shingling and bone grafting, will stimulate the fracture healing process.
If there is malalignment or a gap, resection of the scar tissue is essential followed by eduction, shingling and stabilization and bone grafting.
Gap nonunion
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. Occurs after open fractures, sequestration in osteomyelitis, and resection of tumors.
Pseudarthrosis
The term pseudarthrosis implies a nonunion with false joint formation in which the medullary canal is sealed off, with new cartilaginous surfaces covering the bone ends and the nonunion surrounded by a fibrous capsule having a synovial lining.
Pseudarthrosis means false joint.
These nonunions are excessively mobile and often are associated with near ankylosis of a neighboring joint.
Diagnosis of Nonunion
Diagnosis is made on clinical examination and x-rays. On clinical examination, the fracture fragments would show relative mobility and there would be an absence of tenderness on the fracture site. The absence of tenderness differentiates nonunion from a delayed union and denotes the absence of any biological activity.
Xrays would show
- The absence of bone crossing the fracture site (bridging trabeculae)
- Sclerotic fracture edges
- Persistent fracture lines
- No changes toward union on serial x-ray
Presence or absence of callus is not a very reliable finding especially in cases of rigid fixation.
Treatment of Nonunion
Non-operative Treatment
Nonunion is a failure of the healing process. The treatment principle is to augment the healing process by freshening the ends of the bone and bone grafting and provide adequate immobilization.
Some superficial fractures may respond to bone stimulation which may be tried as part of nonoperative treatment. Few selected nonunions may be tried with fracture brace immobilization
Contraindications to non-operative treatments are synovial pseudoarthroses, nonunions that move and greater than 1 cm between fracture ends.
Operative Treatment
Typical treatment of nonunion is surgical. Following are the essential steps
- Exposure of the fracture site
- Freshening of sclerotic edges to get a bleeding surface.
- The opening of intramedullary cavities of fragments to facilitate the flow of blood circulation
- Rigid fixation
- Bone grafting to augment bone healing
- External splintage if required.
Hypertrophic nonunions
These nonunions often have biologically viable bone ends and may be treated with internal fixation to provide mechanical stability. Bone grafting may not be required.
Oligotrophic/ Atrophic nonunions
Because the biological activity is reduced, these nonunions may require biological stimulation along with internal fixation. The biological stimulation is by bone graft taken from autologous iliac crest is the gold standard.
Infected nonunion
The first step is to control infection and the treatment requires a staged approach. There is a need to remove all infected/devitalized soft tissue. Infection is controlled by using local/systemic antibiotics. There may be an associated gap which is treated by bone graft/bone transport. Soft tissue coverage procedures may be needed.
Pseudoarthrosis
Pseudarthrosis may be found in association with infection and principles to control infection remain same. The treatment requires removal of atrophic, non-viable bone ends, internal fixation with mechanical stability. Soft tissue coverage procedures may be needed.
Fixation Methods of Nonunion
Internal Fixation
The aim of the internal fixation is to gain stability after apposition of fragments.
Bone grafting is not necessary in hypertrophic nonunions where callus formation is plenty. Revascularization is encouraged by decortication, petaling, drilling of avascular fracture ends, and cancellous bone grafting.
Depending on the type and location of the nonunion, different implants may be selected for fixation.
Screw Fixation
Screws are not used in diaphyseal nonunions alone but may be used as interfragmentary screws along with neutralization plate in nonunion of a long spiral fracture.
Plate Fixation
Plate fixation may be used with or without cancellous bone grafting and, wherever possible, used with compression. The cancellous bone grafting is not necessary unless the bone ends are sclerotic or when the defect is present or is created by realignment or correction of shortening. In such cases, compression plating is not possible and a neutralization plate is used. Angular deformity may be corrected by applying a plate under tension on the convex side of the bone.
Intramedullary Nailing
Intramedullary nailing is mainly used for nonunions of the lower limb. It has the advantage of lesser soft tissue damage and decreased risk of infection.
