A Comparative Study of Conservative and Surgical Management of Displaced Midshaft Clavicle Fracture

Vol 5 | Issue 1 | Jan-April 2019 | page: 23-27 | Niraj Ranjan, Arvind Agarwal, Atul Garg

Author: Niraj Ranjan [1], Arvind Agarwal [1], Atul Garg [1]

[1] Department of Orthopaedics , Maharaja Agrasen Hospital, New Delhi

Address of Correspondence
Dr. Niraj Ranjan,
Department of Orthopaedics , Maharaja Agrasen Hospital, New Delhi


Introduction: Since long, closed midshaft clavicle fractures, whether undisplaced or displaced, have been treated conservatively with figure of “8” bandage and sling. However, in the past few decades, management trends show an uprise in surgical management of displaced midshaft clavicle fracture with rigid internal fixation providing early pain relief and avoiding deformity, non-union (NU), and sequelae.
Materials and Methods: A total of 60 patients with displaced midshaft clavicle fracture were included in the study. Patients were randomly allocated to the non-operative and operative group with 30 patients in each group. Non-operative management was performed with clavicle brace (figure of 8 bandage) while open reduction internal fixation with plate fixation was the preferred operative treatment. Patients were followed up at 2, 4, and 6 weeks and then at 3, 6, and 12 months. Outcome analysis included standard clinical follow-up, the constant shoulder (CS) score and the disabilities of the arm, shoulder, and hand (DASH) score, and plain radiographs. Statistical analysis was done using Student’s “t” test and SPSS software. The results were considered to be significant at P < 0.05.
Results: There was a statistically significant difference in functional outcome between the two groups at 3-month follow-up (CS; P = 0.0469 and DASH; P = 0.0406), though no such difference was recorded at 1-year follow-up (CS; P = 0.2731 and DASH; P = 0.4915). It implies that the patients in operative group improved functionally and returned to normal activities earlier than the non-operative group. Even patient satisfaction regarding shoulder appearance (cosmesis) was more in the operative group (100%) than in non-operative group (60%). The complications were more in the non-operative group (23), such as symptomatic malunion in 2 cases (8%), NU in 5 cases (20%), shortening in 3 cases (12%), and muscle wasting in 2 cases (8%), whereas only four complications were recorded in the operative group, of which two were implant related.
Conclusion: Surgical management of displaced midshaft clavicle fracture has definite short-term benefits with respect to functional outcome, early return to preinjury activities, and a lower rate of malunion and NU. Furthermore, due to difficulties of non-operative treatment including pain and instability at fracture site, tightness of clavicle brace, difficulties in self-hygiene, and high percentage of NU, especially in high-energy fractures; operative treatment is a good option in displaced midshaft clavicle fracture, especially in active adult patients.
Keywords: Clavicle fracture, Conservative management, Surgical management.


