Treatment of scaphoid fractures and nonunions

Scaphoid fractures are common but present unique challenges because of the particular geometry of the fractures and the tenuous vascular pattern of the scaphoid. Delays in diagnosis and inadequate treatment for acute scaphoid fractures can lead to nonunions and subsequent degenerative wrist arthritis. Improvements in diagnosis, surgical treatment, and implant materials have encouraged a trend toward early internal fixation, even for nondisplaced scaphoid fractures that could potentially be treated nonoperatively. Despite the advent of newly developed fixation techniques, including open and percutaneous fixation, the nonunion rate for scaphoid fractures remains as high as 10% after surgical treatment. Scaphoid nonunions can present with or without avascular necrosis of the proximal pole and may show a humpback deformity on the radiograph. If left untreated, scaphoid nonunions can progress to carpal collapse and degenerative arthritis. Surgical treatment is directed at correcting the deformity with open reduction and internal fixation with bone grafting. Recently, vascularized bone grafts have gained popularity in the treatment of scaphoid nonunions, particularly in cases with avascular necrosis. This article reviews current concepts regarding the treatment of scaphoid fractures and nonunions.     

Management of difficult lower extremity fractures and nonunions

Difficult fractures and nonunions of the lower extremities are defined as compound fractures with soft-tissue loss, segmental bone fractures, and infected nonunions. A variety of methods for managing these defects are presented, including the use of modern fixation techniques and the application of highly vascularized bone and soft tissues. Vascularized bone grafts play a significant role in the treatment of difficult fractures that previously would have required amputation.     

Extracorporeal shockwave therapy: A systematic review of its use in fracture management

Extracorporeal shockwave therapy is increasingly used as an adjuvant therapy in the management of nonunions, delayed unions and more recently fresh fractures. This is in an effort to increase union rates or obtain unions when fractures have proven recalcitrant to healing. In this report we have systematically reviewed the English language literature to attempt to determine the potential clinical efficacy of extracorporeal shockwave therapy in fracture management. Of 32 potentially eligible studies identified, 10 were included that assessed the extracorporeal shockwave therapy use for healing nonunions or delayed unions, and one trial was included that assessed its use for acute high-energy fractures. From the included, studies'' overall union rates were in favor of extracorporeal shockwave therapy (72% union rate overall for nonunions or delayed unions, and a 46% relative risk reduction in nonunions when it is used for acute high-energy fractures). However, the methodologic quality of included studies was weak and any clinical inferences made from these data should be interpreted with caution. Further research in this area in the form of a large-scale randomized trial is necessary to better answer the question of the effectiveness of extracorporeal shockwave therapy on union rates for both nonunions and acute fractures.     

Tricalcium phosphate as a bone graft substitute in trauma: preliminary report

Ceramic tricalcium phosphate (TCP) has been implanted in bony defects in 43 patients following trauma. It is an osteoconductive material that facilitates trabecular bone formation. The average follow-up time was 12 months, with a 6-month minimum. There were 33 fractures in 30 patients and 13 nonunions in 13 patients. Three of the patients with acute fractures were unavailable for follow-up observation. Ninety percent of the fractures and 85% of the nonunions were healed at the time of this review. The resorption of TCP was estimated from the roentgenograms to be approximately 10% per month, with complete resorption occurring in 6-24 months. There were eight complications, five among the 30 fractures and three among the 13 nonunions that were observed later. There were three fractures and two nonunions that failed to heal. There were two fractures that had initially been open and one previously infected nonunion that united but were complicated due to infection. These preliminary results demonstrate TCP's usefulness as a substitute for cancellous bone. This is accompanied by other advantages, including increased patient safety, lack of donor site morbidity, unlimited shelf life and reduced operating time.     