Closed nailing may be sufficient alone but in open nailing, bone grafting is preferred.
External Fixation
The use of the external fixator depends on the type of nonunion.
In cases of hypertrophic nonunion, the chief objective is to stabilize the limb and provide adequate compression
The treatment of bone losses of 3 cm or more may require bone transport with Ilizarov ring fixator.
Combined Internal and External Fixation
Combined internal and external fixation may be considered when femoral or tibial lengthening is necessary. It uses an interlock [locked only on one end] to control alignment and a ring fixator for bone lengthening. Once the desired lengthening is done, the nail is locked and external fixator is removed.
Bone Grafting in nonunions
Autogenous bone remains, even today, the best bone grafting material. Bone grafting can be nonvascularized or vascularized.
Bone grafting can be used as an isolated procedure, associated with internal or external fixation.
Depending on the individual case, packing cancellous bone chips in and around the nonunion may suffice, or it may be combined with a structural corticocancellous graft. A nonvascularized segment of the fibula may be used as a graft to fill a large bone defect in the radius or ulna.
Vascularized autografts are effective but require microvascular techniques.
Biophysical Stimulation of Nonunions
Bone Stimulators
Electrical stimulation is effective in hypertrophic nonunions but less so in atrophic nonunions and in the presence of a gap.
Low-intensity pulsed ultrasound has shown substantial efficacy in accelerating healing of fractures of the upper and lower extremities.
High-energy extracorporeal shock waves is an alternative to surgery in the treatment of ununited fractures and can be applied on an outpatient basis in many patients.
Orthobiologics
Orthobiologics are biological substances that are used to help injuries to heal more quickly. Orthobiologics are used to improve the healing of fractures, injured muscles, tendons, and ligaments.
For example, percutaneous Injection of Autogenous Bone Marrow and other orthobiologics are used in the treatment of nonunion.
Read more about orthobiologics.
Infected Nonunions
Infected nonunions become the special case because infection needs to be controlled before the union could occur. Infected non-union is characterized by
- Atrophic radiographic appearance
- Poor fracture vascularisation
- Inadequate soft tissue coverage
- Loose fixation
These require aggressive patient management.
The treatment includes antibiotics, local debridement, stabilization [often external first, followed by internal], repair of the defect to control the infection, soft tissues and bone reconstruction surgeries when needed.
When active drainage is ongoing, healing will be longer and more difficult.
If drainage has not occurred for 3 or more months and the wound is quiescent, infected nonunions may be treated as atrophic nonunions.
Brief View of Nonunions of Different Bones
Clavicle
Symptomatic nonunions of the middle third of the clavicle should be treated by the application of a plate and iliac bone graft. When the nonunion is within 4 or 5 cm of either end, the short fragment may be resected.
Humerus
In young Nonunited fractures of fracture dislocation of the proximal humerus should be treated by fixing the proximal fragment with a proximal humeral plate. Liberal use of methylmethacrylate cement if needed may be done.
Cancellous bone grafting, best obtained from the iliac crest may be used for grafting.
Successful treatment for these nonunions is difficult.
Prosthetic replacement of the head of the humerus may be considered primarily in old patients or after failed surgery in young patients.
For humeral shaft fractures, the recommended treatment is plate and screw fixation with bone grafting. But in older patients, the physical condition of the patient should be considered and diminished function because of a nonunion may be preferable to the risks of ORIF in some cases.
In such cases, orthosis may help.
For atrophic ununited diaphyseal fractures of the humerus with a bony defect
Nonunions of the distal humerus should be treated by means of two contoured 3.5-mm reconstruction plates, one placed medially, and the other placed posterolaterally.
Total elbow arthroplasty may be considered only as a salvage procedure.
For nonunion of the capitellum, excision may be done.
Radial neck
Radial neck fracture nonunion is rare. Observation, radial head, and neck excision, or ORIF with bone graft may be considered, depending on the level of pain, deformity, and functional restriction.
