treatment

Last reviewed 01/2018

Three objectives underly treatment:

• realignment - restoration of normal stress patterns which themselves, promote healing. Depending on the fracture this may be achieved during stabilisation, or afterwards with external fixators. Where non-union is the result of an intact fellow bone, osteotomy may be indicated - for example, of the fibula to promote healing of tibial non-union. In other situations, soft tissue release may be necessary to correct a contracture
• stabilisation - to enable the fracture to support the load placed on it. Many devices are available such as plates, intramedullary nails and external fixators.
• promotion of new bone formation - by bone grafting, either autograft - patient's own bone - or allograft - cadaver bone; weight bearing through mobilisation; or pulsed electromagnetic field therapy - PEMF

Operative intervention is not always necessary. Often, hypertrophic non-union responds well to simple functional bracing although treatment may be prolonged. PEMF may be applied through a plaster cast to encourage osteogenesis in an atrophic union.

Once alignment has been corrected if necessary, hypertrophic non-union usually responds well to rigid fixation. Some form of bone promotion is always required in atrophic non-union, and most commonly, is achieved by bone graft.

In the case of an infected non-union, the first priority is to control the infection with aggressive local surgery to remove all non-viable material and appropriate antibiotics. External fixation may be used to obtain stability and alignment. It also supports the technique of bone transport in which healthy bone is gradually distracted through an osteotomy to create new bone whilst at the same time, the defect is closed by existing healthy bone.