Bones have high capacity for healing themselves, and with proper treatment, most all fractures will

heal without complication. However, some fractured bones have difficulty healing. When a bone takes longer time to heal, it is called "delayed union" and when a bone does not heal, it is called "nonunion." [2] If the bones have been fixed rigidly with a gap between the ends, the fracture may fail to unite. This is more likely in the leg or the forearm if one bone is fractured and the other remains intact. Causes of non-union are [1]: (1) distraction and separation of the fragments, sometimes the result of interposition of soft tissues between the fragments (2) excessive movement at the fracture line (inadequate immobilization) (3) a severe injury that renders the local tissues nonviable or nearly so (4) a poor local blood supply (5) infection. (6) ill-judged surgical intervention Non-unions are septic or aseptic. In the latter group, they can be either stiff or mobile as judged by clinical examination. The mobile ones can be as free and painless as to give the impression of a pseudoarthrosis. On x-ray, non-unions are typified by a lucent line still present between the bone fragments; sometimes there is thick callus trying but failingto bridge the gap between fracture (hypertrophic non-union) or at times none at all (atrophic non-union) with a sorry, withered appearance to the fracture ends. They are usually arises from impaired repair process, classified into necrotic, gap and atrophic on X-ray. When dealing with the problem of non-union, four questions must be addressed. They have given rise to the acronym CASS [1]: 1. Contact Was there sufficient contact between the fragments? 2. Alignment Was the fracture adequately aligned, to reduce shear? 3. Stability Was the fracture held with sufficient stability? 4. Stimulation Was the fracture sufficiently stimulated? (e.g. by encouraging weightbearing). There are, of course, also biological and patient-related reasons that may lead to non-union [1]: (1) poor soft tissues (from either the injury or surgery); (2) local infection (3) associated drug abuse, anti-inflammatory or cytotoxic immunosuppressant medication and (4) non-compliance on the part of the patient.

What bones are most commonly involved in nonunion? Any broken bone can develop into a nonunion, but several bones are notorious for nonunion development. The reason is that the blood flow to these bones is poor, and therefore, they are a 'set-up' for a nonunion. These problem broken bones include [2]: Scaphoid Fractures Talus Fractures Femoral Neck Fractures Fifth Metatarsal ("Jones") Fractures

What are the symptoms [3]?

Swelling Pain Tenderness Deformity Difficulty bearing weight

What is the treatment of a nonunion? CONSERVATIVE [2] Non-union is occasionally symptomless, needing no treatment or, at most, a removable splint. Even if symptoms are present, operation is not the only answer; with hypertrophic non-union, functional bracing may be sufficient to induce union, but splintage often needs to be prolonged. Pulsed electromagnetic fields and low-frequency, pulsed ultrasound can also be used to stimulate union. OPERATIVE [2] With hypertrophic non-union and in the absence of deformity, very rigid fixation alone (internal or external) may lead to union. With atrophic non-union, fixation alone is not enough. Fibrous tissue in the fracture gap, as well as the hard, sclerotic bone ends is excised and bone grafts are packed around the fracture. If there is significant die-back, this will require more extensive excision and the gap is then dealt with by bone advancement using the Ilizarov technique. Most closed tibial fractures can be treated nonoperatively with good result, but infection risk and fracture stability must be considered. Littenberg et al reviewed 2372 case reports of closed tibial fractures and compared clinical outcomes of cast treatment, open reduction and internal fixation, and intramedullary rod therapy. They showed cast treatment to be associated with fewer superficial infections than open reduction and internal fixation. Open reduction and internal fixation, however, demonstrated a higher union rate at 20 weeks [4]. Plating is used mainly for metaphyseal injuries and should not be used when there is soft tissue compromise.[5]. Compression plating has been shown to have 92-96% union rate after open tibial fractures initially treated with external fixation and posterolateral bone grafting is indicated if there is significant bone loss [6].

What can be done to prevent a nonunion [7]? The best thing a patient can do to prevent a nonunion is to avoid smoking. Other factors that will help prevent nonunions include eating well, and adhering to your recommended treatment plan. Patients who are smokers, obese, diabetics, or have other medical conditions, may be at higher risk for developing a nonunion.

Regarding mr MF, he has been previously operated for distal tibial fracture and been put on ORIF came after a year for difficulty bearing weight without support. Upon investigation, it is confirmed that he has non-union of distal tibia. There was unsure cause of non-union in him. What was done to him was surgically planned. He was subjected to have open reduction internal fixation of the distal right tibial and bone grafting for non-union.

References:

1) (Apleys System of Orthopaedics and Fractures_ 9th Ed.) 2) (http://orthopedics.about.com/od/castsfracturetreatments/g/nonunion.htm) 3) http://my.clevelandclinic.org/orthopaedics-rheumatology/diseases-conditions/foot-ankle-fracturesnonunion.aspx 4) Littenberg B, Weinstein LP, McCarren M, et al. Closed fractures of the tibial shaft. A meta-analysis of three methods of treatment. J Bone Joint Surg Am. Feb 1998;80(2):174-83. [Medline]. 5) http://www.orthofracs.com/adult/trauma/knee-tibia/fractures-tibiashaft.html#sthash.sp8sIkNM.dpuf 6) http://www.orthobullets.com/trauma/1045/tibia-shaft-fractures 7) http://orthopedics.about.com/od/castsfracturetreatments/g/nonunion.htm)