Radius and ulna
In proximal and midshaft nonunions, a compression plate and cortical screws should be used for fixation.
Distal radius nonunions should be treated by a volar or dorsal small T plate as a buttress.
Carpal scaphoid
Nonunion of the carpal scaphoid may be treated by trapezoidal bone grafting and internal fixation. K wires, AO cannulated screw, Herbert screw has been used successfully.
Femur
For femoral neck fracture nonunions, prosthetic replacement is the best treatment, especially in elderly persons.
In younger people, an attempt should be made to achieve union. Valgus intertrochanteric osteotomy is the best method for that. A dynamic hip screw should be used for fixation, as well as a bone graft at the nonunion site.
Nonunion of intertrochanteric fractures is tackled by a medial displacement and valgus osteotomy.
Subtrochanteric fractures nonunions are difficult to treat and treated by intramedullary locked device or dynamic hip screw or dynamic compression screw.
Fractures of the femoral shaft can be treated by intramedullary nailing or plating and bone grafting.
Supracondylar fracture nonunions may be treated by intramedullary nails or a 95° dynamic condylar screw.
Condylar buttress plate is another choice.
Tibia
Proximal tibial fracture nonunions usually are treated by internal fixation using tibial plating and bone grafting.
Nonunions of the tibial shaft fractures are treated best by intramedullary nailing or plating. While in hypervascular nonunions, the graft is not required, in avascular nonunions, decortication of the bone ends and bone grafting should be done.
Nonunited pilon fractures of the lower tibia and fibula can be salvaged by intraarticular osteotomy and lag screw fixation with bone grafting. Ankle fusion and stabilization is considered in arthritic joints.
Malunion of Fractures
Malunion refers to fracture union in an abnormal position. The abnormal position may be shortened, lengthened, angled, or rotated. Malunion may result in, though not always, insufficient or abnormal function and cosmetically unacceptable limb.
Malunion may cause alteration of normal dynamics of joint motion. For example, limited pronation-supination after forearm fractures or the development of pelvic obliquity, scoliosis, and back pain secondary to leg-length inequality.
Malunion may be the result of inaccurate initial reduction or loss of position because of inadequate immobilization. In physeal fractures of children, physeal damage or growth disturbances may result in deformities.
The clinical problems presented by malunion of long bones differ
- According to their location
- Diaphyseal and metaphyseal
- Articular surface
- Skeletal maturity of the patient
- Child
- Adult
Diaphyseal and Metaphyseal Malunion
The abnormal position of a healed fracture alters the biomechanics of a specific joint by shifting the weight-bearing axis. The abnormal joint mechanics lead to joint instability and cause local stress overload on the articular cartilage. Both instability and increased or abnormal loads can increase the probability of post-traumatic arthrosis, especially in weight-bearing joints.
However, the degree of gross deformity is not always related directly to the degree of loss of function or to the long-term development of osteoarthrosis and for the same deformity, function affected varies among the individuals.
The functional impairment also depends on the bone and its compensation offered by the body. For example, a malunion of a proximal humeral fracture often results in minimal functional limitation and cosmetic irregularity.
The deformities near joints, especially those that are not in the plane of motion of the joint, may impair function seriously.
Rotational deformities are not apparent on radiographs, may be disabling.
In lower limbs, shortening of a limb by more than 2.5 cm may present enough of a functional and cosmetic problem to warrant shortening of the opposite limb or, in some circumstances, lengthening of the affected segment.
The object of surgery for malunion is to restore function. If the functional disability is minimal, surgical correction of malunion may not be justified. A period of intense physical therapy or weight bear¬ing may be necessary before surgical intervention for malunion to restore atrophic muscle strength.
Articular Surface Malunion
Like metaphyseal/diaphyseal malunions, the amount of functional impairment cannot be quantified for a given grade of malunion though the causal relationship between articular surface step off resulting from malunion of an intraarticular fracture and the development of arthrosis is clearer.
