DELAYED FRACTURE HEALING

By : Nabilla Huda binti Mustapa

COHORT 1A

SLOW UNION

DELAYED UNION

NON-UNION

SLOW UNION

– Fractures takes longer than usual to unite, but passes through the normal clinical and radiological stages of healing without any departure from normal

– Mx : Reassurance of the patient

DELAYED UNION

DEFINITION Healing has not advanced at the average rate for the location and type of fracture for three months.

• Biological process of repair is continuous.–As compared to slow union, radiographs

may show abnormal bone changes. – There is, however, no sclerosis of the bone

ends.

CAUSES

• Inadequate blood flow• Severe tissue damage• Periosteal stripping

Management

– The problem is to differentiate between delayed union which is going to proceed with proper encouragement to union, and delayed union which is going to go on to non-union

– Disadvantage of delaying intervention : irreversible stiffness in joints which are immobilised with the fracture

Treatment

• CONSERVATIVE Encourage muscular exercise and weight

bearing by case or brace

• OPERATIVEInternal fixation or Bone graft

NON UNION

DEFINITION A minimum of nine months has past

since the injury and the fracture shows no clinical and radiological progressive signs of healing continuously.

• Complete suspension of biological process of repair.– Radiological changes which indicate that this situation

will be permanent.– i.e. the fracture will never unite unless there is some

fundamental alteration in the line of treatment.

Types of non-union(muller and weber)

a. Hypervascular b. Avascular

• # ends are viable and capable of biological reaction

• Rigid internal fixation is enough

• # ends are inert and incapable of biological reaction.

• Rigid internal fixation with bone grafting is required

1. Elephant foot non union 1. Torsion wedge non union• It is seen in segmental #

2. Horse hoof non union 2. Comminuted non union• It is seen in comminuted #

3. Oligotrophic non union 3. Defect non union• Seen in open fractures.4. Atrophic non union• The ends are tapered thin and sclerotic

with excessive scar tissue in between

Septic

Non-union with

underlying osteomyelitis

Aseptic

Hypertrophic Non-union(Pseudarthrosis)

Excessive callus formations around the fracture gap → d/t insufficient stability of

the internal fixator

‘Elephant Foot’Bone ends appear sclerotic

and are flared out diameter of the bone

fragments at the level of the fracture is increased

Fracture line is clearly visible, Gap being filled with cartilage and

fibrous tissue cells

Good blood supply (eventhough increase in

bone density)

Atrophic Non-union

No callus formations d/t impaired healing process

No evidence of cellular activity at the level of the fracture

Bone ends are narrow, rounded and osteoporotic

Frequently Avascular

Types of Non-union

“Elephant foot” appearance

CAUSES OF NON-UNION

Injury

Distraction at fracture site

Soft tissue loss

Bone loss

Soft tissue interposition

Bone

Poor blood supply

Hematoma

Infection

Pathological lesion

Surgeon

Poor splintage

Poor fixation

Impatience

Patient

Age

Poor medical

condition

Smoking and

Alcohol

Drugs

NSAIDs

Fluoro-quinolone

MANAGEMENT

1. Open reduction and bone grafting2. Electrical stimulation3. Rigid internal fixation by DCP/interlocking nail ±

Bone grafting.4. Ilizarov’s technique

Difference between non-union and delayed union

NON UNION DELAYED UNION

• No bony tenderness• No bony crepitus• Frank painless abnormal mobility

at fracture site.

Clinical Features

• Bony tenderness present• No bony crepitus• A little (painful) or no abnormal

mobility at fracture siteVisible # line without bridging callus. The fragments are rounded smooth and sclerotic. The medullary canal may be obliterated.

X-Ray Visible # line with inadequate callus bridging the fracture site.

It is absolute indication for surgery (no role of conservative treatment).

Treatment Conservative – prolonged immobilization for longer period (sometimes it may need surgical intervention)

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