1. Neer C. Fractures of the clavicle. In: Rockwood CA Jr., Green DP, editors. Fractures in Adults. 2nd ed. Philadelphia, PA: Lippincott; 1984. p. 707-13.
2. Lenza M, Faloppa F. Surgical interventions for treating acute fractures or non-union of the middle third of the clavicle. Cochrane Database Syst Rev 2015;5:CD007428.
3. Nordqvist A, Petersson CJ. Incidence and causes of shoulder girdle injuries in an urban population. J Shoulder Elbow Surg 1995;4:107-12.
4. Crenshaw AH. Fractures of the shoulder girdle, arm and forearm. In: Crenshaw AH, editor. Campbell’s Operative Orthopedics. 8th ed. St Louis: Mosby; 1992. p. 989-1053.
5. NEER CS 2nd. Nonunion of the clavicle. J Am Med Assoc 1960;172:1006-11.
6. Rowe CR. An atlas of anatomy and treatment of midclavicular fractures. Clin Orthop Relat Res 1968;58:29-42.
7. Zlowodzki M, Zelle BA, Cole PA, Jeray K, McKee MD, Evidence-Based Orthopaedic Trauma Working Group. et al. Treatment of acute midshaft clavicle fractures: Systematic review of 2144 fractures: On behalf of the evidence-based orthopaedic trauma working group. J Orthop Trauma 2005;19:504-7.
8. Hill JM, McGuire MH, Crosby LA. Closed treatment of displaced middle-third fractures of the clavicle gives poor results. J Bone Joint Surg Br 1997;79:537-9.
9. Nowak J, Holgersson M, Larsson S. Sequelae from clavicular fractures are common: A prospective study of 222 patients. Acta Orthop 2005;76:496-502.
10. Robinson CM, Court-Brown CM, McQueen MM, Wakefield AE. Estimating the risk of nonunion following nonoperative treatment of a clavicular fracture. J Bone Joint Surg Am 2004;86-A:1359-65.
11. McKee MD, Wild LM, Schemitsch EH. Midshaft malunions of the clavicle. J Bone Joint Surg Am 2003;85-A:790-7.
12. McKee MD, Pedersen EM, Jones C, Stephen DJ, Kreder HJ, Schemitsch EH, et al. Deficits following nonoperative treatment of displaced midshaft clavicular fractures. J Bone Joint Surg Am 2006;88:35-40.
13. Lenza M, Belloti JC, Andriolo RB, Gomes Dos Santos JB, Faloppa F. Conservative interventions for treating middle third clavicle fractures in adolescents and adults. Cochrane Database Syst Rev 2009;2:CD007121.
14. Canadian Orthopaedic Trauma Society. Nonoperative treatment compared with plate fixation of displaced midshaft clavicular fractures. A multicenter, randomized clinical trial. J Bone Joint Surg Am 2007;89:1-0.
15. Nowak J, Holgersson M, Larsson S. Can we predict long-term sequelae after fractures of the clavicle based on initial findings? A prospective study with nine to ten years of follow-up. J Shoulder Elbow Surg 2004;13:479-86.
16. Robinson CM, Goudie EB, Murray IR, Jenkins PJ, Ahktar MA, Read EO, et al. Open reduction and plate fixation versus nonoperative treatment for displaced midshaft clavicular fractures: A multicenter, randomized, controlled trial. J Bone Joint Surg Am 2013;95:1576-84.
17. Judd DB, Pallis MP, Smith E, Bottoni CR. Acute operative stabilization versus nonoperative management of clavicle fractures. Am J Orthop (Belle Mead NJ) 2009;38:341-5.
18. Smekal V, Irenberger A, Attal RE, Oberladstaetter J, Krappinger D, Kralinger F, et al. Elastic stable intramedullary nailing is best for mid-shaft clavicular fractures without comminution: Results in 60 patients. Injury 2011;42:324-9.
19. Böhme J, Bonk A, Bacher GO, Wilharm A, Hoffmann R, Josten C, et al. Current treatment concepts for mid-shaft fractures of the clavicle results of a prospective multicentre study. Z Orthop Unfall 2011;149:68-76.
20. Kulshrestha V, Roy T, Audige L. Operative versus nonoperative management of displaced midshaft clavicle fractures: A prospective cohort study. J Orthop Trauma 2011;25:31-8.

How to Cite this article: Ranjan N, Agarwal A, Garg A. A Comparative Study of Conservative and Surgical Management of Displaced Midshaft Clavicle Fracture. Trauma International Jan – Apr 2019;5(1):23-27

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Management of Acetabulum Fractures – Basic Principles and Tips and Tricks

Vol 2 | Issue 2 | May – Aug 2016 | page:20-24 | Atul Patil, Ashok Shyam, Parag K Sancheti

Author: Atul Patil [1], Ashok Shyam [1], Parag K Sancheti [1]

[1] Sancheti Institute for Orthopaedic and Rehabilitation, Pune. Maharashtra, India.

Address of Correspondence
Dr. Ashok Shyam,
Sancheti Institute for Orthopaedic and Rehabilitation, Pune. Maharashtra, India.
E-mail address:


Acetabulum fractures require systematic approach for understanding the fracture pattern and also for planning the treatment plan. The fractures have to be correctly identified radiologically and clear definition of fracture patterns should be made before planning. The radiological parameters must be kept in mind in planning of surgical approach and also the fixation method. This may require a long learning curve but these basics have to be kept in mind while dealing with acetabulum fractures. There are new techniques like 3d CT, virtual assessment of the fracture, 3D print modelling of the fractures that may help in complex fractures, but the basic principles remain the same. Advancements in technology simply refines the ways and means of interpretation and implementation of the basic principles. The current article is compilation of experience gathered over a period of time. The entire article emphasizes on the basics of understanding and managing acetabular fractures and also includes important tips and tricks that facilitate the treatment.
Keywords: Acetabulum fractures, surgical management, Letournal and judet.