Other factors that may affect the final outcome are variations among joints, associated injuries, joint stability and expected loads.
All said and done, intra-articular malunions are less acceptable than diaphyseal/metaphyseal and rigid criteria have been developed for different joints to serve as guidelines of intra-articular fractures.
The treatment of articular malunion is directed best at prevention because the role of surgery in correction is limited. Associated joint arthrosis often makes joint-ablating procedures such as arthrodesis or arthroplasty the only option. Joint realigning osteotomies sometimes may help.
Diaphyseal and metaphyseal fractures in children can result in growth stimulation and overgrowth.
Physeal and Epiphyseal Fractures
The possible consequences of injury to a physis and epiphysis are a progressive angular deformity, progressive limb-length discrepancy, and joint incongruity with resultant posttraumatic arthrosis. Causes include avascular necrosis of the epiphysis, crushing or infection of the physis, bony bridge formation at the periphery, joining of the epiphysis and metaphysis, nonunion, and hyperemia producing local overgrowth.
The anatomical reduction is therefore of utmost importance in epiphyseal fractures.
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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?
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
@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.
@Anne,
I have already answered that.
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.
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.?
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.
@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.
@Alok Lall,
Please go through following article
https://boneandspine.com/fractures-dislocations/fa…
@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?
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..
@Judi,
Please take an opinion from a concerned specialist, namely neurosurgeon.
He/she would explain it better.
@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?
@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?
@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.
@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.
@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?
@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.
I am a very healthy 49 y/o (no smoking, no alcohol use, work out with a trainer, and no underlying medical conditions). I fell down 5 steps and fractured my femur. Had emergency surgery with a rod and 7 screws inserted. I am now 4.5 months post op. I have constant pain from my hip to my ankle. I still cannot walk without assistance. The ankle pain has increased to the point that I cannot bear weight on that leg. My diagnosis is now considered non union and I started a bone stimulator 4 days ago. No one seems to know why I have not healed, why I have ankle pain, and lower leg pain. I have a very good trauma surgeon. Any suggestions, advice, or comments?
@regina,
If you have a good trauma surgeon I do not think you need any further advice. Non union is a complication and many factors govern it though it cannot be said what mattered in an individual case.
How are you now?
I am so sorry so many people are having problems with femur fractures with no relief of pain or union of the bone. I honestly felt my son had a competent surgeon doing the best that he could (but he almost lost his leg). Had I continued believing in my son's surgeon he would have lost his leg (at 17 years of age)…. I did my research and found Dr. [Ed. note – Name Edited]at the [Ed. note – Name Edited] Orthopedic Center in Houston… It was inconvenient to fly there but he is a top notch surgeon and fixed my son's non-union with a 31 degree internal rotation in only 3 months…. I had dealt with the first surgeon,[Ed. note – Name Edited], for over a year with NO results. I don't believe anyone has to believe they can't get better! Do your research and find the surgeon that is right for YOU…. I will state again, I thought my son's surgeon was doing all he could but later found out just how BAD he really is….. Please… do yourself a favor and do some research. I am overwhelming happy I did.
i fractured my fourth toe on right foot 4weeks ago . (slanting) it has not healed and the dr said that a minimal callus was formed at the tip of the fracure site not all the way throughout the fracture. i have been asked to walk on heal .my foot swells along the the fourth toe and upto the ankle.I AM VERY DEPRESSED AND WORRIIED. PLEASE HELP ME I NEED YOUR ADVICE AND WANT TO KNOW IF THERE IS ANY THING TO WORRY OR THINGS ARE GOING NORMAL IN MY CASE
On 23/10/2011 I met with an accident. Both of my tibias got multi fractured. I left leg a rod ow placed without opening up the leg as there wer pieces of bones. My right leg was opened up and a plate was placed. It also had multi fractures. Around 9 months have been passed but legs have not been healed. Xray reports say 'healing' but in x ray fils still there are gaps between fractures. Doctor says it's delayed union. I am not able to understand whether it's non union or delayed union as 9 months have already passed. Kindly advise me. Doctor says wait and watch. He has advised me to resume my duties. But I am on wheel chzir and no weight bearing. What should I do?
