Nonunion Fractures: Definition and Treatment
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Haziq AnuarNonunion Fractures: Definition and Treatment
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Haziq AnuarCommon questions
Powered by AISurgical treatment options for nonunion fractures include fibular osteotomy, bone grafting, plate osteosynthesis, intramedullary nailing, and external fixation . Fibular osteotomy assists with deformity correction and stabilization of the tibia . Bone grafting involves osteoinductive and osteoconductive processes that stimulate healing by attracting vascular ingrowth and providing scaffolding for new bone growth . Plate osteosynthesis stabilizes fracture fragments and may compress them to enhance healing, often in conjunction with bone grafting . Intramedullary nailing stabilizes and corrects malalignment, initially impacting blood supply negatively through reaming, which later recovers and aids biological healing . External fixation primarily manages infected nonunions and corrects malalignment .
Potential causes for nonunion in a tibial shaft fracture include comminution of the fracture, distraction and separation of the fragments, interposition of soft tissues, poor blood supply, and infection . These factors disrupt healing by preventing adequate mechanical stability, permitting excessive movement, blocking vascularization, or introducing pathological conditions that inhibit repair processes .
Reaming during intramedullary nailing is significant as it initially disrupts the intramedullary blood supply, which can impede immediate healing. However, the process is believed to later stimulate biological healing at the fracture site due to recovery and re-establishment of blood supply, ultimately supporting fracture stabilization and healing by promoting cellular and vascular activity .
Bone grafting is beneficial for atrophic nonunion as it stimulates the biologic response essential for healing by providing osteoinductive and osteoconductive properties. Osteoinductive components include proteins or chemotactic factors that promote vascular ingrowth and healing, while osteoconductive aspects offer a scaffold for new bone growth. This dual action is crucial in healing nonunions, particularly where the biological capacity to heal is compromised, as in atrophic cases .
The presence of an intact fibula can influence healing negatively by not allowing adequate compression at the fracture site, contributing to insufficient stability and potentially leading to nonunion. In cases of a tibial fracture, the intact fibula absorbs the load that would otherwise encourage callus formation and thereby healing at the fracture site .
Hypertrophic nonunions manifest on x-ray with florid streams of callus around the fracture gap, often described as 'elephant's foot' or 'horse hoof'. This appearance indicates that while there is sufficient biological capacity to heal due to hypervascularity, the lack of mechanical stability at the fracture site prevents union, causing excessive callus formation without effective consolidation .
External fixation is primarily used in managing infected nonunions as it allows for corrective mechanical alignment while avoiding internal hardware that can become a nidus for infection. This stabilizes the bones while enabling effective local treatment of infection, facilitating a favorable environment for healing without exacerbating the infection .
Nonunion fractures are classified into hypertrophic, atrophic, and oligotrophic types. Hypertrophic nonunions are hypervascular and possess the biological capacity to heal but lack mechanical stability; callus formation is present on x-ray, often described as 'elephant foot' or 'horse hoof' . Atrophic nonunions are avascular and lack the biological capacity to heal, exhibiting features similar to oligotrophic nonunions on x-ray . Oligotrophic nonunions show no callus on x-ray but do have vascularity as evidenced by bone scans .
Bone marrow injections are intended to promote healing by introducing osteogenic cells that contribute to new bone formation, thus enhancing biological healing potential at the fracture site. These injections are administered percutaneously to the level of the fracture, ensuring direct delivery of healing-enhancing components to the site in need .
Ultrasound in nonunion fractures theoretically increases callus response, though its effect on nonunions is considered theoretical, having shown an ability to shorten the time for visible callus on x-ray in fresh fractures . Electric stimulation leverages the piezoelectric nature of bone, using stress-generated electric potentials to influence callus formation, vascularization, fibrocartilage, cell proliferation, and matrix production through electromagnetic fields .