Acetabular fractures are still difficult fractures to manage and are a major challenge to treating orthopaedic surgeon [1]. Pioneering work was done by Letournal and Judet in 1964 [2]. They systematically classified acetabular fractures and developed a logical line of thinking for dealing with these fractures. They improved the understanding of morphology and popularized surgical principles for management of these injuries. Letournal and Judet put forth the two column theory of acetabulum anatomy. They envisioned acetabulum to be made of two columns. Anterior column from below the sacroiliac joint to the ischial tuberosity and posterior column from superior iliac crest to pubic symphysis with both columns attached to the sacrum by thick strut of bone lying above greater sciatic notch and called sciatic buttress [Fig. 1].

Based on these anatomical factors they suggested the first systematic classification of acetabular fractures.2 Although comprehensive classification is necessary for investigational purposes such as prognosis and outcome studies, it is less important in making decisions on individual cases. Every acetabulum fracture case is different, therefore, trying to force square plug in a round hole is  counterproductive. The surgeon must know the basic fracture types, but even more important, he must be able to interpret the radiographs and draw the fracture lines on a dry skeleton. The 3d CT virtual model and 3D print life size models of fractures acetabulum also need the basic understanding of the fracture anatomy and are helpful only when such clear understanding is present. This clarity also helps in selecting the surgical approach. Most of the innovative work was performed by Letournal and Judet and their recommendation is still valid till date [2,3]. Anatomical reduction of the articular fragment and restoration of a congruent and stable hip are the two most important factors in management of acetabular fractures. Fractures reduced to less than 1 mm of articular step have less incidence of posttraumatic hip arthrosis and a better and long lasting functional restoration as compared to fractures reduced with 1 – 3 mm residual articular displacement [4,5].

To meet these goals congruent and stable hip joint, four objectives are to be kept in mind
1. Correct interpretation of the radiographs
2. Identification and understanding the fracture pattern
3. Choosing the appropriate management
4. Striving for best surgical result.

1. Correct interpretation of radiographs-

On the antero-posterior pelvis radiograph, six lines are identified: the ilioischial line, iliopectineal line, the weight bearing dome (sourcil), teardrop, anterior rim (acetabulo-obturator line), and posterior rim (ischioacetabular line) [Fig. 2].

The iliopectineal line represents the anterior column. The ilioischial line is equated with the posterior column but is not actually created by the posterior border of the innominate bone but by the cortex of the quadrilateral surface. Thus fractures that disrupt the quadrilateral plate are seen as discontinuity of the ilioischial line even though these fractures do not disrupt the posterior border. The radiographic roof represents the cranial portion of the acetabular articular surface namely the weight bearing dome of the acetabulum. The lateral limb of the teardrop represents the floor of the cotyloid fossa while the medial limb represents the lateral wall of the obturator canal. Splitting of tear drop is seen when fracture line transverses through these areas. The anterior and posterior rims give some idea about the wall fractures however they are better diagnosed on Judet views.
Obturator view- is taken with injured side up and pelvis tilted 45 degrees. The posterior column and the anterior wall are visualized well (Figure 3a).
Iliac view – taken with pelvis tilted 45 degrees and injured side down. The posterior column and the anterior wall are visualized well (Figure 3b).

2. Identifying and understanding the fracture pattern-

According to Brander and Marsh [6], answers to following eight questions about the radiographic observations are used to determine the acetabular fracture pattern:
A) Is a fracture of the obturator ring present? If the obturator ring is broken then the fracture is either a column type of’ fracture or a T-shaped fracture.
B) Is the ilioischial line disrupted? Disruption of the ilioischial line occurs in fractures involving the posterior column or fractures in the transverse group.
C) Is the iliopectineal line disrupted? Disruption of the iliopectineal line indicates anterior column involvement or one of the transverse-type fractures.
D) Is the iliac wing above the acetabulum fractured? Iliac wing fractures are observed in fractures involving the anterior column, anterior column with posterior hemitransverse or both column fractures.
E) Is the posterior wall fractured? Posterior wall fractures may occur in isolation or in combination with posterior column or transverse fractures.
F) Does the fracture divide acetabulum into front and back halves or front and bottom halves? T type fracture divides pelvis into top and bottom halves while a column type divides pelvis into front and back halves
G) Is the spur sign present? The spur sign is observed exclusively in the both-column fractures. The spur is a strut of bone extending from the sacroiliac joint. Usually, this strut of bone connects to the articular surface of the acetabulum. In the both-column fracture, this connection is disrupted; a fractured piece of bone that resembles a spur remains. The spur sign is best depicted on the obturator oblique view [Fig 4]
H) What is the orientation of major fracture line on CT scan?
According to the answers of these eight questions, the fractures can be classified using Letournal and Judet classification as shown in Table 1