Treatment of delayed and nonunited fractures and osteotomies with pulsed electromagnetic field in children and adolescents

Nonunion of fractures or osteotomies in the pediatric population is rare. The gold standard for the treatment of nonunions involves harvesting autologous iliac crest bone graft and sometimes internal fixation, which are invasive procedures. The purpose of this study was to evaluate the effectiveness of pulsed electromagnetic field on a non-united fracture or osteotomy in the pediatric population. A retrospective study was performed on all patients at the authors' institution who used pulsed electromagnetic field as part of their treatment for nonunion or delayed union. Success of the initial nonunion treatment was defined as complete union of the fracture or osteotomy site. Two types of treatment were administered once delayed bone healing was identified: pulsed electromagnetic field alone or pulsed electromagnetic field plus an adjunct treatment. Twenty-one patients were included; 8 osteotomies and 14 fractures developed a nonunion. Average patient age was 11.7 years. Average age for patients who healed with the initial treatment was 10.7 years, whereas nonhealers had an average age of 14 years. Eighty-nine percent of osteotomy nonunions healed with their first management. Fifty-seven percent of fracture nonunions healed at the first attempt. The use of pulsed electromagnetic field is a good option for the initial treatment of pediatric nonunions, especially for patients who develop nonunions secondary to osteotomies. Adding bone marrow aspiration improves the outcomes and is minimally invasive compared with autologous iliac crest bone graft, with no complications.     

Scaphoid fractures and nonunions: diagnosis and treatment

Background Scaphoid fractures are commonly seen in orthopedic practice. An organized and thoughtful approach to diagnosis and treatment can facilitate good outcomes. However, despite optimal treatment, complications may ensue. In the setting of nonunion or an avascular proximal pole, vascularized bone grafting may be needed. Methods and results In this article we review the literature regarding these injuries and describe an approach to diagnosis, treatment, and management of scaphoid fractures and nonunions. Conclusion Scaphoid fractures and nonunions may present as challenging problems in practice, but a systematic and deliberate approach can facilitate optimal results.     

Complications of locked nailing in humeral shaft fractures

BACKGROUND: The purpose of this study was to investigate the complications of humeral locked nailing. METHODS: Between 1994 and 2000, 161 humeral shaft fractures (98 acute fractures and 63 delayed unions or nonunions) in 159 patients treated with humeral locked nails were followed up for an average of 25.4 months. There were 89 men and 70 women, with an average age of 53.5 years. Acute fractures included 68 closed, 18 type I, 8 type II, 3 type IIIA, and 1 type IIIB open fractures. Thirty-six nonunions had previous operations. In general, acute fractures were treated with closed nailing and nonunions were treated with open nailing with bone grafting. Since 1998, interfragmentary wiring has been added in nonunions to compress the fracture. RESULTS: In total, 30 patients had 31 significant complications. Nine of them were persistent nonunions, six from acute fractures and three from nonunions. Fracture gap was associated with a significantly higher risk of nonunion. The risk of operative comminution was significantly higher in retrograde nailing, and operative comminution resulted in a significantly higher risk of nonunion. Seven of the nine nonunions underwent revisional nailing and achieved eventual union. Removal of the protruded screws was performed in two cases. Other complications included shoulder impairment, elbow impairment, angular malunion, and post-nailing radial nerve palsy. CONCLUSION: Many complications of humeral locked nailing can be prevented by improving the implant design or surgical techniques. The patients with persistent nonunion can be reliably treated by revisional nailing and bone grafting.     

The role of reamed intramedullary nailing in the treatment of nonunions and malunions following femoral shaft fractures

Summary This retrospective consecutive clinical series describes our satisfactory experience with reamed intramedullary femoral nailing in the treatment of nonunions, axial or rotational deformities as well as length discrepancies following the primary treatment of femoral shaft fractures. 31 patients (32 fractures) treated at our institution from 1992 to 1997 were reviewed for age, gender, cause of injury, type of femur fracture, primary treatment, indication for secondary nailing, operative procedure, complications, need for additional procedures and time for consolidation. 3 patients were lost for follow-up, leaving 28 patients (29 fractures) for evaluation. The average follow-up was 79 weeks (range 24 to 192). The indications for secondary nailing were: 18 nonunions, 7 rotational or axial deformities, 4 length discrepancies. Consolidation was achieved in 25 patients (26 fractures) at an average time of 38 weeks (range 12 to 104). Nonunion was recorded in 3 patients. They were treated successfully with an additional procedure (one exchange intramedullary nailing and two autologous bone grafts). The reamed intramedullary interlocking nail offers many advantages, especially a good initial and middle term stability which is important in case of a slow process of consolidation. By the treatment of atrophic and long lasting nonunion, simultaneous bone grafting seems to be indicated. We conclude that interlocking reamed femoral nailing is a safe treatment option for nonunions and malunions following primary treatment of femoral shaft fractures, resulting in successful union without additional procedure in 26 of 29 fractures in this series.     