Can someone please explain the following report?
Wrist is in ulnar deviation. There is dorsal tilt of the lunate. There is an ununited Ulnar Styloid Fracture with associated degenerative arthrosis between the ulna and the fracture fragent with associated bone oedema.
There are small first carpal-metacarpal joint margin osteophytes. There is tenosynovitis of the second dorsal extensor compartment tendon sheaths and a little fluid around the first extensor compartment tendon sheath and within the ECU tendon sheath. Fibres from th e triangle fibrocartilage insert of the ulnar styloid fragment.
I don't understand a word of this MRI report that was done on my right wrist. Please help????
I'd like to hear your opinion about this:
I broke my Ulna from a direct blow and was treated non-surgical.
Here are my X-rays [Moderated for privacy sake]
Do you think it is going Nonunion? What are the solutions?
I have no pain and 95% extension with little pain at the point of the fracture when I try to extend more.
I'd like to know also about lifting weights and practicing Martial Arts.
Thank you!
@ruhi,
How are the things now?
@Mysterri2002,
You must have discussed it with your treating doctor. What part have you not understand. In short the MRI says you have a fracture and swelling of wrist tissues.
Does anyone else have any experience with non-union skull fractures? Neither do my doctors…. I have three plates in my skull, etc., but it hurts, is tender to the touch, and I can predict the weather better than the meteorologists!!!!!
The only skull non-union evidence I can find is for children, I had a neurologist say "nice to meet you and see your nice brain, bye-bye" after seeing my fracture SEVEN YEARS after my injury. I am not a child, but I am young enough (30s) to not need to live with chronic pain. Is there hope of healing?
All the docs here seem to simply say "talk to a/your doctor". What good is this thread if no one ever gives any opinion, solution, suggestion, etc.
We HAVE our diagnoses…. I guess this is not a medical advice thread, but there are obviously people like us out there who have NO advice!!!! Are there any doctors who specialise in non-unions, and do actual research (i.e. would like to use us to publish a paper)???? They should.
@Judi,
Skull fractures are seen and managed by neurosugical specialty. This website does not cover head injuries as these are not orthopedic injuries.
Non union in skull fractures should also be seen by neurosurgeon.
Due to limitation of interface, patients cannnot be prescribed treatment or diagnosed. Any such query is bound to get an answer of seeing a doctor because that is one ought to do.
It needs a lot of work to diagnose and treat and that mandates physical interaction with patient.
If somebody breaks his leg and asks me what to do, what should be the obvious answer!
He needs be examined and investigated, type of injury determined and then treated.
That cannot happen on a website.
Therefore these queries are answered like 'see a doctor'.
Some of the people who are under treatment and ask questions like when to bear weight or how long I exercise.
Answering these questions is like interfering with there present treatment. They need to ask these questions from there treating physicians.
If someone is looking for a second opinion, it is not a place again. Giving a second opinion require physical presence and interaction of doctor and patient.
You might question what can be answered?
You can ask to expand your knowledge on a disease, if you are confused about details of disease.
As for as you are concerned, a neurosurgeon would of help, not a orthopedist.
Take care.
thanks Dr. Singh. I understand, I just think it is frustrating for many of us. My neurosurgeon doesn't give me the time of day either. The system seems to wash its hands of untreatable ailments (like non-unions) – especially those that involve pain.
Take care.
@Naval Puri,
Please let me see your xrays. You can send them to contact [at] boneandspine [dot] com
Dear Dr Arum I fell and fractured my neck of femur unstable intertroncheric fracture. Post operation my left operated leg was 2 inches longer than the other, My pelvis was laterally rotated and tilted why did thid happen and also my adductor is dead.