3. Choosing the appropriate management pathway:

Need for surgical intervention can be determined by following two criteria’s
Fracture criteria’s – Unstable hip [the femoral head and acetabulum are non congruent on AP radiograph], Roof arc angle is less than 45°, Intraarticular fragments, Marginal impaction, Unreduced fracture dislocation
Patient factors – Age [>50 yrs think of conservative treatment and later date Total Hip arthroplasty when arthritis develops], Severe co morbidities [ASA grade III or more – Cx], pre existing hip arthritis [Cx and THA later], severe osteopenia, patients with psychiatric disorders, patients with restricted pre injury mobility.
First decide whether radiograph will require surgery, and then assess the patient for feasibility of surgical intervention. If answer to any of the above question is negative the fracture is treated conservatively.
Few Tips in patient assessment –
Morel-Lavalle´lesions contain liquefied hematoma and have been known to be culture positive nearly 30-50% of times. In such cases drain the hematoma and perform delayed surgery.
Complete neurological examination and documentation is necessary especially in posterior dislocation as it is associated with high incidence of sciatic nerve injuries [20%] which if discovered later gives unsatisfactory result to the patient and may lead to legal issues.
In case the surgery is delayed, skeletal traction is essential

4. Striving for best surgical result.

This involves a definite learning curve. Surgical approach is determined based on the fracture classification. There are four main approaches used for acetabular fractures viz.
A. Kocher-Langenbeck: Posterior wall, Posterior column, Transverse, Transverse PW, Posterior column PW, T shaped [Fig 5, 6].
B. Ilioinguinal: Anterior wall, Anterior column, Anterior Posterior Hemitransverse, Both- column fractures, Transverse (rare) [Fig 7].
C. Extensile iliofemoral approach: Both-column fractures, T shaped, Transverse PW, Fractures > 3 weeks involving both columns [Fig 8]
D. Combined: A single approach is always preferred however combined approaches may be needed for more complex fractures involving both columns.

4. Striving for anatomical reduction.

This is by far the most important variable affecting the outcome of acetabular surgery along with severity of initial trauma. It has a long learning curve and this aspect is highlighted by Matta and Merritt in their study of their first 100 acetabular fracture fixation cases [7]. They grouped the surgical reductions chronologically in groups of 20 consecutive patients and clearly established that with increased experience the ability to achieve anatomical reduction improved along with ability to avoid unsatisfactory results.

Tips and pearls for acetabular surgery

§ Keep three points in mind – Avoid Devascularization of Fragments, remove all intra-articular fragments, and try to achieve anatomical reduction.
§ After exposure, open and clean the fracture site and get intraarticular visibility by a wide capsulotomy which will help in assessing the intraarticular reduction. Keep a low throeshold for widening the exposure
§ Special instruments in form of reduction clamps etc must be kept ready and used when necessary to hold reduction and achieve provisional K wire fixation
§ Reduction of the fragments – this will require two things – traction to the femur and opening through the fracture.
-Traction can be applied by a traction table or direct traction via a corkscrew through femoral neck or a hook on greater trochanter might work as well.
– Open the fracture by removing the major piece out of the way and appreciate the impacted fragments. These fragments have to be reduced to achieve best result.
– In cases where there is a major posterior fragment [high transverse and major T – type], a Schantz pin with a T-handle can be introduced into the ischial tuberosity to manipulate the reduction.
§ Provide stable fixation – most reliable fixation is a lag screw compression. Achieve reduction of the fracture fragments and provisionally fix them with K wires. The fragment can be predrilled first, then reduced and held with two 1.6-mm smooth Kirschner wires. Then each wire is then sequentially replaced by lag screws. This method will prevent shift/toggle of the fracture fragment while insertion of the lag screws.
§ It is desirable to have two points of fixation for each fragment, however this may not be possible because of small size although use of mini screws may be considered
§ After this a neutralization plate is applied to augment the fixation. Here one should keep in mind that lag screws should always be placed along the rim of posterior wall fragments, and care should be taken to ensure that the plate buttressing the posterior wall are positioned as lateral as possible. Applying the buttress plate too medially, especially without rim lag-screw fixation, might result in loss of stabilization of the posterior wall
§ Keep in mind two points while fixing the fractures -Avoid over-contouring of the plate, put in more lag screws rather than a bigger plate
§ In cases with bi-columnar fractures the anterior fragment is fixed with lag screw in first stage. While reducing the posterior column sometimes the anterior column screw needs to be backed out to help get the best reduction after which the screw is re-tightened.