Cement spacers with antibiotics for the treatment of posttraumatic infected nonunions and bone defects of the upper extremity

Treatment of patients with posttraumatic infected nonunions or highly contaminated open fractures with segmental bone loss of the long bones of the upper extremity is demanding. The use of a 2-stage reconstruction technique, being the first stage characterized by thorough debridement, copious lavage, soft tissue coverage, and placement of a cement spacer with antibiotics at the infected site, and the second stage by cement spacer removal, internal fixation, and placement of bone graft with local antibiotics, is presented. We carried out this technique in 20 cases, in 12 cases the cement was molded to fit the defect and placed as a solid interposition mass, in 3 cases it was placed lateral to the affected bone, and in the remaining 5 cases a Rush nail covered with a cement mantle was used. Follow-up averaged 18 months. All nonunions and fractures healed after an average of 5 months. Disabilities of the arm, shoulder, and hand (DASH) score at last follow-up in nonunions averaged 14 points and 21 points in bone losses. Although generally 2 surgical procedures are needed, 1 to cure or prevent infection and another to achieve bony union, this approach for complex open fractures with segmental bone loss and for infected nonunions of the long bones of the upper extremity represents a valid treatment alternative.     

Surgical treatment of the aseptic femoral shaft nonunion

Femoral shaft nonunions is difficult complication and a big challenge for the orthopaedic surgeons. These complications occur after open femoral fractures, comminuted fractures, segmental fractures, the infection, after the inadequate fixed osteosynthesis, the systemic disease, and smokers. The paper presents the results of treatment aseptic femoral shaft nonunion in 18 patients. They were primarily operated by the method of internal compresive plate fixation and external fixation (open fractures). For fixation we used dinamic internal fixator by Mitkovic. All nonunions treated by this method are healed. In patients with atrophic femoral shaft nonunions in addition to fixation was performed and bone grafting. This implant has proved successful in the treatment of femoral shaft nonunion. During the fixation no periostal and intramedullary vascularization damage, which is an important prerequisite for bone healing. Implant enables biological and mechanical conditions for nonunion healing.     

Altered relative expression of BMPs and BMP inhibitors in cartilaginous areas of human fractures progressing towards nonunion

The present study was conducted to evaluate the hypothesis that an imbalance in the local production of bone morphogenetic proteins (BMPs) and BMP inhibitors exists within the cartilaginous intermediate of nonhealing fractures. Biopsies were recovered intraoperatively from human fractures that, upon follow-up, were found to heal normally or become nonunions. The samples were examined by immunohistochemistry to determine the expression of BMP-2, BMP-14, and the BMP inhibitors noggin and chordin. Expression was determined semiquantitatively based on the area of positive staining per area of cartilage and by determining the number of positively staining cells and the intensity of staining. There was a significant reduction in BMP-2 and BMP-14 expression in cartilaginous areas of nonhealing fractures compared to healing fractures. However, there was no difference in the expression of the BMP inhibitors between the two groups of fractures. This imbalance in the expression of BMPs and BMP inhibitors within cartilaginous areas of developing nonunions may account for their reduced bone forming ability. These data suggest strategies for preventing the development of nonunions by altering levels of BMPs and their inhibitors within fracture sites. © 2008 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 27: 752–757, 2009     

Diaphysäre Oberarmpseudarthrosen – operative und konservative Behandlung

Operative treatment of acute humeral shaft fractures represents a major source of nonunions. The analysis of the biomechanical and biological causes of diaphyseal nonunions of the humerus is a prerequisite for the successful treatment of ununited humeral shaft fractures. Biologically active nonunions heal after debridement and correction of deformities with an improvement of mechanical stability, preferably by fixation with a compression plate. In atrophic nonunions, the restoration of the biologic capacity to restore osteogenesis by bone grafting is additionally necessary. The treatment of synovial pseudarthrosis and infected nonunion requires removal of bone and debridement of synovial and infected avascular tissues, respectively. Intramedullary nails to improve mechanical stability and nonoperative treatment with extracorporeal shock waves should only be used in a few special cases which do not have any severe deformities.     