The xray shows an ununited fracture. How ong since injury now?
@Judi,
Its frustating for the physicians too. But we have to accept the limitations.
@carrowmore,
Can I have a look at your postop xrays.
Dr. Singh – My name is Daljit Singh Randhawa. I had a trip and fall, and hurt my left wrist badly. Emerg Dr. is not sure (from looking at Xray's) if there is a fracture, but pain is there. He asked me to see the the Orthopaedic clinic. I am sending my Xray's folder (Dr. Purewal) to your contact.
Thanks for your time
Seek ur opinion, I m very tensed, what to do, what not to do…. I met an accident ten years back my color bone got fractured that time(it is non union clavicle fracture) doc suggested not to operate it that time, so I didn’t BT now from last four- five months I m suffering from non stop severe pain, I consulted four five diff docs few are saying go for surgery, other says surgery is not required, although there is a wide gap in a broken bone… I am confused…
plz guide me for better possibilities….
Munmun,
Non union of clavicle does not generally affect the function but if it has become source of pain, it would require surgery. If you are concerned about surgery and unwilling at the movement, try conservative treatment for four weeks. If the pain goes [the bone would not unite], then you can avoid the surgery.
Take care.
Sir,
I had an accident resulting the fracture in humerus. After significant time i.e. 10 months, fracture is not healed completely. So, my doctor suggested me bone grafting.
I do have some problem in breathing and nose, i am also looking for septorhinoplasty.
Can i undergo both the surgeries within 7 days. Although my orthopaedic doctor suggested that i can go for both, Still I am not sure.
Will multiple surgeries affect the healing process?? should I wait for septorhinoplasty??
Aditya Mishra,
I do not think you should get operated for both within a short span. Technically, it can be very much done. Both the surgeries are planned surgeries and there is no emergency as such. Every surgery is a burden on the body and there is a potential risk of complication with every procedure.
In any case, we are spacing the procedure. I think you should get second surgery after results of first have been obtained.
Take care.
Hi I fell on an outstreched hand and broke my radius bone in March 2015. I had pins and an external fixture was was removed after 8 weeks. I still had pain on my ulna side afterwards which I thought was because of stiffness. I have been for physio for 6 months however the pain and stiffness is still there. Its a year later and I still experience pain on my ulna side especially when rotating. Please advise. Do you think my ulna bone is also fractured. If so can it heal naturally or would I need to operate again? If I leave it like it would I pick up any complications later on such as athiritis etc
Ismail,
A simple xray and visit to orthopedic surgeon is required to answer your query. if x-ray is normal and pain does not improve, get an MRI to rule out TFCC injury.
I suffered a fracture at the base of my 3rd metarsal of my foot 6 months ago. X-rays show some evidence of healing but not complete. I have been using a bone stimulator for about 2 1/2 months. My doctor has wanted me to wear a walking boot for times when I’m out of the house and to discontinue physical therapy I was previously doing in the hopes it will heal. I am continuing to be in pain. Even upon waking in the morning having been off my foot all night.
Giselle,
Can I see your xrays – initial and latest. You could send to contact [at] boneandspine [dot] com
I do not have the films.
Okay! It becomes difficult to comment on your situation unless I see something. Try if you can get them.
All the best.
My wife has an operation at the bunion of her right foot. At the same time there was an operation for a hammer toe. After 4 weeks they took out the needle in the hammer toe. After 6 weeks they recognized a nonunion and got a new plaster for 4 weeks. The hammertoe was folded to the left.
Now after 12 weeks there exist still a nonunion. They advised us just to wait again for 4 weeks to see if the union of the bone is started. What could be a good advice to get the foot well recoverd?
Harry.
Harry Wijnen,
12 weeks nonunion. Most likely she would need a surgery again with bone graft enhancement.
All the best.