A word of caution about the posterior approach:
The sciatic nerve must be identified and protected by knee flexion. Muscle belly of short rotators should be used to protect the nerve while retraction. Sciatic nerve may vary with respect to its relationship with pyriformis but always lies behind the quadratus muscle and is best identified by this relationship.
. Superior gluteal artery and nerve lie in the greater sciatic notch in close relationship with the bone. They can be injured while stripping of the the periosteum and can retract into the pelvis where they can bleed profusely and are difficult to handle.
. Retraction of the hip abductors might be required for visualization of superior acetabulum; however this may cause traction injury to the superior gluteal nerve which supplies the major hip abductors and the gluteus medius and minimus muscles.
Risk of iatrogenic osteonecrosis of the posterior wall fracture fragments is caused by excessive stripping of their soft-tissue attachments. Every attempt should be made to maintain the capsular attachments to these posterior wall fragments.

Recent Advances

Rapid prototyping and 3D printing are fast coming up as refined diagnostic and planning tool for acetabulum fractures [8,9]. These techniques help in visuospatial visualization of fracture fragments and also determine the best approach and fixation methods and implants. Trajectories of the lag screws can be determined on the virtual 3D models and the same can be utilized during surgery. However the role will be limited to more complex fractures and further refinement of the procedure will help in establishing its role in definitive management of acetabular fractures.


1. Tile M, Helfet D, Kellam J. Fractures of the Pelvis and Acetabulum. Baltimore. Lippincott Williams & Wilkins; 3rd edition, 2003.
2. Judet R, Judet J, Letournel E. Fractures of the acetabulum: Classification and surgical approaches for open reduction. J Bone Joint Surg. 1964;46A:1615-38.
3. Letournel E. Fractures of the acetabulum. A study of a series of 75 cases. 1961. Clin Orthop Relat Res 1994;(305):5-9.
4. Letournel E, Judet R. Fractures of the acetabulum, 2nd ed. Berlin: Springer-Verlag, 1993.
5. Matta JM. Fractures of the acetabulum: accuracy of reduction and clinical results in patients managed operatively within three weeks after the injury. J Bone Joint Surg Am 1996;78(11):1632-45.
6. Brandser E, Marsh JL. Acetabular fractures: easier classification with a systematic approach. AJR Am J Roentgenol. Nov 1998;171(5):1217-28.
7. Matta JM, Merritt PO: Displaced acetabular fractures, Clin Orthop Relat Res 230:83, 1988.
8. Zeng C, Xing W, Wu Z, Huang H, Huang W. A combination of three-dimensional printing and computer-assisted virtual surgical procedure for preoperative planning of acetabular fracture reduction. Injury. 2016 Oct;47(10):2223-2227.
9. Duncan JM, Nahas S, Akhtar K, Daurka J. The Use of a 3D Printer in Pre-operative Planning for a Patient Requiring Acetabular Reconstructive Surgery. J Orthop Case Rep. 2015 Jan-Mar;5(1):23-5.

How to Cite this article: Patil A, Shyam AK, Sancheti PK. Management of Acetabulum Fractures – Basic Principles and Tips and Tricks. Trauma International May-Aug 2016;2(2):20-24.

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Non Union Distal Femur Fracture: Causes and Management Options

Volume 2 | Issue 1 | Jan-April 2016 | Page 28-33|Puneet Maheshwari, Pramod Maheshwari

Author: Puneet Maheshwari[1], Pramod Maheshwari[1]

[1] Maheshwari Nursing Home, 163, Bhagat Singh Marg
Dewas M.P. 455001, India

Address of Correspondence
Dr. Puneet Maheshwari
Maheshwari Nursing Home, 163, Bhagat Singh Marg
Dewas M.P. 455001, India


Distal femur fractures are common but complex fractures and often are associated with complications. The cases of failure may be secondary to mechanical failure or biological failure. The current review offers overview of these complications and tips and tricks on how to manage these complications.
Keywords: Distal Femur Fractures, Complications, Surgical management