Proximal pole scaphoid fractures and nonunion

Proximal pole fractures and nonunions of the scaphoid present an extremely challenging treatment problem. Untreated, proximal pole fractures have a high rate of developing a nonunion that may lead to painful arthritis. Cast immobilization is not adequate, and surgery is recommended for the treatment of acute fractures and nonunions. The fractures are difficult to treat through a conventional volar approach, and the preferred treatment is open reduction and internal fixation using a dorsal approach with a screw that is specially designed for the scaphoid. The type of fixation implant used is important, because the end of the screw must be buried beneath the articular cartilage when the dorsal approach is used. The main blood supply of the scaphoid enters through the dorsoradial ridge of the scaphoid. By definition, proximal pole nonunions have partial ischemia or complete avascular necrosis, because the fracture line isolates the proximal pole from the perforating vessels. The definitive treatment for these fractures is a standard or vascularized bone graft, depending on the vascularity of the proximal pole of the scaphoid in addition to internal fixation via a dorsal approach. Using this treatment algorithm, the surgeon can optimize the success rate of achieving a successful scaphoid union in the shortest possible time of immobilization. Copyright © 2001 by the American Society for Surgery of the Hand     

Low-intensity pulsed ultrasound for bone healing: an overview

Low-intensity ultrasound is a biophysical form of intervention in the fracture-repair process, which through several mechanisms accelerates healing of fresh fractures and enhances callus formation in delayed unions and nonunions. The goal of this review is to present the current knowledge obtained from basic science and animal studies, as well as existing evidence from clinical trials and case series with the different applications of ultrasound in the management of fractures, delayed unions, nonunions and distraction osteogenesis. Low-intensity pulsed ultrasound is currently applied transcutaneously, although recent experimental studies have proven the efficacy of a trans-osseous application for both enhancement and monitoring of the bone healing process with modern smart implant technologies.     

Scaphoid nonunions. Pitfalls and pearls.

Our ability to treat scaphoid nonunions has improved dramatically. The degree of collapse and bone loss can be accurately assessed in waist fractures using sagittal images on CT scans. These nonunions require reduction and bone grafting to re-establish the normal geometry of the scaphoid. Magnetic resonance imaging helps evaluate whether or not avascular necrosis is present in the proximal pole. Because of the poor prognosis of conventional bone grafts, a vascularized bone graft is recommended as the primary treatment when AVN is present. The volar collapse of the humpback deformity is best corrected with a volar approach and the proximal pole nonunion is best approached using a dorsal approach. Nearly all proximal pole nonunions require a vascularized bone graft and all acute proximal pole fractures require open reduction and internal fixation. Using specially designed cannulated screws, the nonunions can be stabilized accurately to decrease the time to resolution of the nonunion and minimize the amount of time in a cast. Stable fixation requires that the screw fixation target the central portion of the scaphoid regardless of the type of screw design used. Using these techniques, the hand surgeon should be able to provide a reasonable prognosis for patients presenting with a scaphoid nonunion, and the treatment should result in functional range of motion, grip strength, and relief of pain.     

Midshaft clavicular fractures: the role of operative treatment

Plate fixation remains a staple for open fractures, closed fractures requiring open management, and nonunions, especially if bone grafting is required.     