Namaste.doctor,I have a jones fracture.I am not in pain but I do not put full weight on it and I have it in a cam walker.The DR. said I had a non-union the second visit I had with him after two weeks.he says I must have surgery.Now it is three months and he still says non-union with a lot of scare tissue formed.I do not want surgery.I have been using a bone stimulator for almost a month.and have been massaging it everyday w/ arica oil and comfry.I have 3 x rays and one ct scan I can send you.I feel his heart is not in my best interest this is a wo.comp case.I just want to heal I dont care how long it takes.Thankyou for any light you can shed on this
Jason,
Standard treatment for non-union is surgery. However, you may want to exhaust the available options first, it seems.
Take care.
Dr. Please look at my Forearm xray . My case was quite complicated So One bone Forearm Ulnius Technique Used .i’m happy with its range of motion. What you think about its Healing progress . expected How much time should it take to Heal completely…
Xray is here..
90 day post op xray
[Edited]
Farhan,
It is still not united. Needs more time. Get an x-ray after two months for comparison.
Take care.
Hello Sir,
I am pankaj jain and left Humerous in my hand and operated on 6th March with plate & screw. Now I have a X-Ray on 12th July doctor says Delayed Union. Now what can i do that develop my delayed union.
Pankaj Jain,
There is nothing much that you can do about that except for a balnced diet and follow doctor’s advice. Some people are observed to heal slowly.
Take care.
Thanks………Exercise daliy do it or not…….
How much weight put in hand?
Hi
I had a craniotomy over three years ago- i have had lots of cracking, popping and pain, just discovered a large nonunion bone flap, surgeon wants m to have it repaired, would this be considered an urgent surgery?
Tina,
Sorry! Not a domain of Ortho. YOu would need to consult a neurosurgeon for that.
Hi.
I have an old ununited fracture of the Ulna Styloid Process. (It was first an Avulsion Fracture) It has not healed after five years and has been giving me pain all throughout those years. Originally the doctor thought it was going to heal, no original treatment such as Stabilization was given. Why was this? It is still a non-union to this day and still hurts, especially after activity? I am on a waiting list for Ortho but that is still months away. Could I have a tfcc tear or a few??
Thank you.
Stephanie,
It is not possible to offer specific advice like whether you have TFCC injury or not. I think it is prudent to wait for your appointment to clear all the doubts.
i had an accident where a motorcycle swept me to the ground and this resulted to open fracture of the tibia and fibula.the surgery was carried out 10 days later where an external fixation was on my leg for about 18weeks.The xray shows no callus has been formed after 18 wks though the large opened wound has closed up and healed.Two points where the pin of the fixator enterd into my body degenerated and soft tissue came out,bleeding with pains that is better imagined.I had to insist that the metal be removed and a pop cast.For more than 3weeks now the soft tissues that shoot out from one of d pin point has refused to go inside like the other one which has gone inside and healed up. Please,what is my hope of the callus that has not formed and the soft tissue that is not healing?
Debo,
If your bone has not healed after 18 weeks of surgery and the wounds have healed [good thing], its time to consider the next surgery. The aim of first surgery in open fractures is soft tissue healing. The bone healing may be achieved in few cases with first surgery but often a next surgery is required.
Take care.
Hello Sir,
I am pankaj jain and left Humerous in my hand and operated on 6th March 2017 with plate & screw. Now I have total 11 months is going on and in my hand pain. Doctor says Delayed Union. Now what can i do that develop my delayed union. Normally how many times to take complete healing process in Delayed Union.
Pankaj,
After 11 months, the chances are more of non union than delayed but if union process is visible on x-ray, we can wait for few months.
The treatment of non union is surgery+bone grafting.
Take care.
Hello Sir,
I am pankaj jain and left Humerous in my hand and operated on 6th March 2017 with plate & screw. Now I have total 13 months is going on and in my hand pain. Doctor says Union process is stoped, it’s Non Union. Dr suggest treatment is Bone Grafting. it’s not possible to other option without surgery.
Pankaj,
Non union almost always require surgery and bone graft.