Distal femoral fractures are a common orthopaedic problem in all age groups of patients with and incidence of about 37 per 100,000 person years.(1) Distal femoral fractures since a long time has been considered difficult to treat using traditional implants due to high failure rate and secondary varus collapse. (2)
Distal femoral fractures in young age group is most commonly due to high energy trauma while in older age group it is mostly associated with fall from height or walking along with osteoporosis of bones. Treatment of these fractures can be successfully done with variety of plates(3-6) and retrograde intramedullary nails(7-10).
Early studies of treating distal femoral fractures with locked plates reported excellent out come with non-union rates of 0-14% (mostly less than 6%) (4, 11-21).
However, with the recent data being analyzed and reported the non-union rates are now as high has 17-21% (11, 22, 23). This can be partially attributed to wider variety of fracture morphology and in patients prone for development of non-union.
Definition of Non-union
Non-union definition is based on three factors namely, duration of time since injury, characteristics of fracture on serial x-rays and lastly clinical parameters assessed by the treating surgeon.
Presently, US FDA defines non-union as fracture bone that has not completely healed in 9 months since injury and which has not shown any signs of healing over 3 consecutive months on serial x-rays.(24)
Multiple literatures indicates that optimal time for healing is in between 4 to 12 months, taking into account the type of bone fractured, nature of injury and quality of the soft tissues around the fractured bone. (25-33)
Along with these factors one more important factor is the physiologic capability of the individual in mounting a healing response.

Distal femur fractures (AO classification)
As per the AO classification the distal femur (33) can be classified in to 3 types namely extra-articular, partial articular and complete articular factures, which are further classified.
Distal femur fractures are:
Type 33A: extraarticular fracture
o A1: simple
o A2: metaphyseal wedge and/or fragmented wedge
o A3: metaphyseal complex
Type 33B: partial articular fracture
o B1: lateral condyle, sagittal
o B2: medial condyle, sagittal
o B3: frontal
Type 33C: complete articular fracture
o C1: articular simple, metaphyseal simple
o C2: articular simple, metaphyseal multifragmentary
o C3: articular multifragmentary

Weber and Cech have classified femoral non-union based on the viability or blood supply of the fracture into two broad groups viable and non-viable types. (24)
Viable type of non-union has an intact blood supply to the fracture area and thus body can mount a healing response to injury. Viable type is further divided into hypertrophic and oligo-trophic non-union.
Non-viable type of non-union is also called as atrophic or avascular non-union. The vascularity of the fracture area is absent and thus it cannot mount a healing response to injury. Type of non-union can be determined on plain x-ray in AP and lateral view or more accurately on bone scans.
Classification of non-union is important not just for documentation purposes but also for management point. In a viable non-union minimally invasive or non-invasive treatment can lead to union and thus saving the patient from another major surgical procedure.
These procedures would be give a questionable healing response in case of atrophic non-union and there the surgeon need to be more aggressive and has to plan a more extensive treatment.

Diagnosis and Evaluation
It is extremely important for the treating surgeon to timely diagnose, evaluate and document a non-union both for management as well as for legal purpose.
Diagnosis begins with a detailed history and examination of the patient and the affected limb. Patient-related risk factors like tobacco addiction, use of analgesics peripheral vascular disease, diabetes should be looked for and documented. Any clinical symptom that may point towards infection (occult/overt) like fever, malaise, night pain or history of wound healing problem should be elicited.
Physical examination should identify and document any deformity, pain over fracture area, soft tissue cover problems, increased local temperature, drainage, abnormal mobility, crepitation, and limb length discrepancy.
Radiological evaluation should be done with plain x-rays of the affected part in AP, lateral, and both oblique views (45 degrees internal and external views). In majority of patients this will get the accurate diagnosis of nonunion and its subtype. CT scan is a more accurate modality than plain x-rays in diagnosing the non-union.(34)
Infection should be cause in all cases of femoral non-union unless ruled out. Hence proper blood work-up is must which should include complete blood count, ESR and CRP. Deep tissue culture at the time of secondary surgery is the gold standard for diagnosis of infection. (35)

Causes and Risk factors
Main causes of distal femoral nonunion are
Inadequate fracture stabilization leading to motion at fracture site
Avascularity at the fracture ends – due to compound fractures, excessive stripping of soft tissue during surgery
Fracture gap
Patient related
Surgeon related

Inadequate fracture stabilization leads to micro and macro movements at the fracture site, which may result due to inadequate fixation at the time of primary surgery or due to implant failure.
Avascularity or diminished blood supply to the fracture end results due to compound injury (27), excessive stripping of soft tissue during surgery, comminuted fractures.(36) Decreased blood supply leads to a poor healing response and causes atrophic non-union.
Multiple literature supports that in fractures with significant comminution the soft tissue stripping is more and thus injuring the blood supply.(28)
Presence of gap at the fracture site either due to bone loss or during surgery (fracture fixed in distraction or debridement) also contribute to the occurrence of non-union.(29) Any gap present is usually bridged by the fracture callus, but when the body fails to bridge this gap non union results.
Infection can result as a complication of open injury or surgical treatment. Infection leads to formation of dead necrotic bone in the form of sequestrum, ingrowth of infected granulation tissue, osteolysis and motion at fracture site due to loosening of implant or implant failure.
Patient factors like age, smoking, tobacco use, chronic use of analgesics (NSAIDs), medical comorbidities and obesity to name a few can lead to non-union (22, 37).
Surgeon related factors include technical factors like plate length, screw density of plate, material of implant (titanium vs. stainless steel) and cortical reduction. Studies have shown that use of titanium implants significantly reduces the chances of non-union and thus need for a secondary surgical procedure (22).
In case of implant failure, the most important factor is the length of plate used. Shorter plates are prone to fail earlier than longer plates due to relatively lower fatigue properties because of mechanical disadvantage. Usually, a plate with 9 or more screws are is less liable to give away (37).

