Medical Program: Overcoming Obstacles in Treating Nonunion Fractures

Overcoming Obstacles in Treating Nonunion Fractures

Overcoming Obstacles in Treating Nonunion Fractures

Fact: Between 5 and 10 percent of fractures don’t heal properly. Do you know the risk factors and the treatment interventions to deploy?

  • Overview

    Diagnosing and treating nonunion fractures comes with its set of challenges. Fortunately, Dr. Michael McKee is here to share his expertise and recommendations for success to benefit your patients with nonunion fractures.

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    Overcoming Obstacles in Treating Nonunion Fractures

    Broken bones have an astounding ability to mend themselves, and most fractures will, in fact, heal without any complications. But not all of them do.

    In fact, up to 10 percent of fractures don’t heal properly—despite good interventions—and the consequences of these nonunion fractures can be devastating for patients.

    So how can we better anticipate, identify, and treat fractures that lose the ability to heal? That’s the question Dr. Michael McKee, Professor and Chairman of the Department of Orthopaedic Surgery at the University of Arizona College of Medicine, helps us answer.

    Understanding the Risk of Nonunion Fractures

    Although nonunion fractures can affect any fracture in any bone, there are certain areas where it’s more common, like in the tibia, humerus, and clavicle. There are also some specific risk factors that put patients at a higher risk of developing a nonunion fracture, including heavy smoking, diabetes, and disorders of vitamin D or calcium metabolism.

    In addition to those risk factors, another important element that can help clue you into the presence of a nonunion fracture is time.

    While it depends on the bone and the patient, a good rule of thumb is that if a bone hasn’t healed by six to nine months after the original injury or if there hasn’t been any progression of healing shown on x-rays, then the chance of that bone healing without some kind of treatment intervention becomes progressively less over time.

    The 4 Steps to Diagnosing a Nonunion Fracture

    If a patient has one or more of these risk factors and you begin to suspect that treatment may become necessary, a firm diagnosis of a nonunion fracture is needed, which encompasses four elements:

    1. Careful History: Ongoing instability or pain at the fracture site is often the first sign that there may be something impaired about the bone healing.
    2. Physical Examination: If the patient has pain with stressing of the fracture or if you sense motion when looking at the stability of the fracture site, that’s another common sign.
    3. Regular Radiographs: Taken at different time intervals, an x-ray can show any signs of bone healing across the previous fracture.
    4. Confirmatory Tests: A CT scan is usually the preferred method to confirm whether there’s any bony bridging across a fracture or not.

    This gradated series of four tests can help you confirm the diagnosis of a nonunion fracture, but completing these tests is only the first—albeit critical—step.

    Treatment Options for Nonunion Fractures

    Even though it seems like a fairly simple thing, a bone that doesn’t heal properly can have a number of severely negative consequences, like instability, pain, unemployment, bankruptcy, and depression. That’s why it’s so important to employ effective treatment strategies, and fortunately, there are plenty of options available, including:

    Medical Approaches

    Maximizing the patient’s biology to minimize negative effects is an effective and essential strategy. For instance, if the patient is a heavy smoker, smoking cessation strategies can help promote the bone healing process.


    Bone Stimulation

    This involves providing a biological stimulus at the fracture site to increase the rate of bone formation and bone healing. There are several types of bone stimulation; some are noninvasive, like electromagnetic waves, and others involve ultrasound.

    An example of one of the latter types of bone stimulation is LIPUS. Short for low-intensity pulsed ultrasound, LIPUS is most successful when a nonunion fracture is relatively stable and doesn’t have any significant deformity.


    Surgical Approaches

    If a nonunion fracture is badly deformed, completely unstable, or is infected, the patient will need to undergo further surgery, possibly with bone grafting, to stimulate healing.


    Key Practice Pearls

    While it’s true that most fractures heal promptly and in a good position, that isn’t always the case, especially when a fracture occurs in the tibia, ankle, humoral shaft, and clavicle shaft. And when it comes to treating these nonunion fractures, the success of any approach is heavily dependent on the type of fracture, where it’s located, and—perhaps most importantly—the patient themselves, so it’s essential to consider these three factors when managing patients with nonunion fractures.

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