title: Common avoidable problems in nonunions.
abstract: Fracture-healing problems today occur predominantly in the weight-bearing tibia and femur. This review of 83 lower-limb nonunions out of a series of 100 fracture-healing problems identified avoidable causes in 30%. These included rigid fixation, which produced fracture gap, fibulectomy, which destabilized the tibia, and soft-tissue procedures, which impeded fracture management. The significance of these factors was evident when treatment to avoid the above-noted adverse factors did produce union. The fact that complications occur with certain techniques does not interdict their proper use. However, critical analysis of a large number of cases suggests the following three principles for avoiding nonunion: (1) Rigid fixation eliminates the critical external callus response of the first six weeks after fracture. Consequently, less than rigid fixation obtained with functional fracture braces or intramedullary rods, which maximize external callus and avoid fracture distraction, is generally preferable for weight-bearing bones. (2) Fibulectomy may encourage impaction across a tibial fracture gap. However, the resection should be performed well away from the tibial fracture site, thereby avoiding tibial instability. (3) With the open fracture, priority of management should be given to achieving fracture union rather than to absolute soft-tissue coverage. No fracture in this series failed to heal because of exposed bone.
mesh_terms: D000328:Adult; D005260:Female; D005264:Femoral Fractures / Q000150:complications* / Q000000981:diagnostic imaging / Q000628:therapy; D005592:Fracture Fixation / Q000009:adverse effects; D005593:Fracture Fixation, Internal / Q000009:adverse effects; D005597:Fractures, Open / Q000150:complications*; D005599:Fractures, Ununited / Q000150:complications* / Q000000981:diagnostic imaging; D006801:Humans; D008297:Male; D008875:Middle Aged; D011859:Radiography; D013978:Tibial Fractures / Q000150:complications* / Q000000981:diagnostic imaging / Q000628:therapy; D013997:Time Factors; D014945:Wound Healing; D014946:Wound Infection / Q000150:complications