Treatment Options
Ultimate aim of the surgeon is to achieve osseous union without complications. Along with this it is important for the surgeon to correct any mal-alignment control infection if present, achieving sufficient muscle strength and rehabilitation.
Currently the accepted method of primary fixation of distal femur fractures is retrograde nail and lateral plating either lateral locked plates or fixed angle plates.

1.    Nail dynamisation
2.    Exchange nailing
3.    Plate osteosynthesis
4.    External fixation
5.    Adjuvant treatment options
a.    Electrical stimulation and ultrasound therapy
b.    Bone grafting
c.    Bone graft substitutes and biologic agents
d.    Bone marrow infiltration

Nail Dynamisation
Nail dynamisation is the term used when the statically locked nail is converted to a dynamically locked plate. This is accomplished by removal of screw/s adjacent to the dynamic hole of the nail.
Mechanism of healing with this technique is that it allows for a controlled axial instability of the bone and implant at the fracture site. This allows transfer of weight bearing forces to non-union site and promotes healing.(38)
Dynamisation is most effective when done at an early stage of non-union or delayed union as judged by serial radiographs. Optimal time for dynamisation is around 3-6 months of injury and primary treatment.(36)
Available literature suggests a success rate of about 50%. Nail dynamisation should be done is axially stable fractures like transverse or oblique fractures.
There are few complications associated with this technique namely shortening, implant failure. Thus a regular follow-up of the patients is a must.

Exchange Nailing
Exchange nailing refers to the surgical technique where an already present nail is removed and a larger diameter and stiffer nail is inserted after reaming. It is desirable that the second nail should be atleast 1-2mm larger than the earlier nail and the reaming should be done until the osseous chatter is heard.
This method provides both mechanical and biological stimulus for healing. A larger diameter and stiffer nail provides more mechanical stability along with increased working length of the implant thus decreasing the chances of implant failure. Biologically reaming causes deposition of fresh marrow material in the non-union site and stimulates periosteal reaction.(39) Union rates reported with this technique is variable with some studies showing union rates as high as 97%. (31, 32) Studies show that chances of non-union are more when reaming is not done.(40)

Plate Osteosynthesis
Plate osteosynthesis is the most common and gold standard treatment option in cases of distal femoral non-unions.(37) Plating offers increased mechanical stability to fracture specially in hypertrophic non-unions. Plate osteosynthesis (open reduction and internal fixation) provides an excellent opportunity of the surgeon to correct any associated deformities along with providing an excellent axial and torsional stability. Traditionally fixed angled 95 degree angled blade plate was used for distal femoral fractures, applied on the lateral aspect.(3, 41) The newer locked plates now available are the implant of choice in present scenario.(4, 5, 11-13, 15, 16, 18-20, 42, 43) With the use of compression holes excellent direct compression of the fracture site can be achieved.(44)
Few studies have reported union rates for distal femur non-unions with plate osteosynthesis around 91% to 100%.(45, 46) Even in case of poor bone stock and long standing non-unions the union rates are in range of 95 to 98% (31, 47)
This method of achieving union has its own risks and disadvantages. There is increased risk of infection, blood loss, increased tissue stripping, implant breakage, screw loosening etc. (6, 45, 47-50). Another disadvantage is that patients treated with plate osteosynthesis require strict immobilization for some duration, which may lead to joint stiffness and decreased range of motion of joints along with delay in starting rehabilitation.
Abdel-Aa et al (46) reported in their study that about 13% of patients treated with plate osteosynthesis for distal femoral non union required quadricepsplasty and knee arthrolysis within one year of surgery.
Another technique has been described in literature where both nail and plate are used simultaneously in achieving union. In this technique with an intramedullary implant in situ, a plate is fixed in compression mode at the fracture site. This method provides positive points of both the techniques in the form of early weight bearing, fracture fixed in direct compression thus chances of early union, improved torsional and rotational stability. If required bone grafting can also be done at same time to further increase the osteogenic potential and to fill up any bony defects if present. In studies using this method there has been a union rate of 100% within one year of surgery.(49, 51, 52)

