Non-Union

Tibial Fractures
General Considerations
Delayed union is the term applied when a fracture has not healed within the period of time that
would be considered adequate for bone healing for that particular sites
Holds out the promise that union will eventually occur without further intervention
For tibial fractures, healing should occur in 16 weeks
Non-union is the term applied to a fracture that will not unite without additional
intervention
Usually by 6-9 months for tibial fractures
Non-union of tibia is fairly common
Estimated to range from 2-10% of all tibial fractures
Associations
Most closely associated with the type of tibial fracture
Open or compound fracture
Degree of comminution
Less soft tissue covers fracture
High energy fractures (automobile and motorcycle accidents)
Cigarette smoking places patient at higher risk
Use of nonsteroidal anti-inflammatory medications may inhibit bone healing
Types
Hypertrophic nonunions
Exuberant callus formation
Because of their vascularity, they have excellent healing potential
Result from inadequate immobilization of the fracture
Atrophic (oligotrophic) nonunions
Absence of callus and bone ends that may be tapered and osteopenic or sclerotic
Because of their lack of vascularity, they have poor healing potential
A subcategory of this type may be freely movable and form a pseudarthrosis
Normotrophic nonunions
Share characteristics of both of the above
Imaging Findings
Conventional radiographs are the study of first choice
In established non-union, the ends of the fracture fragments are sclerotic and typically smooth
Bones are joined by fibrous tissue
CT may be helpful in establishing presence of bony bridging
MRI is most sensitive for osteomyelitis
Differential Diagnosis
Congenital pseudarthrosis of the tibia
Occurs in children
Associated with neurofibromatosis and fibrous dysplasia
Treatment
Hypertrophic nonunions are treated with rigid stabilization
Atrophic nonunions require augmentation
May be in the form of bone grafting or biologic stimulation
Complications
Infection of a previously aseptic non-union
Malalignment
Shortening
Continued non-union


Tibial non-union. Frontal radiograph of the distal tibia shows a smooth and sclerotic line at the fracture ends (blue arrows) in a patient 14
months after the original fracture, signs of non-union. There is some external callus formation present (white arrow). There is also non-union of
an associated fibular fracture.
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