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Delayed union of fracture — Clinical Guidelines

Overview

Delayed union of fracture, also known as non-union, occurs when a fracture fails to heal within the expected timeframe despite appropriate treatment, leading to persistent bone discontinuity and potential complications such as pain, deformity, and functional impairment 4.

Diagnosis

Persistent pain and swelling at the fracture site 4

Lack of radiographic signs of healing after 6-9 months 4

Inability to bear weight or perform normal activities 4

Imaging studies (X-rays, CT, MRI) to assess bone alignment and healing progress 4

Bone scan or MRI for more detailed assessment of healing status 4

Management

First-line treatments:

- Surgical intervention: Exchange nailing, primary intramedullary nailing, fine wire external fixation 3 - Bone grafting (vascularized or non-vascularized) 1

Adjunctive treatments:

- Adjunctive techniques: Fibula osteotomies, fixation dynamization, PRP 3 - Mesenchymal stem cells (MSCs) with or without scaffolds to enhance healing 2 - Vitamin D supplementation in cases of hypovitaminosis D 5

Special Populations

Hypovitaminosis D: Routine assessment and supplementation recommended in elderly and other populations at risk 5

Pediatrics and Pregnancy: Specific management strategies not detailed in provided abstracts; individualized care advised [Expert opinion]

Key Recommendations

Surgical intervention is crucial for managing non-unions, with exchange nailing or fine wire external fixation showing high union rates (Evidence: Strong 3).

Incorporate bone grafting techniques, particularly vascularized grafts, to improve healing outcomes (Evidence: Moderate 1).

Consider mesenchymal stem cell therapy as an adjunctive treatment to accelerate bone union, though larger clinical trials are needed for definitive evidence (Evidence: Moderate 2).

Evaluate and correct vitamin D deficiency in patients with non-union, as supplementation may significantly impact healing (Evidence: Weak 5).

References

1 Bocchino G, Cannella A, Santoro A, El Motassime A, Cavola F, Sassara GM et al.. Surgical treatment of carpal scaphoid non-union: a systematic review. European journal of orthopaedic surgery & traumatology : orthopedie traumatologie 2025. link 2 Khan S, Peracha A, Abro AA, Sufyan M, Rahim Najjad MK, Aziz S et al.. Clinical studies investigating the role of mesenchymal stem cells in healing of fracture non-unions: a systematic review. JPMA. The Journal of the Pakistan Medical Association 2023. link 3 Fortuin F, Burger M, Ferreira N. Contemporary management of aseptic diaphyseal tibia non-unions - A systematic review. Orthopaedics & traumatology, surgery & research : OTSR 2022. link 4 Wildemann B, Ignatius A, Leung F, Taitsman LA, Smith RM, Pesántez R et al.. Non-union bone fractures. Nature reviews. Disease primers 2021. link 5 Moonen L, Gorter E, Schipper I. The importance of vitamin D in treatment of fracture non-union: A case report. Nutrition (Burbank, Los Angeles County, Calif.) 2021. link 6 Tzioupis C, Giannoudis PV. Prevalence of long-bone non-unions. Injury 2007. link80003-9)

Delayed union of fracture