What is the current evidence?

Still at experimental stage for all these treatments, but strongest evidence in humans is for the Ultrasound devices, worn for only 20 minutes per day.

How much does it cost?

Ultrasound and PEMF are available from manufacturers on a no-heal, no-fee basis for non-unions, but the devices would have to be bought for fresh fractures. They are sold for prices ranging from around £900 up to £2000.  

Growth factors cost thousands of pounds for each dose and this therapy will be subjected to trials first.

Bisphosphonates and teriparatide cost a few hundred pounds per month

What may be possible in the near future?

We are hopeful that Clinical Trials of injectable growth factors will show encouraging results in the next few years. The unit costs will come down if they can be used in fresh fractures. We are also hopeful that PEMF and ultrasound machines will become common treatments for fractures which may strugge to heal. Clinical Trials of medication will also be done over the next few years and we hope these results will be encouraging.

What are the long-term prospects?

There are relatively cheaper options that may be used in the future. Early research suggests that small, cheap proteins can simulate and do the work of the complex BMPs and other growth factors.

Bone glue and other methods to bond bone immediately may be possible in the long term, but there are no agents currently on Trial or being published in pre-clinical studies at present.

Fractures ‘at risk’

Why do fractures sometimes fail to heal?

Poor blood supply, advancing age, poor fixation, infection, smoking, nonsteroidal tablets all contribute.

How long do fractures actually take to heal?

6-8 weeks for the upper limb, twice as long for the lower limb (to be strong enough for weight bearing)

How do we know when a fracture is healed?

Your surgeon will know if your fracture is healed based on examination of your fracture. In general, if your fracture is painless and your limb can bear weight with little or no discomfort, then the fracture is healed. X rays may be required in some cases where there is doubt, but, perhaps surprisingly, are often not required to make this assessment.

If a fracture fails to heal, what can be done?

The PEMF and Ultrasound devices described above can be tried in the first instance. These require 3 months for a fair chance of working. Non union is not normally said to be present until the fracture has failed to heal by 9 months post injury. However, if there is no progress towards union, delayed union is said to be present and this often predicts a non-union and action should be taken in most cases.

Bone grafting and / or improved stabilisation of the fracture is the surgical standard of care, usually with compression of the fracture.

Bone graft substitutes have been proposed more recently. Osigraft (a BMP) has been licenced for use in long-bone non-union at 9 months post injury. This is an alternative to having bone graft taken from the hip, reducing the complications from this procedure. It is an expensive treatment, and some NHS Trusts will refuse to fund this treatment. Demineralised Bone Matrix (treated bone extract from deceased humans) is also effective, but has not been evaluated against bone graft in a formal clinical trial. Thed risk of contamination from the donor is less than from a blood transfusion, since the products arewashed with acid, heat treated, and gamma irradiated.

What fractures fail to heal most frequently?

Tibia, scaphoid, humerus, clavicle, ulna and femoral neck (intracapsular type)

Can we anticipate the slow healing or likely failure-to-heal of a fracture?

Yes we can - displacement (ends more than 1cm apart), comminution (the number of bits), site, bone, patient risk factors (above, such as age, gender, smokers, certain drugs) all add up to give your sugeon an idea of the risk that this fracture will not be likely to heal uneventfully.