Fracture Non Union

An ulna non-union of many years duration

Same fracture united after plating and addition of 'Osigraft'

Click here for video of me applying Osigraft to the above fracture

A fracture usually heals.

In fact, most people believe that fractures always heal.

I even saw a poster in a ski cabin of a leaping snowboarder with the caption: 'Fractures heal, but glory goes on forever!'

Sorry - not always true. Glory fades, and fractures do NOT always heal.

The most common definition of a fracture non union is 'a fracture that will not heal without further intervention', and that it has not healed by 9 months post injury usually indicates that it will never heal without help.

9 months often feels like a very long time to wait and so people have suggested that if a fracture shows no sign of progressing towards healing for 3 months, it is likely that a non-union will result.

Some surgeons will even apply the definition of a non union being present if the fracture has not healed in the time an experienced fracture surgeon would expect it to heal (because all fractures have different expected healing times).

There are various ways of making bones heal when there is a non union.

The commonest means is the traditional method of fixing the fracture and adding bone graft (morcels of bone taken from the patient's own pelvic brim).

This has the downside of the additional pain of the donor site, keeping patients in hospital longer, and possible donor site wound infection, bleeding or numbness down part of the thigh or buttock.

Because of these problems, there has been a huge amount of interest in recent years in 'bone graft substitiutes'

These can be summarised as:

Simple calcium salts: not sufficient on their own, but sometimes useful as a supplement to other agents

Demineralised Bone Matrix (DBMs): these are taken from dead donors, usually from the USA. There are very strict regulations in place to ensure minimal risk of transfer of infection from the donor and the risk is less than from blood transfusion because of processing of the products. They can be as effective as bone graft, but there are no large scale, well designed trials yet.

Single growth factors: currently BMPs are the only commercially available products for non-union and BMP-7 (known as Osigraft in the EU and OP1 in the US) is the only product licenced for use in long-bone nonunion after having been found to be as effective as bone graft in a large Trial in the USA.

If you have a non union of a fracture and would like me to give you an opinion on how it may be treated, please go to the send me your problem page of this site, follow the instructions, and I will be happy to advise.

Mr A Mark Phillips MA FRCS(Tr&Orth)