External Fixation
Multiplanar (Ilizarov technique) and uniplanar external fixation for treatment of non-union of femur has been reported in literature with modest success (53, 54). Compression and distraction at non-union site has been demonstrated to show signs of healing(55). However, with the high complication rate (eg osteomyletitis, severe pain requiring opiod anagesics, septic arthritis, pin failure, joint stiffness etc.) use of external fixation for non-union healing is restricted to small number of patients. Along with this, the technical complexity and cost factor also restricts its use to tertiary level centres (54).

Adjuvant Treatment
These treatment options can be used as an isolated treatment option or as a supplementary treatment for achieving union.

Electrical Stimulation
Multiple studies show that mechanical forces, electrical forces, magnetic forces and ultrasound waves have variable level of effect on bone healing and growth (56-59). Electrical stimulation is thought to be effective non-invasive modality for promoting fracture healing and in treatment of non-unions.
Generation of electrical potentials around bone occurs when mechanical stress is applied(60, 61). Electronegative and electropositive potentials are generated with compression and tension respectively (62). It has been proven that in electronegative potential bone growth occurs and with electropositive potential bone is resorbed (63).
There are three techniques of electrical stimulation, namely, direct electric current, capacitive coupling and inductive coupling.
Direct electrical current is an invasive technique involving one or more cathode electrodes being implanted in the bone and an anode usually placed on the skin over the fracture site(64). In a case series by Brighton et al. (65) out of 168 fractures, 76% showed good bony union by 12 weeks of electrical stimulation therapy.
Capacitive coupling is a noninvasive technique where two electrodes are placed over the skin such that fracture site lies in between the electrodes. Here alternating current (AC) is used and an electric field is generated in and around the fracture site. It is a dose dependent technique whereby the greater electrical field leads to more osteoblastic cell response along with increased time of exposure leading to increased osteoblastic cell proliferation (66, 67).
Inductive coupling uses the principle of Pulsed Electromagnetic Field (PEMF) generation using specific device. The device is placed over the skin (non-invasive) over the fracture site. Passing current in the device generates the magnetic field. This magnetic field induces an electrical field, which leads to a bone healing response. This time-varying electrical field simulates normal response of osteoblastic cells to mechanical stimuli (68).

Bone Grafting, bone marrow aspirate and biologic agents

These procedures and materials can be used as an isolated or adjuvant treatment depending of the non-union type.
Autogenous bone grafts are considered gold standard for grafting procedures(69). Autologous bone grafting in past has got a bad review mainly due to donor site complications(70). With advances in harvesting techniques there is a renewed interest in this procedure(71-73).
Biologic agents like Bone Morphogenic Proteins (BMP) have been studied in detail both in animals and in humans and gives promising results.
Bone Morphogenic Proteins are part of the Transforming Growth Factor-Beta (TGF-B) superfamily and with a cascade sequence of events leads to bone healing via chondrogenesis, osteogenesis, angiogenesis and extracellular matrix remodeling (74). There are more than 20 BMP identified in humans. Studies in animals and in-vitro have shown BMP -2,4,6,7,9 have high osteogenic potential (75-78). Recombinant BMP-2 and 4 are in use clinically (74) but with questionable safety and efficacy profile(79-82).

Every surgically managed fracture is a race between bony union and implant/biological failure leading to non-union. Management of acute distal femur fracture with a nail or plate has good union rate or more than 90%. But when non-union occurs, it becomes a challenging task for the surgeon and patient both. It presents a significant mental, emotional and financial implication on the patient and his/her family.
Careful history taking and meticulous examination during routine follow-ups can help a surgeon to diagnose a delayed union or non-union in early stage and can modify the management as per the need to achieve bony union. Established non-union requires a well planned out management protocol to be decided before hand. Surgeon should decide the management plan (either non-invasive or invasive) on case-to-case basis to achieve union, correction of deformities. Surgeon should also take care of the patient modifiable risk factors like use of NSAIDs, smoking, medical co-morbidities and nutritional status of patient.



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How to Cite this article: Maheshwari P, Maheshwari P. Non Union Distal Femur Fracture: Causes and Management Options. Trauma International Jan-Apr 2016;1(2):28-33.

Dr. Pramod Maheshwari

Dr. Pramod Maheshwari

Dr. Puneet Maheshwari

Dr. Puneet Maheshwari


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