Changing concepts in the treatment of scaphoid nonunion: vascularized bone graft based on the 1,2 intercompartmental supraretinacular artery

Scaphoid fractures are a common injury encountered by hand surgeons. Fracture union can generally be achieved with cast immobilization or open reduction and internal fixation. Occasionally, these fractures fail to heal despite proper treatment or a nonunion may result from an unrecognized fracture. Traditionally, scaphoid nonunions have been treated with autologous bone grafts from the iliac crest; however, if the proximal pole is poorly vascularized, union may be difficult to achieved. Vascularized bone grafts are an alternate technique for difficult scaphoid nonunions, particularly those with avascular necrosis of the proximal segment. A graft from the distal radius based on the 1,2-intercompartmental supraretinacular artery is an excellent option for scaphoid nonunions. This article describes the anatomy of the 1,2-ICSRA and the surgical technique of harvesting a graft based on this pedicle. Vascularized bone grafts represent a changing concept in the treatment of scaphoid nonunions and provide a powerful tool for a difficult problem. The indications for this procedure continue to increase.     

Exchange nailing of ununited fractures

Exchange nailing is most appropriate for a nonunion without substantial bone loss. There is no clear consensus regarding the use of exchange nailing in the presence of active, purulent infection. The exchange nail should be at least 1 mm larger in diameter than the nail being removed, and it has been recommended that it be up to 4 mm larger when the nail being removed was greatly undersized. Canal reaming should progress until osseous tissue is observed in the reaming flutes. Exchange nailing is an excellent choice for aseptic nonunions of noncomminuted diaphyseal femoral fractures, with union rates reported to range from 72% to 100%. On the basis of the available literature, exchange nailing cannot be recommended for distal femoral nonunions at this time. Exchange nailing is an excellent choice for aseptic nonunions of noncomminuted diaphyseal tibial fractures, with union rates reported to range from 76% to 96%. On the basis of the available literature, exchange nailing is generally not indicated for humeral nonunions.     

Screw fixation without bone grafting for scaphoid fracture nonunion

IntroductionWe previously reported the classification of the scaphoid fracture nonunions as linear, cystic, and sclerotic or displaced types based on radiographic findings. We have been treating the linear and cystic type fractures via screw fixation without bone grafting and the sclerotic or displaced type fractures via screw fixation with bone grafting. In this retrospective study, we report the treatment outcomes of the linear and cystic types of scaphoid fracture nonunions.MethodsNineteen patients with linear and cystic type scaphoid fracture nonunions were included. Two patients had linear type and 17 had cystic type fractures. All the patients were male, their mean age was 29.2 years. All patients were treated with screw fixation alone by a single surgeon.ResultsBone union was achieved in 17 cases. The mean time to bone union was 3.7 months. Bone union was not achieved in one case of linear type and one case of cystic type fracture. The former was thought to be due to misdiagnosis of displaced type as linear type fracture; however, no obvious reason could be found for the latter.DiscussionScrew fixation alone could help achieve bone union in linear type scaphoid fracture nonunions. However, if the type of the fracture is difficult to diagnose based on plain radiography, evaluation using computed tomography should be performed. The cystic type fractures may need to be subclassified according to the location or size of the cyst as well as the viability of the proximal bone fragment.     

Reamed interlocking intramedullary nailing for the treatment of tibial diaphyseal fractures and aseptic nonunions. Can we expect an optimum result?

The need for reaming and the number of locking screws to be used in intramedullary (IM) tibial nailing of acute fractures as well as routine bone grafting of tibial aseptic nonunions have not been clearly defined. We describe the results of reamed interlocked IM nails in 233 patients with 247 tibial fractures (190 closed, 27 open and 30 nonunions). Ninety-six percent of the fractures were united at review after an average of 4.9 years. No correlation was found between union and nail diameter (P = 0.501) or the number of locking screws used (P = 0.287). Nail dynamization was effective in 82% of fractures. Locking screw(s) breakage was associated with nonunion in 25% of cases. Bone grafting during IM nailing was found not to increase the healing rate in tibial nonunions (P = 0.623). None of the IM nails were removed or revised due to infection. A dropped hallux and postoperative compartment syndrome were found in 0.8 and 1.6% of cases, respectively. Anterior knee pain was reported in 42% of patients but nail removal did not alleviate the symptoms in almost half. This series confirms the place of reamed intramedullary nailing for the vast majority of tibial diaphyseal fractures. It provides an optimum outcome and minimizes the need for supplementary bone grafting in aseptic nonunions.