Fracture: Nonunion Fundamentals
Every fracture carries the risk of failing to heal and resulting in a nonunion. While nonunions can occur in any bone, they are most common in the tibia, humerus, talus, and fifth metatarsal bone.
Several factors contribute to a nonunion. If the bone ends that are fractured have been stripped away from the blood vessels that provide them with nutrition, they will die. As a result, the bone ends cannot contribute to new healing, and a nonunion is more likely. Without a good blood supply and growth of new blood vessels, no new bone will form and the fracture cannot readily heal.
What are the symptoms?
- Difficulty bearing weight
What are my treatment options?
Treatment for nonunions is always customized to the patient. In general, your doctor will seek to determine why the fracture did not heal. A plan is then formulated to try to eliminate or limit any physiological reason why healing has not been successful.
In some cases, union can be achieved without surgery. Several non-invasive methods are available, such as electrical stimulation or specialized braces.
Most nonunions require surgery. Surgical treatment of nonunion is usually focused on three goals:
- Establishing a healthy vascular area of bone and soft tissue around the fracture site.
This is accomplished by removal of any poorly dead bone or poorly vascularized tissue or scar from the fracture site. In some cases, the local tissues may be so badly damaged that plastic surgery in the way of rotational or microvascular free muscle flaps may be necessary to bring new healthy tissue to the fracture site.
- Establishing stability at the fracture site
This usually involves use of a rod, plate or screws. This may also involve use of an "external fixator" -- external pins to hold the bones above and below the fracture.
- Stimulating a new fracture healing response using a bone graft
Bone grafts most often involve borrowing healthy cancellous or "spongy" bone from the pelvis, through a small incision at the level of the hip. This brings in many new bone forming cells and other supportive cells.
What are the risks of surgery?
Risks include neurovascular injury, infection, bleeding, and stiffness.
How do I prepare for surgery?
- Complete any pre-operative tests or lab work prescribed by your doctor.
- Arrange to have someone drive you home from the hospital.
- Refrain from taking aspirin and non-steroidal anti-inflammatory medications (NSAIDs) one week prior to surgery.
- Call the appropriate surgery center to verify your appointment time. If your surgery is being done at Cleveland Clinic, call 216.444.0281.
- Refrain from eating or drinking anything after midnight the night before surgery.
What do I need to do the day of surgery?
- If you currently take any medications, take them the day of your surgery with just a sip of water.
- Do not wear any jewelry, body piercing, makeup, nail polish, hairpins or contacts.
- Leave valuables and money at home.
- Wear loose-fitting, comfortable clothing.
What happens after surgery?
Elevate your upper body while you sleep and take acetaminophen for pain. If wearing a cast, apply heat to the injured area to improve blood circulation and promote healing. After the cast is removed, massage the injured area with ice.
Finally, follow a nutritious diet and exercise the non-affected muscle groups to maintain your overall health during the recovery process. Most importantly, avoid smoking, as nicotine has shown to inhibit fracture healing. Additionally, avoid, if possible, radiation therapy, chemotherapy, NSAIDs and systemic corticosteroids, as all of these treatments are known to slow the bone-healing process.
Ask your surgeon for complete post-operative instructions.
How long is the recovery period after surgery?
Your doctor will use an x-ray to determine whether the fracture has fully healed. This will determine the length of the recovery period.
What is the rehab after surgery?
Your doctor will provide instructions regarding weight bearing and physical therapy.
How can I manage at home during recovery from the procedure?
Your doctor will provide instructions regarding activity at home.